Homeopathy and the NHS

David Mowat Excerpts

Wednesday 29th March 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mr Hanson. I congratulate my hon. Friend the Member for Bosworth (David Tredinnick) on yet again leading the charge—we have debated this issue in various parts of Parliament—and on securing this debate in close proximity to Homeopathy Awareness Week, which starts on 10 April. He normally corresponds with my colleague, the Minister for Public Health and Innovation. I apologise that he has to put up with me today, but I will do my best to address the points he raised and set out as specifically as possible the Government’s and the NHS’s position on homeopathic remedies.

The Government have no particular position on the efficacy or not of any type of treatment, but we have a position on evidence-based medicine, and I will come on to talk about how we expect an evidence base to determine how we spend public money. There is an acceptance that there is great popularity for some parts of this medicine across the world, as my hon. Friend said. The Government have no particular control over how people spend their money in terms of these treatments. He was involved in the Walker report and review, which put in place a regulatory environment involving the Professional Standards Authority system and the voluntary lists for that.

As well as that popularity-led issue, there is the issue of how we spend public money in the NHS. I will come on to that process, but it is about the evidence base. It is right that there is a method of evaluating competing drugs, technologies and treatments. I will come on to talk about that and what it means in this context. We have no overall position on this issue. My hon. Friend made a good point about the over-prescription of antibiotics. He said that, in certain areas, homeopathic remedies may be an alternative.

I used the phrase “evidence-based medicine”, which means that the medicine is clinically cost-effective. Typically, the drugs that are used across the NHS are subject to trials—possibly lasting many, many years and involving large populations, statistically clear correlation and all that goes with it. A requirement of those drug trials is that their results are not anecdotal, but clearly repeatable. The drugs must demonstrate efficacy. When the National Institute for Health and Care Excellence evaluates them, it uses a threshold to measure their cost versus the quality of life and the years that are obtained by their use. Precisely the same criteria would be applied to any homeopathic or alternative remedy; they would be evaluated in that way. The Department’s position is that medicine must be evidence-based. Within that constraint, we use what the evidence tells us to use. For non-NHS expenditure, it is up to the public to buy what they wish, provided it is safe. There are some controls, and if I have time I will talk a little about the Walker review and what the controls are.

The NHS’s commissioning power is set locally by CCGs, which are GP-led. They set out their policies, in terms of what the CCG uses, but as they do that we expect them to be advised and informed by best practice and, where they are available, by NICE guidelines. Within that, GPs have considerable discretion. As my hon. Friend knows, some GPs still prescribe such remedies, where that is permitted by the CCG. That is not something that the Government have chosen to interfere with, although the drive towards evidence-based medicine means that over the past decade the amount of prescribing has decreased considerably. Last year, something like 9,000 separate prescriptions were made in primary medicine at a cost of about £100,000. A decade ago, the figure was nearer £150,000. That decline has been driven not by a Government diktat, but by our requirement that all CCGs use an evidence base for their decisions.

My hon. Friend gave various views about the evidence base. In 2010, the House of Lords Science and Technology Committee said:

“There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious.”

More recently, NICE said that it is not aware of any evidence that demonstrates therapeutic effectiveness, and it does not currently recommend that homeopathy should be used as a treatment for any health condition. As a consequence, there has been a tail-off in the use of such remedies.

I accept that, in certain circumstances, patients may feel that they have tried many other things, and a physician working with them might say, “Let’s have a go at one of these things. What have we got to lose?” As I say, it is not the Government’s job to stop a GP taking that position in that situation. Very often, that will be done in conjunction with a patient who, as my hon. Friend said, feels as though they have tried everything else, and will have a go at it as a last resort. It may well be that, anecdotally, it works, whether that is through a placebo effect or for whatever other reason. It is not the Government’s job to stop that.

In the last minute that I have, I want to talk about the Walker review, of which I think my hon. Friend was the vice-chairman—he certainly helped to inform it. A system of regulation was brought in. We have been talking about the potential need for statutory regulation of the use of such remedies outside the health service. The Walker review looked at a variety of issues with respect to such medicines and concluded that we should put in place a voluntary system of regulation accredited by the PSA—something of a middle way.

[David Tredinnick]

The Society of Homeopaths is now regulated by the Professional Standards Authority, and will be looking to the health service to make better use of its services.

[David Mowat]

The Society of Homeopaths is accredited by the PSA, as my hon. Friend says. When somebody gets accredited, that is an endorsement that that practitioner is committed to safety and to work of good practice. It is not necessarily an endorsement of the technique that is being used, but it is accreditation that it is a safe technique. We accept that, and we would like more professionals working in that area to go down that route. I will finish on that note. I hope that I have been successful in setting out the Government’s position.

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

Preventing Avoidable Sight Loss

David Mowat Excerpts

Tuesday 28th March 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mrs Gillan. I congratulate my hon. Friend the Member for Wealden (Nusrat Ghani) not only on leading the charge today but on her work on the APPG more generally. A number of Members have made the point this morning that we have not debated eyes and sight in this place very much over the past few years. It is good that we have the time to put that right today, so I congratulate her on doing so.

I start by acknowledging what a number of Members have said—that 50% of sight loss is preventable. I think my hon. Friend said that 85% of people regard sight as the most precious of all our senses. Frankly, I am surprised that the figure was not higher than that. This is clearly massively important. We can debate numbers—the hon. Member for Burnley (Julie Cooper) just talked about £28 billion—but the key figure is the statistic that my hon. Friend the Member for Twickenham (Dr Mathias) started with. Some 20 people a month are losing their sight, whether due to lack of prevention or lack of early treatment, in ways that are preventable. That is not acceptable, and we need to work collectively to address it—I will try to set out the Government response to it now.

I will talk first about prevention and the need for early detection and improved treatment. We heard about waiting lists in Great Grimsby, which I will come to. I will also talk about the social exclusion that can occur, and the mental health issues that can come from that. As I go through, I will try to address the points raised during the debate by Members on both sides of the House. If I do not, I am sure Members will remind me that I have not; in any event, we will write on any points that are not directly addressed.

The UK vision strategy was produced jointly with the RNIB, which does a lot of extremely good work in this space, for which the Government are grateful. Both the Department of Health and NHS England fully support that strategy, and need to continue to drive it forward. We also support global issues; Members have talked about the WHO global plan, which intends to eliminate preventable sight loss by 2020, and my hon. Friend the Member for Wealden talked about some of the work we do globally. She talked about patient choice and the referral process—whether it is via GPs or direct—which is an interesting point that I will come to. She talked about STPs, as did the hon. Member for Burnley, cancelled appointments and the need for a national strategy in England. I will come back on those points, if I do not get to them during my remarks.

To frame the issue, 2 million people in the UK have sight loss—because sight loss is so related to age, 4 million people will almost certainly be affected by 2050—and 80% of those are over 60 years old. Several Members cited statistics illustrating the demographic changes, including the hon. Member for Strangford (Jim Shannon), who spoke about Northern Ireland. As we debate these things across health and social care, we have to recognise the incredibly significant changes to our demography.

When the national health service was set up in 1948, one person in four lived to be over 65. We have totally fixed that, in the sense of increasing longevity. In the last 10 years, our population has increased by 10% and our population of over-85s has increased by nearly 28%. That trend will continue and accelerate, which gives us all challenges, including resourcing and all that that means. I heard a very apposite phrase recently: “We have done a good job of increasing quantity of life, but we haven’t yet increased quality of life to the same extent.” That is true of sight loss. As we heard, 148,000 people are certified blind in this country, with all that that means in terms of benefits and tax changes. That figure has been fairly stable—indeed, it has gone down slightly in the past three years—but nevertheless, it presents us with a big challenge.

In responding to those changes, we have to look at prevention and understand the risk factors. I have just covered the first risk factor, which is age. We cannot do a great deal about that, other than note that we are all getting older. Like the hon. Member for Strangford, I am over 50—considerably so—and the fact is that the sight loss numbers are driven by age. Smoking and obesity also play a big part in eye health, as they do in other aspects of health. Our tobacco control strategy will be produced imminently. We have done a good job in this country of reducing smoking, but we need to go further and faster, and I hope that the strategy will be a big part of that. There will be specific targets by age group for what we need to achieve. Obesity is equally and possibly more important; it is a risk factor for all sorts of things. I perhaps did not fully understand that obesity affects people’s chances of getting cancer, dementia and suffering from sight loss as much as it does. We need to drive home the potential benefits of the obesity strategy that we published, which aims for a 20% sugar reduction by 2020.

Hon. Members, including the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), mentioned cataracts. Obesity doubles the probability of getting a cataract. That is an extraordinary statistic given that it is not intuitive that those are linked, even though they clearly are. I do not want this debate to be about money—what we are talking about is more important than money—but the cost to the country of obesity and diabetes put together means that we now spend more in the NHS on treating them than we do on the police service, the judiciary and the Prison Service combined. That puts into perspective the magnitude of the cost and what we need to achieve.

On prevention, we have not talked about the screening programme that we have introduced for diabetic eye disease, which was the principal cause of blindness in working-age people until recently. As a result of the programme, which involved offering a digital photograph to all people with diabetes over the age of 12, something like 2 million people were screened last year. For a screening programme, there was a very high uptake—over 80%—and some evidence shows that it has resulted in significant progress in preventing that type of blindness. This is the first year for which we have those figures, and diabetic eye disease is no longer the principal cause of blindness in working-age adults. That has largely been achieved through that very effective screening programme.

Let me talk briefly about the four most common causes of blindness, which are cataracts, age-related macular degeneration, glaucoma—that is the most prevalent, as we have heard—and diabetic eye disease. All of those can be treated most effectively through early diagnosis—frankly, that applies in most areas of health, but it is particularly true of eye health—and the first part of that is timely sight tests. Sight tests are free for children at school, although parents have to arrange them. They are also free for the over-60s, for anybody who is in a high-risk group, including those with diabetes or glaucoma, and for people on various income-supported benefits. There were 13 million eye tests last year, which was an increase of 2%. There is always a case for doing more, and I say to anyone who is listening to this debate, even if they are not of such an advanced age as me or the hon. Member for Strangford, that these things are worthwhile.

Treatment is CCG-led in this country. The principal reason relates to some of the issues that we heard about from the hon. Member for Great Grimsby (Melanie Onn), who spoke well about the large numbers of people on the waiting list of the Northern Lincolnshire and Goole NHS Foundation Trust and the extra clinics that had to be put on. That is a CCG responsibility. With national strategies, there is a choice about whether something should be locally focused, with local commissioners having the resources and money—although resources are a different issue—or whether there should be an overarching national plan.

I was struck by what the hon. Lady said about the actions that were taken. Those were local actions, which were completely appropriate. In England, we produce a public health outcomes framework—I do not think that is the case in Scotland, notwithstanding the excellent speeches by the Scottish National party Members about what is done in Scotland. The framework sets out for every local authority area in the country the extent to which there is glaucoma, diabetic eye disease and age-related macular degeneration, and the total number of people who are certified blind. Those data are tracked over the years and ought to inform local commissioners, and indeed, local health and wellbeing boards in the priority areas. There are striking differences and clusters of different types of blindness and different issues in different areas.

