NHS Wholly Owned Subsidiary Companies

Dan Poulter Excerpts

Tuesday 6th March 2018 Westminster Hall

[Liz Twist]

I most certainly agree that the issue is a dangerous one that needs to be looked at, and it is a very worrying one because, whatever happens, the staff who have transferred are in a very difficult position.

In the longer term, the establishment of the wholly owned subsidiaries leaves services open to privatisation in the future, continuing the fragmentation of our NHS, which is not in the long-term interests of all who use the NHS. There is no evidence that the plans will improve efficiency or productivity in the NHS. They exploit a tax loophole and seek to exploit the future workforce.

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

The hon. Lady and her colleagues are right to highlight the fact that the financial pressure on the NHS is the main driver for this situation. Does she agree that it is very difficult in some services to differentiate between administrators and back-office services, and frontline services? Sometimes, administrators and back-office workers are embedded in clinical teams, and this actually worsens fragmentation and makes it much more difficult to deliver high-quality patient care.

[Liz Twist]

The hon. Gentleman makes an excellent point. NHS staff, whatever their job, are all part of a team that delivers a service, and they all work together. For example, the catering and cleaning staff who looked after my mum’s hospital ward when she was in hospital recently were also a part of the NHS caring process. I think that is a really important point.

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[Stephen Barclay]

Again, that is a complete misrepresentation. The trust itself has pointed to the benefits of the arrangement. Let me give a concrete example of how the arrangement is delivering to the trust savings in the interests of patients.

Under the previous delivery system, local pathology samples were sometimes lost and delayed—that is not in the interests of patients. The QEF brought in a revised system of procuring all sample containers and issuing those to GPs across the region before delivering samples to the hospital pathology laboratory hubs within four hours. The trust forecasts that that will deliver significant benefits—indeed, other trusts are interested in the services. By operating on a more commercial model, therefore, not only has the trust improved how it deals with samples and prevented those samples from being lost as in the past, but it has put in place a system that is better for patients and attractive to GPs in other trusts who now want to contract the services.

[Dr Poulter]

The Minister is slightly at odds about the point being made. The point is not how it is open to the trust to procure the best clinical services but how, later, through a company, staff might be re-employed on a lower salary. Clearly, trusts already have flexibility through “Agenda for Change” to start people on a higher pay point, but I wondered more generally whether my hon. Friend supports national pay bargaining and “Agenda for Change”.

[Stephen Barclay]

The Chancellor made his support for the “Agenda for Change” programme clear in the Budget. My hon. Friend is aware of the commitment that the Chancellor made to fund that outwith the spending review 2015 process. That is a matter of record and one my hon. Friend is well aware of. The point being made, however, is that the flexibilities are popular with staff within the trust. Again, that is not simply a matter of me saying that; it is reflected in the staff survey of those working at the trust.

NHS Negligence Cases

Dan Poulter Excerpts

Tuesday 30th January 2018 Westminster Hall

[Andrew Gwynne (Denton and Reddish) (Lab)]

I beg to move,

That this House has considered NHS negligence cases.

As always, Mr Rosindell, it is a pleasure to see you in the Chair. I know that it is highly unusual for a member of the shadow Cabinet to speak from the Back Benches, so I am grateful to the Opposition Whips and to Mr Speaker for allowing me to do so as a final opportunity to seek some form of closure for my constituent in this very serious matter. I am especially grateful to Mr Speaker for granting this debate.

Sadly, I have to publicly outline how my constituent, Mr Hawkins, has been let down by public authorities. The law and NHS rules have been abused to avoid giving him the justice that is rightfully his. His attempts to seek that justice, along with some semblance of honesty and humility, have already passed the decade mark, so I shall be grateful for the Minister’s reply after I set out the case.

Mr Hawkins was admitted to Tameside General Hospital on 28 June 2006 to undergo surgery to repair a ruptured left Achilles tendon. Rupturing an Achilles tendon can tear it partially or completely, making walking difficult and the ankle feel weak. The surgery was listed for theatre in the afternoon under the care of an orthopaedic consultant surgeon, Mr Ebizie, but then postponed to the evening. My constituent believes that the most simple and sensible solution would have been to postpone it until the next day, allowing him to remain under the care of the same surgeon. He believes that that did not happen, however, because it would have meant the hospital missing its five-day Government target for a patient to receive treatment or surgery after attending accident and emergency. Records indicate that the surgery was instead carried out by Dr Manikanti, assisted by Mr Kumar. Mr Hawkins states that the change of surgeon was made without his knowledge or consent. Subsequently, both clinicians have left the hospital and the country, and the names and titles of those who carried out the surgery have been disputed.

Mr Hawkins states that the surgeon made a critical clinical error. He believes that the surgeon misunderstood the positioning of the two diagonal sutures forming part of the modified Kessler suture. They were brought to the surface and closed, which permanently fixed the repaired Achilles tendon to the rear of his leg. On 7 July 2006, nine days after the surgery, the plaster cast was removed, revealing an open wound between the two sutures. Steri-strips were applied in an attempt to close the wound, but the duty consultant wrote in his records that the wound had healed very well after surgery. Mr Hawkins states that despite being aware of the error, the hospital failed to correct it by releasing the repaired tendon from the rear of his leg as soon as was medically possible. This allowed serious adhesion and tethering to form as the sutures disintegrated.

On 12 January 2007, Mr Hawkins was discharged from the care of Tameside Hospital. Throughout the previous months, the repaired Achilles tendon had been continually swollen because of the aggravation of the fixation. Mr Hawkins raised concerns, which were ignored. Weekly and monthly appointments at the hospital were required thereafter. Mr Hawkins believes that he was discharged by Tameside Hospital before he was clinically prepared and regardless of his condition. He feels that that was done to conform to Government targets.

Mr Hawkins immediately made a complaint through the hospital trust’s internal complaints procedures. He believes that on receipt of his letter of complaint, the trust should have called him in for an examination and a scan. It should have admitted that a serious problem had occurred and carried out a further operation to release the Achilles tendon from the rear of his leg. In Mr Hawkins’s mind, the matter would then have been resolved. However, the trust decided to take a different route: it instantly instructed Hempsons solicitors.

Although, obviously, Mr Hawkins is concerned about the clinical errors that have caused him lasting damage, he is rather more appalled by the actions of a variety of organisations afterwards. He believes that those actions were deliberately designed to cover up the fact that a clinical mistake had been made, caused primarily by the replacement of a consultant surgeon with a junior doctor.

In 2008, Mr Hawkins instructed a solicitor, who requested disclosure of all full medical records. The trust passed his request on to Hempsons. However, in the immediate period after his request he received only a very selective number of his own medical files from Hempsons. Mr Hawkins’s solicitor failed to ensure that all full medical evidence was disclosed within statutory time limits and failed to apply for a court controlled disclosure, while knowing that the records he had listed were missing. Mr Hawkins’s solicitor instructed a clinical litigation medical expert, who produced a case-closing report that failed the objectivity test and was therefore invalid. The trust and Hempsons initially failed to disclose relevant medical records, doing so only after continued and considerable pressure from Mr Hawkins.

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

The hon. Gentleman is a strong advocate for his constituent and makes a compelling case about the difficulties that his constituent has faced. Does he agree that the case flags up a wider problem? He mentioned solicitors being involved at a very early stage in the process. The current system for dealing with medical negligence in hospitals pushes defensive medicine and defensive approaches from hospitals. That fundamentally needs to change, because it is not good for doctors and it is not good for patients. Does he think that no-fault compensation may be a good way forward?

[Andrew Gwynne]

The hon. Gentleman makes an important point. As Mr Hawkins himself acknowledges, if the hospital trust had taken his complaint down a different route by accepting that it had made a clinical error and deciding to put it right, I would not be standing in Westminster Hall today raising his case.

Mr Hawkins continued with his complaint. In 2013, the trust eventually conceded and his remaining medical records were fully disclosed. On analysis of the records, it was plain to see that there were omissions and that pre-action protocol time limits had been exceeded. In response, Hempsons sought the opinion of a medical litigation expert. A report was produced, but it was based on the selected medical records that I mentioned earlier, as well as on the falsified information. Mr Hawkins believes that that report would fail any objectivity test and is therefore invalid.

Mr Hawkins had involved the Information Commissioner’s Office on two occasions: in 2009 and in 2013. In both instances, it judged that the Data Protection Act 1998 had been breached by the trust’s failure to disclose relevant medical records on several occasions. After much time and effort from Mr Hawkins, on 11 December 2013 the new management team at the trust finally admitted to maladministration and awarded remuneration for it. In a move that Mr Hawkins believes was an attempt to close his complaint and prevent the case from going back to the Information Commissioner, or to the court for disclosure, the new management team disclosed that it would no longer discuss actions taken by the old management team. Mr Hawkins also believes that the Limitation Act 1980 was breached from 2008 and that rules 31 and 35 of the Civil Procedure Rules 1998 were breached in compiling medical reports, because the medical experts failed in their duty to the court to be objective.

The delays in disclosure of information meant that Mr Hawkins’s complaint to the Parliamentary and Health Service Ombudsman was ruled out of time. My constituent believes that that makes a mockery of the trust’s failure to disclose his medical records within statutory time limits, which he believes the ombudsman ignored while upholding the strict time criteria regarding his making a complaint to the ombudsman.

Mr Hawkins appealed the decision on several occasions when the evidence was retrieved through the Information Commissioner. However, he was unsuccessful in overturning their original view that a letter from the trust indicated that the complaint was closed in 2007, which he utterly refutes. Hempsons later apologised and admitted that that letter did not clearly state that the local complaints procedure was closed. However, the ombudsman still refused to investigate the complaint and, in doing so, Mr Hawkins feels that the ombudsman has assisted the trust to conceal the cause and effects of a clinical error.

In 2013, Mr Hawkins wrote to the NHS Litigation Authority, as the trust was not reporting clinical mistakes. Initially, the NHS Litigation Authority would not get involved and requested my involvement, as Mr Hawkins’s Member of Parliament, which I duly offered. Two replies were received that indicated that the NHS Litigation Authority was involved in the case, despite previous assertions and written evidence that it was not involved. Mr Hawkins was notified in writing that the trust, on receipt of his letter of complaint, had instructed Hempsons in January 2007, with the NHS Litigation Authority directly instructing Hempsons and the trust from November 2007 to February 2009.

Hempsons was aware of a breach of the Limitation Act 1980 and the Data Protection Act 1998 when it disclosed to Mr Hawkins his missing medical records in October 2009. This means that the trust and Hempsons had illegally avoided disclosing all full medical records within statutory time limits and successfully passed the three-year limit for litigation. Mr Hawkins believes that indicates that the NHS Litigation Authority was aware that rules had been broken, yet failed to take retrospective action based on the strength of the evidence that he had disclosed to it in 2013.

The actions taken by the trust, assisted by Hempsons and the NHS Litigation Authority from January 2007 to December 2013, clearly indicate that the trust was covering up a clinical incident and its cause. With so much time having passed since my constituent first exited the operating theatre in the summer of 2006, I hope that today the Minister of State will be able to afford Mr Hawkins guidance and support in this matter, and finally bring to some closure what has been a dreadful episode for my constituent.

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[Stephen Barclay]

The hon. Gentleman will appreciate that the events took place more than 11 years ago and that it is, therefore, not for me to comment on what the trust knew at that time or their actions accordingly. I think we all, across the House, recognise that resolving issues without recourse to litigation is preferable, where possible, to lawyers being involved at an early stage—and I say that as a former lawyer. That is why the Government seek to improve how complaints are handled, including improving the regulation. The Care Quality Commission now rigorously inspects all trusts and primary and adult care providers, and a duty of candour—a new protection for whistleblowers—encourages staff to speak up for safety and hence fosters greater transparency. There is also the development of a culture of learning, through patient safety collaboratives and the national Sign up to Safety campaign, and last April the healthcare safety investigation branch became a fully operational and independent branch of NHS Improvement, to investigate serious incidents in the NHS with a strong focus on system-wide learning.

