Accelerated Access Review

David Mowat Excerpts

Tuesday 13th December 2016 Westminster Hall

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

It is good to serve under your chairmanship today, Sir Alan. I congratulate the hon. Member for Dudley North (Ian Austin) on leading the charge in this debate. The right hon. Member for Leigh (Andy Burnham) rightly said in his very good speech that this is not really a political issue. Every Member in this Chamber has constituents who would benefit from these drugs. There are 10,500 people in the country with cystic fibrosis and it is massively important that we do everything we can to make progress on the issue. I also congratulate the Cystic Fibrosis Trust on its work and on its “Stopping the Clock” campaign. Debates such as this give prominence to these issues and to the need to make progress.

The debate is really about two drugs, a drugs company and an evaluation process. I shall speak about all of those and about where we are going with the accelerated access review. The two drugs are Kalydeco, which applies to something like 4% of cystic fibrosis sufferers, and Orkambi, which would apply to a further 40% of sufferers. Both are relatively small populations: for Kalydeco it is something like 400 people in England, and for Orkambi it is something like 2,700 or 3,000. Kalydeco has been routinely available on the NHS since 2013. As mentioned today, it was extended on 4 December to children aged two to five. It makes a big difference and we are pleased to have made that progress. Both Kalydeco and Orkambi are produced and owned by a Boston-based drugs company called Vertex, which I shall talk about later.

Orkambi could be used by around 3,000 patients. It has a price of something like £100,000 per annum—the implication being that the cost of its approval in England would be in the order of £300 million or £400 million a year. As several Members have said, it is obviously right that there is a process that weighs that cost of £300 million to £400 million a year against other NHS priorities and other drugs. That process is the NICE process. A number of comments have been made about the efficacy of that process, and it has been suggested that it may have deficiencies in respect of providing precision drugs to small numbers of users. I will try to address those concerns. I think everybody agrees that we need a consistent method of evaluating these matters, and there needs to be a way forward based on that.

When NICE evaluated Orkambi in July, it found that it had clinically significant and important benefits, which several Members have spoken about. There is no dispute about that, but the evaluation process—which is based on quality-adjusted life years, as has been said—also found that it was not cost-effective. I spent some time last night reading the NICE evaluation, and make the point to colleagues and other Members that it was not a near miss. It looks like there is a factor of 10 in NICE’s evaluation of its cost-effectiveness. I guess that is largely driven by the price of £100,000 per annum and what that would mean.

[Andy Burnham]

It is obviously reassuring to everybody that the Minister has taken such a close interest in the issue before coming to the debate. He says it was not a near miss. That may have been the case on the data that NICE had, but does he accept the point made by my hon. Friend the Member for Dudley North (Ian Austin) and other Opposition Members that those data were very limited indeed? The 96-week trial data that are now available would probably have produced a very different overall calculation.

[David Mowat]

To be honest, I am not qualified to have an opinion on that. The right hon. Gentleman rightly said that decisions of this sort should not be made by politicians and that there has to be a process around them. It is clear that if NICE is presented by Vertex with new clinical data, or indeed new price data—this is perhaps equally relevant, but we have not really discussed it—a review could be carried out quickly without any need for us to go through the whole process again. There is a precedent for that, and if those data exist and Vertex presents them, they would be looked at. I give my commitment, and certainly that of the Minister responsible for this policy area, that that would be the case and there is no impediment to that. I do not want to raise false hopes by saying that, and I do not think I have done so. The fact that it is not a near miss—it is possibly out by a factor of eight or 10—implies that there is quite a lot of work to do on pricing.

It is worth recapping what other countries have done. Orkambi is available in Germany, although it appears from the data available that its use there is quite mixed, with perhaps no more than one in five eligible people having access to it. In France, the other country in Europe that has authorised it, Vertex has booked no sales yet this year. The picture seems quite mixed in those countries. The countries that have not authorised Orkambi include Scotland.

[Jim Shannon]

In my speech I mentioned a young girl from my constituency, Rachel, who has been on the Orkambi trials and shown exemplary improvements in her health. That is an example we can all point to of where goodness has come out of the drug for those who have had the opportunity to have it, and that is true not only in my constituency but throughout the whole of the United Kingdom of Great Britain and Northern Ireland.

[David Mowat]

There is no dispute that the drug works, and there is no dispute at all that it is life-changing. The issue before us is the extent to which it justifies a price tag of £300 million to £400 million versus other NHS priorities. All I can say on that is that it is right that the decision is not made by politicians, for the reasons given earlier by the right hon. Member for Leigh.

I was discussing the countries that have so far not authorised Orkambi. Neither Scotland nor the Republic of Ireland accepted that it was cost-effective, and it is not used in Scandinavia or Canada either.

[Mark Durkan]

The Minister mentioned Scotland and the Republic of Ireland, where there are clearly challenges—we only have to look at the pictures in The Irish Times yesterday to see the graffiti about Orkambi in Dublin. Will he commit to working with colleagues from across these islands to use the underdeveloped and underused machinery of the British-Irish Council to literally get our act together when it comes to rare diseases? We should combine our purchasing power when negotiating with the drugs companies and ensure that there are much better networks for referral and treatment. We should improve that collaboration and literally get our act together on these islands.

[David Mowat]

I, too, saw the press. I think the Republic of Ireland drugs Minister has talked about writing around to that effect, and it would be a great idea were we to use our combined procurement muscle in that regard. He is certainly pressing at an open door.

I wish to spend a little time talking about Vertex. The company owns the drugs we are discussing and is worth $18 billion. As well as looking at the NICE review last night, I spent quite a lot of time looking at Vertex’s financial position. The company needs to sell these products; indeed, its continued functioning as a major pharmaceuticals company depends on that. Its share price has fallen by a third during the course of this year—I estimate that is a loss of value of something like $7 billion—because its sales are not adequate. There needs to be a meeting of minds here. I am sure that people from Vertex are listening to this debate, as will people from other places, too. We all want a solution whereby the drug becomes available at a cost-effective price, but the negotiation is not a one-way street; Vertex is part of it as well. Were the company to come forward with different pricing data, those would be looked at very quickly. At some point in the future—I know it will be a long time—the drug will be available generically, although I accept that that will not give hope to some of the people we have heard about today.

In the couple of minutes I have remaining, I wish to discuss the accelerated access review, which was a manifesto commitment we made at the election. We set up the review panel. The basic intent was to enable transformative drugs to come forward more quickly and for there to be, as Members have mentioned, a commercial unit in the NHS that is empowered to do deals and bring treatments forward more rapidly. In October the review team and panel published the final report, to which something like 600 stakeholders contributed. It is a valuable piece of work and we know its direction of travel: bringing drugs into the system more quickly, allowing the NHS to set priorities for the drugs its wants, and giving drugs companies some notice and knowledge that if they develop drugs, they will be used. That will mean that a lot of the commercial discussions can happen earlier and progress can be made more quickly.

The Government are reviewing the results of the accelerated access review. There is much in it, if not all of it, that will be accepted, although I am not in the position to accept it today—that is not my role here. We do, though, want to make progress, which should give some hope for the potential of another review of the matters we have been discussing. Nevertheless, I must say again to Government and Opposition Members that the NICE process and the people carrying it out—they are rigorous scientists and serious doctors—need to be treated and understood with respect. We can all agree that the current situation is heartbreaking for many people. The world has a drug that would change people’s lives, but the world has not rolled that drug out to them because of real and reasonable financial issues. I accept that that is a very difficult thing to explain to people and it is very difficult to accept.

