Antibiotics: Research and Development

Daniel Zeichner Excerpts

Tuesday 26th April 2016 Westminster Hall

[Daniel Zeichner (Cambridge) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Evans. I congratulate the hon. Member for York Outer (Julian Sturdy) on securing this debate on an issue he has long championed. I became interested in the issue having listened to presentations by clinicians and scientists in my constituency. They made it absolutely clear that incentivising research into and the development of new antibiotics is essential not only for our generation but for future generations. Antimicrobial resistance and its consequences are happening now. The World Health Organisation has cautioned:

“A post-antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st Century.”

Last year, antimicrobial resistance was added to the Cabinet Office’s national risk register for civil emergencies. The Government rightly warned that without effective antibiotics, even minor surgery and routine operations could become high-risk procedures.

Long lead times for developing new medicines and the relatively low commercial returns on investments have unsurprisingly hampered investment in antibiotic development. In 2014, the Select Committee on Science and Technology highlighted the fact that only 22 new antibiotics have been launched since 2000. The Association of the British Pharmaceutical Industry—I thank it for its help in preparing for this debate—points out that whereas 18 large pharmaceutical companies were actively involved in antimicrobial research and development in the 1990s, that number had fallen to four by 2010.

To ensure that new antibiotics are developed, it seems that we need a new reimbursement system, as other Members have said. Unless the environment for companies to invest in antibiotic development becomes more attractive, the problem will continue to grow. Looking at the wider field of the development of new drugs, I fear that some indicators suggest we may be going in the wrong direction. In 2010, 6% of international clinical trials were based in the UK, but the figure now stands at a mere 2%.

There are a wide range of suggestions for what we might do, including altering the regulatory framework to incentivise innovation and developing new economic models, perhaps through innovative pricing and reimbursement mechanisms to incentivise more investment in researching new antimicrobials. There may be possibilities through the emergence of what is termed venture philanthropy, which is an exciting development for some of the big research charities.

It has to be said, however, that if there is not enough money in the system as a whole, it is hard to see a way forward. Some caution that whatever the accelerated access review brings, chronic funding shortages will continue to hamper innovation. If we add to that the changes in capital allowances that make other countries more attractive and the uncertainty over the replacement of the political fix known as the cancer drug fund, it is easy to become pessimistic.

The industry needs to think hard about the future. As the independent O’Neill review said:

“Big pharma…needs to look beyond short-term assessments of profit and loss, and act with ‘enlightened self-interest’ in tackling AMR, recognising that it has a long term commercial imperative to having effective antibiotics, as well as a moral one.”

The fact remains that the Government must position the UK as the most compelling global location to develop new treatments. Methods for doing that might include committing to, and funding, a reimbursed early access to medicines scheme; and ensuring that there are sufficient funds to continue funding some of the important schemes focused on innovation, such as the biomedical catalyst. Indeed, the World Health Organisation recommends that policy makers can help to tackle antimicrobial resistance by rewarding innovation and the development of new treatment options. A global innovation fund was one of the preliminary recommendations of the O’Neill review, and we await the final recommendations, which are due to be published this summer.

In addition to incentivising research and the development of new antibiotics to tackle antimicrobial resistance, as we have heard, the Government must focus on preventing the inappropriate prescription of antibiotics, which is causing resistance to spread. The Science and Technology Committee has said that the Government

“needs to set clear responsibilities at all levels of the NHS and veterinary medicine to achieve better stewardship of the antimicrobial drugs vital in modern medicine.”

Indeed, the National Institute for Health and Care Excellence has warned that more than 20% of prescriptions issued for antibiotics are likely to be unnecessary. That is about 10 million prescriptions.

Another problem that is contributing to growing antimicrobial resistance is the use of antibiotics in livestock production. Other European countries have already set targets for reducing the use of antibiotics in farming, but the UK Government have not. Considering that farm animals account for almost two thirds of antibiotics used in Europe, and about 40% of those used in the UK, it is hard to overestimate the significance of that in the increasing problem.

Antimicrobial resistance is a grave threat that is only going to grow and intensify. The Government must act now to tackle the barriers to the development of new antibiotics and make the environment for researching and developing new drugs less challenging. The alternative, to go back to a world without antibiotics where almost half of people in this country died of infection, must be avoided at all costs.