[Dr Poulter]

I do not wish to distract from the main purpose of the debate, but my hon. Friend makes an important point about a culture of openness and transparency in dealing with complaints. How does he feel that the recent High Court judgment about a doctor being struck off by the General Medical Council might play into doctors’ and other healthcare professionals’ willingness to engage with such a culture? Might it be inhibitory, in that they would be concerned about the impact on their future careers of being open and willing to own up to mistakes?

[Stephen Barclay]

As a former Minister, my hon. Friend knows that there are conventions regarding Ministers of the Crown commenting on court judgments. The Secretary of State has already made clear his position on that matter, and this debate on a specific constituency issue is not the forum for moving beyond that scope.

It is important for us all that we improve the handling of complaints. In a system as large as the NHS, we all recognise that, with the best will in the world, things will go wrong and mistakes will be made. The latest Care Quality Commission annual “State of Care” report, published in October 2017, recognises that the vast majority of patients get good care and that many parts of the NHS have improved thanks to the hard work of the staff. The key issue that the hon. Member for Denton and Reddish has rightly brought before us today is how we learn from things going wrong and how, when a patient thinks something has gone wrong, the issues are aired and resolved.

I commend the hon. Gentleman for securing the debate, notwithstanding his elevated position in the shadow Cabinet, and for ensuring that his constituent’s issues have been aired before the House. The Government are committed to building a learning culture within the NHS that listens to patients and relatives and learns from mistakes, so that patients do not suffer avoidable harm. The Secretary of State deserves great credit for his championing of patient safety as a specific issue within his portfolio. We are also working to improve the complaints handling system so that it is more responsive and joined-up between organisations. I hope that the improvements that are in place will help Mr Hawkins to get some closure on the matters we have debated today.

King’s College Hospital

Dan Poulter Excerpts

Tuesday 16th January 2018 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Hollobone. I draw your attention and that of Members to my declaration in the Register of Members’ Financial Interests. It is probably worth pointing out, too, that I had the pleasure of being a medical student at King’s many years ago.

I pay tribute to the hon. Member for Dulwich and West Norwood (Helen Hayes) for securing this important debate. King’s certainly crystallises a number of the challenges faced by the NHS more generally in terms of financial pressures and those pressures manifested by difficult finances in the ability of hospitals to care appropriately for patients.

I want to pick up on a couple of the points that the hon. Lady made. I was the Minister who took through the Care Act 2014, together with the right hon. Member for North Norfolk (Norman Lamb). Through the Act, we considered and learned lessons from some of the problems in the reconfiguration of the South London Healthcare NHS Trust that failed in 2013. I am sure that the hon. Lady is absolutely right that we could learn lessons about how not to do hospital reconfiguration from how that reconfiguration was done.

I again reference the Register of Members’ Financial Interests. At the time, there was a natural synergy, in medical school terms and in other terms, developing between King’s, Guy’s and St Thomas’, and the King’s Health Partners. There is a shared local health economy between those hospitals and a shared interest in patient care. Each of those hospitals are centres of international excellence and tertiary centres of care, and are important local general hospitals for their communities. That synergy would have been a much more natural alignment of healthcare interests in that area but, unfortunately, that did not happen. Lessons have been learned from what occurred.

One of the major issues was the inheritance by King’s of the huge private finance initiative debt of the Princess Royal University Hospital, which in 2017-18 I believe amounts to about £37 million a year—about half the King’s deficit. It would be wrong to blame those running King’s for that deficit. It was very unfortunate for Lord Kerslake—I will come to him later—as chair of that trust, to inherit a de facto deficit due to that huge PFI cost.

The hon. Lady was right to talk about the rate of funding increases for the NHS being at a record low for many years. We had a very difficult economic situation in 2010, but I do not think that anybody expected austerity to last for the best part of a decade. Certainly, many of our public services are now feeling the squeeze as a result of the funding pressures that they face.

The funding pressure on the social care system has an impact on the NHS. Local government finances are in a challenging situation in many areas. Pressures on the social care system reduce the ability of the NHS to work in an integrated, joined-up way with social care and reduce the ability of hospitals such as King’s to discharge patients effectively into the community, because the resources are not there to look after them. There are also additional pressures on admissions, because there is not the preventive care in the community that a well-funded, properly integrated health and social care system would be able to provide.

There is welcome talk from the Secretary of State of a Green Paper on better integrating health and social care—I am sure the Minister will be involved, too, and I welcome him to his place and to his role. Having a sustainably funded, fully integrated system must be part of that and must be part of dealing with the challenges faced by King’s, by the local health economy and nationally.

I had not intended to speak for very long, but as I said, the example of King’s College Hospital crystallises and pulls together the overwhelming challenges faced by NHS trusts. The overwhelming majority of NHS trusts and foundation trusts are in debt. That was not the case five years ago. As in the case of King’s, many of those trusts have worked very hard to bring those annual deficits under control and to manage the additional challenges of increasing patient demand and pressure from more and more patients with multiple medical comorbidities. In 2018, there are around 3 million patients with three or more long-term conditions in England. It is a very big human challenge to look after those patients, but it is also a very big financial challenge.

The percentage of GDP in this country spent on health and social care falls well below that which is spent in many comparable western economies on healthcare. I know that the Government will look at that as part of their plans for the sustainability of the health and social care system in the Green Paper. I do not expect the Minister to talk about that in detail today, but it is well overdue and I know he will pay keen attention to that.

I had the pleasure of working with Lord Kerslake when I was in Government. He and the board did a lot to reduce what the hospital paid out in temporary staffing costs; some good work was done to reduce unnecessary expenditure on agency and other costs. It is a great shame when a very distinguished and long-standing public servant feels that, despite all their experience and their best efforts to grapple with some of the challenges of King’s finances, they need to stand down from their role because there is no other option. I am sure that Members from all parts of the House will echo that sentiment.

Some good efforts were made in 2015-16 to begin to tackle some of the hospital’s deficit and debt, but in this financial year the finances have worsened and as a result, as the hon. Lady outlined, the hospital has been put on special measures. It seems extraordinary that the hospital and the board have been put in that position when, as I mentioned earlier, one of the reasons for the hospital’s deficit is the PFI, which effectively they had no choice but to accept when they merged with the PRUH. As I mentioned, in 2017-18 that amounts to an estimated £36.9 million, which is a substantial amount of money. Without that PFI debt, the hospital would not be in robust finances but it would be in a better state to meet some of the challenges.

The problem faced by King’s and other hospitals is that when their finances become pressurised, they have to meet annual targets and the financial situation becomes paramount, patient care begins to suffer. That is not because the staff want it to suffer—staff always do their best to look after patients—but because they are not necessarily given the resources to deal with day-to-day care. There are winter pressures, but for many hospitals in debt such as King’s, there are year-round pressures.

We do not want to see more distinguished public servants who bring a vast wealth of experience to hospital boards, such as Lord Kerslake, being put in a positon where they feel that their only option is to resign. We need a better way of supporting hospitals that are in financial difficulty. In this case, part of that has to be to help King’s with some of those PFI debts. PFIs lock hospitals in for a long period of time to sometimes eye-watering and escalating repayment regimes. Sometimes the maintenance costs for the buildings are driven up even further when problems arise.

I hope that the debate provides the opportunity to look at King’s and other hospitals that have large PFI debts that are causing ongoing financial problems. I hope that that issue is looked at to help this hospital and other hospitals around the country that are in a similar position. I hope that the Minister, who I know will take to his post with great vigour, will want to make sure that some of the longer-term challenges that the NHS faces are looked at in the Green Paper for a sustainable, integrated health and care system that is properly funded. I hope that he will take that message away from the debate.

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[The Minister of State, Department of Health and Social Care (Stephen Barclay)]

It is a pleasure to serve under your chairmanship once again, Mr Hollobone, albeit in a different role. I begin by paying tribute to the hon. Member for Dulwich and West Norwood (Helen Hayes) for securing the debate and for the powerful case she set out on behalf of her constituents. I recognise the importance of King’s not just to her family but to the community she serves, to other hon. Members present, and more widely.

In her remarks, the hon. Lady drew out three specific points, suggesting that the Government have responded to this situation as if it had arisen suddenly, that it is reflective of other hospitals and that the roots go back to the Princess Royal decision in 2013. I will seek to address each of those in the course of my remarks, but at the heart of this matter is the concern that the board and King’s have lost or eroded the confidence of the regulator by the manner in which the deficit target has significantly deteriorated, and the concern that the cost improvements are an outlier when pitched against comparable trusts. That is really the crux of the issue.

My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) brought the value of experience both as a clinician and as a former Health Minister. I was very taken by his remarks. Specifically, on the point he raised about the PFI debt, it is helpful to remind colleagues that support was agreed by the Department at the time, in 2013-14, for the additional costs of that PFI financing. That was taken into consideration by the board, which agreed to it at that point. It is not the case that the PFI has been a material contributor to the current deficit.

[Dr Poulter]

My hon. Friend makes a fair point, although it is difficult for a board that has effectively had a merger foisted on it to appreciate fully how a hospital will run across two sites—or even three sites, with Orpington as well. I am sure the Minister will go away and think about that in the context of the PFI and whether something more could be done to help with the PFI debt.

[Stephen Barclay]

Indeed, I am happy to give consideration to the point my hon. Friend makes, although if one looks at the deficit for this year, which I will come on to in my remarks, one will see that the bulk of the deficit is not from the Princess Royal but from the other sites, so it does not pertain to the 2013 decision. I will come on to that more fully as I develop the case.

I will also say to the right hon. and learned Member for Camberwell and Peckham (Ms Harman), who recognised that the staff at King’s want to deliver, that I agree with her on that point. It is not about apportioning blame to those members of staff. Indeed, the financial special measures are about giving additional assistance to King’s to address those points, rather than seeking to blame them. I think there is a shared desire from both sides of the House to get the right outcome for King’s. I am very happy to agree with her on that.

It is a fact that King’s is a challenged organisation. We are putting a lot of effort into supporting it. King’s is receiving substantial financial support from the Department. The trust has received more than £100 million of support to maintain frontline services, the second-highest level of support to any individual trust across England. Placing King’s in special measures for financial reasons is a regulatory action to bring about swift improvement and address the trust’s financial challenges. NHSI is working with the trust to undertake a rapid review and agree a financial recovery plan.

Under the financial special measures programme, the trust will receive extra help and oversight, with the appointment of a financial improvement director. The organisation will also be required to draw up and deliver a plan to improve its finances, which NHSI will closely monitor. That will include support from peer providers where appropriate. On top of those special measures, NHS Improvement has also appointed Ian Smith as a new and experienced interim chair for King’s, to take control of the organisation’s position. He was appointed, as I am sure the hon. Member for Dulwich and West Norwood is aware, on 21 December and took up that role with immediate effect.

It is a fact that some profound financial issues at the trust need to be addressed. The trust agreed a budget deficit of £38.8 million in May 2017, yet just five months after the board had agreed that deficit it submitted a re-forecast deficit of £70.6 million, and a further two months later, in December 2017, the trust informed NHS Improvement that its current mid-case projection had worsened again to around £92 million. So, an agreed board position of a deficit of £38.8 million had within seven months gone up to a deficit of £92 million. That is really at the heart of this. When measured, that level of deterioration is an outlier, which is why the chief financial officer and chief operating officer both resigned in November 2017, and the chair resigned, as hon. Members have pointed out, in December 2017.