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

Social Care Funding

David Mowat Excerpts

Monday 12th December 2016 Commons Chamber

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

(Urgent Question): To ask the Secretary of State for Health if he will make a statement on the crisis in funding in social care, and the effect it is having on the NHS and on the care of vulnerable older people.

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

I thank the hon. Lady for raising today’s question. All Members of this House will agree that there are few areas of domestic policy that touch on so many lives and that are so important to so many of our constituents.

I wish to start by acknowledging the work of more than 1.4 million professional carers, the vast majority of whom provide excellent, compassionate care. I also wish to acknowledge the 6 million informal carers who also do so much.

Spending on long-term care in our country is more than the OECD average—in particular, it is more than comparable economies such as France and Germany. Nevertheless, I accept that our system is under strain, and that pressure has been building for some years now.

The Government response has been to ensure that councils have access to funding to increase social care spend by the end of this Parliament. We estimate that the increase could be around 5% in real terms. Additional funding comes from the better care fund, the additional better care fund and changes to the precept.

Another response has been to put into place and enforce a robust regulatory system. Between 2014 and early next year, all homes and domiciliary providers will have been re-inspected. Seventy-two per cent are classified by the Care Quality Commission as good or outstanding. Where homes are inadequate, powers now exist to ensure improvement or force closure. Those powers are being used.

Another Government response has been to work with local authorities to ensure that a continuing market exists. In the past six years, the total number of beds has remained constant, and there are 40% more domiciliary care agencies now than in 2010. Finally, the Government have responded by driving further and faster the integration of the care and health systems. We have seen that those councils that do that best demonstrate far fewer delayed transfers than those who adopt best practice more slowly.

Any system would benefit from higher budgets, and social care is no exception—but quality matters too. Today is not a budget statement or a local government settlement. I wish to end by commending again the many hundreds of thousands of carers who work hard to make the current system work for so many.

[Barbara Keeley]

That was a disappointment. Before the autumn statement, we debated the funding crisis in social care—it is not a strain but a crisis—and the serious concerns expressed by local government health and clinical leaders. We on the Labour Benches called on the Government urgently to bring forward promised funding to address that crisis. The Chancellor did not listen and did not bring forward any funding for social care—he did not even mention it. Will the Minister tell us in his response why Health Ministers do not stand up for vulnerable and older people in this country and fight harder to get extra vital funding for social care?

Over 1 million older people in this country have unmet care needs, 400,000 fewer people have publicly funded care than did so in 2010 and, as he recognises, a heavier burden now falls on unpaid family carers. The crisis in social care has been made by this Government as a result of £5 billion being cut from adult social care budgets. Can the Minister confirm what is reported by The Times—that the Government intend to dump this funding crisis on local councils and council tax payers by increasing the social care precept?

The King’s Fund has called that proposal “deeply flawed” because local councils in the least deprived areas would be able to raise more than twice as much as those in the most deprived areas. This year that means that the precept raises £15 per head of the adult population in Richmond, but only £5 per head in Newham and Manchester. That would widen inequality of access to social care across the country. Is it the care Minister’s intention to support a solution that widens inequality of access and denies social care to hundreds and thousands of vulnerable older people?

[David Mowat]

The hon. Lady fought the last election on a manifesto that said not one penny more for local government spending. She is against the change to the precept that we brought in in the spending review. She talked this morning about being against taxpayers and council tax payers having to meet the cost of increased social care. That raises the question who she thinks should be paying for it. Is it borrowing, or is it the magic money tree? She said that the precept increases inequalities because some councils are able to raise more than others from it. That would be true, if it were not for the fact that the additional better care fund is distributed in a way that balances that. That is precisely what we do.

[Several hon. Members rose—]

[Andrew Selous (South West Bedfordshire) (Con)]

Thank you, Mr Speaker. I hope that in looking at co-ordinated policy across Government, the Minister will look not only at good join-up between the Department of Health and local government, but at other policies, such as lifetime homes, family strengthening and flexible employment policies, all of which will help us deal with these issues. Can he give us some encouragement on that score?

[David Mowat]

My hon. Friend is right. There is a raft of measures that need to be taken on informal carers and on the holy grail of better integration of health and social care funding, and we are pursuing that vigorously.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

This was the substance of the letter from the Health Committee to the Chancellor, calling for extra money not for the NHS, but particularly for the capital budget and social care, because the back pressure from social care is what is causing the NHS to struggle. I totally agree with the Minister as regards integration. In Scotland, where we have the integrated joint boards, it has brought a change more quickly than we would have hoped. Our delayed discharges are down 9% in a year; in England they are up more than 30%. But this is not easy and it needs to be funded. We have debated the sustainability and transformation plans, which could be the basis for the future integration of the NHS, but all we hear within those plans is community hospitals being shut, losing the opportunity to have step-up and step-down beds, A & E departments being shut, and beds within hospitals being shut. This is the wrong way round. STPs could work, but they cannot start with the number they must reach—they have to design themselves around a service that keeps patients at home and keeps them well.

[David Mowat]

The hon. Lady made two points, both of which I agree with. The first was that in Scotland there has been a 9% reduction in delayed transfers of care. It is also true that in England many parts of our system, particularly those that have integrated most quickly, have achieved reductions of that size and more. She is right that the STPs are part of the process of re-engineering the system. Adult social care and the integration of adult social care are a big part of that and we need to ensure that we deliver.

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

Does the Minister agree that better integration could be driven by better patient data, which could help to show us where quality practices exist and how to spread best practice?

[David Mowat]

I do agree. I had a discussion with the Care Quality Commission on the dataset that is reported, and I hope that over the next months and years we can improve how we do that.

[Dame Rosie Winterton (Doncaster Central) (Lab)]

I think that the Minister completely missed the point made by my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) from the Front Bench about the unfairness of asking councils to deal with the problem. A 1% rise in council tax in Doncaster raises 21% less than would the same rise in a council in the Prime Minister’s constituency. Does that not mean that the problem is being pushed on to the areas that can least afford it?

[David Mowat]

The right hon. Lady would be right that I had missed the point, had I not said that that issue is addressed by how we distribute the additional better care funding, which uses a formula that takes into account relative need.

[Steve Double (St Austell and Newquay) (Con)]

The Minister will know that following recent events I have taken a particular interest in this issue. Does he agree that saying that it is just about money is too simplistic, and we see a wide variety of the quality of care from homes with the same funding packages? Does he also agree that we need to improve the inspection regime to ensure that concerns are taken seriously?

--- Later in debate ---

[David Mowat]

I agree and I commend my hon. Friend for his work on the Morleigh homes in his constituency, which had significant issues and have now been substantially closed down. He is right that the issues there were not principally about money; they were about quality and about people doing their jobs properly.

[Norman Lamb (North Norfolk) (LD)]

Does the Minister share the view of the CQC that the system is close to tipping point, and does he understand the impact that has on many frail elderly people? Does he not agree that now is the time to bury our differences and work together to come up with a long-term settlement for the health and care system?

[David Mowat]

Today is not the day on which to announce a royal commission on the funding of care in the future, but I do agree that it is important that we put care funding on to a better structural footing for the future. The right hon. Gentleman is right to say that.

[Rebecca Pow (Taunton Deane) (Con)]

I applaud the Government’s commitment to £10 billion to the NHS by 2020, but does my hon. Friend agree that social care and healthcare must be better integrated across the whole country? Somerset County Council’s sustainability and transformation plan has that at its heart. It is a good model. Does my hon. Friend agree that such models should be copied, but that councils must be given the tools?

[David Mowat]

The STP for Somerset is excellent in that regard and my hon. Friend is right to raise it. She is also right to emphasise again the integration of health and social care, which is the holy grail of this. Those councils and health systems that do it best are making a huge difference.