Mental Health Taskforce Report

Daniel Zeichner Excerpts

Wednesday 13th April 2016 Westminster Hall

[Norman Lamb (North Norfolk) (LD)]

I, too, congratulate the hon. Member for Halesowen and Rowley Regis (James Morris) and thank him for all the work he has done in advocating for mental health. I also congratulate Paul Farmer, Jacqui Dyer and their whole team on their substantial piece of work.

This is a historic injustice. The disadvantage suffered by people with mental ill health in accessing treatment is not the responsibility of any particular Government; it has always been there, but the report gives us the opportunity to end that historic injustice, and we have an absolute responsibility to ensure that that happens. It is both morally wrong and economically stupid to ignore mental ill health. The case is made so well on page 5 of the report, where it says:

“Those with conduct disorder—persistent, disobedient, disruptive and aggressive behaviour—are twice as likely to leave school without any qualifications, three times more likely to become a teenage parent, four times more likely to become dependent on drugs and 20 times more likely to end up in prison. Yet most children and young people get no support. Even for those that do the average wait for routine appointments for psychological therapy was 32 weeks in 2015/16.”

That encapsulates the problem. It is scandalous that children with such needs do not get access to treatment. It destroys their life chances, and the cost to society of the outcomes described in the report is enormous.

I am conscious of the time available to me, so rather than highlight a number of issues from the report I will address some key points directly to the Minister. First, we know that there will be £1 billion of additional funding, but it is due to come late in this Parliament. Between now and then, the NHS Confederation believes that mental health will lose out on funding and that in 2016-17 the bulk of the front-loaded money will go to acute hospitals. I have a real concern that the ambition in this document will not be realised unless that investment is made. Will the Minister ensure that that investment is delivered?

[Daniel Zeichner (Cambridge) (Lab)]

Will the right hon. Gentleman give way?

[Norman Lamb]

I do not have time; I want to ensure that others can speak.

Secondly, there needs to be a clear implementation plan—others, including the Royal College of Psychiatrists and NHS Providers, have made this point. We need to understand exactly the practical mechanism for making these things happen. NHS providers say the plan should be delivered by August of this year. Can the Minister confirm that that will happen and that there will be reporting back on progress, so that we understand exactly what is happening? We need proper governance arrangements to make sure that these things happen.

Thirdly, the report endorses the approach that I took of implementing comprehensive maximum waiting times standards. That is an essential component of achieving equality—an equal right to treatment on time, whether someone has a physical or mental health problem. The Government have endorsed the report, yet there is no funding attached to ensuring we get comprehensive waiting times standards. How will the Government ensure that that happens? It is fundamental to ensuring that we end the historic injustice.

I am delighted that there is now a commitment to end the outrageous practice of out-of-area-placements. It is outdated, it treats people appallingly, and we know that there is a higher risk of suicide among people who end up being sent out of area. To do it by 2020 takes too long. The Royal College of Psychiatrists report—Lord Crisp’s report—says it could be done by October next year, so I urge the Minister to follow that timescale. Will he also commit to implementing all the recommendations in Lord Crisp’s report, which has been widely welcomed? Everyone recognises that it makes sense, so I hope he will confirm that.

There is a responsibility on all of us to ensure that we do everything we can to implement the recommendations. I chair a commission on mental health in the west midlands. Is the Minister interested in a briefing on the progress we are making? There is a real opportunity to implement early some of the recommendations in the report.

Finally, I will make the case for preventive healthcare. Relate, the organisation, has made a powerful case for the value of couple therapy and ensuring that every provider of IAPT—improving access to psychological therapies—provides that among the other evidence-based interventions.

Oral Answers to Questions

Daniel Zeichner Excerpts

Tuesday 9th February 2016 Commons Chamber

[Daniel Zeichner (Cambridge) (Lab)]

10. What progress his Department has made on reviews investigating the end of the contract between Cambridgeshire and Peterborough clinical commissioning group and UnitingCare Partnership.

[The Minister for Community and Social Care (Alistair Burt)]

The CCG expects to publish its internal review by the end of February, and NHS England’s independent review is expected to be completed by the middle of the month. Monitor is assessing the project from the providers’ perspective and will share its findings with NHS England in due course.