When announcing the financial special measures, Ian Dalton, the chief executive of NHSI, noted of other hospitals that

“none has shown the sheer scale and pace of the deterioration at King’s. It is not acceptable for individual organisations to run up such significant deficits when the majority of the sector is working extremely hard to hit their financial plans, and in many cases have made real progress.”

Junk Food Advertising and Childhood Obesity

Dan Poulter Excerpts

Tuesday 16th January 2018 Westminster Hall

[Maggie Throup]

I agree completely, and I thank the hon. Gentleman for that intervention. I was always taught that measures put in place with no targets or goals to meet are meaningless. We need to know where we want to be, and by when.

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

I congratulate my hon. Friend on securing this debate. I am sure she will agree that the obesity problem is growing and that measures to tackle it have been wholly inadequate. As with smoking, when we know something is harmful, we need a step change in measures to deal with it. An out-and-out ban on advertising—other hon. Members may comment on that—and a consideration of how we could severely restrict how high fat, salt and sugar foods and drinks are sold may be ways to take the strategy forward.

[Maggie Throup]

My hon. Friend is right—his background makes him an expert in the field—that no one measure will solve the problem. The Health Committee has called for “bold and brave action”, but we are a long way from seeing that.

No one measure will successfully tackle childhood or adult obesity. It is more than just sugar—many different aspects of food are causing the obesity epidemic. The soft drinks industry levy will play its part, as will Public Health England’s message, which was well publicised over Christmas and new year, that children should have only two snacks a day. Tackling junk food advertising is an important part of the jigsaw.

--- Later in debate ---

[Maggie Throup]

I completely agree. Some of the new restrictions imposed by the Committee of Advertising Practice in July aimed to do that, so that whatever method a child is viewing by, whether it is gaming or whatever, it is controlled. At a meeting just before Christmas, the committee said that it had still not been able to analyse the impact of the restrictions. Hopefully, in a few months’ time, we will get some feedback as to whether they are working or not—let us hope that they are.

Children are viewing TV—and lots of other media, as the hon. Lady said—in different ways, so we are calling for that to be taken into consideration to ensure that legislation is up to date. The rules are outdated and we urgently need an update to reflect changing viewing patterns.

We could debate whether restrictions on advertising are the responsibility of the Department of Health and Social Care or of the Department for Digital, Culture, Media and Sport, but ultimately we are discussing the health of our future generations. The Department of Health and Social Care should grasp that responsibility and make a difference.

The soft drinks industry levy, which has received a tremendous amount of attention, is a matter for the Treasury, but it appeared in the childhood obesity plan published by the then Department of Health in August 2016. There is no reason why introducing advertising restrictions for the sake of our nation’s health should be deemed to be under the DCMS remit.

The Minister indicated to me that it was too early to have this debate as he may not be able to give any concrete answers, but it is never too early to have a debate on an issue that affects our children’s health. “Childhood obesity: a plan for action” states that it is just the “start of a conversation”. It would be wrong of us, as parliamentarians, not to take every opportunity to continue that conversation. I hope that this debate influences the next stages of the measures to tackle childhood and adult obesity.

We have passed the stage of assuming that the implementation of further restrictions to the advertising of food and drinks high in fats, salt and sugar is part of a nanny state. There is now consensus across the House that responsibility and duty of care needs to be shown to our children and young people through bold and brave actions that will have an impact not only on future generations but on people today.

Before I finish, I have two more thoughts to throw into the mix. First, we should be mindful that there must be an element of personal and parental responsibility. Secondly, it is not a coincidence of scheduling that these adverts run alongside some of our biggest TV shows, such as the “The X Factor”, “Britain’s Got Talent”, “I’m a Celebrity”, “Hollyoaks” and “The Simpsons”. If we are to truly effect change, we need some of that star magic, as Jamie Oliver demonstrated.

The power of celebrity cannot be underestimated. With that in mind, I call on household names such as Simon Cowell, Ant and Dec, Dermot O’Leary and Amanda Holden to take some corporate responsibility, stand up to broadcasters and say that they will no longer be used as a hook to sell harmful junk food to our children and theirs.

[Dr Poulter]

My hon. Friend has made excellent points throughout her speech. Certain sports teams and events are sponsored by junk food advertising and companies such as KFC. In that context, corporate responsibility is important, but do the Government need to look at banning such advertising, as they did with tobacco advertising in Formula 1 many years ago?

[Maggie Throup]

As ever, my hon. Friend makes a good point. Everybody has responsibility: the Government have responsibility for their legislation and how it is implemented, and there is corporate responsibility.

Finally, perhaps we will start to see organic change from within the industry itself, rather than needing the Minister to formally effect change through regulation. That is the most effective way to get the change that we need, as we have seen with the reformulation that is going on already. If the industry gets the message loud and clear, it can do it on its own terms rather than being forced into it.

--- Later in debate ---

[Steve Brine]

It is on my list.

We also challenged the food and drink industry, with Public Health England’s sugar reduction programme, to reduce the amount of sugar in the foods our children eat most by 20% by 2020. Some of the biggest players in the industry, including Waitrose, Nestlé and Kellogg’s, which a number of hon. Members mentioned, have already made positive moves towards that target. Data will be available in March this year to give us a better picture of how the whole market has responded—we will be naming names—and to show whether we have met our year one target of a 5% reduction. We remain positive, but we have been clear from the beginning that if sufficient progress has not been achieved, we will consider further action. We rule nothing out.

We further built on the foundations of the childhood obesity plan in August 2017 by announcing the extension of the reformulation programme to include calories. The Government will publish more detail of the evidence for action on calorie reduction, and our ambition and timelines for that, in early 2018.

Our plan also includes school-based interventions, which a couple of hon. Members mentioned, including the expansion of healthy breakfast clubs for schools in more deprived areas, with £10 million per year of funding coming from the soft drinks industry levy. That is on top of the doubling of the school sport premium, which is flowing into schools as we speak, and represents a £320 million annual investment in the health of our children. The hon. Member for Bristol East (Kerry McCarthy) asked whether that cash will continue to flow as companies take action. I will come back to that point, but the Treasury has guaranteed a level of funding over the next three years, regardless of what comes in from the levy. If she wants me to write to her to put that in more detail, I am happy to do so—I have found the note I meant to read out, but we have covered it anyway. Such actions will ensure that we are tackling the healthiness of the food offer available to all families. The evidence shows that that is absolutely the right thing to do.

On marketing restrictions, another part of the jigsaw is how these foods are marketed, in particular to children, which is of course the central tenet of today’s debate. I thank the Centre for Social Justice and Cancer Research UK—I met both last week—and the Obesity Health Alliance for their recent reports highlighting the marketing of products high in fat, sugar and salt, or HFSS, to children. All are welcome updates that add to the debate.

This month marks 10 years since the first round of regulations to limit children’s exposure to marketing of products high in fat, salt and sugar, when we banned advertising of HFSS products in children’s television programming. We monitor that closely, including in my own home. At the weekend I tried to explain the premise of this debate to my children and, last night, when I phoned home, they told me that while watching a well-known commercial television channel they saw a slush drink mixed with sweets. Such products are being monitored closely in the Minister’s household as well as by my officials. When I get home, I will ask my children to show me that.

Recently, we welcomed the Committee of Advertising Practice strengthening the non-broadcast regulations to ban marketing of HFSS products in children’s media, including in print, cinema, online and on social media. That point was made strongly by my hon. Friend the Member for Angus (Kirstene Hair) in her excellent speech.

The restrictions that the UK has in place, therefore, are among the toughest in the world, but I want to ensure that in the fast-paced world of marketing—many people spoke about how quickly that world is moving—it stays that way. We heard lots of “go further” calls, including by the hon. Member for Bristol East, and that is why we have invested £5 million to establish a policy research unit on obesity that will consider all the latest evidence on marketing and obesity, including in the advertising space. That is also why we are updating something called the nutrient profile model, which does not sound exciting but is important. It is the tool that helps advertisers determine which food and drink products are HFSS and, as a result, cannot be advertised to children. The purpose is to ensure that the model reflects the latest dietary advice. Public Health England expects to consult on that in early 2018.

[Dr Poulter]

In that context, what measures are in place or is the Minister considering putting in place regarding online advertising to children?

[Steve Brine]

I will come on to that—if I do not, I will write to my hon. Friend—so I ask him to bear with me.

My hon. Friend the Member for Erewash, who opened the debate, said that the Department should have the lead on advertising. I am not sure that my friends in the Department for Digital, Culture, Media and Sport will agree, but I understand her point. I have noted that the Department for Digital, Culture, Media and Sport, the Ministry of Housing, Communities and Local Government, the Department of Health and Social Care, the Department for Education and the Department for Environment, Food and Rural Affairs have all been touched on in the debate. I reassure the House that tackling the challenge is a cross-Government concern. The childhood obesity plan that was published is a cross-Government plan, and all Departments have a rightful role to play, which continues to be the case as that plan is delivered.

The hon. Member for Westminster Hall, otherwise known as the hon. Member for Strangford (Jim Shannon), spoke well as always. I know he had to leave—he let the Chair and me know that. He spoke about food management and touched specifically on diabetes. He actually said, “If only I had known the damage being done”—I have heard that so many times. On Friday, I visited a brilliant organisation called LifeLab at Southampton General Hospital, which is partly funded by Southampton University. LifeLab empowers children through scientific inquiry to understand the impact on their bodies of their behaviour, the food that they eat and the drinks that they drink. A new spin-off called Early LifeLab goes into primary schools, while secondary schoolchildren from Southampton, across the south of England and further afield come into LifeLab to understand. So in answer to, “If only I had known,” that is what LifeLab does. I am very interested in looking at evaluations of LifeLab as it goes forward and in how that work might be built into a wider public policy roll-out.

My hon. Friend the Member for South West Bedfordshire made an excellent speech, as he always does. He rightly said that the poor are the most negatively affected, and we have touched on that point. I thank him for his Thailand, Popeye and spinach example. He also mentioned local authorities and planning. Local authorities have a range of powers to create healthier environments in their area through local plans and individual planning decisions. The national planning policy framework makes it clear that health objectives should be taken into account. The DHCLG is in the process of updating the framework to see if other aspects can be strengthened.

I thank my hon. Friend for making that point, and for the offer of a weekend together among the spring tulips in Amsterdam, which is very appealing on a cold January morning in Westminster. He also mentioned the Centre for Social Justice which, as I said, I met last week. I am very interested in its work. He touched on Making Every Contact Count and GPs. He is absolutely right about that and we could do much better. It is a subject that I am sure will come up over dinner later this week when I go to the annual dinner at the Royal College of General Practitioners.

My hon. Friend was intervened on by our colleague, my hon. Friend the Member for St Ives (Derek Thomas), on the daily mile. At every single school that I go into, whether as a local MP or as a Minister, I ask if the daily mile is being done. That has been a brilliant import from north of the border and it is excellent. I hope that every Member who goes into a school talks about the importance of the daily mile and encourages them to do it.

Many other points were made. My hon. Friend the Member for South West Bedfordshire talked about colour coding and the traffic-light system. Our colour-coded, front-of-pack labelling scheme is voluntary at the moment. It covers about two thirds of the market. We will consider other available labelling options as part of our withdrawal from the European Union—he has my guarantee on that.

The hon. Member for Reading East (Matt Rodda) spoke about the imbalance of information. His point was well made, I thought, about manufacturers and industry providing more information than the NHS does in his constituency. I would say that the Government have a strong voice in this debate, and rightly so, which is why we are seeing good progress on delivery of the plan, but we are also investing in the highly successful Change4Life programme, which I am responsible for through Public Health England. It informs families about healthier eating. Can we do more? We can, without doubt, in the public health and prevention space.