[Mr Dennis Skinner (Bolsover) (Lab)]

But is the Minister aware that in the course of the past few years local authorities—let us say in Derbyshire—have lost more than £200 million from cuts promulgated by the Government? On top of that, they are closing community hospitals in Derbyshire, including Bolsover, with a total of more than 100 beds between them. Does it make sense when those community hospitals bear the burden of looking after people who cannot occupy other hospital beds?

[David Mowat]

The hon. Gentleman is right that there have been changes to the funding regime, but councils such as Knowsley and St Helens have virtually no delayed transfers of care and they have the same budget issues as his council.

[Justin Tomlinson (North Swindon) (Con)]

An ageing population, the welcome introduction of the national living wage and the rightly greater expectations on services provided are causing exponential growth in adult social care costs, to a far greater amount than can simply be found through efficiency savings. Although the council tax cap has delivered financial discipline, we have to be realistic, so may I urge the Minister to explore further flexibility with the social care precept?

[David Mowat]

I said in my answer to the hon. Member for Worsley and Eccles South (Barbara Keeley) that this is not a spending statement or a statement on the local government settlement, so I will just leave it at that.

[Liz Kendall (Leicester West) (Lab)]

It would be a huge mistake to think that the Minister can plug the gaping hole in care funding with the social care precept alone. The poorest areas, which most need publicly funded social care, are the least likely to be able to get it by raising council tax. If not today, when will the Minister come to the House with a plan to solve this crisis and help families, care users and the NHS?

[David Mowat]

I have acknowledged that the system is under pressure, but I have also acknowledged that different councils respond to that pressure in different ways. For example, Leicester City Council has increased its adult social care budget for next year—2016-17—by 7% in real terms.

[Mr Stewart Jackson (Peterborough) (Con)]

Shroud waving by the Labour party is particularly depressing given that it did virtually nothing on this issue during 13 years in power. Does my hon. Friend agree that it is important for the Department for Communities and Local Government and the Treasury to use fiscal incentives to encourage the construction of more extra care facilities? Does he also agree that it is important to iron out the disparities between different local authorities in the quality of care delivered?

[David Mowat]

Yes, there is disparity—still—in the marketplace and between local authorities, and we need to do everything we can, working with the CQC, to ensure that it is eliminated.

[Mr David Winnick (Walsall North) (Lab)]

Does the Minister not realise that his statement today is totally inadequate for the crisis in social care and that the complacency he shows is totally unrealistic, given what has happened in the country? What we require is a very different response from what we have been given today.

[David Mowat]

I am tempted just to say, “No, I don’t acknowledge that,” but I make the point again that I am not complacent. We understand that the system is under pressure, and we acknowledge and accept that. That is not the same as saying that there are not things that we can do in terms of quality provision to manage better, and that is what we are trying to do.

[Andrew Stephenson (Pendle) (Con)]

Adult social care accounts for about 45% of Lancashire County Council’s budget, and that is a growing share. The key to addressing this challenge will be the better integration of health and social care to better manage demand. What funding is being provided to Lancashire County Council to allow that transformation to take place?

[David Mowat]

The better care fund is predicated on the assumption that we will drive that integration. I also make the point that not just Leicester, for example, but many councils right across the country—something like 40%—have increased, and will increase, their social care budget in real terms next year.

[Dr Rosena Allin-Khan (Tooting) (Lab)]

By 2020, we will see a national shortfall of £2.6 billion in adult social care funding. If the Government are forcing councils to increase council tax, what percentage will they be expected to increase it by? How much of that percentage increase would go solely to adult social care services? How will the Government ensure that that happens?

[David Mowat]

The spending review increased the precept by 2%—that is what we brought in at that time. As I said earlier, this is not the local government settlement, and I have nothing to say on council tax.

[Mr Peter Bone (Wellingborough) (Con)]

Many people on, I think, both sides of the House feel that the social care system is broken because we have councils and the health service involved. Would it not be a good idea for the Secretary of State or the Minister to work with Members on both sides of the House, with good will on both sides, rather than for us to have this petty point-scoring from the Opposition? [Interruption.] No, this is much more serious than politics—we have to get this right for future generations. Should we not work together and come up with a solution that both sides of the House can agree on?

[David Mowat]

My hon. Friend is right that this whole system is more important than politics: there is nothing more important to more people—and more old people in terms of the dignity and quality of their lives—than getting this right, and it is essential that we do that.

[Several hon. Members rose—]

[Maria Eagle (Garston and Halewood) (Lab)]

Liverpool City Council has seen £330 million cut from its budget since 2010—58% of all its money. A further £90 million has to be found by 2020. In those circumstances, how will it be possible for the council to increase, as we all wish it could, the money it spends on adult social services, when it already spends more on them— £146 million—than it can raise in council tax?

[David Mowat]

It is not my role to lecture Liverpool City Council on how to deliver adult social care. I make the point, though, that Knowsley and St Helens, which are very close to Liverpool, have virtually no delayed transfers of care, and so possibly some best-practice sharing would be in order.

[Several hon. Members rose—]

--- Later in debate ---

[David Mowat]

I have made the point already, and I will make it again, that we acknowledge that the precept is uneven in the way that it was announced in the spending review. That is why the additional better care fund component is allocated on a basis that remedies that.

[Jess Phillips (Birmingham, Yardley) (Lab)]

Thank you, Mr Speaker; this is a timely moment to call me, given what the Minister says about remedies. I put in a freedom of information request about the adult residential weekly rate across every single council in the country. Buckinghamshire gets £615 a week, while Birmingham, including the home where my grandparents both died, gets £436 and has to make an additional charge of £55 per week on the residents who live there, who are no doubt poorer than those who live in Buckinghamshire. Does that sound like a discrepancy that is being solved by the Government’s system? Are nans and granddads in Buckinghamshire worth more than they are in Birmingham, Yardley?

[David Mowat]

In terms of quality in Buckinghamshire and Birmingham, we look at the CQC reports right across the system, and we are not finding a geographic variation based on those sorts of statistics. That is just the fact of the matter.

[Dr Roberta Blackman-Woods (City of Durham) (Lab)]

I have heard nothing from the Minister to demonstrate that he understands the severity of the situation facing social care. Last week, the Local Government Association met a cross-party of group of MPs. It said that local government needs £1.3 billion to stabilise social care, and pointed out that that money cannot be raised by a council tax increase, especially because that raises the least money in the areas with the highest need.

[David Mowat]

In terms of council tax increases, this is not about the local government settlement that has already been announced. The additional better care fund will start to deliver more money from next April, and will deliver more money after that. During the course of this Parliament, there will be a 5% increase, in real terms, in money spent on adult social care.

[Diana Johnson (Kingston upon Hull North) (Lab)]

I hear what the Minister says about the better care fund, but that obviously applies from next April. How is it fair that this year the area I represent—the 19th most disadvantaged constituency in the country—will be able to raise only half of what an area like Kingston upon Thames can raise? We can raise about £5; it can raise about £10. How can that be fair for social care?

[David Mowat]

This year, 42% of councils are increasing their adult social care funding in real terms. The discrepancy caused by the precept is addressed by the way in which we allocate the additional better care fund component and the formula that is used for that.

[Nic Dakin (Scunthorpe) (Lab)]

I think the Minister recognises that there is a crisis and that the precept alone will not address it, so does he agree with the former Health Secretary, Stephen Dorrell, who said this morning that it was a missed opportunity in the autumn statement not to invest in social care?

--- Later in debate ---

[David Mowat]

I am not giving the autumn statement, but I will say again that there is a 5% increase in real terms in adult social care funding during this Parliament, and that 42% of councils are increasing the budget in real terms this year.