[Daniel Zeichner]

The UnitingCare contract in Cambridgeshire was an attempt to join up unintegrated services. We now appear to be having a series of unintegrated reviews. What is actually needed is a single overarching review that looks at the roles of NHS England, Monitor, the strategic projects team, and, of course, Ministers. When are we going to get that review?

[Alistair Burt]

As I said, there are ongoing reviews concerning the precise responsibilities of each individual part. There is no doubt that this is a very serious matter—a serious failure—that raises series concerns. We want to know what went on as much as the hon. Gentleman does, so once the reviews have been completed and we have been briefed, I will be very happy to talk to him about their consequences.

NHS Trusts: Finances

Daniel Zeichner Excerpts

Monday 1st February 2016 Commons Chamber

[Daniel Zeichner (Cambridge) (Lab)]

The hospital in Cambridge that serves my constituency, Addenbrooke’s, is one of the trusts with the most challenging deficits. Today, it is urging people not to attend accident and emergency, which it explains by saying that it is seeing more and more frail, elderly patients. At the same time, the Conservatives in Cambridgeshire are refusing to levy the 2% that the Chancellor has offered them. We have a crisis in social care and health funding in Cambridgeshire. How can it possibly help hard-pressed staff at Addenbrooke’s to hear the instruction that numbers should be cut? Will the Minister assure me, patients and staff in Cambridgeshire that that diktat will be withdrawn?

[Ben Gummer]

No. I cannot assure the hon. Gentleman that we will stop trying to find efficiencies across the NHS. The important thing is to make sure that we channel money right to the frontline, which means doing so in his hospital, as in others. It will sometimes mean finding efficiencies in individual trusts and commissioning groups, and making sure that the money is rediverted. I should say to the hon. Gentleman that the problems at Addenbrooke’s go much further than A&E. The hospital is in special measures and there is much to put right. I am confident that that will be managed, under the stewardship of the new chief executive, who has proven himself to be excellent.

Cambridgeshire CCG and UnitingCare Partnership

Daniel Zeichner Excerpts

Monday 18th January 2016 Commons Chamber

[Daniel Zeichner (Cambridge) (Lab)]

I thank you, Mr Speaker, for allowing the House the opportunity to consider the extraordinary collapse, after just eight months, of one of the biggest tendering exercises conducted in the NHS: the £800 million contract between UnitingCare Partnership and Cambridgeshire and Peterborough clinical commissioning group.

Two weeks ago, I spent a morning out with an ambulance crew working from the ambulance station on the Addenbrooke’s site outside Cambridge. I saw the NHS at its best: top-quality care, provided quickly; people in pain and discomfort treated with dignity and respect; a swift, seamless transfer into hospital; and fantastic, caring, committed staff, on ambulances and in hospital. It was our NHS at its best and we should be proud of it.

When health leaders in Cambridgeshire said they wanted to create an integrated service for older people that would focus on prevention, it was a worthy aim, albeit polluted by the need for a competitive tender, insisted upon by the Health and Social Care Act 2012. When the contract was finally signed with NHS providers, it should have been the start of a new way to provide care, so what went wrong? That is what I want to quiz the Minister on tonight, because the failure of this contract matters way beyond Cambridgeshire, and it has rightly attracted national attention. A recent editorial from the Health Service Journal said:

“When a five year contract of this size and this importance to some of the most vulnerable people in society fails, it is not enough to shrug and walk away. As NHS England develops capitated, outcomes based contracts for national rollout, it is important to understand and explain what has gone wrong in Cambridgeshire so the lessons can benefit the health service as a whole.”

It is right.

This is a long and complicated story, which some of us have followed closely over many years. You will be glad to hear, Mr Speaker, that I will give an abbreviated account, but I must pay tribute to some of the campaigners who spent many, many months at meetings across Cambridgeshire questioning and challenging: my friend and colleague, Huw Jones; Steve Sweeney, then of the GMB; Jo Rust; Tracey Lambert and Martin Booth from Unison; and many, many others. We always knew something was not right and, sadly, we were proved to be correct.