The hon. Member for Bristol East mentioned the “eatwell plate” in reference to the public sector. To respond, we have in place robust standards for public sector procurement, the Government buying standards for food and catering services. DEFRA is the lead Department and comes into the story here. It continues to drive compliance across other Departments and among NHS hospitals, which are required to meet the standards through the NHS standard contract. The hon. Lady makes a good point. She also raised the issue of academies, and I understand that the Department for Education will shortly begin a campaign to get them all signed up. I thank her for making that point.

In conclusion, from day one we have been consistently clear that the childhood obesity plan marked the start of the conversation—it has never been the final word. We continue to learn from the latest evidence. We are confident that the measures we are taking will lead to a reduction in childhood obesity over 10 years, but we take nothing for granted and will keep everything under review. I thank all Members for their contributions and look forward to further ones.

HIV Treatment

Dan Poulter Excerpts

Wednesday 29th March 2017 Westminster Hall

[Mike Freer (Finchley and Golders Green) (Con)]

I beg to move,

That this House has considered the all-party parliamentary group report Impact of Health and Social Care Act on HIV treatment.

I associate myself with your comments, Mrs Main, which are exactly right, and it is a pleasure to serve under your chairmanship. I also put on the record my appreciation of the Minister and other colleagues, but especially the Minister, who has been extremely supportive of the all-party parliamentary group on HIV and AIDS and who has always been helpful when I have raised issues to do with HIV/AIDS. I am grateful, too, to other Members on what is a busy day, with other demands on their time. Their attendance at this debate is much appreciated.

Since 2015, when I was elected chair of the all-party parliamentary group on HIV and AIDS, our main objective has been to draw on evidence from clinicians, patients, HIV charities and research groups concerned about the potential impact of the Health and Social Care Act 2012 on HIV treatment in England. In December 2015, therefore, we started to collect written evidence so that we could investigate whether such concerns were based on reality.

Our inquiry took about a year to conclude. We heard from clinicians, local authorities, public health officials, people living with HIV, and the charity sector. We took both written and oral evidence. After a year of gathering evidence, it is fair to say that we concluded that fragmentation has occurred, creating a degree of uncertainty and presenting opportunities for aspects of HIV care to fall through the gaps between the commissioning bodies. I will outline that later.

The purpose of our report, “The HIV puzzle: Piecing together HIV care since the Health and Social Care Act”, was not to turn back the clock, but to reach out to the sector for evidence and recommendations so that we may make tangible improvements to the commissioning of HIV services. We need to work together to make such changes to ensure that people continue to maximise the benefits of the world-class treatment and clinical care service available in the UK.

I emphasise that the majority of the report recommendations focus on the need for clarity and accountability in all parts of the HIV care pathway, because the lack of clarity in the 2012 Act is what came into sharp focus. It was exemplified by the debate surrounding the provision of PrEP—pre-exposure prophylaxis—and the uncertain future of HIV support services. I and my APPG colleagues who advocate central funding for PrEP welcome NHS England’s announcement of a new PrEP trial to reach 10,000 people.

Our report concluded that the Health and Social Care Act increased fragmentation to many aspects of the care pathway, from prevention to long-term condition management. For example, fragmentation has created risks for HIV support services. The separation of sexual health and HIV is another example. There are new potential barriers to testing and prevention. Most importantly, there is confusion over the commissioning of new prevention techniques. I will highlight some of our key findings and offer suggestions as to how the APPG believes the report’s recommendations can help address them.

HIV support services—non-clinical services—have long been considered a vital part of the care pathway for people living with HIV. The British HIV Association, BHIVA, which is accredited by the National Institute for Health and Care Excellence, provides official guidance on HIV treatment and care. BHIVA states that the following are necessary for effective long-term condition management: peer support; support from other trained professionals; and information about HIV treatment, healthy living with HIV, diet and lifestyle, and optimisation of general health issues. People living with HIV also need support to access general health services, financial advice, and housing and employment support.

That view is endorsed by NHS England:

“The effectiveness of specialised HIV services depends on other elements of the HIV care pathway being in place and effectively coordinated”,

Those elements include:

“Third sector HIV care and support services for treatment adherence, peer support and self management…Social care, mental health and community services for rehabilitation, personal care or housing”.

Not everyone living with HIV requires support, and most will only need to use those services periodically, such as when they are newly diagnosed, experiencing employment issues, pregnant or considering disclosing their status to others, and if they are experiencing discrimination. The UK stigma survey identified that 28% of people diagnosed within the previous 12 months reported suicidal thoughts. Sadly, the suicide rate for HIV-positive men in the first year after diagnosis is more than five times higher than for men in the general population.

Similarly, while the side effects of treatment have improved in recent years, many people still have real difficulty in managing them, especially when starting medication or transferring regimens. People who are long-term diagnosed may experience ongoing and irreversible side effects of older HIV treatments, such as neuropathy and lipodystrophy. Most recently, there is emerging evidence on diabetes.

Support services in those instances not only ensure that people have access to a trained professional or volunteer at the point of crisis, but reduce the pressure on healthcare professionals. The National AIDS Trust reported that 50% of attendees at expert patient groups subsequently reported fewer GP visits. For an investment of £400 per attendee, the average net saving to the NHS for each patient with a long-term condition was £1,800. In addition, Positively UK reports that 88% of people reported that peer support has helped them to adhere better to their treatment plans.

Unfortunately, however, we have heard from the National AIDS Trust and other local support organisations that HIV support services are vulnerable under the 2012 Act, because commissioning responsibility has not been clearly defined. Therefore, the clearly mandated service provision has instead taken priority, in particular where there have been reductions to public health grants for local authorities. Last year, for example, HIV services in Berkshire and Oxfordshire were reduced by more than £100,000. In Berkshire, that equates to a loss of a third of the funding, which will directly affect 300 people living with HIV in Slough and Bracknell.

In Public Health England’s guidance to commissioners, “Making it work”, HIV support services are the only part of the care pathway left “to be determined locally”. That means that either the clinical commissioning group or the local authority can provide such services, but in a number of cases it appears that no one is commissioning services such as community-based HIV clinical nurse specialists.

The value of support services in other disease areas is well recognised. CCGs already commission cancer care, peer support for mental health services and the DESMOND —diabetes education and self-management for ongoing and newly diagnosed—programme for diabetes. The APPG has therefore recommended that the responsibility for providing HIV support services is met by NHS England and CCGs as part of the patient care pathway provided for long-term condition management.

Local authorities have a responsibility to provide public health and social care services, but the ambiguity in the 2012 Act and reduced funding mean that the responsibility has been deprioritised. Support services sit comfortably within the mandate that CCGs and NHS England already have to provide HIV treatment and care. Importantly, what we are asking is that the Department of Health reiterate the need for a mandated whole-treatment plan, from start to finish.

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

My hon. Friend is making some good points, and I commend him for bringing forward this important debate. Does he agree that one of the fundamental challenges thrown up by the Health and Social Care Act 2012 is the fragmentation of services? As a clinician, it is strange to me—I made this point when I was on the Health Committee—that sexual health services are now commissioned by local authorities and a lot of HIV diagnoses are first discovered by contact with sexual health services.

[Mike Freer]

My hon. Friend makes a good point. I will go on to identify what is almost a lottery or a roulette, where people can access testing only if the parts of the health service or social care services that they come into contact with know what to do. I will also comment on the problem that some services—particularly GP services—feel that they are under so much pressure that they do not always know how to refer people for testing. One of the implications of the rationalisation of genito-urinary medicine clinics—GUM clinics—is that people risk falling through the cracks. My hon. Friend makes a good point that because services are provided in a number of places by a number of parts of the health service and it is not clear who is responsible for doing what, there is a great danger that people will think, “Someone else is doing it,” or, “Someone else is paying for it,” and we end up with no one doing it or no one having the funds to do it.

Civil society groups have highlighted that, under the Health and Social Care Act, some HIV services have been separated from sexual health services, which seems to have had the unintended consequence of creating different commissioning responsibilities for different aspects of caring for people living with HIV. HIV clinical services are commissioned by NHS England. HIV clinics traditionally sit in or next to sexual health or GUM clinics. That is the logical place for them to be; it helps with referrals and the continuation of care. Most HIV diagnoses are picked up during routine sexual health check-ups.

For example, the team at the Marlborough clinic at the Royal Free hospital, which serves my constituency, offer HIV testing and treatment alongside sexual health advice, testing and treatment for sexually transmitted infections, and contraception services. Where an HIV-positive diagnosis is made, staff can quickly link the newly diagnosed person into care at the adjacent Ian Charleson day centre, almost by walking them from one part of the building to the next, to ensure that there is continuation of care and no gap between someone being diagnosed and referred. In every part of the health service, whatever the illness or condition, if there is a gap between diagnosis and referral to a specialist service, some patients simply do not turn up. The collocation of services improves the continuation of care. The threatened merging of GUM clinics, which might take them away from HIV clinics, is therefore a cause for concern. I fear that it will make fragmentation worse.

Although local authorities are entirely responsible for providing sexual health services, they are not responsible for the entire HIV care pathway. That has resulted in sexual health services being put out to tender without a plan for the HIV service. That disruption of care presents a real problem for keeping track of patients and ensuring that they remain in the care pathway.

[Dr Poulter]

One of the other practical problems that was not thought through very well in the run-up to 2012 is communication between services, which my hon. Friend rightly mentioned. IT systems in the NHS often do not talk to one another very well, and they certainly do not communicate well with local authority databases or those of private sector providers, which may store information about the same person. That is at the core of the problem, and I wonder whether he might look at that issue when he makes recommendations to the Minister in the future.

[Mike Freer]

My hon. Friend makes a good point. The APPG is currently considering an informal report about the future of social care. Because HIV is no longer a death sentence but a manageable condition, people are living to ages by which they expected to be dead, or by which the health service expected them to be dead. We have early indications that the social care sector simply is not geared up for handling admissions or placements of HIV-positive people into care homes and nursing homes. Some care workers are simply uneducated about how to provide support. My hon. Friend is right: as people are moved into private placements, whether they are funded by the local authority or self-funded, we will have the problem of a lack of joined-up support—not just in IT, but between social care, which is a local authority responsibility, and care for health conditions, which is the responsibility of HIV clinics with NHS support. He makes a very good point.

The disruption caused by dislocating HIV and sexual health clinics presents a real problem in keeping track of patients. As I said, collocation ensures that patients stay in the care pathway. Integrated HIV and sexual health services support young people living with HIV as they transition from paediatric care into adult services. Navigating adult HIV services for the first time can be challenging for young people. Including those services alongside sexual health services ensures that they have a one-stop shop for their HIV care and other tools for ensuring good sexual health.

The reality is that, in many cases, sexual health has become fragmented from HIV. Sexual health is the more profitable aspect of tenders, so some providers have purchased only the sexual health service, leaving no provision for HIV. In oral evidence to the APPG last year, the British Association for Sexual Health and HIV—BASHH—said that it believed that that had been a genuine oversight in the tendering process. Its president said:

“I don’t think the connection of what would happen if, particularly in a small service, the sexual health element of the tender was won by another provider. I don’t think anybody thought what would happen to the HIV service that was there. I think they thought it would just continue to be provided…and of course that may well be the case if it’s a large HIV unit, but in many cases it isn’t and it’s financially not viable, and that’s where the problem lies”.

Others report that when sexual health tenders were purchased without the HIV service, HIV clinics were left understaffed and with little certainty about the commissioning of the service. That means that people living with HIV have been required to access services elsewhere, which has led to small but significant numbers being lost to care. In its written evidence to the APPG’s inquiry, BASHH also noted:

“In a sexual health service that went out to tender a few years ago the contract was awarded to a community NHS provider. The outreach HIV clinic that had been well established was not sustainable and the service was discontinued. The majority of the service users transferred their care to other HIV providers some miles away but 9% were presumed to have disengaged in care.”