[Kerry McCarthy (Bristol East) (Lab)]

The Minister needs to recognise that not only can it be more difficult for cities to raise money—we have already heard from colleagues comparing the amount that would be raised by increasing council tax in cities as opposed to more affluent rural areas—but demographic concerns make delivering health services more challenging in cities such as Bristol. We are already looking at £92 million of cuts or savings that we have got to find over the next five years. Will the Minister come to Bristol to talk to the Mayor and see what challenges we are facing?

[David Mowat]

Cities do have issues with delivering social care, but so do rural areas, which quite often have a very high proportion of older people. That, in itself, can absorb a great deal of cost. The truth is that, as I have acknowledged, the whole system is under pressure, including in Bristol. We acknowledge that, and we are increasing the total spend by 5% during this Parliament.

[Daniel Zeichner (Cambridge) (Lab)]

We have heard from my hon. Friends about the failings of the social care precept model to address this issue, but what of councils such as Cambridgeshire, which chose not even to take the meagre resources available? Offered 4%, the council took just 2% this year, leaving the local hospital with 100 over-85-year-olds with nowhere to go. When are the Government going to stand up for older people in Cambridgeshire?

[David Mowat]

That was a decision made by Cambridgeshire County Council, and a number of other councils, such as Hammersmith and Fulham, made the same choice not to increase the precept. Presumably, they did not feel as though they needed to use that money for adult social care. That is a choice that those councils have, and it is a choice that they must take to their voters.

[Louise Haigh (Sheffield, Heeley) (Lab)]

Sheffield is about to lose its last emergency respite care centre for patients with complex dementia needs. Those patients cannot be cared for in the community, and people desperately do not want to see that centre go. Sheffield already has the second-largest better care fund in the country. If today is not the day for the Minister to issue a royal commission, when will he act?

[David Mowat]

I am not aware of the specific issue that the hon. Lady has raised about the respite care centre in Sheffield that is on the point of closure, and I would be happy to discuss that with her so that I understand it better. I can only repeat that today is not the day that we are going to announce a royal commission into funding.

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

Care providers in my constituency tell me that they are losing staff to Asda because they cannot compete on pay and conditions, because the council cannot commission care at a price that enables them to do so. What is the Minister going to do to stem the haemorrhaging of careworkers from the profession and, therefore, the haemorrhaging of the provision of care?

[David Mowat]

There is an issue with that, and that issue exists in various parts of the country. We acknowledge it and we need to manage it. We also need to manage the total number of beds in the system and the total number of domiciliary providers in the system. The total number of beds, as I said earlier, is the same now as it was six years ago. The total number of domiciliary providers is around 40% higher.

[Derek Twigg (Halton) (Lab)]

The Minister, in a debate on 16 November, congratulated

“both Halton and Warrington Councils on being two of the best performing councils in the country on delayed transfers of care and on increasing their budget.”—[Official Report, 16 November 2016; Vol. 617, c. 350.]

Halton still has a massive shortfall, because the precept goes nowhere near meeting the demand on the services in the area. The simple fact is this: there is no coherent national strategy or funding package in place to solve this crisis we now face. The Government are abrogating their responsibility, and the system will tip over.

[David Mowat]

The hon. Gentleman is quite right. I congratulated Halton and Warrington Councils on being two councils that have particularly low rates of delayed transfers of care. The fact that they are achieving that in spite of the budget constraints that he mentions demonstrates that this is not just about money; it is about quality, it is about leadership and it is about best practice.

[Paula Sherriff (Dewsbury) (Lab)]

The chief executive of Care England has said that under the current regime,

“about 40% of care services will no longer be viable,”

meaning that a number of services will be lost. When does the Minister intend to do something about this crisis?

[David Mowat]

The number of beds available in the system right now is about the same as it was six years ago. There is an issue with managing the financial performance of significant care providers. One thing we brought in two years ago was a robust process, led by the CQC, to look at the financial performance of the biggest providers and to warn us of any issues that may arise. We are very keen on pursuing that and making sure that it happens.

[Liz McInnes (Heywood and Middleton) (Lab)]

This is a national crisis that this Government have wilfully ignored for years. The Minister said in his opening statement that there is no issue that cannot be solved by throwing money at it. Is it not about time that he put his money where his mouth is?

[David Mowat]

The hon. Lady paraphrases what I said rather inaccurately. I said that money would help with any system, but the issues are about quality, leadership and best practice as well. All those things are within the ambit of my job, and that is what I am pursuing.

[Joan Ryan (Enfield North) (Lab)]

Everything we have heard today from the Minister seems fundamentally to deny that the council tax precept is no solution to the problem and in fact exacerbates it. Is he aware that Ray James of the Association of Directors of Social Services has said:

“The Council Tax precept will raise least money in areas of greatest need which risks heightening inequality”?

If that is what experts in the field are saying, why does the Minister think he knows better?

[David Mowat]

I often discuss this and other issues with Ray James. It is true that the precept on its own would result in an uneven distribution of revenue, which is why the additional moneys coming from the better care fund will be allocated using a formula that corrects that.

Cancer Strategy

David Mowat Excerpts

Thursday 8th December 2016 Commons Chamber

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

It is a pleasure to respond to this really important debate. I, too, would like to start by paying tribute to my hon. Friend the Member for Basildon and Billericay (Mr Baron). I wish him and his wife the best in the journey they are on. I have been in this job a few months now and he has been extremely diligent in coming to see me and talking to me to ensure that cancer is, as it should be, right at the top of my radar screen. He also organised, with the hon. Member for Scunthorpe (Nic Dakin), an excellent Britain against Cancer event on Tuesday, which was attended by 400 people.

What has happened to my hon. Friend and his family reinforces what we all know: cancer affects us all. One person is diagnosed with cancer every two minutes. During the course of this debate, 100 people will have received a cancer diagnosis in England. That shows how important the issue is and how we need to make progress. There are a lot of chairs of all-party groups in the Chamber and all Members have spoken from a lot of personal knowledge and experience. I will not have time to respond in detail to every point raised.

I will start by making a generic point that this debate and others like it remind us that our health service is not principally about bricks and mortar. Survival rates are far more important. The hon. Member for Scunthorpe gave a very fair and reasonable introduction to the debate in terms of what the priorities ought to be. On a typical day, when I walk across the Chamber and the Lobby about two Members will talk to me about their concerns in relation to some aspect of hospital reconfiguration or A&E downgrades and so on. Those are fair concerns, which we all need to be concerned about in our own patches. However, I am not accosted by Members saying they are concerned that their clinical commissioning group has lower than average survival rates. Over time, we need to learn to think about them, too. We have not talked about this in any detail, but the Government have published four indicators that rank every clinical commissioning group in the country. The news was not brilliant when it came out, but that transparency is very powerful. We all ought to get used to this being as important to our constituents—arguably more so—than some of the bricks and mortar concerns that we tend to spend our time on.

As I said, the hon. Member for Scunthorpe was fair. I think the phrase he used was that a lot has been done, but that more needs to happen. I think all Members would probably agree with that. A lot of good things are being done. Our one-year, five-year and 10-year survival rates are all improving for all cancer types. What we have learned in this debate is that we talk about aggregate cancer survival rates, but there are very large variabilities. My hon. Friend the Member for Castle Point (Rebecca Harris) made a very good point with regard to brain tumours having a 19% five-year survival rate, against a target for all cancer types of 70%. That is absolutely true. One of the themes of the debate has been that we are making less progress on some rarer cancer types and we need to do better.