I believe the story really begins back in 2012, when the future of Cambridgeshire Community Services NHS Trust, which had itself only a few years earlier been separated from the predecessor to the CCG, was thrown into doubt when it failed in its bid to become a foundation trust. Under Government guidance at the time, through the Trust Development Authority, trusts that were not foundation trusts faced being wound up. That was a foolish policy and, as so often, it was later rescinded, but given that this was happening when the infamous 2012 Act was under massive discussion, the real possibility was raised that many care staff would be transferred to private providers. That did not happen, because Cambridgeshire County Council, which many staff had originally worked for, took many of them back, but the consequence was a disintegration of services—the very opposite of what was needed. Integrated teams were ripped apart—an act of vandalism that set care back. The Trust Development Authority, the body overseeing this early-stage debacle, remains the line of accountability for NHS trusts. Those trusts are now being merged, in their regulatory function if not statutorily, into Monitor, which is yet another Executive non-departmental public body of the Department of Health.

It is worth noting in passing that, since the time it was denied foundation trust status, causing the disintegration of care, Cambridgeshire Community Services has gone on to be named as the best community trust to work for by the Health Service Journal, and is now doing very well, albeit by working mainly with others outside Cambridgeshire.

Against that backdrop, and because of the 2012 Act taken through Parliament by the then local MP and Secretary of State for Health, the Cambridgeshire and Peterborough clinical commissioning group, in wanting to move to a new model of outcomes-based care, was forced in 2013 to put health services for older people out to tender. The process attracted national attention and was very controversial locally, mainly because of its focus on trying to attract private providers. Shrouded in commercial confidentiality, rumours abounded. Many organisations expressed interest including Virgin Care, Care UK, Circle, Capita and UnitedHealth and more.

Over many months, campaigners and I sat through numerous CCG board meetings and what were described as public consultation meetings where we were assured that all was well and that the many concerns we raised were unjustified. It was announced that the three final bidders for the contract to lead the services were Care for Life, UnitingCare Partnership and Virgin Care. Eventually, in October 2014, it was announced that the five-year outsourcing contract to run older people’s healthcare and adult community care was to be awarded to the UnitingCare Partnership, which was not a private bidder but an NHS consortium of Cambridgeshire and Peterborough NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust. The five-year contract was worth £800 million and covered: urgent care for adults aged 65 and over, including in-patient and A&E services; mental health services for people aged 65 and over; adult community services for people aged 18 and over, including district nursing and rehabilitation services; and health services to support the care of people aged 65 and over. It is one of the biggest contracts the NHS has ever tendered.

The partnership started delivering services last April, and regular updates were issued outlining how the new services would work. We now know that, behind the scenes, much wrangling over costs was going on, but that was withheld from public gaze. Then came the bombshell. After eight months, and just one month of the new system operating fully, a joint statement was issued by Cambridgeshire and Peterborough CCG and UnitingCare. Not much detail was given, other than an assurance that services would continue, that patients should be reassured but also that the provider and the commissioner had agreed that

“the current arrangement is no longer financially sustainable.”

The contracts that had been established were to be honoured by the CCG, and patients and carers were promised that services would go on as usual and would not be disrupted. It was also said that it would try to retain the new model of integrated service delivery.

Let us briefly review some of the damage. We still do not really know how much the procurement process cost, but on the public side it was certainly millions, and probably at least as much again for private providers working up failed bids—doubtless to be recouped from somewhere else in the NHS later.

Let me turn now to the impact on staff. Back when Cambridgeshire Community Services failed in its bid for foundation status, a transition steering group was established to oversee the future of thousands of its staff. Teams were ripped apart and, with the new contract, more than 2,000 staff were transferred to Cambridgeshire and Peterborough Foundation Trust and Cambridgeshire County Council.

That was a massive task for the Cambridgeshire Community Services Trust, distracting it from other work. There was huge uncertainty and stress for staff over the future of their jobs. Throughout the entire process, across the NHS in Cambridgeshire, senior managers and local health service leaders were spending large amounts of time on all of this. Was it really time well spent, when last year we saw so many major hospitals repeatedly in crisis?

I have said nothing so far about the strategic projects team. What was its role? Many would ask, “Who are they?” To many who follow these things, the STP is, in effect, the pro-privatisation arm of NHS England, and it played a key role throughout this process. Its website tells us that the team specialises in competitive procurement, the re-design of patient pathways via an integrated care model, change management, service reconfiguration and integration, trust development and culture change.