With that in mind, the APPG’s report, “The HIV puzzle”, recommends co-commissioning of HIV and sexual health services by local authorities and NHS England. Those two commissioning bodies should work collaboratively to ensure that a service assessment is in place so that the new provider, whoever it is, has a responsibility to ensure that the HIV service is maintained and not lost. The Department of Health needs to ensure that there is mandatory guidance for sexual health service bidders to undertake risk assessments and produce action plans detailing how the HIV treatment service will be transitioned and implemented.

The separation of HIV clinics from sexual health clinics is an unintended consequence of the Health and Social Care Act that needs to be addressed. The split of responsibility for different aspects of HIV care between local authorities and NHS England is leading to confusion in commissioning, and as I mentioned, early indications are that a small but significant proportion of HIV patients have fallen out of the care pathway as a result. Previously, sexual health services were all commissioned by primary care trusts and the separation of HIV services from sexual health services was unheard of.

The inquiry also identified that there remains no whole service specification for HIV and sexual health, which we believe is causing health professionals to deprioritise the service. The service specifications that do exist relate to either sexual health or HIV services through “Integrated sexual health services: national service specification” and the NHS England service specification for adult HIV services, and it is the same for paediatric HIV. Those guidelines are useful, but what is really lacking is a comprehensive service specification for HIV and sexual health that encompasses all aspects of the HIV care pathway.

That is why we recommended that the Government develop a whole service specification for HIV and sexual health, bringing together the various existing strands of clinical guidance to ensure clear and consistent advice is available to all local authorities, CCGs and NHS England. A clear service specification for HIV and sexual health would mean that there is a one-stop shop for local authorities or CCGs, which would help to remove the sense of fragmentation experienced by both patients and health professionals.

We recognise that public health is a devolved issue, but the Secretary of State must ensure that local authorities have enough guidance to ensure that there is a minimum service requirement that they must provide. At the moment, the 2012 Act does not provide enough clarity or accountability to any one commissioning body. The nature of HIV as an infectious disease means that HIV services do not start at the point of diagnosis.

Let me turn to testing and prevention, which are a critical part of encouraging safe sex. The APPG is extremely pleased with the Government’s recent announcement that relationships and sexuality education will be made compulsory in all secondary schools. Properly informed and sensitively taught, that will go a long way to ensuring that young people are able to make informed decisions about safe sex and preventing the transmission of sexually transmitted infections and HIV.

None the less, testing and prevention are subject to similar fragmentation of commissioning responsibility, so confusion over commissioning responsibilities remains. As an example, HIV testing can be paid for by any of three commissioning arms—local authorities, NHS England and CCGs—depending on the setting and context in which the test is offered. HIV testing—including community outreach—for most-affected groups and routine population screening in areas of high prevalence is the responsibility of local authorities. HIV testing clinically indicated in a hospital—and termination of pregnancy services—is paid for by CCGs. Testing and treatment for STIs, including HIV testing, provided in general practice when clinically indicated or requested by individual patients, is covered by NHS England as an essential service under the GP contract. Different settings, different funding, total confusion.

In short, if someone is offered an HIV test by a hospital doctor because they arrive in A&E with shingles, it is paid for by the CCG. If they are offered the same test for the same reason by their GP, it is paid for by the NHS primary services contract. If they are offered a test by the same GP simply because they live in an area of high prevalence, as NICE recommends, it is paid for by local authority.

The evidence for prevention and early diagnosis is overwhelming. People living with HIV can expect a near-normal lifespan if they are diagnosed early, but people diagnosed late continue to have a tenfold increased risk of death in the year following diagnosis. NICE also estimates that the costs of HIV care remain 50% higher for each year after diagnosis if the diagnosis is late. Likewise, preventing onward transmission is crucial not only for individual and public health but in terms of the sizeable lifetime costs of treatment. In 2011, PHE estimated that each infection prevented would save between £280,000 and £360,000 in lifetime treatment costs. NICE estimates that, if national testing guidance is implemented fully, 3,500 cases of onward transmission could be prevented in the next five years, saving the NHS more than £18 million a year in treatment costs.

I mentioned that GPs say they are under time pressure, and for a number of health issues that is widely reported as a barrier to proper intervention. The availability of education for GPs on offering HIV tests remains a problem. GPs feel they do not have enough information about the most appropriate time at which to intervene on HIV testing. As the Royal College of General Practitioners notes,

“There is...the issue of effective implementation—including training and support for practices to adopt these schemes...GPs and our teams are already under immense resource and workforce pressures making it incredibly difficult to implement any new programme”.

Many in primary care will therefore refer patients to GUM services for testing. However, that has the potential to entrench existing inequalities in late diagnosis rates, given that high-risk communities—particularly black African communities—are far less likely to access sexual health clinics and much more likely to access primary care.

Although healthcare professionals’ knowledge of when to offer an HIV test is not directly related to the Health and Social Care Act, the expectations from patients and the NHS England to mandate commission testing based on clinical indicators mean that educating healthcare professionals on the subject in line with NICE public health guidance must be a priority. The APPG has also called for protection of local authority public health grants from further funding reductions, in line with the Government’s commitment to ring-fencing the NHS budget. I would be grateful if the Minister could outline what plans she has to ensure that public health investment is not lost under further changes to local authority funding.

Finally, arguments over commissioning responsibilities have led to a stalemate on the introduction of innovation in HIV prevention. In 2015, studies from the UK, France and the US reported that, when taken regularly, PrEP can reduce the risk of HIV transmission by up to 86%. As the National AIDS Trust notes:

“PrEP is exciting, new, and currently, unique. It is not a vaccine, although it has a similar impact. We can draw comparisons to statins, in terms of preventing illness, or contraception, in terms of preventing unwanted consequences of sex. But actually, there is nothing quite like it. It is the definition of healthcare innovation.”

I do not wish to repeat the arguments made for and against the centralised commissioning of PrEP, but it does serve as an important case study in highlighting how the fragmentation outlined already risks HIV services that are focused on both lifelong condition management and preventing onward transmission.

As I mentioned at the beginning of my comments, I am enormously grateful to the Minister and NHS England for the announcement of an expanded clinical trial phase, including at least 10,000 participants, which will be launched early in 2017-18. I hope she will be able to update us on that trial in her response. I thank everyone who participated in the inquiry, particularly those who travelled across the country to attend our oral evidence sessions, and all the members of the APPG who took enormous time out of their diaries to support the inquiry.

--- Later in debate ---

[Mr Ben Bradshaw (Exeter) (Lab)]

I congratulate the hon. Member for Finchley and Golders Green (Mike Freer) on securing this debate, on his all-party group’s excellent report and, indeed, on all the work he does on HIV and AIDS. I draw attention to my entry in the Register of Members’ Financial Interests and declare an interest: I am a trustee of the Terrence Higgins Trust.

The hon. Member for Finchley and Golders Green is absolutely right, as is his report, on the impact of the Health and Social Care Act 2012 passed in the previous Parliament. I am sure the Minister has read not only his APPG’s report but the Health Committee report that we published last year on public health in general and the impact of that 2012 legislation on the delivery of public health, and particularly the delivery of sexual health and HIV services across the country.

The hon. Gentleman is right that, in our report, we identified a number of problems and challenges with the new landscape and commissioning structure. We heard from people up and down the country in evidence—HIV/AIDS organisations, those who work in sexual health, consultants and virtually everyone else—that the area that has been hit most negatively by the Health and Social Care Act and the changes in commissioning arrangements are HIV services and sexual health services more generally. We all have our own ideas of why that might be the case. Although the jury is still out about the decision to pass the responsibility for public health to local authorities, there were concerns expressed at the time of the Health and Social Care Act—some of us warned the then Health Secretary, Andrew Lansley—about the potential impact of giving local authorities the responsibility for HIV support and other sexual health services, but I am afraid those concerns were not listened to. I hope the Minister will explain to hon. Members and to the country at large what monitoring the Government have been doing on the impact of the Act on services and what measures or action the Government will take as a result of anything they find.

[Dr Poulter]

I agree with the right hon. Gentleman. Does he agree that one challenge is the fact that local authorities are now commissioning the provision of health services in complete isolation from many of the other HIV and associated services? That is very different from our general understanding of public health at the core of the Act—it is a fault.

[Mr Bradshaw]

I completely agree with that point. The different commissioning responsibilities for different bits of sexual health and HIV and AIDS are all over the place. On top of that, although the Government can, with some justification, claim to have protected NHS spending in cash terms if not in real terms, they cannot claim to have done that when it comes to public health, which has taken significant cuts and will continue to take significant cuts over the next few years. Of course, those cuts are being imposed on local government. As the hon. Gentleman and other hon. Members know, local government faces huge financial challenges across the piece. There is also the threat of the withdrawal of the ring fence on public health funding in the next two or three years. In our report we made it clear that we thought that was a risky move indeed.

I do not want to repeat a lot of what was said by the hon. Member for Finchley and Golders Green, who made a comprehensive and excellent speech, but I hope the Minister will explain to us what monitoring the Government are doing on the impact. What will they do in response both to the concerns raised and the recommendations of the all-party group report and our Select Committee report to address the problems? We have known about them for some time—our report is now more than a year old.

The news about PrEP is very welcome, but will the Minster clarify the timing of the commencement of the trial? While we are on the subject, another potentially welcome development is the big fall-off in HIV presentations or positive tests at some of the London clinics in the past few months, which some people suggest may be to do with the availability of PrEP. Can the Minister tell us whether she has made an assessment as to whether that is the case, in which case it is a promising development indeed?

Finally, one of the things that concerns me is the plight of older people living with HIV and AIDS. Around a third of the people in Britain now living with HIV and AIDS are over 50. About 60% of them live at or below the poverty line. When many of them were originally diagnosed, they did not expect to have a long life expectancy, but they are still here thanks to the fantastic treatment and care that has been invented and developed, which has not only helped to keep people alive but enabled them to lead lives of reasonable quality. Back when they were diagnosed, they may have been less cautious about spending their money to get by at that time, and now they find themselves hopefully with many years stretching ahead and no more means at their disposal, so there is a particular challenge when it comes to older people living with HIV and AIDS. That will require the Department of Health to work more closely with the Department for Work and Pensions. Some of the people that my charity—the Terrence Higgins Trust—deals with face problems when it comes to benefits and benefits sanctions. Those sorts of things add extra pressure and misery to the challenges that people living with HIV already face.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Nicola Blackwood)]

It is a pleasure to serve under your chairmanship, Mrs Main. I congratulate my hon. Friend the Member for Finchley and Golders Green (Mike Freer) on securing this important debate, and all Members who have contributed to what has been a highly informed discussion. I welcome the opportunity to discuss the findings from the recent and interesting report “The HIV puzzle”, which was produced by the all-party parliamentary group on HIV and AIDS. I pay tribute to my hon. Friend for his work on HIV innovation, and to all the members of the APPG for the work they do to champion HIV within Parliament.

Preventing the spread of HIV and supporting those who already have the disease remains a Government priority. As colleagues present will have heard me say before, and as the shadow Minister, the hon. Member for Washington and Sunderland West (Mrs Hodgson), also said, when we look back at the HIV epidemic in this country we can be proud of our achievements so far. In particular, we have made considerable progress in recent years towards meeting the UN 90-90-90 ambitions to eliminate HIV-related mortality and transmission by 2020. We have already met two of the ambitions, with 96% of people diagnosed with HIV receiving antiretroviral treatments and 95% of those treated virally suppressed. We have made significant progress on the third goal—to reduce undiagnosed HIV so that diagnosis is over 90%. The proportion of undiagnosed cases was 13% in 2015, which means we have seen a fall of almost half, from 25%, in just five years. However, that is still too high and we need to redouble our efforts to ensure that those who are positive receive a timely diagnosis.