To cite a few of those differences, Barnsley has three times the national average of age-related macular degeneration and twice the national average of people who are certified blind. To me, that suggests that the commissioners in Barnsley should, in particular, be putting effort and resources into treating AMD. London has something like 20% more diabetic eye disease than other parts of the country. That may be to do with the large south Asian population in parts of London and the diabetes that that implies. Those sensible decisions should be taken by local commissioning groups in the knowledge of the facts. I commend the public health outcomes framework to hon. Members, who may not have looked at it for their own constituencies and patches. That should be considered and understood, because for this and other issues, it tells us where the priorities ought to be.

[Melanie Onn]

If CCGs are to focus on providing more support for a particular service, it prompts the question, “What will support be taken away from?” The trust in my constituency has now gone into financial special measures. There is only so much give in the system. What does the Minister think is the solution?

[David Mowat]

I did say, when I was making the point, that I was not talking about priorities in terms of total resource there. We must make choices. I will come to the point about the £20 million budget.

The hon. Member for East Kilbride, Strathaven and Lesmahagow mentioned concerns that cataract operations were being rationed. In response, the Secretary of State requested that NICE issue guidelines this year rather than next year, and we will pursue that. However, I make the point that 17% more cataract operations are being done in England now than five years ago. That does not imply rationing to me, but we need to be careful. Operations should not be rationed, and we want NICE guidelines in place to ensure that they are not.

I will address some of the points made by hon. Members. My hon. Friend the hon. Member for Wealden mentioned referral pathways. She is right to say that different CCGs do things differently. Some CCGs will require an optician to refer a patient to a GP, who then refers onward to the hospital or ophthalmologist; around 11% of CCGs do not do so, which is quite odd. I will ask officials to investigate why. The principle is that CCGs are responsible for setting their own pathways. It is not for the Government to tell them what to do, but it is possible—indeed, likely—that some might not have wholly addressed the issue.

There is a general drive right across the health service to do more things in the community and fewer things in hospitals. Part of that involves using opticians in the best way possible, and not just on this issue. Although it has not been mentioned in this debate, I would like to see opticians used much more for glaucoma monitoring and other such things that, at the moment, tend to happen in hospitals, because as we have heard, there is a great deal of strain on a number of hospitals. We will try to make progress on that issue. I am happy to sit down with my hon. Friend and the Royal National Institute of Blind People, as she asked, to talk about it in more detail.

My hon. Friend mentioned shared delivery plans. She said that only 50% of STPs include a coherent eye strategy, and the hon. Member for Burnley said that some of those looked like tick-box exercises. I accept that, and I have two points to make. One is that an STP is not an organisation but a planning document, which must be put in place to begin to establish planning areas across the country where we can marry up prevention, primary care and secondary care. Not all STPs have yet addressed all the issues that they should; they are a process, not an event. I say to the people concerned about that that they should keep lobbying their local STP leadership, who are responsible for addressing it. Frankly, many STPs have a long way to go to become coherent plans, and eye health is just one area on which we need to make more progress.

We heard about the issue of cancelled appointments. They are a particular problem with eye appointments, which can be time-critical; the figure of 20 avoidable sight losses a month was quoted. The principles governing missed appointments across the NHS apply in exactly the same way to eyes as they do to all other things. The NHS constitution sets out an 18-week limit. I have heard speakers in this debate mention clinics where 50% of appointments are not attended. Such numbers are completely unacceptable. What is hard to understand in that context is that in the last five years we have increased the number of consultant ophthalmologists across the patch by around 27%. That does not imply that the problem is staffing, but I will take the issue away and consider it. I reiterate that the same provisions that apply to all aspects of our NHS apply to eyes and to national waiting lists. People who fail to get appointments for which they are clinically ready should be on a national waiting list. We should performance manage it in that way.

My hon. Friend the Member for Wealden mentioned choice, rightly saying that people are entitled to choice in their secondary care. The same principle applies to eye care as to all other types of care, but there is more that we can and must do to build awareness.

I will touch briefly on the issue of an eye strategy. I have asked why NHS England feels that it is better for it to be owned and controlled locally; I made the point previously about the degree of local variation. We heard some instances from Northern Ireland, where there is an eye strategy, that show that it is not a panacea. As a Minister, I have a general view. There are a lot of strategies, but many fewer clear action plans with deliverables and accountabilities. It is rather like what we heard about in Great Grimsby. My preference is to work with NHS England and with Health Education England, if it is a question of getting more people into roles and all that goes with that. Having said that, I am happy, as I said, to talk to my hon. Friend the Member for Wealden and the RNIB more generally, but overall, across the health system, I do not see a lack of strategies. I sometimes see a lack of action plans with accountabilities and clear deliverables. My bias is towards the latter, not the former.

On the point about rationing, the NICE process is an attempt to create, across the whole health system, coherent guidelines and structured ways to evaluate different medicines. Broadly speaking, a cost of £20,000 per quality-adjusted life year is used by NICE to decide whether a drug should be offered or not. However, the point about the £20 million cap is slightly different. The cap is being introduced, potentially, for new drugs; it would not apply to any existing treatment. We are accelerating new drugs coming into the system. The cap would act as a trigger point: after £20 million has been spent, a renegotiation with the manufacturer would take place. On that point, I will sit down and allow my hon. Friend to sum up.

Cochlear Implantation

David Mowat Excerpts

Friday 24th March 2017 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) on securing this debate on such an important subject. Profound hearing loss is a major issue; the points he raised are substantial and I will address them. I also congratulate him on his work on the all-party group on deafness, and on raising awareness. I also want to offer congratulations in respect of the emailed stories that the hon. Gentleman used in his speech, and, in particular, I want to congratulate Diane Matthews on the petition, which also raises awareness of this important matter.

The hon. Gentleman has raised two substantive issues. One relates to NICE and the question of whether the BKB test and the threshold of 90 dB are appropriate, compared with what is used in other parts of the world. It is not for me to instruct NICE on what to do, but I will come back to the question of NICE guidance later. This is a particularly important piece of guidance because it is technical, which means that it is compulsory, unlike some NICE guidance, which is just for consideration. Therefore, it is important that we get this right.

The hon. Gentleman also talked about awareness among commissioners. He mentioned the action plan not being implemented as effectively as perhaps it should be, and I will say more about that as well. In doing so, I have been informed by, among other things, the extremely good paper that the Ear Foundation put out last October on improving access and by a paper written by Brian Lamb of the University of Derby about better assessments for cochlear implants. Both pieces of work were very good, and I would not have read them had I not needed to prepare for this debate. So we have achieved that, at least.

We know that around 700,000 adults in this country have severe or profound deafness, and that 80% are over retirement age. That demographic is increasing, so this issue is increasing, and, as I have said, it is important to get this right. We also know that between 370 and 400 children are born each year with profound deafness. This excellent technology can be a life-changer for children and for adults. The hon. Gentleman told us that, unless we get this right, employability can be affected. He mentioned the tax base, but this is important for all sorts of reasons. People’s mental health can be affected, and those with hearing loss are something like five times more likely to contract dementia than the rest of us. That is a sobering statistic. There is also an increased risk of isolation. As he said, all those factors lead to a greater reliance on our NHS and social care systems. That is set out in a number of papers. Indeed, a World Health Organisation paper went into great detail about it.

Let me describe our response to these points and our view on how the system ought to be working. Cochlear implants are commissioned by the specialised commissioning part of the NHS through 17 specialist centres across the country. There is effectively a two-tier approach involved. The clinical commissioning group should do a general assessment to identify the issue, then send the individual for further assessment involving the tests that the hon. Gentleman has described. If appropriate, they go on to get an implant, followed by the necessary rehabilitation and maintenance work.

Roughly speaking, we do between 1,100 and 1,200 of these implants every year in this country. That is split approximately 60:40 between adults and children. Those figures have been fairly static over the past five or six years. The NICE guidance that drives those figures was last done in 2009 and updated in 2011. As the hon. Gentleman said, however, the technology is moving quickly and we need to address the question of whether that guidance is still appropriate. He mentioned the action plan on hearing loss, which we introduced in 2015. It set out in some detail what best practice was and what action the CCGs should be following. They are the first point of contact for prevention, early diagnosis and patient-centred management. There is also a commissioning framework, which came out after the action plan. It set out a requirement for consistency and the removal of the inequalities of access that we have heard about today. It requires “clearly defined referral arrangements” that will provide

“timely access to cochlear devices when required”.

Of course, the devil is in the detail, and the words “when required” have led to some of the issues that we are discussing. Following on from that, we are currently working on a joint needs assessment toolkit and a “what works” guidance, with case studies that should help to increase awareness and knowledge of all this among commissioners at CCG level and more generally.

The problem that still exists, and the one we are really debating today, is that, in spite of all that, there is evidence of the technology being under-utilised despite its life-changing characteristics, particularly among the adult population. The hon. Gentleman talked about 5% of adults being able to benefit from the technology. My figure is 7%, but that is not something that we will quibble about. The uptake is much higher among children with profound hearing loss, with 74% of such children under the age of three and 94% of under-17s having an implant. That could lead us to think that commissioners do not always consider the technology as an appropriate solution when a retired or older person has profound hearing loss. In a sense, I suppose that is age discrimination.

As for international comparators, the Ear Foundation paper talked about the US, Germany and Australia as being stronger users of the technology than we are, which is true, but it is not clear that we are behind the field as badly as the paper may imply. I looked at some detailed numbers from across Europe, and we are stronger than Luxembourg, Belgium and others, but it is fair to say that we are probably in the third quartile, at best, so there is room for improvement.

The NICE guidance is the crux of the hon. Gentleman’s point and also what the Ear Foundation talked about. The first thing to say is that I do not tell NICE what to do. Politicians do not influence what is a technical, scientific evaluation. However, we understand that the guidance has not been updated since 2011. There have been a series of quite rapid changes to the technology, surgical procedures have improved, and there is more evidence of the technology’s cost-effectiveness.

I am pleased to say—the hon. Gentleman did not mention this, but it is a fact and nothing to do with anything that I have done—that NICE is currently reviewing the guidance, and that review is due to be completed in the summer of 2017. NICE will be considering all the new evidence, including the work of the Ear Foundation, the World Health Organisation and, indeed, Brian Lamb’s paper. I will also see to it that the issues raised in this debate, in both the hon. Gentleman’s remarks and my remarks, go to NICE as part of the process, so that it is under no illusion as to whether Parliament has considered the matter, and so that it knows that we are extremely keen that it comes to the right answer. It is for NICE to decide whether the BKB test is right and whether 75 kHz is the right measure. The good news for this debate is that that process is happening and is due to be completed in the summer.

On GP awareness, the hon. Gentleman mentioned the action plan, and there probably is an issue there. If we look at the figures for children and the figures for adults, we see that there may be a reluctance to commission the technology for older people just because it is not seen as one of the natural things to do if someone has lost their hearing in their 70s or 80s. There is no pressure from the Government for that to happen, and it should not happen. We work with Health Education England and others on GP training and similar matters. We will make sure that the fact that cochlear implants can make such a radical difference to people’s lives is emphasised with GPs as part of the process. In any event, when new NICE guidance comes out, particularly the technological guidance, which is compulsory, that is likely to create quite a lot of impetus for getting the knowledge out to the CCGs and specialist centres, and therefore to the people who have to make the decisions.