We are making progress on early diagnosis. There are eight cancer targets and we are now meeting seven of them. As Members have pointed out, however, not least the hon. Member for Washington and Sunderland West (Mrs Hodgson) who speaks for the Opposition, one very important cancer target is not being met: the 62-day target. The strategy needs to drive and develop that and we need to work harder.

We have been reminded that, in spite of the progress made, we are not, by any means, the best in the world at this. We are not even the best in Europe. Indeed, there is evidence that we are below the average in Europe for most cancer types. It is fair to say that we are catching up in many cases but not in all. In particular, we are not closing the gap with the rest of Europe on lung cancer, which several hon. Members have talked about. We need to be aware of that and focus on it.

As I said on Tuesday at the conference, when I started this role I was struck by the discovery that we had had five cancer strategies in the last 20 years. We can deduce two things from that: first, this is a cross-party issue—all Governments do cancer strategies—and secondly, and more importantly, we do not need another strategy. We do not need more ideas about what we need to do; instead, we need to deliver, with a strong focus, the 96 points set out in the cancer strategy and drive them through over its final four years. We need to make that happen.

The hon. Member for Washington and Sunderland West used a very good phrase when she said we must be “critical friends” in this process, and so we must. Every Member, despite their having different perspectives, needs to support Cally and her team in driving this strategy through. My role is to ensure clear accountability around what is being done, by when and by whom, and to ensure that we have milestones, targets and deliverables. Frankly, though, we have some way to go before we get that as clear as it needs to be. My hon. Friend the Member for Basildon and Billericay has pointed out to me several times that we need to focus on output measures, not on process and input measures, and that, too, is true. It is something we could make work better.

In the strategy, there are six programmes of work, including on prevention, early diagnoses, commissioning, high-quality modern services and, importantly, patient experience and living well beyond cancer. My hon. Friend the Member for Bosworth (David Tredinnick) made some very good points about the overall approach. This is not just a technical matter; we need to get better on patient experience and living beyond cancer. I spoke at an event organised by the all-party group on ovarian cancer. At that event, I met a lady who had been given a prognosis of six months to live, and she told me that she had no support in terms of an ongoing dialogue with a clinical nurse—that clearly is a failure and completely inadequate. My hon. Friend the Member for Bury St Edmunds (Jo Churchill) talked about clinical nurses. Our response, through the strategy, is to put in place cancer recovery packages for everyone with a diagnosis. That is important, although the point was well made about the staffing implications. We need to address that as well, and we will.

A point was made about rarer cancers, particularly brain and blood cancers. We need to make more progress more quickly on research, as we do not have as many answers on those cancers as on others. I am talking not just about research by the Government, but about Cancer Research UK and the other charities. As several colleagues said, the voluntary sector is extremely important, and of course it is. Macmillan, Marie Curie, Cancer Research UK, plus the hundreds of small charities in our constituencies, make a big difference.

We also know that the workforce matters. This is a consistent stream in the strategy and something that it needs to get right.

I was asked by the hon. Member for Scunthorpe in his opening comments how we are holding Health Education England to account on the workforce requirements. I meet Professor Cummings regularly, as does my right hon. Friend the Secretary of State, not just on this aspect of the workforce but on other related responsibilities, such as increasing the number of GPs working in primary practice.

We need to make progress quickly on certain issues. We know that we do not have enough radiographers, for example. The point was made that there is no point in having linear accelerators if we do not have people to work them. That is right, but let us at least be grateful for, and pleased about, the fact that we are now rolling out the linear accelerators that Simon Stevens announced this week at 15 locations in all parts of our country. Endoscopy has been a real area of shortage, and it has been called out as a specific work stream within the 96 aspects of the cancer strategy. We will have 200 extra endoscopists trained by 2020, 40 of whom are already in place, and we will continue to build on that. Workforce generally is of massive importance.

I have not answered all the questions and points raised in the debate. I have not so far talked about the tobacco control plan. Several Members mentioned this issue. All I can say now, I am afraid, is that it will happen soon. That is the answer. The relevant Minister has informed me that she is determined to get this right, and I guess we can all agree that getting it right is indeed important. I am probably as disappointed as some Members that the process of the strategy is not as developed as we would like, but let me say that we are doing a lot on smoking by placing explicit images on packages and that type of thing. We are doing more than many other countries on that, and we should not forget it. It is not all about strategy.

I am about to finish, but I will say that we need to come back to this debate in a year’s time. I hope that the Backbench Business Committee and the chairmen of all the cancer all-party groups will make sure that we have a debate in this place every year about the cancer strategy, so that the Government can be held to account by critical friends. We all need to make sure that we focus on getting this strategy delivered. We absolutely do not need another strategy until 2020, and we will have made massive potential steps forward if we achieve what we have set out.

[David Tredinnick]

My hon. Friend tempts me by saying that he is about to sit down with three minutes to go. May I come to see him to discuss the announcement of the £200 million for support services?

--- Later in debate ---

[David Mowat]

I would be happy to speak to my hon. Friend about that. He made the point that there was no investment in a number of areas. I was briefed that we are putting in £5 million to the two Haven centres that are being put together. I would be happy to speak to my hon. Friend about the £200 million, although I did not agree with every point he made. At this point, I will sit down.

Terminal Illness: Support

David Mowat Excerpts

Monday 5th December 2016 Commons Chamber

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

I congratulate the hon. Member for Newcastle upon Tyne North (Catherine McKinnell) on bringing this debate to the House. This is an important subject and it is good that we have the chance to talk about it.

It is also good, as the hon. Lady said, that we are debating it on the UN’s International Volunteer Day. She reminded the House, if it needed reminding, how much of the palliative care burden is taken up by volunteers. We should all reflect on the fact that there are 6 million informal carers in this country. Without those people, things would be much more difficult. We have a carers strategy coming out in the next few months, which I will discuss during my speech.

The hon. Lady talked about her hospice, the work that the Marie Curie charity does there and the helper service it has pioneered in Newcastle. I am happy to acknowledge the fantastic work that hospices do. I have one in my constituency, St Rocco’s, which also does brilliant work. The hon. Lady used a good phrase: we should recognise that at their best hospices celebrate life. That is important.

The Government’s position is that high-quality, end-of-life care, reflecting individual needs, choices and preferences, should be available to everyone. That is our objective; that is what we are working to achieve. Much is being done, despite perhaps the tone of the hon. Lady’s remarks. However, of course there is more to do: more can always be done. This is not something that will ever be finished, but I want to set the context in which we are working.

[Jim Shannon (Strangford) (DUP)]

The Minister has rightly acknowledged, as has the hon. Member for Newcastle upon Tyne North (Catherine McKinnell), the importance of charities and the work that they do. In his response to the points that she has made, will he say what the Government intend to do for young carers who look after those who are at the end of life? I am aware of the pressure on those young carers given their age, and their ability to cope with the life-changing event that will happen to them and their family very shortly. We need something for them, Minister. Can I make a plea for them?

[David Mowat]

I thank the hon. Gentleman for that intervention. He is right. There are about a quarter of a million informal carers under the age of 25, half of whom are under the 16-to-18 age range. There are issues for education and future employment. The carers strategy is addressing that and I will have more to say about that.

On the context, 480,000 people in England die every year. Thirty-six per cent. of those are over 85 and about 350,000 of those deaths are expected, in the sense that they are not a surprise. Roughly half that number get some specialist palliative care as part of the pathway. The hon. Lady talked about that not being enough, and I will come back to that. Forty-seven per cent. die in hospital, which is an improvement: 57% of people were dying in hospital 10 years ago. There is an emphasis—the charities, particularly Macmillan, are offering a lead on this—on ensuring that fewer people die in hospital.