The right hon. Member for Exeter (Mr Bradshaw) was right that we must have robust monitoring to ensure that we understand what is happening. He identified some particularly encouraging reports from London; there were some encouraging reports during 2016 from London clinics, particularly Dean Street. Those trends are welcome. Public Health England is actively investigating the trends, and whether the reduction has also been seen in other parts of the country and in other risk groups. It will report on that when the 2016 HIV data are published later this year, and I shall be happy to notify him if he would find that helpful.

Many Members today have reported concerns about how public health funding in the future might affect the provision of HIV prevention and support services. In line with recommendation 6 in the report, we have decided, in relation to this aspect and wider public health funding, to retain the ring fence on the public health grant for a further year, until 2019, as we move towards the implementation of local business rates retention. This is a step on the way to a more locally owned system, but that will help to smooth the transition by providing certainty for the next two financial years. It means that grant conditions will continue to apply and Public Health England will have a clear assurance role in relation to grant spend. I recognise that local authority funding remains tight and that councils have tough decisions to make to ensure that vital public services remain sustainable. Returns from local authorities have identified that more than £82 million was spent on sexual health.

[Dr Poulter]

I thank my hon. Friend the Minister for the constructive approach that she is taking in replying to this debate, as indeed she does in all debates on health matters. Does she recognise that there are areas with very high demographic change, that some of them have high rates of people living with HIV and that the funding formula is beginning to be out of date and needs to be reviewed? There are some parts of the country that need more money than that funding formula makes available for public health purposes.

[Nicola Blackwood]

I am going to come to what we are going to do in the future. The current situation will remain in place for one year, but we have identified the public health spend. A significant proportion of the funding will be allocated to HIV testing and prevention activities. We also recognise that there are reasonable concerns about the practicalities as we move towards business rates retention, and how it will work in practice, in particular in relation to health. The fact is that the only way we are going to get the scale right is if we continue to engage closely with Members. One thing we are looking at is how we manage the move towards mandation and how we look at transparency and accountability in public health spending. We will be doing that in a very consultative way—

O’Neill Review

Dan Poulter Excerpts

Tuesday 7th March 2017 Westminster Hall

[Kevin Hollinrake]

My hon. Friend is a fantastic champion of the natural environment, and she makes a very good point.

The World Health Organisation has stated that antimicrobial resistance is

“one of the greatest challenges for public health”

and that the problem is increasing and we are

“fast running out of…options.”

Antibiotic resistance is just one form of antimicrobial resistance—others concern viral and fungal infections—but my focus is antibiotics, which the public more readily understand and should have real concerns about. Bacteria undergo an eternal battle for survival, and natural resistance occurs as a result of bacteria fighting that battle, but when we use antibiotics—particularly when we overuse them—that natural resistance accelerates significantly and becomes super-charged, and we end up with many more antibiotic-resistant bacteria.

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

I congratulate my hon. Friend on bringing the debate. He is right to highlight the scale of the challenge not just here but globally: it is difficult for countries to bring forward large-scale programmes to deal with the problem of antimicrobial resistance. Does he agree that, apart from inappropriate prescribing, one of the key issues in this country is people not always completing courses of antibiotics, which increases the challenges and problems of bacteria developing resistance?

[Kevin Hollinrake]

I defer to my hon. Friend’s in-depth knowledge in this area. I recognise my father’s habits in taking antibiotics when he felt a bit unwell—he had a little cupboard in the corner of his lounge. That is a problem, and that is why we need to improve the education on treatment of illnesses for which people are prescribed antibiotics.

The point about antibiotic resistance spreading is that it can be spread in so many ways: on aeroplanes; in our water; from contact with unwashed hands of people who carry bacteria resistance; coughing and sneezing; and from animals to humans. Some Members may have come across the excellent BBC Radio 4 drama “Resistance” —the first episode was aired on Friday and the second episode is this Friday—which talks about the transference from animals to humans. That means we must tackle this problem both in agriculture and in our health services.

Bacteria do not recognise national borders, so, as many hon. Members have already pointed out, this is a global problem. We would think that with those apocalyptic visions of the future we would be spending an awful lot of money on tackling this issue, but that is not the case. About $100 billion is spent every year on cancer research, but only about $5 billion is spent every year on tackling antimicrobial resistance. The reason for that is the commercial return that large pharmaceutical companies will get from bringing forward a new antibiotic to tackle this issue. Almost by definition, any new drug is held as a last line of defence, so there is not a significant commercial return for the pharmaceutical companies who we rely on for such new drugs. About $50 billion a year is spent on antibiotics but only about $5 billion a year is spent on patented antibiotics, which is equivalent to one cancer drug. It is a better commercial activity to be involved in cancer research and cancer drug development than in antimicrobial resistance. There has been a huge reduction in the number of pharmaceutical companies involved in research and development—in 1990 there were 18 and in 2010 there were only four—and no new classes of antibiotic drugs have been developed in the past 25 years.

Of course, the O’Neill review has studied that and come up with clear and compelling recommendations such as rapid diagnostic testing, which the right hon. Member for Oxford East (Mr Smith) referred to. Yesterday we had a Twitter debate, which was interesting, listening for an hour to people’s experiences. Many clinicians got involved in that particular Twittersphere, and we trended nationally at one point, which was certainly a new experience for me. One thing that came across was the pressure that clinicians were under to prescribe antibiotics to people who felt ill. Obviously, if we had diagnostics that could show people that they did not carry something that could be treated by an antibiotic, they would be much less likely to put that pressure on doctors.

Agenda for Change: NHS Pay Restraint

Dan Poulter Excerpts

Monday 30th January 2017 Westminster Hall

[Catherine McKinnell]

I very much agree. That is a factor right across the NHS and the social care sector, and it is an issue we see arising increasingly as staff come under increasing pressure, with the increased pressure to make efficiency savings, which ultimately compromises the health and safety of staff who find themselves in such situations.

Just last week the National Audit Office published its report into NHS ambulance services, which concluded, among other things, that:

“Increased funding for urgent and emergency activity has not matched rising demand, and future settlements are likely to be tougher”.

Crucially, in the context of this debate, it also concluded that:

“Ambulance trusts face resourcing challenges that are limiting their ability to meet rising demand. Most trusts are struggling to recruit the staff they need and then retain them. The reasons people cite for leaving are varied and include pay and reward, and the stressful nature of the job.”

That very much ties in with the concerns the hon. Gentleman raised.

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

I congratulate the hon. Lady on her speech; I agree with a number of the points she has made. On ambulance trusts and the point about very senior managers, we need good managers and senior managers in the NHS. However, ambulance trusts are a particular example—my trust, East of England, is an example—of where managers have sometimes received huge pay rises at the expense of frontline staff, who have received pay rises of nought or 1%. That is unacceptable. Does she agree that that further lowers the morale of frontline staff in a difficult period of pay restraint?

[Catherine McKinnell]

The hon. Gentleman makes an important point, which is why it is important that staff under Agenda for Change have the opportunity to have their voices heard today. When the Government look at how the NHS’s limited resources are distributed among the workforce, they need to approach the matter very much in the round.

I have no doubt that the Minister, when he responds to the debate, will be tempted to repeat the Prime Minister’s mantra that the Government are putting an additional £10 billion into the NHS by the end of this Parliament. However, as we all know, that figure has been comprehensively debunked by the hon. Member for Totnes (Dr Wollaston) and her fellow members of the Health Committee, and more recently by the chief executive of NHS England, Simon Stevens, when he appeared before that Committee. Indeed, Ministers confirmed only last week that NHS England will face a 0.6% real-terms fall in per capita funding in 2018.

How would an end to pay restraint for Agenda for Change staff help address the enormous difficulties the NHS faces? As the Royal College of Nursing has highlighted, chronic staff shortages have led to an “over-reliance” on “expensive agency staffing” to the extent that spending on agency nurses equates to about one tenth of the NHS’s total nursing pay bill. Indeed, the Royal College goes on to state that

“the over-reliance on agency staffing is a reflection of a nursing shortage and a direct consequence”

of the limit on pay for nurses working in the NHS.

We therefore have the nonsensical situation whereby nurses are leaving the NHS because of increasing workloads, stress and feeling undervalued following years of pay restraint, so the NHS has to turn to expensive agency nurses to fill the gaps left behind. Those concerns are mirrored by the Royal College of Midwives, which, following a freedom of information request, uncovered that NHS trusts in England spent almost £72.7 million on agency, overtime and bank midwives in 2015—enough to pay for 2,063 full-time experienced midwives or 3,318 full-time, newly qualified midwives.

The Minister might also refer to an increase in the number of nursing and other NHS staff since 2010. Again, that addresses neither the fact that there is currently a shortage of about 24,000 nurses in England and Wales, nor the shortage of nearly 3,500 midwives across the UK. Nor indeed does it address Health Education England’s worrying confirmation that last year some 8.8% of nurses left the NHS—the highest number since 2011. All that surely shows that the NHS is facing a perfect storm, not least in the light of the Minister’s ludicrous decision to axe bursaries for new nursing, midwifery and allied health students—I should perhaps say “Ministers’ decision”, rather than directing that comment at the Minister of State—the Government’s continued disgraceful failure to confirm the long-term future of 33,000 nurses from other EU countries working in the NHS, and the fact that one third of nurses are due to retire in the next 10 years. I look forward to hearing him explain how continued pay restraint for Agenda for Change staff will help resolve the staffing crisis.

[Dr Poulter]

The hon. Lady makes a good point about bursaries. Most nurses enter the profession in their late 20s—at about 28 or 29. We are talking about a recruitment challenge in nursing and the fact that the number of applicants for nursing courses dropped by 25% this year. Surely that demographic group needs the bursary as an enticement into nursing.

[Catherine McKinnell]

The hon. Gentleman makes another valid point. I hope that the Minister is listening, because although we are focusing specifically today on pay restraint for Agenda for Change staff, there is a much wider issue for the Government to take on board. A variety of factors is affecting recruitment and retention of NHS staff. The axing of bursaries is just one significant factor that the Government should seriously examine, and reverse.

What has the pay restraint for Agenda for Change staff meant to individual nurses, midwives, paramedics, cleaners and other healthcare professionals since 2011? Depending on the measure of inflation used, it has resulted in a drop in real-terms earnings of up to 14%. To put that in context, the trade union Unison has calculated that it is equivalent to annual pay cuts of £2,288 for a cleaner, £4,846 for a nurse, £6,134 for a midwife and £8,364 for a clinical psychologist. Indeed, ahead of the 2017-18 NHS pay review process, Unison surveyed its members working in the NHS and received the following responses, which are a matter of deep concern: nearly two thirds felt worse off than they did 12 months ago; 49% had asked for financial support from family or a friend; 13% had used a debt advice service; 11% had pawned possessions; 11% had used a payday loan company; 15% had moved to a less expensive home or remortgaged their house; and just under one fifth took on paid work in addition to their main NHS job, 64% of whom did so because their NHS salary was not enough to meet their basic living costs. More than 80% said they had considered leaving the NHS in the past year.

--- Later in debate ---

[Andy Burnham]

That is how it begins to appear. The Government are pushing people beyond their limits. There was the attempt to introduce regional pay, and there was the attempt to cut what is called the unsocial hours payment—there has been a whole series of initiatives that try to strip away support for the profession. It begins to feel like an attack on the profession. That is certainly how junior doctors felt, and I think GPs feel the same. The nursing profession is making clear today that it feels the same too.