I finish by thanking the hon. Gentleman again for securing this important debate. I have not discussed deafness in this Chamber since I have been a Minister, so it is good that we have had the opportunity to do so. I hope that he finds my remarks encouraging.

Question put and agreed to.

NHS England: Mandate 2017-18

David Mowat Excerpts

Tuesday 21st March 2017 Written Statements

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I have laid before Parliament the Government’s mandate to NHS England for 2017-18, in accordance with the Health and Social Care Act 2012. This outlines our objectives for NHS England and sets direction for the NHS as a whole. It also confirms NHS England’s budget for the coming year, including a 1.4% real-terms increase.

NHS England is responsible for arranging the provision of health services in England. Building on the current multi-year mandate, which came into effect on 1 April 2016 and set long-term objectives and goals to 2020, the renewed mandate focuses on the same seven high-level objectives:

to improve local and national health outcomes, and reduce health inequalities, through better commissioning;

to help create the safest, highest quality health and care service;

to balance the NHS budget and improve efficiency and productivity;

to lead a step change in the NHS in preventing ill health and supporting people to live healthier lives;

to improve and maintain performance against core standards;

to improve out-of-hospital care; and

to support research, innovation and growth.

The mandate sets out the key annual deliverables in each area to achieve the 2020 goals.

The Government continue to support the NHS’s own five year forward view blueprint for transforming services to respond to the challenges of the future. The Government have committed to a £10 billion increase, over and above inflation, in NHS funding by 2020-21. In parallel, it is vital that the NHS delivers the productivity and efficiency gains set out in the five year forward view to live within its means and that NHS England ensures financial balance in the NHS, alongside NHS Improvement.

Core to the mandate is delivery of the NHS’s A&E turnaround plan to return the majority of trusts to the 95% standard by the end of the financial year. This will require close working with local authorities to reduce delayed discharges from hospital, following the Government’s injection of additional funding for social care in the spring Budget 2017; rolling out new models for urgent and emergency care to ensure patients receive care in the safest and most appropriate setting; and streamlining governance and oversight of A&E across NHS England and NHS Improvement.

The Government are investing more in mental health than ever before to support delivery of the ambitious goal, set out in the mandate, of 1 million more people with mental health conditions to access services by 2020. This includes embedding the first ever access and waiting times standards for talking therapies, eating disorders and early intervention in psychosis; and developing and implementing a five-year improvement plan for crisis and acute care.

The five year forward view set an ambitious vision for transforming out-of-hospital care for patients, including improving access to general practice; greater integration of primary, community and social care to provide personalised care for patients; rolling out new models of care across the population; and achieving early diagnosis, service and improved outcomes for cancer patients.

In the coming weeks, NHS England will set out its plan for delivering the five year forward view, which will summarise progress to date and set out a plan for future delivery, including the next stage of development for sustainability and transformation plan footprints and progress towards establishing accountable care organisations: 2017-18 should be the year in which we see concrete progress on these local sustainability and transformation plans, with NHS England supporting local leaders to drive improvement in outcomes. As part of this effort, the Government have already made £325 million of capital funding available for the best STPs over the next three years. In the autumn a further round of local proposals will be considered.

We are also laying before Parliament today a revised mandate for 2016-17 to take account of changes to NHS England’s budget, including for primary care transformation funding and the move to market rents by NHS Property Services.

Copies of the 2017-18 mandate and revised 2016-17 mandate can be viewed online as attachments at:

http://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2017-03-21/HCWS547/.

[HCWS547]

Oral Answers to Questions

David Mowat Excerpts

Tuesday 21st March 2017 Commons Chamber

[John Mc Nally (Falkirk) (SNP)]

3. What steps his Department is taking to ensure that clinical commissioning groups follow best practice commissioning policy on access to cough-assist machines for people with muscle-wasting conditions.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

Cough-assist machines are one of a variety of respiratory treatments that may be appropriate for sufferers of conditions such as motor neurone disease or muscular dystrophy. In the end, it is a matter of clinical judgment.

[John Mc Nally]

There are good examples of best practice cough-assist commissioning policies for muscle-wasting conditions that can be followed by health boards and CCGs. Given the hard work being done to extend the lives of those who suffer from muscular dystrophies, what support and assistance can the Department provide to Muscular Dystrophy UK to ensure that such policy is more widely adopted?

[David Mowat]

It is not for the Government to direct clinicians regarding the efficacy of particular treatments; it is for clinicians to decide, based on guidance from the National Institute for Health and Care Excellence and others. In developing its recent motor neurone disease guidance, NICE found that the evidence base for the routine use of cough-assist machines was weak. However, the matter is kept under review, so that may change as and if new data emerge.

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

4. What assessment he has made of the effectiveness of the export of procedures developed by NHS professionals.

--- Later in debate ---

[Anna Turley (Redcar) (Lab/Co-op)]

11. What steps his Department is taking to ensure that NHS England’s “General Practice Forward View” has the funding necessary to achieve its goals.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

“General Practice Forward View” announced that investment in general practice will increase from £9.6 billion in 2015-16 to more than £12 billion in 2020-21. This represents an increase of 14% in real terms, which is almost double the increase for the rest of the NHS. Two years into the forward view, we remain on track to deliver that.

[Anna Turley]

I appreciate the Minister’s response, but the reality on the ground in areas such as Redcar and Teesside is that we face a deficit of £281 million by 2020. How can he reassure my constituents, who are already finding it hard to get an appointment with a GP, that already scarce services will not become even more so?

[David Mowat]

We do recognise that in parts of the country there are shortages of GPs. As Members have heard, we are planning to have 5,000 more doctors working in general practice by 2020, and a proportion of those will be in Teesside. It is important that we meet that goal.

[Mr Steve Baker (Wycombe) (Con)]

GPs in Wycombe cite long hours, bureaucracy and the declining attractiveness of the partnership model as reasons why people do not want to be in general practice. Will the Minister ensure that funding within the forward view is directed to deal with those key problems?

[David Mowat]

Yes, and the contract discussions that we have just completed with the British Medical Association addressed a number of the issues that my hon. Friend talks about, in terms of the pressures on doctors working in general practice. We acknowledge that the workload pressures are enormous, and, through the contract, we need to do all that we can to mitigate them.

[Margaret Greenwood (Wirral West) (Lab)]

More than 80% of clinical appointments are carried out by GPs, but they receive a proportionately much lower level of funding. What steps will the Department of Health take to make sure that all sustainability and transformation plans abide by NHS England’s recommended allocation of funding to general practice?

[David Mowat]

One of the criteria by which STPs are being judged is the extent to which they are making this tilt from secondary into primary care, exactly as the hon. Lady suggests. That is precisely why the extra funding for primary care that I have set out is so important and why it is happening.

[Jo Churchill (Bury St Edmunds) (Con)]

“General Practice Forward View” talks about supporting general practice to improve digital technology for patients. Given the recent data challenges, does the Minister agree that putting a national data guardian on a statutory footing to protect patients and professionals is becoming an imperative?

[David Mowat]

I know that my hon. Friend has introduced a private Member’s Bill in this area, and the Government intend to support it.

[Kate Green (Stretford and Urmston) (Lab)]

The support that is provided to GP practices in relation to IT, information and so on is absolutely crucial to their effective operation, but problems continue today in my constituency with the service provided by Capita. Capita cannot, for example, now get prescribing certificates for locums and new GPs. When are the Government going to get a grip on this failing contract and, if Capita cannot perform adequately, get someone else to do it?

[David Mowat]

The hon. Lady is right. There have been issues with the Capita contract, and we have been let down by Capita. We are working hard to get that sorted, and my colleague the Under-Secretary of State for Health, my hon. Friend the Member for Oxford West and Abingdon (Nicola Blackwood), meets Capita weekly to get this fixed. We are making progress, and we believe that the issues that the hon. Lady refers to will be fixed in the foreseeable future.

[Mr Philip Hollobone (Kettering) (Con)]

There is a shortage of GPs across Northamptonshire, especially in Kettering, and the age profile of local GPs means that a very large number are about to reach retirement, which will make the problem worse. What can be done to encourage experienced GPs to stay on longer and to encourage those who have retired to come back?

[David Mowat]

My hon. Friend is absolutely right that one of the things we need to achieve is either to encourage older GPs to work part time or to make it easier for them to step down into more of a mentoring role. With the Royal College of General Practitioners, we have brought forward a scheme called GP Career Plus, which enables GPs in 10 pilot areas—the pilots are being rolled out now—to work as mentors across practice areas, and not to feel as though they have to retire, as GPs too frequently do at the moment.

[Dr Tania Mathias (Twickenham) (Con)]

12. Which hospitals providing congenital heart disease services do not meet the standard for the co-location of paediatric services; and what plans his Department has to stop providing congenital heart disease surgery at those hospitals.

--- Later in debate ---

[Rosie Cooper (West Lancashire) (Lab)]

14. What plans his Department has to increase the provision of social care for people with unmet needs.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

Social care continues to be a key priority for the Government. That is why local authorities in England will receive an uplift in the money available for social care over the next three years of 17% in cash terms. That significant uplift will allow councils to support more people and sustain a diverse care market.

[Rosie Cooper]

Does the Minister recognise that the figure he has just given—the additional £1 billion in the Budget—is just half of what is needed to fill the shortfall in social care? Will he tell the House what he is doing to ensure that the sector gets the additional money and to stop councils being bankrupted by their social care requirements?

[David Mowat]

The 17% cash uplift over the next three years exceeds what we have been asked for by a number of stakeholders in the sector. I have conceded at this Dispatch Box many times that the sector is under pressure. The additional moneys that we have come forward with will help to alleviate that and will make a big difference. In Lancashire, the figure is not 17% over three years; it is 18% over three years.

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

The Minister is quite right that central Government are providing extra money for essential care and allowing local councils to raise a precept on the council tax for social care. How will the Government ensure that councils actually spend that money on social care?

[David Mowat]

Much of the money will go through the better care fund and there is conditionality on that. We expect councils to spend this money, as they have requested it, on social care and we believe that that will be the case. We understand the pressures and have acted.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

But 1.2 million older people are living with unmet care needs. The £1 billion that was announced in the Budget for this year is not enough to prop up the failing care sector, when many councils are suffering contracts being handed back. Given that 1 million people over the age of 65 do not have adult children, will the Minister explain how all those people living with unmet care needs are meant to manage?

[David Mowat]

The figure on unmet care needs comes from an Age UK analysis. I am meeting Age UK to go through its recent report, but we do not accept that analysis because the Care Act 2014, which had cross-party support, set statutory consistent definitions for what care councils have to provide. It is illegal for that not to be met, and our follow-up work with the Local Government Association has indicated that it is being met. Furthermore, we have put in a 17% increase over the next three years.

[Rushanara Ali (Bethnal Green and Bow) (Lab)]

15. What recent assessment he has made of the Government’s effectiveness in tackling childhood obesity in the inner cities.