In terms of authoritative evidence of how that is working—the hon. Lady mentioned some of the points made by Marie Curie—the Office for National Statistics conducts a yearly survey called “Bereaved VOICES”, which looks at how carers and bereaved people evaluate the last three months of the end-of-life care for their loved ones. About 75% of those services are regarded as good, excellent or outstanding. Ten per cent. are regarded as poor. Ten per cent. is 48,000 deaths a year, and that is still too high. Nevertheless, 75% of those services are regarded as good, excellent or outstanding. The highest proportion of those services are in hospices. Care homes rated about the same as hospices, with hospitals doing less well. The figures are patchy, however, and that is generally linked to deprivation. They are not as good in areas of relatively high deprivation as they are in other areas. That is partly because hospice availability is somewhat skewed by the fact that the charities that run them tend to operate in more affluent areas.

The hon. Lady mentioned the need for spiritual and emotional attention at the end of life, and I can tell her that 70% of those who responded to the survey regarded their loved ones as having received good or outstanding spiritual or emotional care. That reflects well on those in the voluntary sector and the NHS who provide that care, and we should acknowledge that.

I do not wish to sound complacent, because I acknowledge that things could and should be better. I have had this job for four or five months, and there are very few of the areas I cover in which the UK could be said to be the best in the world. Let us take cancer outturns as an example. We know that our one-year survival rates for most types of cancer are worse than those of most other countries in Europe. Last year, however, the Economist Intelligence Unit compiled a quality of death index, which evaluated 50 or 60 countries in the world against a number of criteria, and the UK came top in end-of-life care. As I have said, I do not know the situation across all the areas for which I am responsible, but we should acknowledge this finding. To put it into context, Germany came seventh, France came 10th and Sweden came 16th. That has been achieved through the work of people in charities and in the NHS, but we must also acknowledge that things could be better.

The hon. Lady spoke about social care funding—although that is a slightly different area—and about delayed transfers of care and all that results from them. I have acknowledged many times in the Chamber that social care funding is under pressure and that that can cause delayed transfers of care, or bed-blocking, if we want to use that term. However, in terms of adult social care, if we compare the top 10% of councils with the bottom 10%, we see that there is a factor of 30 times in the difference between their performance in delayed transfers of care. That is not related to budgets; it is related to best practice, leadership and all that goes with that. We are sometimes quick to say that money is always the issue, but although that is of course part of it, it is not the only issue. It is important to understand that other factors are involved. Among other areas that need to be improved, we need to continue our drive to ensure that more people do not receive their end-of-life care in hospitals, where they generally do not wish to be. We should also acknowledge that there can be non-uniform commissioning among clinical commissioning groups, and we can do better in that regard as well.

The hon. Lady talked about the choice review, which was produced in 2014 by the National Council for Palliative Care, helped by Macmillan and Marie Curie. It contained some 62 recommendations. The Government’s response came out in July—it was one of the last acts of my predecessor—in the form of a five-point charter. In it, we accepted that we would have personalised care plans in place by 2020, that everyone was entitled to an honest discussion about their end-of-life care and to support in making informed choices, that family and carers would be involved in those choices, and that all people going through an end-of-life process would have an identified contact at all times.

Those elements will need to be implemented right across NHS processes, technologies and pathways, and we have set up the end-of-life care board under Bruce Keogh, the chief medical officer, to oversee that. All arm’s length bodies will be represented on the board. This has not yet been published—it is my role to ensure that it is—but the requirement now is to turn the commitments in the review response into tangible milestones, deliverables and responsibilities. I recently met several members of the End of Life Care Coalition and undertook to have a transparent process so that between 2016 and 2020 we know what we are implementing and when and how that is being done. It is important that that happens. We are extremely committed to it—it is a Government priority. We could do things better as a country, but we do pretty well and we need to do this to make things even better.

[Thangam Debbonaire]

I thank the Minister for his responses to my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell). On that point about the plan for between 2016 and 2020, given that the last days of someone’s life are etched into the memories of those who are left behind—I can remember every single moment of the day 23 years ago yesterday when I lost my father—will the Minister commit to report back to the House at various points over that four-year period, or will he report on progress in other ways?

--- Later in debate ---

[David Mowat]

That is a very reasonable request. That intervention was not quite what I was expecting, but it is entirely reasonable and I will commit to do that either in debates such as this or at Question Time, or whenever. I am unsure whether a statement would be appropriate, but it is a reasonable thing to request of a Minister and I am happy to do it. I will at least write to the hon. Lady on the process, because I am determined that the programme of work will be transparent and meaningful with clear deliverables that achieve what we need to achieve.

In addition to implementing the choice review, other ongoing and day-to-day work needs to happen. The Liverpool care pathway was pretty much supplanted last year by the five priorities for dying people that were mentioned in an earlier intervention. We are trying to embed those things within the structure of the NHS. They exist in training programmes, in Health Education England, and in the choices that people make when working in this sector. It is not rocket science; the priorities relate to sensitive communication, the need for individual plans covering food and drink, and also spiritual things for those who need or want them. Fundamental to all this—it should not really need saying —is that the dying person is involved in all aspects.

We put end-of-life care as a priority in the NHS mandate. Clinical commissioning groups must commission end-of-life and bereavement care, and there are NICE guidelines for that. That does not mean that it is not patchy, as the hon. Member for Newcastle upon Tyne North said, but those are the requirements. When the CQC evaluates care homes, hospitals and hospices, it specifically looks at end-of-life care, and those that want high rankings will need to address such things and work effectively.

I talked about milestones. One important initiative that I expect to come out of the choice review is electronic palliative care records, through which care plans are accessible to the many different workers who need access. I recently saw that happen in London, where the system is called “Coordinate My Care”. The idea is that if a person is in need of an ambulance or paramedic, the paramedic will have access to the care record on the way to the call-out. The record might explain that the person may not want to go to hospital, depending on the issue, and such decisions will become embedded in the process, which is important and good. I want that technology to be rolled out as quickly as possible.

[Catherine McKinnell]

I was concerned at the beginning of the Minister’s remarks that he sounded complacent about this issue, but he does certainly seem committed to making this review work over the next few years. Will he just acknowledge that if the NHS is not able to get the support from the social care sector and is not able to utilise the funding required, it will fail in its efforts? It will fail unless the funding is there within the community sector and the NHS itself in order to achieve what the Minister sets out as a very important strategy going forward.

[David Mowat]

I am getting towards the end of my speaking time, so I will finish by answering that as best I can. Of course money matters, and every process works better if there is plenty of money for it. The facts of the matter are that both adult social care and the NHS are under cost pressures. To be honest, that will always be the case in every system, and I just gently say to the hon. Lady that she may be surprised to know that we spend about a third more on adult social care, which is a particular responsibility of mine, than either France or Germany.

[Catherine McKinnell]

The Minister acknowledged that the challenge in addressing this issue properly is often the patchwork nature of services in our country and the postcode lottery. He also acknowledged that some of the areas that fare the worst are the most deprived, and they are also the areas facing the biggest cost pressures in terms of social care funding. Will he acknowledge that something needs to be done to ensure that that does not undermine these efforts?

[David Mowat]

This is not the autumn statement, and I cannot make commitments on funding other than to say that many Members on both sides of this Chamber would like to see, when the time is right, more funding for our vital public services. I again just gently make the point to the hon. Lady that we spend considerably more on adult social care than countries such as France and Germany, those it would be reasonable to compare us with, and it is not just about money in terms of the delayed transfers of care performance of different councils—it is hugely different.

Let us agree that what really is important is that over the next few years we implement the choice review: what is important is the Government’s commitment to implement that and our clear intent, as signalled by Bruce Keogh leading the implementation board, that we will be held accountable for it. I will be held accountable for it, and I will report back to the House in due course on that.