As I said, this is a false economy. As well as damaging the good will and the extra hours that people were willing to offer before, it has also, as my hon. Friend the Member for Foyle indicated, pushed people into the arms of private staffing agencies. That, in the end, is another false economy for the national health service. Over recent years, we have seen the bill for private staffing agencies in the NHS increase year on year, to the point where it is now in the region of several billion pounds every year. Many trusts are in the grip of the private staffing agencies. That, of course, is also a factor in the cuts to nurse training that we have seen in recent years.

[Dr Poulter]

The right hon. Gentleman is making some very fair points. I hope he recognises that one of the first things I did in ministerial office was to reverse what was happening on regional pay and stick to the national pay contracts. He makes an important point about temporary staffing. If we look at the approach with the junior doctors’ contract, many junior doctors will now see a huge reduction in in-house locum pay for the work they are doing; it is sometimes a reduction of £10 an hour. That will feed locum agencies and drive up the temporary staffing bill. We need to see nurses and other Agenda for Change staff paid properly, to stop them needing to do agency work. That is one of the main drivers of the agency business.

[Andy Burnham]

I am glad to hear the intervention of the former Minister, whom I worked well with in the previous Parliament. I want to take this opportunity to say that he did listen on regional pay. We made an argument about that issue, backed up by the RCN and others, and, to be fair, it did not go any further than the experiment in the south-west. I give credit to him for that. I also give credit to him for consistently showing a real regard for the pressures faced on the frontline.

The hon. Gentleman makes an important point that the Minister would do well to reflect on. There is a huge false economy here. It makes sense to have fairness in terms of headline pay for staff, to maintain good will, but on top of that, it makes sense to provide them with incentives to give any additional shifts or time to the in-house bank, rather than private staffing agencies. The Government have lost sight of that in recent times.

--- Later in debate ---

[Mr Dunne]

The hon. Lady must have access to figures that my Department and I do not have. My information is that we have yet to receive any formal numbers from UCAS; there may be some early indications, but they do not represent the actual numbers. We will just have to wait for them. There is no point in speculating any further.

A number of hon. Members mentioned the potential impact of Brexit on EU staff, who currently represent a significant number of the professionals working in the NHS. Some 43,000 non-UK-born nationals work in the NHS—about 15% of the workforce—and about half of them come from the EU. It is very important that none of those staff are unnecessarily concerned about their future. The Prime Minister has sought to make it clear on several occasions that she wants to protect the status of EU nationals who are already living here and that the only circumstances in which that would not be possible would be those in which the rights of British citizens living in EU member states were not protected in return. We wish to provide as much reassurance as we can, both to NHS workers and to their employers, that they have a constructive future here in the UK.

However, it is important that we move towards a self-sustaining workforce. Frankly, that is at the heart of the reason behind the change in funding for nursing places, which is to bring nurses in line with doctors and those doing other degrees in England, so that from this autumn onwards they receive funding through student loans rather than bursaries.

[Dr Poulter]

The Minister is right to highlight the increases in many staff numbers across the NHS. He will also be aware that because of the increased focus on quality of care, many trusts have had to acknowledge that they did not have enough staff in the first place. If there are enough staff working in the NHS at the moment, why is the locum bill about £3 billion a year?

[Mr Dunne]

I will come on to agencies shortly. I am not denying that there are vacancies within the NHS, but my point is that there has been and continues to be a significant investment in increasing the number of people working in the NHS, which was not the impression that other hon. Members gave.

--- Later in debate ---

[Mr Dunne]

Because I have been very clear that at the moment nobody will be paid less than the national living wage, and that is all I am going to say on that.

[Dr Poulter]

On the current position, can my hon. Friend clarify what the average annual increase in pay in real terms is for NHS staff who have been at the top of the Agenda for Change pay scale since 2010?

[Mr Dunne]

I will come to that point. If my hon. Friend will bear with me for a few minutes, I think I will be able to satisfy him on that.

--- Later in debate ---

[Mr Dunne]

I am not sure that that provides much clarification, but I thank the hon. Gentleman for having a go.

Employers in the NHS know that they need to deliver greater efficiencies and improved productivity to help protect frontline jobs. Making the workforce more expensive, through higher pay rises, will not help.

It is therefore disappointing that trade unions have alleged that staff have suffered a pay cut of about 14% in real terms—an allegation that has been repeated by a number of hon. Members in the debate. The truth is that the Government have ensured that no NHS employee —indeed, no employee—should be paid below the national living wage. As I have said, no NHS employee employed under the Agenda for Change pay system is paid below that.

The truth is that average earnings of NHS staff as a whole remained well above the national average salary for 2015, which was £27,500, and have increased by more than annual pay awards. For most NHS staff groups, half of employees employed in 2010 and still in employment in 2015 benefited from double-figure increases in earnings, equating to between 2.2% and 2.9% annually, depending on staff group. The average annual consumer prices index figure over the same period was 2.4%.

[Dr Poulter]

I specifically asked about those who are at the top of the Agenda for Change pay scale, which many Agenda for Change staff are. Can the Minister confirm what the figures are for that group, because I think that the figures he has given include those in receipt of incremental rises?

[Mr Dunne]

They do, and it is important for hon. Members to understand the impact of incremental pay rises. The truth is that some half a million Agenda for Change staff are eligible for incremental pay rises each year of more than 3% on average, on top of annual pay awards. I am not saying that NHS staff should have no concerns about the level of pay award they receive; what I am saying is that since the 2008 recession, NHS earnings and public sector earnings have generally compared well with those in the wider economy.

A number of hon. Members talked about regional pay and in particular the challenges of working in London. Of course, we are very sympathetic to individuals who face the pressures of working in London—in both inner and outer London—and that is why we have the increments available to recognise the extra costs of living there.

[Catherine McKinnell]

rose—

[Dr Poulter]

rose—

[Mr Dunne]

I will make a little progress, if I may.

NHS organisations spend about two thirds of their entire expenditure on pay. Ensuring that the NHS has the staff it needs relies, crucially, on controlling pay and on making every penny count for the benefit of patients.

I give way to my hon. Friend.

[Dr Poulter]

My hon. Friend the Minister may not have the answer to my specific question here today, but will he write to me after the debate to confirm the answer to my question about those members of staff who are at the top of the Agenda for Change pay scale? What, in real terms, has been their pay increase since 2010?

[Mr Dunne]

I will be happy to look at that; if my hon. Friend would write to me with his precise question, of course we will give him an answer.

NHS and Social Care Funding

Dan Poulter Excerpts

Wednesday 11th January 2017 Commons Chamber

[Maria Caulfield]

These problems are not new. I have also worked in out-patient settings where A&E targets have had an impact on patients waiting for elective surgery. The sheer determination to meet those targets due to pressure from the Labour Government led to patients with breast cancer having their elective operations cancelled time after time owing to emergency admissions. I had to tell a young mum, whose mastectomy operation following breast cancer had been cancelled three times while her young family were waiting for Christmas, that the only bed we had left was in a post-natal ward, where she woke up and recovered from her operation next to young mums learning to breastfeed. That was in an attempt to meet four-hour targets, so do not tell me that services have reduced. Targets were met, but staff were put under severe pressure not with quality of care but with targets in mind. I make no apologies in making that clear.

I am a supporter of four-hour targets. I was enthusiastic when they were introduced as a way of monitoring performance and improving the service, but they became the absolute king, above everything else. I congratulate the Secretary of State on introducing the consideration of outcomes. What happens to a patient when they are admitted? If they have to stay for four and a half hours to avoid admission or to get full care, what is the problem with that? If they can leave within two hours because they have been adequately treated, fantastic, but we should not be held to account by an arbitrary four-hour rule that has no clinical significance. I support the four-hour rule, but there are other measures that we also need to be aware of and that should be treated with equal status to the four-hour target.

Of course money is important. As our ageing population and our ability to treat more patients grows, we will need more funding for both healthcare and social care. It is worth noting that the trusts either side of my constituency receive the same funding and look after the same types and numbers of people. One is in special measures, is unable to deal with its discharges, has queues and is unable to meet its four-hour targets; the other, five miles along the coast, is rated outstanding, does not have the same pressures or four-hour waits and is able to discharge its patients speedily. There is something about what happens to the money, as well as about how much the money amounts to.

Labour did put huge amounts of money into the NHS over the years, but much of it was squandered—£10 billion on a failed IT project that never saw the light of day, and PFI deals that are still costing the NHS £2 billion a year. How much could be done with that £2 billion?

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

Will my hon. Friend give way?

[Maria Caulfield]

I will take one brief intervention.

[Dr Poulter]

I commend my hon. Friend for making a balanced speech and for rightly saying that meeting targets does not necessarily equate to delivering good healthcare, although they do have their place. Does she agree that one of the biggest challenges is the consistent inability of a number of A&Es across the country to recruit middle-grade doctors? That is one of the biggest problems that has not been addressed to date.

[Maria Caulfield]

I absolutely agree that there is a problem in recruiting staff, particularly in the south-east—including in my constituency—in all healthcare professions because it is an expensive place to live. I agree that there is an issue with recruitment, but if we are to move forward, we need to work in a more cross-party way. Continually using four-hour targets as a stick to beat the Government with does nothing for cross-party working, so we need to stop the political cheap shots and recognise that money is not always the solution—it is about how the money is spent and the difference it can make. This also has to be clinically led. We can work together as politicians, but if we do not work with healthcare professionals, in both primary care and secondary care, I fear that we will be sitting here again in the years to come to talk about another winter crisis.

Social Care

Dan Poulter Excerpts

Wednesday 16th November 2016 Commons Chamber

[Andy Burnham (Leigh) (Lab)]

I congratulate my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley)—my good friend—on an excellent speech. She has no equal in this House as a champion for older people and their carers. Her speech, unlike the speech by the Secretary of State, was firmly rooted in the real world.

This is the century of the ageing society. Caring for people as they live longer lives is the greatest public policy challenge of our times, but for years Parliament has shown itself to be unequal to that challenge. I want to speak today to tell the story of the efforts to reform social care over the last decade, because I want the facts to be on the record, so that people can understand what happened and vow to do better. The story explains the mess we are in today. To be honest, it is quite a shocking story of partisan point-scoring and, worse, political cowardice, which have seriously failed millions of older and disabled people.

The story started nine years ago at the spending review in 2007. I was Chief Secretary to the Treasury at the time, and at the insistence of the Treasury I gave the Department of Health the condition on its spending review settlement that it would conduct a root and branch review of the funding of social care. There was a recognition, even in the Treasury, that if we allowed the situation to continue, it could, in the end, damage the national health service. Quite clearly, the funding was not sustainable, and if social care was left to collapse, it would drag down the NHS with it.

The urgency of such action had been recognised almost a decade earlier, in 1999, when a report by a royal commission on the matter recommended free personal care, paid for by general taxation. It did so for the reason that if we pay for free preventive care in people’s homes, those people do not end up in hospital and costing us all more. Nothing was done, and by 2007 the need for reform was urgent. So between 2007 and 2009, a huge amount of detailed modelling work was done and options were looked at.

When I arrived in the post of Health Secretary in 2009, the work had come to a head. The analysis supported a clear conclusion that radical reform, rather than patching up, was needed. Department of Health officials supported the Treasury analysis that there would be risks to the NHS if social care was allowed to decline. A Green Paper was published in July 2009, and the idea of a national care service was first put forward. The thinking was that only by bringing the systems together, with a system of clear national entitlement, would we be able properly to move towards integration. The maintenance of two entirely differently funded systems—one free at the point of use and the other means-tested and charged for—would mean that they would never be able to speak the same language and there would always be barriers to integration.

I was ready to grasp the nettle, because it was clear to me that the NHS was facing a decade of lower funding from 2010 and 2020, and that one of the ways it could cope with that was with the efficiencies we could unlock through properly and fully integrating health and social care and by moving from a hospital-based medical model to a person-centred social model of care starting in the home.