--- Later in debate ---

[Oliver Colvile (Plymouth, Sutton and Devonport) (Con)]

T8. As the Secretary of State knows, I am the vice-chairman of the all-party group on pharmacy. Will he update the House on the progress of the decriminalisation of dispensing errors by pharmacists? What is the hitch?

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

There is no hitch. The Government remain committed to putting this into place, and the legislation will be brought forward shortly.

--- Later in debate ---

[Matthew Pennycook (Greenwich and Woolwich) (Lab)]

Last week, to the distress of its vulnerable residents, Aldingham House care home in Blackheath became the latest care home in south-east London to close. Do the Government accept that the care home industry is at breaking point, and, if so, what are they doing about it?

[David Mowat]

The number of care home beds in the country has remained broadly constant at just over half a million over the last 10 years. There is variation and churn between areas, but I believe that the 17% cash-terms increase that we have injected into the social care market in the Budget, and the better care fund that is to come, will make a difference.

[Mrs Flick Drummond (Portsmouth South) (Con)]

I welcome the new nursing associates role that is currently being piloted. Will other areas, such as Portsmouth, be able to offer the same opportunities in the future, and will the new role be open to older people wishing to return to the workplace?

--- Later in debate ---

[Steve McCabe (Birmingham, Selly Oak) (Lab)]

I do not know if you spotted the rather topical news story about children’s dentistry this morning, Mr Speaker: there were 1,464 hospital admissions for children for teeth extractions across one clinical commissioning area of Birmingham last year, the highest figure since 2010-11. How does the Minister account for this, and what is he going to do about it?

[David Mowat]

The figures for child extractions are clearly disappointing and two key actions need to take place: less sugar, which we expect the soft drinks levy to help with; and getting more fluoride on to teeth, particularly through fluoride varnishing. That has increased across the NHS over the last year, and by 12% in Birmingham. We hope that that will make a difference.

[Dr Sarah Wollaston (Totnes) (Con)]

The NHS mandate was published yesterday, just days before coming into force. Can the Secretary of State set out the reason for the delay, because it allows very little time for scrutiny of this important document by this House? Will he also set out how he is going to prevent money being leached from mental health services and primary care to prop up provider deficits, so that we can meet objective 6 on improving community services?

GP Indemnity Costs: England

David Mowat Excerpts

Wednesday 15th March 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mr Turner, and I congratulate my hon. Friend the Member for Cheltenham (Alex Chalk) on bringing this really important subject to Westminster Hall this afternoon. The NHS spends between £1.5 billion and £2 billion a year on legal and indemnity costs. If we could find a way to spend that massive slug of money better, that would be better for patients and our constituents, and all that goes with that.

I will start where my hon. Friend started in his really lucid speech. We need to emphasise how much we value GPs, as all Members did who have spoken today. In a speech that I gave recently to GPs, I used a sentence from the foreword by Simon Stevens to the “General Practice Forward View”, and I will use it again now:

“There is no more important job”

in the country

“than that of the family doctor.”

I think that is very good—everybody is nodding, so I think we all agree. There is no harm in our reminding any family doctor who may be listening to this debate of the esteem in which they are held.

My hon. Friend the Member for Cheltenham made some interesting points about the potential for legal reform. We are consulting on that and I will say a bit more about what we are doing. I will give the House one statistic that stuck in my mind as I was preparing for this debate: for legal cases with awards of £10,000 or less, the average costs are three to four times higher than the actual amount paid to the patient. That is indicative of a broken system that we need to fix. He made a point about using the central scheme, which applies to hospital doctors, for GPs. That is an option, but as he also said, the three insurance organisations are non-profit-making, so it is not absolutely clear how it would help.

Another thing I was surprised about was an interesting point that my hon. Friend and, I think, the hon. Member for Burnley (Julie Cooper) made about the way in which costs are estimated for difficult and complex cases. We would all concede that it is right that we properly recompense people who have been damaged through negligence and so on, but one of the things that that is based on is private health insurance rates, not the NHS doing the work. I have discovered the reason for that: it is what was set out in the National Health Service Act 1948, which set up the NHS. We are looking at options around that, but the history of how that evolved and why it became the case is interesting.

[Mr Baker]

I am grateful for the opportunity to recommend an excellent book: “Working-Class Patients and the Medical Establishment”, by David G. Green, who now runs Civitas. It tells that history, and there are a great many similar examples where we might look at how we can reconnect the whole system with the patient.

--- Later in debate ---

[David Mowat]

I thank my hon. Friend for that intervention and for the interesting comments he made. He talked about the transfer of risk due to specialisation, which is an interesting concept. I will push back a little on that, however. Of the £50 billion of reserve that the NHS needs to hold for legal cases and compensation payments into the future, the vast majority is around maternity, because the money tends to be focused on babies who are injured and have to be supported throughout their life. I am not absolutely sure he is right about that concept.

My hon. Friend made a point about the status of partners in GP practices. Partners have unlimited liability unless they have indemnity, which potentially makes it less attractive to be a partner than a salaried GP. We are seeing that trend. There is a double edge to that, and I will not go into other aspects of how GP practices are structured, but increasingly—I do not know whether this applies to my hon. Friend’s wife—we are finding that things are working better with GP practices being put into hubs of 35,000 to 40,000 people. They are able to employ pharmacists and physios and do more things at scale than they could as a single GP practice or as a practice of two or three GPs, which has historically been the norm.

We are migrating over time from a position where we have 7,500 GP practices to one with something more like 1,500 super-hubs, but it is true to say that the contract position has not caught up with that, and it is a long road. Tomorrow, I am going to visit a hub in Dudley. Super-practices are emerging, which have tens and possibly hundreds of GPs who can provide services across much wider areas. That is a different model, and there is some evidence that such hubs can provide more career structure for GPs and the opportunity to specialise in a way that they have not been able to in the past.

[Mr Baker]

I must admit that I missed the Government’s plans to move to super-hubs. It sounds quite suitable for Wycombe. Without wishing to make this debate about my wife, she is with the Ministry of Defence. At the moment, the MOD is providing healthcare to units or stations, or whatever bases they may be. How would the super-hub proposal work with the armed forces?

[David Mowat]

I had forgotten to talk about MOD locums. My hon. Friend raised that issue, and I do not know the answer, but I will write to him and give him the information he needs, and he can talk to his wife about that. I was surprised by that example. I am sure that between the various parts of the Government, we can get an answer.

In the hour available to me, I will discuss in more detail the environment in which the NHS finds itself, the impact and the Government actions we are taking, but I will start with this: we all want access to justice. That is a fundamental of our country, and we should do or say nothing that causes people who have been badly treated to lose out. Lawyers have to be part of how they get access to justice, and that is right, but we also need to protect the viability of our NHS.

We are spending towards £2 billion a year in this area. That is £2 billion a year that we are not spending on nurses, doctors and the improvements we would all like to see. We often have debates about the level of NHS spend compared with other countries in Europe and different parts of the world, but one area in which we can say we are a leader in Europe is the amount of money we spend on litigation and all that goes with that. That is not because our NHS is less safe than other systems; it is to do with some of the points that were made earlier about the litigation culture that has built up. To an extent, that has been encouraged to build up because of our treatment of costs and some of those things. That spend of £1.5 billion to £2 billion has been increasing by something like 20% a year in the past three or four years. We cannot afford to continue to spend money in that way.

GPs are not the most expensive part of the system, but as my hon. Friend the Member for Cheltenham said, GPs typically have to spend £7,900 out of their own pocket on indemnity. That figure is increasing by 10% a year. Indemnity costs for GPs who do out-of-hours work are increasing by 20% a year, which has knock-on effects for the attractiveness of that work. As we discussed earlier, it also impacts on people in other ways, such as propensity not to become partners in GP practices.

What has made the acceleration in legal costs evident is not so much the major claims that everyone would agree need to be sorted out and dealt with—for example, babies who are damaged at birth and need to be looked after for their entire life—but the significant increase in the number of minor claims, which tend to have a higher proportion of associated legal costs. As I said, claims of around £10,000 would typically have legal costs in excess of three times the amount that the patient would receive. My hon. Friend the Member for Cheltenham said that many claims are successfully defended, and the fact is that 99% of all claims are settled out of court. There can be a tendency to settle minor claims for relatively small amounts—claims under £100,000—just because of the volume that are coming in and because it is cheaper to settle than fight to the end. All of that takes money out of our NHS.

We have talked a little bit about why this is happening. The life expectancy of people with complex needs is increasing, so if someone is damaged at birth, typically the awards they need go on for much longer than in the past. That is a good thing in terms of life expectancy, but it drives cost. There is a view that the best-quality care becomes more expensive. Technology is a part of that. We also have an environment in which, for whatever reason, there has been an explosion in small claims against the NHS, which particularly affects GPs, and there is a legal environment in which even unsuccessful claims or claims without merit can sometimes be rewarded. All of that is made worse, as we have heard, by the change to the discount rate made by the Lord Chancellor, which will come into effect next week on 20 March.

The time value of money essentially was 2.5% and is now going to be -0.75%. That will have a significant impact on all insurers in the private and public sectors. It particularly affects the health sector. The £59 billion reserve that the NHS has for central litigation costs will increase because of the change that has been made by something in excess of £5 billion or £6 billion. Those are significant and serious sums of money in the public purse. The Government’s position is that doctors will not have to pay as a consequence of the technical change in discount rate. We are working through how that will work in the central litigation authority and the three insurance companies that my hon. Friend the Member for Cheltenham mentioned. Nevertheless, the cost is significant in the context of all the other pressures on the health system.

A couple of Members talked about the fact that the issue affects not only doctors in primary care but pharmacists. Increasingly, clinical or prescribing pharmacists are working in primary care and they need indemnity, as do nurse practitioners. We need to remember that that is all part of the picture.

[Julie Cooper]

On that point, is the Minister prepared to acknowledge that professional indemnity is a significant burden for community pharmacists? That is something he might want to consider before going ahead with his funding cuts.

[David Mowat]

I will not be dragged into the issue of community pharmacists other than to say they are extremely valued and have a major part to play as we integrate them with the clinical pharmacists working in GP practices. I will simply say, since the hon. Lady has raised it, the Government are committed to getting community pharmacists to move into a much more service-oriented way of working. We will not do that by overpaying for prescribing or by acknowledging or encouraging clustering, which is what the reforms we have talked about will address.

So what are the Government doing? First and foremost, we need to continue the drive to improve standards and quality in the NHS. I made the point earlier that accidents happen and negligence takes place. When it happens, we need to learn from it and ensure that there is a duty of candour within the service. Doctors and nurses need to do what they can to make sure that the systems failure or breakdown that occurred does not happen again. To use a rather trite management consultancy-type phrase, the NHS needs to become a learning culture. It is true, however, that people need to learn from errors and continually try to improve standards. We need to avoid errors as much as possible, but at the same time we cannot have the medical profession being overly defensive, because that is not the right answer either.

My hon. Friend the Member for Cheltenham discussed what we have done so far in the “General Practice Forward View” to protect GPs from the rising costs of indemnity. Some £30 million a year is being paid out for the year just gone. There is a clear commitment in the forward view. The increases in indemnity costs, which are not a consequence of GP actions or failures or whatever, will be indemnified by the Government. I repeat that again today. I have already made the point about specialist nurses and pharmacists.