I thank the hon. Lady for raising this important issue.

Question put and agreed to.

Clinical Commissioning: North Durham

David Mowat Excerpts

Wednesday 23rd November 2016 Westminster Hall

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

It is a pleasure to serve under your chairmanship today, Mr Davies. I, too, congratulate the hon. Member for City of Durham (Dr Blackman-Woods) on obtaining the debate, and I congratulate the other hon. Members who spoke too. It is good to have a chance to discuss the matter and weigh up the pros and cons of what is being done.

The context is the CCG in the hon. Lady’s area, which consists of 31 GP practices. It has been rated as a good CCG by the Care Quality Commission. Its treatment referral time is above the national standard, at 92% within 18 weeks. I want to talk first about the policy area, and then about the specifics of the decision to employ About Health in North Tyneside and North Durham.

The first thing to say about the policy is that referral management is not a new area. In 2007, something like 70% of primary care trusts had a type of referral management system in place. The intention is fairly clear: when a GP is making a referral, it will be absolutely obvious in many cases that it needs to happen. In many other cases it will be clear that a referral is not needed. There will also, frankly, be a grey area in the middle—that will happen in any profession.

[Dr Blackman-Woods]

Will the Minister focus on this specific referral system, under which, we understand, all referrals to specialists from GP practices in the CCG area are subject to private company screening and there is also a target to send back at least 50% of all referrals made?

[David Mowat]

I was explaining the purpose of the policy and the fact that this referral mechanism was used widely in 2007. A King’s Fund report from 2010 sets out the pros and cons of using referral management—I suggest the hon. Lady reads it.

These things are not new. They are a mechanism by which a consultant, or a GP with a specialist interest in the area of what is being referred—there are six areas of referral in this CCG, as the hon. Lady said—has two to three days to either accept that the referral goes on to the secondary system, or to contact the GP and have a discussion about what the best alternative pathway might be. There is an appeals process if the GP does not agree with that decision.

The hon. Lady asked where else such referral management was being done across the NHS in England. It was introduced in 2007, as I said, and it is being done very commonly. It is being done in Bromley, Cambridge, Peterborough, Imperial in London, and Southampton. I saw a similar system in Tower Hamlets to the one working in her area—indeed, the GP was very proud of the way they reacted, with an email referral system, when there was every possibility of things not going ahead.

This is not rationing. It is completely wrong to say that. It was brought in by the CCG, which is GP-led. If the GPs in the CCG do not agree with it, they have the mechanism to replace the chairman of the CCG.

[Mr Kevan Jones]

I understand what the Minister is saying, but what about the patient? Where does the patient come into this? If I go to my GP and he says I need a referral, that is between me and my GP. If it was not for my hon. Friend the Member for City of Durham (Dr Blackman-Woods) or the BBC raising this, none of my constituents—or myself and my hon. Friend, who are patients of the CCG—would have known about it. Will the Minister please answer the point about the patients?

[David Mowat]

The point I was in the middle of making—which I will finish making—is that if the GPs in the CCG have difficulty with the scheme, they have the mechanism to replace the CCG chairman and therefore to not go ahead with the scheme, so the GPs in his area are presumably content with it.

[Mr Jones]

The patients are not being consulted.

[David Mowat]

The fact is that the GPs vote for the head of the CCG who has put the scheme into place. On the patient issue, which is a fair one, if the patient expresses a preference to go to a secondary or an acute hospital and have an appointment, which could typically be six to eight weeks away, of course that is part of the process, and of course the referral management schemes will take that into account.

[Mr Jones]

I am sorry, that is not the case. In North Durham, patients have not been told about it. If I went to a GP who said I needed a referral, I would not be told that. What the Minister is saying is in complete contrast to what he told me during a debate on coeliac disease a few weeks ago, in which he condemned CCGs for not consulting people before awarding contracts.

[David Mowat]

We are moving around a little bit here, but I will come to the point about consultation. The GP that the hon. Gentleman refers to is a part of a CCG that has made the decision to extend the North Tyneside pilot to North Durham. All I am saying is that those GPs are part of the CCG and that presumably the CCG is doing this because it believes the clinical out-turns are right. We have a locally driven system. I will make some progress on the benefits of this for patients.

[Julie Cooper]

Will the Minister give way?

[David Mowat]

I will make some progress; I have taken a lot of interventions.

The benefits to patients are that a consultant will review their case within two or three days of a GP referral and a decision will be made on the appropriate pathway. That is why the King’s Fund recommended these sorts of systems in 2010—in terms of patient out-turns—and that is why it is of benefit to patients.

One example that the hon. Member for City of Durham talked about was a skin case that resulted in cancer. That is a very serious situation, and if it happened in the way that she says, it should be investigated. Another example is when a patient with acne was referred to a dermatologist at a hospital. The referral system said, “Why have we not tried a cream for this first?” That process was put into place two or three days later, as opposed to having an eight-week wait for a specialist appoint. That is of benefit to the patient.

[Julie Cooper]

Will the Minister give way?

[David Mowat]

I have given way a lot; I want to make some progress.

That is also of benefit to GPs, because they can quickly validate decisions on the best pathway for those grey areas that may or may not require a referral with a consultant who knows more than them about that particular discipline. Of course, it is of benefit to the providers because it takes away something like 20% of unnecessary outpatient appointments. Indeed, one of the providers for the scheme in North Tyneside has asked for it to be extended to an additional discipline, because they feel that some of the referrals they receive are unnecessary and that the referral management system—in the way we have been doing it in the NHS for the past decade—is a mechanism for preventing that.

[Dr Blackman-Woods]

The only information that North Tyneside CCG has put into the public domain is how much money it has saved through this system. It has not made an assessment of clinical outcomes for patients at all.

[David Mowat]

I am going to talk about the About Health situation and the people who have been awarded the contract in North Durham. It is a one-year pilot that builds on the one-year scheme in North Tyneside. I think it started last month; it covers six disciplines and it does not cover urgent referrals, in particular cancer. All the national requirements for referral-to-treatment times still count in exactly the same way. The local CCG performed a risk analysis before it decided to take the scheme forward and build on what happened in North Tyneside, and the scheme is monitored.

I have been told that a very important feature is that there is a clear GP appeals process. If they are not happy with a decision that has been taken, that process can happen very quickly.

[Mr Kevan Jones]

What about the patients?

[David Mowat]

The GP represents the patients in the health system; that is the fact of the matter. If there are out-turns that are detrimental to patients, as the hon. Member for City of Durham implied, that is a serious situation and should be investigated.

About Health is CQC-regulated—with all that goes with that—in exactly the same way as a GP practice. It is staffed by NHS consultants and GPs with a particular interest. As I said, there is a two or three-day turnaround, and they have to have the same indemnity cover as everybody else. Part of what the CCG is doing is to save money—that is true. Inappropriate outpatient appointments mean that more people than necessary are working. If that can be reduced, there is a cost saving to the national health service. It is about optimising pathways.

[Mr Jones]

Will the Minister give way?

[David Mowat]

I will make a little bit more progress and let the hon. Gentleman in later.

This is about stopping inappropriate treatment; it is absolutely not about rationing. If it was about rationing, the whole referral management system would not have been first introduced by the last Labour Government. I think it is incredible that that point has not come across more strongly.

One of the concerns is that About Health is a private company. It is a private organisation that has won the contract, and the local CCG made that decision. Fair questions were asked about the confidentiality of patient records, in terms of them going across a boundary to a private company. My first point, which is an obvious one, is that GP practices are all private companies. Every partner that works in a GP practice works in a private company, in the same way that the GPs who work for About Health are working for a private company. However, all the requirements around patient confidentiality that About Health needs to make sure are in place apply in exactly the same way as they do in every other part of the national health service.