This is where things went wrong. Picking up that I was ready to up the momentum for reform, the then shadow Health Secretary, Andrew Lansley, approached me in Portcullis House just before Christmas 2009 and asked me for cross-party talks. I thought about it, but I agreed. I thought, as my hon. Friend the Member for Barrow and Furness (John Woodcock) has suggested, that we should take the issue out of party politics, which would be better for everybody. We had a couple of meetings, in which we went round the issues. I favoured the more ambitious, comprehensive reform of paying for social care on the NHS principle—that everybody contributes, but everybody is covered for their care needs and has peace of mind in later life. Andrew Lansley wanted a more voluntary system, in which the insurance market would come up with solutions. That was where we left it.

Then a bombshell was dropped in February 2010: the poster saying, “Now Gordon wants £20,000 when you die.” I very vividly remember the day when it landed. I was told that Andy Coulson had put pressure on Andrew Lansley to do it, and that he did not really want to, but felt he could not say no. I do not know whether that is true, but I know that the Conservatives, who asked me for cross-party talks, betrayed the confidence that I gave, and they have never seen fit to apologise for that. The point is not about the personal political damage that that did, but about the chilling effect the poster had on the social care debate. It instantly killed any talk of radical reform, and it actually had a deadening effect for the rest of the following Parliament—the last Parliament—during which no real progress was made.

That brings me to what happened after the election, when, as shadow Health Secretary, I challenged the Government from the Opposition Front Bench about the poster that they had put out during the election saying that they would cut the deficit, not the NHS. I made the point that if they did so, they would in effect cut social care: if they prioritised NHS spending within the reduced envelope, that would have devastating consequences for social care and would in the end come back to affect the NHS.

From the Dispatch Box at every Prime Minister’s Question Time, the then Prime Minister used to quote me as claiming that it would be irresponsible to give the NHS real-terms increases, but he never commented on the second part of what I had said, which was that it was irresponsible to do so if we were cutting social care. I did say that, and it was irresponsible to social care in the way they did to pay for their commitment to the NHS. Social care was cut by 9% during the last Parliament, with 400,000 vulnerable people losing support in their homes. Those people ended up in A&E or trapped in hospital beds, piling pressure on the hospital system.

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

I pay tribute to the right hon. Gentleman—this may be my last chance to do so—for the work he has done as a Member and wish him well in his future career if he is successful in his election. Does he agree that the chilling effect of the outcome of those conversations before the election and perhaps the betrayal of his confidence, as he puts it, is that there could no longer be a rational conversation about properly funding the health and care system through any form of taxation? That is the problem that has emerged, and perhaps the best way to fix it is through general taxation.

[Andy Burnham]

I am very grateful to the hon. Gentleman for his intervention and the spirit in which he made it. He is absolutely right: that set everything back and meant that there was no possibility of a cross-party approach. There will have to be such an approach if we are to fix social care and, indeed, to give the NHS what it needs, because they will both need more funding during this Parliament. That is the real shame. I did not make my point about Andrew Lansley for political reasons; I just want people to understand what happened, so that the current generations of politicians might do something different.

The answers we have since had from the Government are wholly inadequate. We have heard today that the precept does not raise enough money, particularly for poorer councils. It is no answer; in fact, it just cynically devolves the responsibility for the whole issue to local government, even though councils did not create the problem. I still favour an all-in system. I will say it: I favour a system in which we ask older people to pay a set contribution, so that they have peace of mind in later life, with all their care costs covered.

--- Later in debate ---

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

It is a pleasure to follow the hon. Member for Halifax (Holly Lynch), who articulately outlined several of the human challenges facing some of her constituents due to problems in the social care system. We have heard many contributions from right hon. and hon. Members today, many of whom drew upon their own front-line experience of working in the health and care system and of the difficulty in getting the right care that people up and down the country are facing.

We must remember that we are debating issues that affect real people and real people’s lives, which we sometimes forget in the heat of political debate. We need to remember that social care and good social services are about providing basic dignity in the care of older people and disabled people with things such as dressing, eating and washing. No Member should forget the importance of personalised care that provides dignity. We need a system that is not only more integrated and joined up, but better funded than the current system, which is not adequately financed to meet the needs of the people it looks after.

I want to talk briefly about welcome initiatives such as vanguards, the better care fund and the STPs, which are moves in the right direction. I also want to discuss the future. The right hon. Member for Leigh (Andy Burnham) was right when he highlighted some of the missed opportunities over the past two or three decades to grip the issues of improving social care and properly funding a sustainable health and care service. Before I do all that, it is worth pointing out some of the fundamental challenges facing the health and care system today.

However one dresses up the figures, there is an undoubted trend towards increasing delays in transfers of care. That is the truth that the figures show us. Of course, there are areas of good and bad practice, but the national trend in delayed transfers of care shows increasing pressure on the system. Budget reductions in the social care sector are real and amount to about £4 billion over the past decade. It is welcome that more money is coming into the system through the local precept, but that barely touches the sides when we consider the challenge of also meeting the increased demands of paying the national living wage. The NLW is a welcome initiative that will raise the living standards and quality of life of many care workers by properly rewarding them for their work—or make a much better contribution towards doing so—but the change is nevertheless putting budgetary pressure on local authorities, which manifests itself in difficult decisions about how care is provided and rationed on the frontline.

One of the big trends of the past decade has been that many local authorities have tightened the eligibility assessment for social care. It is effectively now the case that someone has to be in severe need to receive social care, so we must recognise that the tightened criteria mean that those who receive social care are no longer those in moderate need. That is symptomatic of some of the budgetary pressures that the system faces.

The welcome initiatives—the vanguards, the better care fund and the STPs—are all about the better joining up of what health and social care do together, but we must remember that STPs have perhaps come about in spite of the Health and Social Care Act 2012 rather than because of it. Prior to the 2012 Act, we had strategic health authorities, which helped to co-ordinate care at a regional level. Those were abolished and disappeared. STPs are now a welcome return to the recognition that we need a degree of regional co-ordination of our health and social care system in order to deliver the right care. That co-ordination must be across primary care, secondary care and social care. Housing providers are equally important, because many delayed discharges from hospital are due to the lack of appropriate housing for people with mental health conditions and dementia who do not have the right houses or the right circumstances at home. That is an important part of delivering those local plans to make sure that the system works better for people.

The elephant in the room is of course funding. Yes, we need to transform services, and more money is needed to do that. There are transformation budgets available through STPs to support clinical commissioning groups in delivering improvements in the NHS, but that will barely touch the sides and will not make enough of a difference. The great tragedy is that if we really want to drive integration, we must put the money into the same place. We must properly fund the integration and joining up of care. The loss of opportunity before the 2010 election was highlighted by the right hon. Member for Leigh. I urge the Government to look again at having cross-party talks to consider a sustainable future for the health and care system in which we all believe.

Alcohol Consumption Guidelines

Dan Poulter Excerpts

Tuesday 28th June 2016 Westminster Hall

[Byron Davies]

I thank my hon. Friend for that intervention. I can only quote my own example, which is one of extreme caution with alcohol, but it has been thoroughly enjoyable at times in the 12 months since I have been here. Of course, we should not be complacent.

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

I commend my hon. Friend for securing this debate. Does he recognise that we have to be wary of some of the statistics on alcohol-related admissions and alcohol-related morbidity and mortality data? Often, data on admissions to mental health hospitals are poorly collected. Indeed, now that public health services are divorced from the NHS and run by local authorities in England, we must be careful in assuming there is a downward trend. In fact, there is still a real problem with the overlap between mental health conditions and alcoholism.

[Byron Davies]

I am grateful for that intervention. I accept that we have to be very careful on that issue.

We should not be complacent. It is essential that public health advice keeps pace with advances in scientific understanding. Crucially, the communication of any guidance from the state must be seen to be above reproach and carry the confidence of industry and the public alike. However, I felt this debate was needed because I and several other hon. Members are concerned that the process by which the chief medical officer reaches their conclusion is flawed and has, in some ways, been hijacked by a group of campaigners with a clear anti-alcohol, total abstinence agenda.

Views are strongly held on this subject, which divides scientific opinion and the medical community. I recognise that that puts the CMO in a difficult position in making judgments about risk and in communicating sensible guidelines to consumers. We are bombarded with health advice from all quarters in this 24-hour social media age, and it is vital that anything published in an official capacity as advice from the Government’s chief medical officer is properly scrutinised and beyond reproach. I argue that the process that has been adopted, the clear conflicts of interest of the panel of so-called experts deployed to deliberate on these matters and the biased presentation of the findings have left a crisis of confidence in the new CMO guidelines among consumers, the media and industry. The Minister needs to address that in her response to the public consultation.

Let me deal with those points in turn. First, on the process adopted to undertake this review, the Department of Health guidance for expert group members states clearly:

“It is important to avoid any impression that expert group members are being influenced or appearing to be influenced by their private interests in the exercise of their public duties. All members therefore must declare any personal or business interests relevant to the work of the expert groups which may or may not be perceived by a reasonable member of the public to influence their judgment.”

Members of the guidelines development group set up to advise the CMO have been active policy advocates during the time in which the guidelines have been developed. Thanks to the investigative journalism of Sean O’Neill, chief reporter at The Times, it has come to light that an academic who played a key role in drawing up the controversial new safe drinking limits, Professor Gerard Hastings, did not even declare his links to the Institute of Alcohol Studies, a registered charity that receives most of its income from the Alliance House Foundation, which states that its aim is spreading the principle of total abstinence from alcoholic drinks. That is not quite putting Dracula in charge of a blood bank, but it is not far off.

Policy advocates such as Professor Hastings have taken strident campaigning positions. Many have a temperance or total abstinence axe to grind. They are clearly not neutral or, I argue, objective in their assessment of the costs and benefits of alcohol consumption. Indeed, the chief medical officer for England, when giving evidence to the House of Commons Science and Technology Committee on the proposed new alcohol guidelines, admitted that the experts

“found remarkably little evidence about the impact of guidelines, but we did not do them to have direct impact so much as to inform people and provide the basis for those conversations and for any campaigns that, for instance, Public Health England and others might run in the future.”

One member of the behavioural expert group, Dr Theresa Marteau, writing in the British Medical Journal, went further and stated that the new guidelines are

“unlikely to have a direct impact on drinking…but they may shift public discourse on alcohol and the policies that can reduce our consumption.”

Minutes from the guidelines development group meeting of 8 April 2015 state:

“It would be important to bear in mind that, while guidelines might have limited influence on behaviour, they could be influential as a basis for Government policies”.

There we have it. Never mind what consumers think about being told by the chief medical officer to think of cancer every time they hold a glass of wine or pour a can of beer, or that, as someone drinking a pint of beer a day, they are drinking more than they should. The not so well hidden agenda of the temperance activists is to influence Government policy to drive down alcohol consumption across the board. Wales has a strong Methodist and temperance tradition, which I respect, but I take issue with organisations such as the Institute of Alcohol Studies, which is funded directly by the temperance movement, helping to produce biased reports that are then given undue influence over the Government’s alcohol policy.

Having raised my concerns with the process adopted in undertaking the review, which I believe may have prejudiced the outcome and has certainly rendered the process lacking in credibility with consumers and the industry, I turn to the presentation of the review’s findings and, in particular, to the assertion that there is no safe level of alcohol consumption, the lowering of the recommended weekly levels for men in line with those for women, and the communication of risk. I believe that that assertion is at the heart of the flawed nature of the proposed guidelines and it is, in some respects, clearly deliberate on the part of campaigners. If the Government accept that there is no safe level of consumption, it becomes much easier to argue for more restrictions on alcohol availability,