We are trying to make progress on the law and address the level of costs awarded in some cases. The 12-week consultation on fixed recoverable costs began on 30 January this year. In the case of smaller claims, proposals include a cap on solicitors’ fees and on the hourly rate for expert witnesses and locums. It is also proposed that both sides share a single joint expert witness, because it is not always sensible to have two expert witnesses arguing with each other: it is possible to do that in a more effective way. The direct aim of the consultation is to reduce the ratio of the amount of money that the patient gets to the amount of money that the lawyer gets, particularly in the lower-value cases. The Government look forward to the results of the consultation and we hope we can move forward.

Another aim—this applies less to GPs, but is also very important—is to do what we can to keep cases out of court altogether by means of the rapid resolution and redress scheme. I have talked a little about maternity cases, but because of the level of the costs and the complexity of the case it can take many years for payments to start being made. That is not right because, from a justice point of view, the baby or the baby’s family needs the money more quickly. It can sometimes takes nine, 10 or 11 years until the legal side is sorted out, and that is not just.

We began a consultation on the rapid resolution and redress scheme in October last year. The scheme tries to keep the whole thing out of court by attempting through mediation and working together to come up with a sensible and fair solution much quicker so that the 11 and 10-year court cases are avoided. We will try and make progress on that. We have not talked about tort reform. The Government are not currently working on that in respect of indemnity, although that was implied in some of the remarks that my hon. Friend the Member for Cheltenham made.

I will finish where I began. Indemnity is a very important area for the NHS. We are spending towards £2 billion a year. That cost is accelerating and will potentially undermine the level of care that we can give. We need to do what we can to moderate costs.

[Alex Chalk]

I am encouraged to hear that some important initiatives and measures are being considered. Can my hon. Friend give us any idea of the timescale as to when an overall final outcome and settlement, or solution, is likely to be presented?

[David Mowat]

The two consultations will take 12 weeks. In a sense, my hon. Friend’s question is false. I do not think there will ever be a final solution because we are trying to reconcile two powerful forces: the need for access to justice and equity for people damaged through negligence and the need to be fair to our NHS. There will always be issues that evolve. The discount rate, for example, which we have talked about during the debate, will vary depending on where interest rates move in the months ahead.

We are talking about something that will always have to be kept under review. There will not be a final solution, but the two consultations that I mentioned will make a material difference and I am keen that we should make progress on them as soon as we are able to.

[Heidi Allen (South Cambridgeshire) (Con)]

I appreciate the Minister’s giving way, particularly as I was late arriving for the debate, and so may have missed some key points. Building on the point made by my hon. Friend the Member for Cheltenham (Alex Chalk), of course I welcome the Government’s interventions, the consultation, the winter scheme and extra money for GPs to cope with inflationary pressures. The problem is that the costs are already so high.

Addenbrooke’s hospital in my constituency is losing trainee doctors, who are put off by the cost. Older doctors are retiring early. Doctors are thinking twice about going into specialisms because there is perhaps a higher associated risk. Is there nothing else that we can do? Hospitals have Crown indemnity. Could we consider that for GPs? Could we extend it to them, as an alternative idea?

[David Mowat]

Those are all fair points, but in the GP forward view we have said that GPs will not bear the cost of increased indemnity—the Government will; and that is a commitment that we are holding to. The increased costs incurred last year are being paid through the GP contract, following the discussions that we have had with the BMA, and the cost of that to the Government for this year is £33 million. That is a commitment that will go into the future.

However, my hon. Friend the Member for South Cambridgeshire (Heidi Allen) makes a fair point that in a country with a shortage of GPs, where we are trying to recruit a further 5,000 doctors to work in general practice by 2020, we need to make the profession attractive. We are trying to do that, and there are different ways to do it. Indemnity is just part of it. To answer her point, I would say that this year the number of medical students going into GP training is the highest ever achieved. Something over 3,000 are going into the training, and we need them all. I responded to a debate here yesterday about a shortage of GPs in Essex. Frankly there are shortages everywhere; we understand that.

In a sense, I share the frustration of my hon. Friends the Members for South Cambridgeshire and for Cheltenham and the feeling “Why can’t we just fix this?” The answer is that there are legal rights that we cannot just take away; we cannot say that it will just not be possible to sue the NHS in future. That is not the system in the country that we live in. However, we need to do moderate, sensible things to bear down on costs, so that we spend a greater proportion of NHS money on doctors than on lawyers. All of us in the Chamber would agree on that.

Primary Care: North Essex

David Mowat Excerpts

Tuesday 14th March 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. I congratulate the hon. Member for Clacton (Mr Carswell) both on obtaining the debate and on the lucid way he put forward his case. I thank my hon. Friends the Members for Colchester (Will Quince) and for Harwich and North Essex (Mr Jenkin) for their points, which I will try to answer.

There is an issue with the number of GPs in the CCG in that part of north Essex. I will talk a little about why that is the case and what we can do about it. It is very hard to make progress on a number of the issues that were raised without fixing that problem. We are short of GPs across the country, but we are particularly short in the North East Essex CCG. Let me give some numbers for context. There are 40 GP practices and a little over 210 GPs within the CCG, which covers 330,000 people. The CCG estimates that it is 28 GPs short. I spoke to it this afternoon, and I was told that if any GP wants to get a job in Clacton, it will not be a difficult process. Indeed, the figures for Clacton and the coast are marginally worse than those I have just given.

That is somewhat mitigated by the fact that the CCG has more nurses than the UK average. That might well be to do with the walk-in centres and minor injury units, which are nurse-orientated. I will come on to talk about how we can work in a slightly different way—this was implied by the remarks of the hon. Member for Clacton—by making use of other disciplines, such as pharmacists, physios, allied health professionals of different sorts and mental health professionals. The CCG now has 10 full-time pharmacists, and there is a plan to increase that number considerably between now and 2020. Frankly, it is easier to recruit pharmacists than GPs, but we need GPs too.

I will spend a little time talking about the reasons for that. I spoke to the CCG about them in some detail today. As the hon. Gentleman mentioned, Clacton has an older population, which causes problems, and there may be contractual issues relating to that, although the GP contract allows extra money for areas of deprivation and those with ageing populations. There are no training GP practices in Clacton, which puts it at a disadvantage, as GPs are likely less to go there as part of their training and then stay. It is also true that Clacton has a higher than average age demographic of GPs, so there is a higher tendency for them to retire, which exacerbates the situation. I concede that there is a problem, and I will talk about some of the things being doing about it. The hon. Gentleman used the phrase “jam tomorrow”, and I am afraid that some of it might sound a bit like that.

I want to draw attention to some of the things that the CCG in north Essex does well. We often talk about issues to do with locations—bricks and mortar—whether minor injury units or hospitals, but all MPs, including me, should properly evaluate our CCGs on the full set of published metrics. We have done an awful lot on transparency. I will just mention some of the things that the CCG does well. The hon. Gentleman’s CCG is well above the national average for cancer diagnosis in stage 1, for dementia care planning, for organising health checks for patients with learning disabilities, and for organising care packages for people with mental health episodes. I say that to put its issues in context. It is clearly true that there are difficulties with access and, to a lesser extent, with getting on lists in the first place.

The hon. Gentleman rightly made the point that we should be following the patient. We do a lot of work across the NHS and with every CCG to poll patients to ascertain how satisfied they are with the level of service they have received. North East Essex CCG received something like 82% patient satisfaction—lower than the national average. It is thought that the figures for Clacton are likely to be lower than the CCG average as a whole, so I will not hide behind that number.

In terms of what we are going to do about it, I will start by talking about some national initiatives—the comment about STPs related to that—and the need to invest more in primary care. There are two national initiatives that I want to mention. First, there is the GP five-year forward view. I know it sounds like jargon, but it redresses the persistent underinvestment in primary care over the past decade or so. Between now and 2020, there will be a 14% real increase in primary care across the country, which will manifest itself in the workforce and in different ways of working. That is real money; it is accepted by the British Medical Association’s general practitioners committee. It is very welcome, and frankly it has been a long time coming.

If we were designing an NHS today, with the sort of patient environment we have now, we would not design it around acute hospitals, as was done in 1948. We would design it much more around long-term conditions—diabetes, dementia, heart disease and so forth—which account for 70% of the NHS’s total cost and mean that much more can be done in the community. That is our very clear direction of travel.

[Will Quince]

Although I very much welcome those plans and the steps the Minister is hoping to take in relation to primary care, there is still very serious pressure on Colchester general hospital. I welcome last week’s Budget announcement of £100 million for triage services in accident and emergency units. Will the Minister give serious consideration to making Colchester general hospital a pilot for that, which would help to alleviate some of that pressure?

[David Mowat]

My hon. Friend may be relieved to hear that Colchester general hospital is not in my portfolio, but I will speak to my ministerial colleagues about it being a pilot and write to him.

[Mr Jenkin]

A moment ago the Minister mentioned some extra money for primary care. Who is responsible for investing that money? Does it come from NHS England and not from the CCG? How do we influence how that money is spent, so that there is some accountability in the process?

[David Mowat]

All money goes into the health service through NHS England, which used to be called the NHS Commissioning Board. The money is then given to the CCGs around the country to spend. In terms of a funding formula and so on, there are some specific primary care initiatives, including infrastructure-based ones for new premises and things of that type, and specific ones, which I am about to talk about, such as recruiting more GPs. We absolutely need more GPs, not only in Essex but across the country, although we do need them in particular in parts of Essex. The responsibility for that lies with NHS England, through the CCG. It is the CCG that has the accountability—to answer the earlier question, “Who do we blame for this situation?”—and I want to make that quite clear.

As for what all that means, we have workforce issues in primary care, and the Government and NHS England are committed to having 5,000 more doctors working in primary care by 2020, which should mean more availability and vacant jobs in Clacton being filled. We are determined to meet that commitment with progress made this year, with more medical students going into GP training than has ever been the case before in the history of the NHS—just over 3,000 of them. The hon. Member for Clacton was right to talk about pharmacists, and we also need to make progress with them. We aim to have 2,000 pharmacists working in primary care by 2020, as well as 3,000 mental health therapists.

All of that matters, but in addition we have to allow people to work in a different way from how they have up to now, and some of that is happening across the CCG in Essex. Broadly speaking, however, we find that a GP hub of 30,000 to 40,000 patients enables more scale. That would let us employ physios, pharmacists, mental health therapists and, indeed, social workers—in terms of the relationship with hospitals and the transfer of patients—and to have longer opening hours. I therefore completely accept the hon. Gentleman’s points about working and being open on a Saturday. We are determined to achieve that by 2020, although we are starting from a difficult position in Essex, given the lack of GPs generally. Only by collaboration and working across practices will we make progress. The model of a single GP practice—and such practices still exist—is self-evidently not viable and does not allow us to do some of the things that we need to in primary care, such as employing pharmacists and other such disciplines.