The STP is part of NHS England. We are told by Lord Prior of Brampton, the Minister responsible for NHS productivity, that in its investigation into the collapse of the contract, NHS England will examine the strategic projects team’s role, and will also consider how similar contracts will be managed and assured in future. So it is NHS England that will investigate its own strategic projects team—a hopeless conflict of interest. That is not good enough. We need a genuinely independent and transparent review.

People are right to ask questions about the strategic projects team. Its list of interventions reads like a roll-call of recent NHS disasters: not just this project, but the private hospital saga at Hinchingbrooke in Cambridgeshire, and the failed tendering process for the George Eliot hospital in Warwickshire, among others. Its website leaves one in no doubt about its leading role in the Cambridgeshire older people’s tendering process. It says:

“SPT delivered an open procurement process on behalf of the CCG”.

It delivered—no room for doubt there. On 8 October 2014, when UnitingCare was announced as the preferred bidder, the SPT was again trumpeting its key role. On 12 November, when it was announced that UnitingCare would operate as a limited liability company, the SPT was there again, and it is worth quoting from the press release still on its website to get a sense of just how central it was:

“Andrew Macpherson, Managing Director of the Strategic Projects Team that managed the procurement on behalf of the CCG said: ‘The Strategic Projects Team are once again proud to have supported courageous leadership in the NHS.’”

The SPT may call it courageous; others might describe it rather differently.

Let us be clear—it is the SPT, very much part of NHS England, that has been calling the shots. On the decision to set up UnitingCare as a limited liability company, it was approved by Monitor, the strategic projects team and NHS England at the time, yet all knew that that meant that there would be no room for flexibility, and no room for losses in years 1 and 2, when the model explicitly expected extra cost at the beginning, in expectation of savings later. Looked at from the outside, it is hard to see how that could ever have worked, so why did Monitor, the special projects team and NHS England give the go-ahead? Did none of them spot the potential VAT problems introduced by a limited liability partnership?

Having given a brief outline, let me come to the further questions that I hope the Minister will be able to help us with. First, on the flurry of investigations being announced, although it is right that individual organisations will want to look at their role, there is a danger not only of duplication but of exactly the kind of fragmentation that has caused such problems already. Given the conflict of interest within NHS England that I have already described, would it not be better to have a genuinely independent review carried out by the National Audit Office—a review in which we could all have confidence?

The Minister should surely be able to tell us about the role played by his Department and by Ministers, at two key moments in particular. When it was clear in October/November 2014 that there was insufficient information on costs to agree a final contract, why was the process not delayed until that had been sorted out? Did Ministers know? What exactly was the rush to achieve implementation for April 2015, coincidentally perhaps just weeks ahead of the general election? And what role did Ministers play in the final decision to end the contract in December 2015? There were clearly detailed discussions going on with NHS England and Monitor about how much was needed to keep the contract running. The figure seems to have been about £10 million, a lot of money, but given that killing the contract may well have cost more, it was certainly worth considering. What was the ministerial involvement at that point? Were Ministers consulted? Who made the decision to let the contract collapse?

Looking forward, which is what matters most, patients have been assured that services will be maintained. That may well be true in the short term, but what next? Will the outcomes model be pursued, just with UnitingCare taken out of the equation? Does the CCG have the capacity, and if it does why did we go through that ludicrous tendering process? This has been a sorry saga. It seems that everyone agrees that our NHS and our care services need to be integrated, but years of fragmentation make it extremely hard to achieve.

This was a well intentioned attempt to deal with the perverse incentives that shackle our health and care services, and we need to find out what went wrong. We have dedicated, hard-working staff who want to provide the best care possible to our citizens. We need to find a way of making it possible for them to do that. In my view that means an end to contractualised market models, and a move to a genuinely integrated public system, an NHS solution based not on competition but on collaboration; an NHS solution that patients desperately need, and that staff, I am sure, would cheer.

--- Later in debate ---

[George Freeman]

That is right. As both questions have highlighted, the change in the care pathway is being pursued by the CCG and there is no reason for patients—the users of the system—to fear any dramatic change to the service. The remaining issue is the residual issue of how the contract came to be put in place. The dispute between the parties is about their different conceptions of the financial and contractual situation. I do not want to prejudge the investigations, but the service reforms will continue.