Those are my general comments, but I completely agree that unless all that lands in Essex, it is just words. Judge and jury on it will be the extent to which we are successful in landing some of that stuff in Essex. To address the specific issues, I will now talk about a number of things that have gone on in the hon. Gentleman’s local CCG. Of the nine practices in Clacton, a number have been closed to new patients, as he said. I am informed that the East Lynne practice, the Ranworth practice and the St James practice all closed to new patients in 2015, but two of those are now completely opened. The other has temporarily closed again but is expected to reopen soon. On the statistic he cited at the start, my understanding is that only one practice in Clacton now has no immediate opening in its list. The CCG has worked hard on that.

There are clearly specific issues with getting people with a GP background to move into the area. The CCG has put in place a workforce plan to address matters of recruitment and retention of GPs principally, but also of pharmacists, nurses and allied health professionals. Again, the judging of that will be in something actually happening and the vacancies in Clacton being filled. The plan exists and is being managed, and I understand that the CCG expects to make progress with it.

The practices in the CCG have come together in three collaborative groups, covering about 80% of the total number of patients seen, although the patient who sees the same GPs from the same practice and goes to the same clinic might not realise that. GPs are working collaboratively in a way that should enable better leverage of their time—I return to that point made in connection with pharmacists. We have to get away from every patient’s principal contact in the primary care system having to be a GP, rather than other professionals who could help a great deal. For example, I was recently in a practice where a pharmacist was conducting a diabetes clinic. Diabetes clinics are routine, happening perhaps every month or so, with a set of standard questions to be asked, and there is absolutely no reason why they need to be conducted by a GP, as opposed to a pharmacist. That applies in Essex, too.

I draw the attention of hon. Members from Essex to a couple of grants lately given to practices in their area. A £46,000 resilience funding grant has gone to the Clacton GP Alliance and, in a specific effort, almost £400,000 of capital funding to three GP practices that are coming together I think in Clacton hospital. The CCG understands that the standard of premises and infrastructure in Clacton is generally weaker than in other parts of the country—certainly weaker than is needed to attract the sort of talent necessary.

I have a “jam tomorrow” point to make, but it is worth putting it on the record. There is a plan to have a medical school in Essex, in Chelmsford, I think in 2018. That will obviously help, because people who train as doctors in that part of Essex will be more likely to live there, enjoy living there and, in time, make their careers and lives there. We have found that to be so in other parts of the country; I hope it works for Essex.

In connection with the minor injuries and walk-in centres, I want to speak briefly about the consultation. Members have pointed out that it would be absolutely ridiculous if, by closing those centres or doing anything to affect patient flows, more patients were to go to Colchester hospital. That is self-evidently true, and the CCG believes so too. Interested Members will know that the consultation, which set out four options, has received more than 3,500 replies. In all fairness, I do not believe that the CCG was consulting in order to close; it was consulting because contracts were up, and it wanted to look at the options and how to do better. One view given to me was it was more confusing than it ought to be for patients to know where they ought to be.

I cannot say anything today about the outcome of the consultation, other than that the CCG board will consider the recommendations received in the 3,500 responses and the various other pressures that have been discussed today. Frankly, people in the CCG will also be listening to our debate today. I would be surprised if closure of the centres was top of the list, given the other pressures on GP practices, the hospital and so on. The decision will be made by the CCG at the board meeting on 30 May.

I will finish as I started, by saying that there is a problem with the number of GPs in Clacton and North Essex. The problem is understood and action is being taken that I hope does not all amount to “jam tomorrow”, to use the phrase of the hon. Member for Clacton. Although progress has been made in getting lists open and so on, clearly a lot more needs to be done. I am happy to continue to meet the hon. Gentleman in the months ahead if we are not making progress and getting things better.

Question put and agreed to.

Social Care (Liverpool)

David Mowat Excerpts

Tuesday 7th March 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

I thank all those who have spoken in the debate. This is a serious subject, and we have had a number of serious contributions. I will answer some of the points that have been made, before talking more generally about the Government’s approach to adult social care, both now and for the remainder of this Parliament.

I congratulate the hon. Member for Liverpool, Riverside (Mrs Ellman) on bringing this debate to the Chamber, because this subject matters. If there is one thing on which we can all agree, on both sides of the political divide, it is that the whole care agenda is very important to very large numbers of people. The care industry employs more people than the NHS: it employs 1.5 million people. As the hon. Member for Worsley and Eccles South (Barbara Keeley) said, many of them are not well paid. I think she said that some of them do not get the minimum wage. If she has evidence of that, she needs to come forward with it and we need to prosecute, because that is illegal.

However, it is right to say that 1.5 million people work in social care—more than in the NHS—and that number will grow over the next decade or two decades. Depending on how he gets on in the forthcoming election, the hon. Member for Liverpool, Walton (Steve Rotheram) may find that his responsibility in that regard is increased greatly. As well as those 1.5 million people, to whom we should all be grateful—I do not think I could do that work very well—6 million people across our country give informal care. Of those, some 300,000 are aged under 18. It is estimated that one in 30 people in schools are giving informal care to an adult or sibling. We should all reflect on that, because that number will also increase over the next decade or so.

A number of Members have made the point that the precept raises less in Liverpool than it does in Surrey. The hon. Gentleman said that many more houses are in council tax bands A or B, and the consequence is that the precept will raise less. That is self-evidently true, and the Government accept that. That is why the way in which the improved better care fund is and will be allocated to councils takes into account the moneys that are available from the precept, so that the total is in accordance with the relative needs formula.

There is one thing I want to get absolutely straight. I do not want to spend the next 18 minutes bandying numbers around, and I am happy to write to all the Members here about the numbers that I am about to give. The hon. Member for Liverpool, Riverside correctly said that the Liverpool spend on social care was £154 million in 2015, and she said that it is budgeted to be £130 million by 2020. I think those were the numbers she used. The number that we have in cash terms—I will write to Members with this—is £194 million by 2020. That is a real-terms increase of 18% between now and 2020. I have spent quite a long time with officials today to make sure that those numbers are correct. The amount that Liverpool City Council will receive from the improved better care fund in 2019-20 is £26 million. That dwarfs the amount that the precept will raise.

[Barbara Keeley]

The Minister said that he does not want to keep on bandying figures about, but as we all know, the difficulty is that the funding that he and the Government keep talking about is back-loaded. The problem is happening now—5,000 people have lost their care packages now, and the problem has been happening since 2010. It is not helpful, in this totally stressed situation, to talk about money in 2019-20.

[David Mowat]

I was just making the point that the figure the hon. Member for Liverpool, Riverside used was £130 million and the figure I have is £194 million. I accept that that number is not for today, and I also accept, as I have said many times in the Chamber, that the social care system is under pressure throughout the country, and Liverpool is part of that.

[Steve Rotheram]

I am trying to be helpful to the Minister. I quoted a former director of adult social care in Liverpool, Samih Kalakeche, who said:

“If we don’t do something within the next six months, I believe social services will not exist”

by the time that the Minister believes we will get the additional funding.

[David Mowat]

Today is not Budget day. I accept that the systems are under pressure. The precept has raised something, and Liverpool’s budget for social care is increasing next year, but it is fair to ask whether it is increasing enough given the pressures we are under—that is a reasonable point. My point about the £194 million figure was in response what was said earlier. Although I and the Government accept that there are pressures, it is important that we share accurate numbers with each other.

The hon. Member for Liverpool, Riverside also made the good point that there is now an increasing tendency for care to be provided in people’s own homes. If we look at the care home market over the past decade, we see that roughly speaking there are the same number of beds today as there were 10 years ago, and that is clearly in the face of a considerable increase in demand. That is because far more people are now being looked after through domiciliary packages in their own home, and that is the market we need to get right and make effective.

The hon. Member for Garston and Halewood (Maria Eagle) raised the potential issue of councils being punished in the Budget for being efficient. I will be very disappointed if that is the case—it is not my understanding of what will happen—but it is a fair challenge, and we will have to see about that when the Budget comes out.

The hon. Lady raised a number of points about the STP. We all share the STP area, and there is work to do on it. I will make this point, however: she talked about cuts of £908 million, but those are cuts against an increase in demand—they call it the counterfactual—of 4% or 5% over the next period. The truth is that Cheshire and Merseyside will be getting real-terms increases in funding for every year up to 2020. Nevertheless, that does not mean that there are not challenges, for some of the reasons we have heard, such as demographics and all that goes with that.

The hon. Member for Liverpool, Wavertree (Luciana Berger) asked for a glimmer of light and hope; hopefully, between myself and the Chancellor tomorrow, we can achieve that. She also raised the cases of Sobia and Veronica and their care packages. It is difficult for me to respond to that, other than to say that the Care Act 2014 set out statutory requirements for what councils need to do. If those statutory requirements are not being met, and the way she described those cases implied that might be the case, that is clearly against the law and there is recourse either to the local authority itself or to the ombudsman. I would be happy to talk to her about that in more detail.

The hon. Member for Liverpool, Walton made a number of points and started by talking about delayed transfers of care. He rightly said that I have talked on a number of occasions about variations between councils in delayed transfer of care performance. I will say that DTOC is not the only measure of the effectiveness of a social care system; it just happens to be one the easier ones that we can get a metric around. The fact is that if we look at the 10% worst and the 10% best councils in the country—Liverpool is round about the middle—the level of delayed transfers differs by a factor of around 20 or 30. I absolutely concede that social care systems work better with more money, but it is not just about money, because that is about different working practices and different people doing things in different ways. It is right that we have the debate about that, as well as about the need for more money.

The hon. Gentleman challenged me to name some councils that were much better than Liverpool in terms of delayed transfer of care, within a similar budget environment. I do not know what the budget environment is, but I have a list I can give him of councils that have fewer delayed transfers of care. As I said, Liverpool is not a particularly bad council, and I do not want to imply that it is, but Durham, Kirklees, Sunderland, Barnsley, Newcastle-upon-Tyne and St Helens all have at least 10 times less delayed transfers of care than Liverpool. I was taken to task at a recent Conservative councillors meeting, in which people said that having a good social services department is not just about delayed transfer of care; it is to do with a whole lot of other things. I absolutely accept that, but in a sense the hon. Gentleman started it, so I wanted to give him those figures.

[Steve Rotheram]

Will the Minister therefore pay tribute to Liverpool for what it has done and its innovative approach? My question was about councils that have had similar cuts to Liverpool of around 60%. None of the councils that he mentioned has had the same degree of cuts as Liverpool City Council.

[David Mowat]

The hon. Gentleman mentioned some councils that were in the south and I picked some that were not, but fair enough—I accept his point. He mentioned that, depending on the result of his election, he would have a summit. I would be delighted to attend, if he were to invite me—although who knows where I will be by then.

[Steve Rotheram]

It’s only in May!

[David Mowat]

Indeed. On Thursday, I am going to Liverpool to give a talk at a care conference. I would be very happy during that visit to come along and talk to the council about some of the issues raised here today. As the hon. Gentleman rightly said, I am sure that the Government can learn from Liverpool. Frankly, we can all learn from each other. When I went to Whiston hospital and saw discharges to St Helens and to Liverpool, I saw some wonderful things happening there. Anyway, the offer stands.

[Maria Eagle]

I am sure that all councils in Merseyside would be happy—I know that Knowsley would—to see the Minister on Thursday if he has a bit of spare time. Does he agree that it will be a bit of a blow if the Chancellor’s reported actions tomorrow reward those with a poorer record with smaller cuts to their resources than Knowsley’s? Knowsley has a good record on delayed discharges, but according to the formulation listed in some of today’s newspapers, it will end up getting very little, if anything.

[David Mowat]

I thought that I had said that I agree with the hon. Lady that it would be wrong to punish those that are doing better. She mentioned that Knowsley is one of the stronger councils in that regard; St Helens is even stronger. It would be completely wrong if that were the basis of the allocation. Frankly, that is not my understanding.

I want to talk a little about what the Government plan to do on social care. Part of that involves recognising the pressures that exist. One thing that we get into quickly in social care discussions is a debate about adult social care and frail people—people on the borderline between being ill and being old. If they are ill, they are in hospital under the NHS, and if they are not, they are old, and care is either means-tested or provided by the council. That is a difficult area.

One third of the pressure on councils such as Liverpool arises not from older people but from people with severe learning difficulties, autism and disabilities more generally. Over the past decade, thankfully, the health inequality from which that cohort suffers has decreased considerably, and the life expectancy of people in those categories has increased. The cost to local authorities is clearly severe. In addition, the Government are determined to press ahead with a programme called Transforming Care, which came out of the Winterbourne View case. Too many people with severe learning difficulties were in institutions and long-term hospitals, with all that goes with that. We are moving them into communities with the help of local authorities. There is a plan to move some 3,000 people out of institutions—places hopefully much better than Winterbourne View—and into care. All of that creates pressures of the sort that we have been hearing about in this debate, but that does not mean that it is not the right thing to do.

[Luciana Berger]

Does the Minister acknowledge that those 3,000-plus people should have been moved a lot sooner? According to various reviews, we should not be in the present situation, with too many people still in that type of accommodation who should not be there.

[David Mowat]

That is a fair challenge. We have a plan, and we are implementing it in that process. Winterbourne View was about seven years ago now. I have met a number of parents of the children affected and there has been a lot of pressure from them to go as far and as fast as we can. I make the point that every one of those facilities is a project of its own in terms of finding other accommodation and putting in place care—sometimes round-the-clock care. To answer the hon. Lady’s question directly, I would like us to go faster, but I think that we are doing as well as could be expected given the starting point. However, it is a fair challenge.

[Barbara Keeley]

I do not know whether the Minister watched last week’s Channel 4 “Dispatches”, “Under Lock and Key”, which showed some serious cases of young people who were not better off in their institution, a private hospital. It seemed very difficult to get them moved out into the community. I know that it was a different part of the country, but there were young people in that institution from across the country. It is great to have a plan, but we see programmes week in and week out showing failures, as I have highlighted.

[Mr Philip Hollobone (in the Chair)]

In responding to the intervention, the Minister needs to make his last point.

[David Mowat]

Mr Hollobone, are we finishing at 6.18?

[Mr Philip Hollobone (in the Chair)]

You have until 6.15.

[David Mowat]

I beg your pardon. I will finish at 6.15.

I saw the programme, and it gave us great food for thought. It is a Government priority to get those people moved. We have done some 1,500, but yes, there are 3,000 left in places like the one in Northampton, and it is not good enough. It is a long process, and it is not something that any of us from either side of the House can do just by clicking our fingers.

I will now sit down. This has been a good debate. I will write to all Members here with the figures that I have given, because the figures are right. It is fair to have this discussion, but it must be had on the basis of correct numbers. Even with those correct numbers, I accept that some of the pressures that we have heard about exist.

Young-onset Parkinson’s Disease

David Mowat Excerpts

Monday 6th March 2017 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

Let me start by congratulating the hon. Member for Torfaen (Nick Thomas-Symonds) on his speech, which the former Minister, my hon. Friend the Member for North Swindon (Justin Tomlinson), called an important one. It is just that, as this is an important subject. It is salutary to think that it is 200 years since this terrible disease was first discovered and we are still some way off finding a cure for it. I know that over the past year or so the hon. Gentleman has asked many questions in Parliament, both written and oral, on this subject. I congratulate him on doing that, because it is only by people doing that that we will continue to keep awareness high.

I also thank the hon. Member for Bridgend (Mrs Moon) for the work she does on the all-party group and for demonstrating the kinetic watch. I had not seen one before this evening, but I look forward to seeing it perhaps after this sitting.

[Mrs Moon]

I met people from Global Kinetic on Friday, when they gave me the watch. In September or October, this watch will also have a docking station, which will mean that on a daily basis the consultant neurologist will be able to get a pattern of sleep, movement and medication consumption from a patient. We hope that will cut the need for neurologist appointments, as is happening in some areas, and I hope that the Minister will want to meet Global Kinetics.

[David Mowat]

Indeed. I am sure other brands are available—

[Mrs Moon]

No, they are not.

[David Mowat]

Well, as I was saying a few moments ago, there is no cure for this disease but it is possible to manage the symptoms and alleviate them. However, to do that we have to have a diagnosis, and that is the issue we are talking about today, particularly in the case of early-onset Parkinson’s disease.

On the prevalence of the disease, something like 130,000 people suffer from it—that is likely to be 160,000 by 2020—and 95% of them are over 60 years old. Because of that fact, there is a tendency in the medical profession and, indeed, in society at large, to think that it is a disease of older people. To an extent that is true according to the statistics, but we also know that something like 5,000 or 6,000 people under 50 have the disease. I will talk about the statistics a little more later, because the hon. Member for Torfaen did challenge them, and it is true that the numbers are all estimates. Nevertheless, the number I have is that something like 400 people under 40 have the disease. Incredibly, it is thought that a few dozen people get the disease under the age of 20, which is a terrible thing as it means that it is with them for their entire working lives.

Parkinson’s is a progressive disease caused by the death of cells containing dopamine. As we have heard, it causes tremors, slowness, speech impediment and gait disorder. Its severity varies, as recognised in some of the points made about the Department for Work and Pensions. There is no cure; the best we can do is to manage the symptoms by trying to address the lack of dopamine through techniques such as brain stimulation, and apomorphine is the most commonly used drug. The hon. Member for Torfaen mentioned the recent debate on Duodopa; I do not intend to go over that in detail, other than to say that it is very much a minority treatment, with something like 75 people receiving the medication. It is typically used when other treatments are not successful.

We all—the Government and the country more generally—need to build awareness of the prevalence of early-onset disease. The NHS Choices website has information on the local and national support groups we heard about a few moments ago. Parkinson’s UK does a huge amount of work in this area, and I would of course be happy to meet it and the hon. Member for Torfaen.

[Justin Tomlinson]

I am delighted that the Minister has agreed to meet Opposition Members—that will be a really worthwhile meeting—but in that vein, as I host our local Parkinson’s group, would he be willing to come to Swindon to meet its members?

[David Mowat]

In principle, I would be delighted to come to Swindon, or my hon. Friend could join the meeting with Parkinson’s UK. I am sure there is a way forward.

[Nick Thomas-Symonds]

It would also be extremely useful for the Minister to facilitate a meeting with another charity called Spotlight YOPD, which has done tremendous work in this area.

[David Mowat]

I heard that charity mentioned and yes, that would of course be a sensible thing to do; the focus of this debate is on YOPD, so that would be appropriate.

There is an issue with GP awareness and diagnosis, partly because there is sometimes an assumption that if someone is young and has dizziness, aching muscles and some of the other early symptoms, those can be symptomatic of more benign conditions, and it is genuinely quite hard to diagnose young-onset Parkinson’s disease. It is important to note that the Royal College of General Practitioners’ neurology training emphasises that all GPs must have a knowledge of the epidemiology of Parkinson’s. The applied knowledge test, which all GPs, wherever they come from, have to pass before they can be a GP, has modules on Parkinson’s and the fact that it can potentially come to people before they are 50 years old, even though it does not usually do so. It is important that we continue to focus on that.

The National Institute for Health and Care Excellence has guidelines on Parkinson’s. Most relevant is the guideline on the best practice on the diagnosis and management of the disease. The draft is currently out for public consultation and will be updated and reissued in April. That guideline also emphasises the fact that early onset is possible and that if patients present with stiffness and slowness of movement, Parkinson’s needs to be considered, because quite often it still is not.

A second NICE guideline, which is also being worked on, is on the more general theme of suspected neurological conditions, with a particular focus on people outside the normal age ranges presenting with symptoms. That applies to children, young people and adults. Such a focus is potentially useful in the identification of early-onset Parkinson’s.

Once the condition is diagnosed, it is obviously important to start treatment. That tends to imply, in England at least, referring a person to one of the 25 neurological centres around the country. A management plan should be put in place by a multi-disciplinary team, consisting of neurologists, neuro-surgeons, nurses and psychologists. Once that plan is in place, treatment can take place through normal primary and secondary care pathways.

[Nick Thomas-Symonds]

The Minister mentioned psychologists in that list. Does he agree that mental health is a vital part of that package?

[David Mowat]

I heard the hon. Gentleman say that in his speech, and I agree with him. We know that we have some work to do in our health system generally in getting mental health to catch up with the rest of the ways that we treat health. I use the phrase “parity of esteem”, and that is something that must happen. Younger people with Parkinson’s are unlikely to be in a major support group of others who have the disease at their sort of age. They can feel lonely, isolated and all that goes with that. In particular, the hon. Gentleman mentioned Hayley and her young family. Yes, he is absolutely right to emphasise that issue, as we do need to have much more mental health provision in our GP practices. We are determined to achieve that by 2020, with 3,000 mental health therapists in GP practices in England.

The hon. Gentleman mentioned the workforce and 10-minute appointments. We have increased the number of neurologists working in NHS England by something like 30% since 2010. The figure has increased to 1,300, so something like 300 more neurologists are needed in NHS England. As the incidence of neurological conditions continues to increase—Parkinson’s will continue to increase as the population ages—we will need to continue with that expansion. That is clearly a priority.

I wish briefly to talk about the new neurology advisory group, which was set up in September 2016 and is led by Professor Adrian Williams, a neurologist. A member of that group is Steve Ford from Parkinson’s UK. The group’s role is to better align services across the country. Currently, there is a disparity in treatment between different clinical commissioning groups and different GP practices. To an extent, that disparity is inevitable, but we need to do what we can to minimise it, and that group will be looking to do that. It will also be responsible for working as part of a neurology intelligence network, which is all about getting data. The very first challenge from the hon. Gentleman was that the figures that I had quoted and that he had quoted were all estimates. We do not gather data in the format that can be used. The estimates came from a report of Parkinson’s UK, and they were based on 2009 data. We need to do much better than that. It is only by having more reliable data that we can track the way in which the disease is developing and can ensure that we have adequate and effective treatments and networks in place.

The hon. Member for Strangford (Jim Shannon) mentioned research. Yes, in the end, research will help us to find a cure. We spend something like £1 billion a year through the National Institute of Health Research. Of that, the spend on neurology has increased over five years from £30 million—it is not the biggest area—to something like £55 million this year. That is something that we should continue to press for, and I am sure that both the hon. Gentleman and Parkinson’s UK will do that.