The final decision to terminate was taken after extensive discussions between the CCG, UnitingCare, Cambridge University Hospitals NHS Foundation Trust, Cambridge and Peterborough NHS Foundation Trust, NHS England and Monitor. Prior to escalation to NHS England and Monitor, the CCG, CUH and CPFT worked hard to try to reach a resolution locally.

[Daniel Zeichner]

Could the Minister enlighten me on the role played by Ministers in that final decision? Did they know it was happening? Who ultimately terminated the contract?

[George Freeman]

As I will come on to say, due process was followed in the correct way. One of the reasons for listing all these acronyms is so that the hon. Gentleman can be reassured that the right bodies carried out their due diligence. I do not believe that there was any reason for Ministers to be concerned at any point until the dispute between the parties became clear. Indeed, the reforms had been generated locally by clinicians and an accountable CCG led by clinicians. As the questions I have been asked have illustrated, the reforms were and remain very sensible. This is a better care pathway, with improved outcomes.

The issue is contractual and relates to a dispute between the parties about liabilities in the contract. As I have said, I do not want to prejudge the ongoing investigations, the point of which is to work out what should have been done differently. I can absolutely reassure the hon. Gentleman and the House that we are hungry to learn any lessons from that commissioning experience. We need novel commissioning. We need commissioners around the country to look into different ways of commissioning the reforms to our integration of health and care, and lessons need to be learned when it goes wrong. I emphasise that this was a contract between the parties. As I have said, the Department is looking forward to the reviews and wants to hear the lessons that others can learn.

The CCG has now taken over all relevant contracts with providers that were previously held by UnitingCare, to ensure that there is no service disruption to patients and carers. In addition, the CCG and CPFT, which employ the majority of the affected staff, have worked closely together to ensure that frontline staff are clear that, while the contractual model has now changed, the service model remains in place.

Of course, I agree with hon. Members that it is a matter of extreme concern that the new arrangements lasted barely six months. That is not ideal. We need to work out how the parties got it wrong and what mistakes were made. There are questions for the reviews to address. For instance, there is the question of why, given full procurement and assurance of the process, the result fell so far short in practice, along with other associated questions.

To describe modern commissioning as back-door privatisation is wilfully to misrepresent what is going on. These are clinician-led improvements to the care pathways, and I do not believe that most service users would consider it privatisation. We are talking about two public sector organisations coming together to form a company for the purposes of jointly commissioning care pathway innovation put together by clinicians in the local CCG. If Labour considers that privatisation, it has a serious problem, because most people would consider it enlightened commissioning for modern care pathways. This is a contract issue. The parties to the contract did not get it right, and we are keen to understand why and what can be done to make sure it does not happen again. I want those answers as much as the hon. Gentleman, and I repeat my invitation, to him and other hon. Members with an interest, to meet in due course to learn the lessons and make sure that the benefits of commissioning for integration go ahead without the contractual errors that have bedevilled this project.

Question put and agreed to.

Oral Answers to Questions

Daniel Zeichner Excerpts

Tuesday 17th November 2015 Commons Chamber

[Mr Hunt]

I can absolutely give my hon. Friend that assurance. This is essential for the constituents of all hon. Members, whichever side of the House they sit on, and this Government will always stand on the side of patients. The weekend mortality rates are not acceptable. That is why we are doing something about them.

[Daniel Zeichner (Cambridge) (Lab)]

Given the acute pressures on the national health service, we are a long way from the vision that the Secretary of State wants to achieve. I met the Indian Workers Association this morning. Thousands and thousands of care workers of Indian origin are trained nurses and could be in our NHS, but the bar for the language test has been set so high that they are excluded. Will the Secretary of State look again at the test?

[Mr Hunt]

I commend the extraordinary contribution made by NHS front-line workers of Indian origin. I have met the Indian doctors association, the British Association of Physicians of Indian Origin, and have had many discussions on that front. It is very important, however, that people speak good English if they are providing care in the NHS. There are real issues for clinical safety when the standard of English is not high enough. We have a lot of fantastic support from immigrants who do a great job on the NHS frontline, but good English is an absolute pre-requisite.