I agree with the thrust of what the hon. Gentleman said about the DWP. Indeed, the Government’s Green Paper, which was published in October 2016, talked about removing continuous assessment processes for people with progressive diseases, such as Parkinson’s. I understand that the DWP is working towards developing the criteria for switching off assessments, and I think that he and I would both agree that the sooner that is applied in this case, the better.

In conclusion, early-onset Parkinson’s is a very tough condition that around 5,000 or 6,000 people across the country have. It is tough to diagnose and there is no cure, although it can be partially managed. I congratulate the hon. Member for Torfaen again on raising awareness of the condition, both today and over the past year or so through the campaign. I also thank Parkinson’s UK for the work it does. I hope that this discussion has been helpful. I would be delighted to meet the hon. Gentleman, the hon. Member for Bridgend, Parkinson’s UK and perhaps even my hon. Friend the Member for North Swindon to talk about how we can take this forward.

Question put and agreed to.

Health and Social Care

David Mowat Excerpts

Monday 27th February 2017 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

The hon. Member for Central Ayrshire (Dr Whitford), who speaks for the Scottish National party, described this as a great debate. I agree that it has been a very good debate. Members on both sides of the House have spoken with a great deal of passion and, in general, with a great deal of knowledge. A number of clinicians, as well as three Select Committee Chairs, have spoken. I join the shadow Minister in thanking the Select Committees for the reports we are discussing today. An awful lot of comments have been made by Members and I will do my best to respond to the majority of them.

The Government accept that these are challenging times for both the NHS and social care. My hon. Friend the Member for Totnes (Dr Wollaston), the Health Committee Chair, talked about this at length. The demographics—both the number of people and their age—are uncompromising. I was at a Health Check conference recently and one of the speakers described the process we have been through. We have been very successful at elongating quantity of life. Until now, however, quality of life has not kept up. Increasingly, older people are living with multiple long-term conditions. Having one long-term condition is becoming unusual, whether it is diabetes, chronic obstructive pulmonary disease or heart disease. This is a fact we all have to face. One reason why we are so keen for the STPs to address this issue is that 70% of total expenditure on the NHS is spent on long-term conditions. Frankly, if we were starting with a blank piece of paper, we would not start with the NHS we have now. Instead, it would be organised around those long-term conditions, meaning more work in the community and all that goes with that. I will come on to talk about the STP process and how we are trying to achieve that.

We know, therefore, that there is an issue with demography. I think it was a Public Accounts Committee report that said that, in 1948, 50% of people lived to be over the age of 65. In 2017, only 14% die before they are 65. That is a massive demographic change and we all need to step up to the mark to meet it. We will try to do that. Drugs and treatment are becoming more expensive. They can do a lot more, but we have all heard the discussions around the cancer drugs fund. The third driver is that patients’ expectations are, rightly, higher than they were decades ago.

The Government response in the spending review was a front-loaded £10 billion injection into the NHS budget, representing an 8% or 9% increase, depending on how it is counted. I agree with the hon. Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, that we should not bicker about these amounts. We can argue about whether it is enough, but the facts are that this is a real increase over the course of this Parliament. There is a discussion to be had on whether that real increase is enough—I accept that. What I do not accept is what we have heard about cuts from some of those on the Opposition Benches. There is a valid discussion to be had about whether an 8% or 9% real-terms increase is enough—I gently remind the Opposition that at the last election they said they would not be in a position to fund more than that—but it is not right to talk about it in the context of cuts, as some Opposition Members have done.

[Barbara Keeley]

We get into this repeatedly. The Opposition have no plans to cut £5 billion from social care or to cut the budgets of local councils. That is the difference between us and the Government. Given that we have talked mainly about social care and cuts to social care, the Minister ought to take that into account.

[David Mowat]

I will come on to social care. We have covered the NHS, which this Parliament will get a real-terms increase of 8% or 9%. Let us accept that and move on. On social care, a 5% or 6% real-terms increase has already been made available—that is not the Budget; I do not know what is in the Budget. Again, we can argue about whether that is enough, given the demographics, but we cannot argue whether it is true.

I want to spend a little time on the international comparisons, about which we heard some discussion earlier. According to the OECD, in 2014 this country spent 9.9% of its GDP on health. The OECD average is 9%, so that is 1% more, but it is true that the OECD average includes countries such as Mexico with which we would not necessarily wish to compare ourselves. The average for the EU15, which by and large does not include the newer states in the east, is 9.8%. So in 2014 we spent more than the EU average. It is true that we spend less than some of our comparator countries—we spend less than France and Germany—but it is completely wrong to say that there is a massive gap between us and the EU.

[Dr Philippa Whitford]

I thank the Minister for giving way, but 2014 was three years ago, and are we not heading towards a figure of less than 7%, which will put us 13th out of 15 among the EU15?

[David Mowat]

No. The 2014 figures are the most recent available—and they do not include the comparatively large settlement on healthcare and the front-loaded money in the spending review.

The Government spend 1.2% of GDP on social care—we spend another 0.6% privately. That is more than countries such as Germany—the Chair of the Communities and Local Government Committee talked about Germany—which spends 1.1%, and more than Canada and Italy. Again, it is less than some countries—Holland, an exemplar country in this respect, spends considerably more; I accept that there are choices to be made—but it is wrong to pretend that we are massively out of kilter with the sorts of countries we would regard ourselves as equivalent to.

[Heidi Alexander]

Does the Minister accept that if we continue on current spending rates as a proportion of GDP, by the end of this Parliament we will be spending less than countries such as Costa Rica and Iceland? Is that the sort of health service his constituents aspire to?

[David Mowat]

There are assumptions in that—to do with our GDP growth, their GDP growth and everything else—so it is a difficult question to answer. I would just refer again to the latest OECD figures, for 2014. Those figures are accurate. There is a valid debate to be had about whether they are enough, given the demographics and all the rest of it—that is fair—but it is not fair to imply that there is a massive disparity between us and our EU neighbours.

[Barbara Keeley]

rose—

[David Mowat]

I have given way to the hon. Lady once already, and I need to make some progress.

[Patrick Grady]

Some Conservative Back Benchers have suggested—not in today’s debate but at other times—that some of the 0.7% gross national income aid budget could be used to fund health and social care. Can the Minister confirm that the Government remain committed to that target? By reading out the proportions of GNI spent on health and social care, he has shown how small that budget is in comparison.

[David Mowat]

The 0.7% budget for overseas aid is not being discussed here today and it is not my ministerial or my Department’s responsibility. I am proud that we are one of the few countries in the world that meets that commitment, and many of the other countries among our EU partners that have been mentioned do not make that commitment. However, I shall not be diverted any further down that road today.

We have of course had a difficult winter in the NHS. We know that A&E targets are on about 86% rather than the 95% we expect; and ambulance targets are at 60% rather than the 75% we expect. As we have heard, delayed transfers of care—not “bed blocking”—have probably doubled over the past three years. In response, I make one point that I am always keen to raise in these discussions: we do not talk enough about cancer. There are cancer metrics, and we should be proud of the fact that NHS England, is meeting seven of our eight cancer metrics. The trend is towards meeting them more easily than in the past. We have heard quite a lot this evening about how well they are doing in Scotland. In fairness, to redress the balance that we have heard about in respect of A&E, I make the point that Scotland is doing somewhat worse than we are on those cancer metrics.

[Karin Smyth]

I regret to say that it has been a disappointing response thus far. We have had a very informed debate, so we do not need to have the figures regurgitated to us as if we have not. Will the Minister address my comment that the money is what it is, but is it sufficient to deal with the programme of care and support in the NHS that has been promised? That has been the subject of the Public Accounts Committee’s report for every single month since last January. Is the money enough to do what has been promised?

[David Mowat]

The money is what we were asked to provide by NHS England’s senior management, and we provided it. At that time, the chief executive said that the Government had listened and acted. That is what we did, and that money is now available. That is not the same as saying that we do not accept that the system is under pressure in certain ways. Again, though, we talk about the money that is being spent in France and Germany. In Munich, 15 of the city’s 19 hospitals stopped taking people in over this winter. Right across the world—this is the point—there are challenges in national health systems, and we need to work to ensure that money is spent as effectively as possible. We know that £120 billion will be in our health system in 2020. What this Government have to do and what this ministerial team is doing is ensure that every penny is spent as effectively as possible.

We have talked about the five year forward view, and I accept that we are two years into it, but we know that the health system must tilt back towards community health, and the STPs are part of making that happen. We know that we need to get better than we are so far in terms of mental health and parity of esteem.

[Mr Betts]

I think the STP approach is capable of being a good one. The problem is that when I go to the chief executive of the Sheffield Teaching Hospitals NHS Trust, Sir Andrew Cash, who is respected in government as well, he tells me that the process of transferring resources to the community will not work unless there is some transitional upfront funding for the whole process. We cannot stop doing what is being done in the hospitals and simply transfer it to the community.

[David Mowat]

He is right about that. NHS England is evaluating the STPs at the moment and during March and April, and it will decide which STPs are high priority, which will be invested in and which will be taken forward at speed. We heard the phrase “accountable care organisations” used earlier, and it is the Government’s intention to ensure that those high-performing STPs that we proceed with—it will not be all of them; frankly, the standards are variable and locally driven—will in time become accountable care organisations.

The shadow Minister asked me to talk about social care, and I will do so. During the present Parliament, accessible funding for social care has risen by 6% in real terms; it fell during the last Parliament. Last year 42% of councils increased their social care budgets in real terms, and in December £900 million was provided in new homes bonus payments.

[Barbara Keeley]

Will the Minister give way?

[David Mowat]

No, I will not.

[Barbara Keeley]

rose—

[Mr Speaker]

Order. The Minister is not giving way at the moment.

[David Mowat]

The Care Act 2014 was introduced by this Government, and it has transformed social care, although we accept that the system is under pressure. The number of delayed transfers of care in Newcastle, St Helens, Bedford and Nottingham is nil. The Chairman of the Public Accounts Committee, the hon. Member for Hackney South and Shoreditch (Meg Hillier), said that she had been told by Simon Stevens that if the top-performing councils—in terms of delayed transfers—were emulated by all the rest, the consequence would be very small. The truth is that there is a 30 times difference between the top 10% of councils and the bottom 10%.

[Mr Betts]

Will the Minister give way?

[David Mowat]

No. I have given way to the hon. Gentleman twice already, and I need to finish my speech in two minutes.

We accept that there are challenges and pressures in social care, but we also know that we need to make progress in mental health care, and we are doing so by working towards parity of esteem. By 2020, there will be 5,000 more doctors in general practice and 2,000 more pharmacists. We have talked about the need for more pharmacists. I visited a pharmacist’s practice in Perivale on Friday, and I know that we can transform the way in which general practices work. There will be 3,500 mental health therapists as well.

Nearly 3 million people work in healthcare, in the NHS and care sectors. Many of them are remarkable people doing remarkable things, and they deserve our support. It is important for us not to weaponise this entire discussion. It is important for us not to produce election leaflets about dead babies, and all that that means. Our healthcare system and the NHS deserve our support, and the Government are committed to ensuring that they receive it. I commend the estimate to the House.