[Mr Jones]

The point about that is that I, as a patient, have not given permission for that. The way this has been done—with no consultation, which the Minister says is wrong—means that no one knows what is actually happening.

[David Mowat]

I was going to come to the point about consultation—I do not have a great deal of time left now. It is right to say there was no consultation on this, and that is because this is an administrative process change. There is no service change—

[Mr Jones]

That is absolute nonsense.

[Geraint Davies (in the Chair)]

Order.

[David Mowat]

We are clearly not going to agree on this point, but there is no service change in what is being done.

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

Self Care Week

David Mowat Excerpts

Tuesday 22nd November 2016 Westminster Hall

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

First, I congratulate the right hon. Member for Rother Valley (Sir Kevin Barron) both on leading the charge on this issue and on his work in the APPG. This has been a shortish debate, but there were very good speeches from all hon. Members. In fact, I agreed with much if not all of the speech given by the shadow Minister, the hon. Member for Washington and Sunderland West (Mrs Hodgson), and I will come on to that.

The right hon. Member for Rother Valley rightly talked about the impact that self-care needs to have on demand in the health service. He used a very important phrase that is spot on: in the course of his remarks, he asked why we are not doing more to try to shape the NHS around long-term conditions, given that, as he rightly said, some 70% to 80% of total NHS expenditure relates to long-term conditions, such as diabetes, chronic pain and dementia. As he also rightly said, increased longevity means that more and more people are living with more and more of those conditions. We need to deal with long-term conditions—this relates to a point made by the hon. Member for Linlithgow and East Falkirk (Martyn Day)—on a preventive basis, on a care plan basis, and not necessarily on an ad hoc, repair basis; I think that was the word that he used. Those points are spot on and are why we need to continue to do better in the whole area of self-care.

It is worth reflecting on why, in many ways, the moment for self-care has arrived. The Self Care Forum has been doing a lot of work in this area for a number of years, but I think that there are several reasons why self-care is particularly critical at the moment. One is demography. We are getting older. That is a good thing, but the consequence is that about 1 million more people aged over 75 will be around in 2025. We will have more long-term conditions. That is just a natural feature of ageing. Those long-term conditions are precisely where self-care gives us the biggest bang for our buck, because there is absolutely no need to continue going to see the GP all the time. People have talked about pharmacies, and I will talk about that.

Another reason is that there is a general perception in the population that people are more empowered vis-à-vis their own health and what they will accept from health professionals. We often hear of people saying, “Well, it’s not a question any more of the doctor telling me what I should do, but of having a discussion with the doctor about that.” Where that takes us to, in terms of our expectations of the health service, is a whole load of things around choice and, in particular, personalisation. Self-care also has a role to play in that. Part of it is about not just clinical outcomes, which is where we have come from historically, but out-turns that consider the general wellbeing of an individual.

The right hon. Member for Rother Valley made the point about social prescribing as a big part of that, and it absolutely is. Increasingly, it is important not just that patients with diabetes manage glucose levels and all that goes with that, but that they exercise. It might be just as appropriate for them to be referred to a football team or to talk to someone else with diabetes, in a mentor group. Frankly, social prescribing needs to be commissioned by CCGs as much as some of the clinical things that have happened in the past.

Another area that has made self-care even more prominent, and which is a component of it, is technology. We have not talked yet about technology, but there is a lot more out there. It ranges from people just being able to look at Google, see what is wrong with them and take a view—that can be dangerous and is not always to be recommended, but nevertheless it empowers people in a way that did not exist at one time—to some 900,000 applications to do with health and fitness that have been developed. I believe that iTunes alone has 47,000 health apps. People who are interested in all that stuff—and possibly more IT literate than I am—can use all those, and they do. The combination of those things has meant that the whole ethos of “Doctor knows best” is giving way to much more of a dialogue and a care plan orientation, and a big part of that care plan will be self-care.

What is the Government’s response? That is the challenge that we received from the hon. Member for Washington and Sunderland West. I suppose there are two areas. There is the whole general area of public health. I will not get into a discussion about the relative size of budgets and all the rest of it, other than to say that the Opposition’s position on where we should spend more money versus less money in the health service and anywhere else would be stronger if occasionally they agreed that in some areas it is right to spend less in order to spend more in other areas. If their position is that we must always spend more money on everything, their comments may be taken by Ministers with a bit more of a pinch of salt. I merely say that in passing.

In terms of awareness and education, the right hon. Member for Rother Valley made a good point, which I had not thought of, about health education in schools being a step up from other types of education. There does need to be more awareness, and I will mention a small thing that I became aware of recently. One of my responsibilities is dementia, and I had not realised that obesity is a major factor in someone’s likelihood of getting dementia. I know that now, and perhaps everyone else in the Chamber also knows it, but I suspect that many people do not; I do not think why obesity and dementia go together is that intuitive. That is an example of the need for awareness.

Let me talk about the sorts of things that the Government need to encourage and are encouraging. We have a campaign on stopping smoking—Stoptober. We have “Everybody Active, Every Day” and Change4Life, which involve people taking control of their diet and how they live. I talked about dementia, and there is the dementia friends initiative. There are some 1.7 million dementia friends now. Dementia has become the condition that most people die of in the UK, and dealing with that will be a real challenge in the years ahead.

That is about public health, but we have a whole stack of things to do with clinical outcomes. We have put into the NHS mandate a clear requirement for it to improve its response to long-term conditions, with a clear requirement for self-care to be part of that. That includes the need for more personal health budgets. Some 4,000 people now have a personal health budget; those budgets are analogous to personal care budgets. Our target for 2020 is between 50,000 and 100,000 people having such budgets. That is about choice and about control. Various tools are available for patient activation and to help patients understand the sorts of choices they can make day to day. NHS England has a target of 1.8 million people accessing tools, as well as being assessed on where they see themselves on the self-care spectrum and what they are doing about it.

It is worth talking briefly about the STP process. The shadow Minister made the point that we spend too much on acute healthcare in this country and not enough on primary care, on mental health and on the self-care options that we are talking about, including pharmacy, which I will talk about. The STP process is a precise attempt to make self-care happen in a structured bottom-up way. If the Opposition oppose the STP process at every turn, as opposed to acting as critical friends, which is how all MPs should act, they oppose what could be some very sensible, thought through and locally driven reforms to healthcare that may well result in higher budgets for prevention, which is a point that she made, and a tilt away from our spending so much of our budgets on secondary care and hospitals, which are very expensive.

NHS England has produced a book about self-care that was printed last week. “Realising the value” is about empowering people to make their own decisions about medicine and care and engaging in the community. There is a lot in the book, which was produced by Nesta, that is valuable and good. I guess it is an attempt to embed some of the things that we have been talking about. National Voices, the Health Foundation and voluntary organisations were involved in it.

Social prescribing is a large part of the initiative, which is about peer groups and making sure that people who have a diabetes issue are not overwhelmed by concerns about losing a limb and about glucose levels changing. It is about managing all of those types of things and ensuring people look at their own diet and at whether they are doing enough exercise or sport and are in a group of like-minded people with the same issues. If I were diagnosed with diabetes, it would be valuable to me to talk to people who had had it for a few years. That is as valuable as going to see the doctor and his telling me what I should be doing.

The right hon. Member for Rother Valley made the point that roll-out is patchy. In truth, many things are patchy. All we can do in the centre is try to encourage CCGs to consider the advantages of what they have in terms of their own business case: a reduction in the number of visits to GPs and so on.

On the role of pharmacy, the hon. Member for Linlithgow and East Falkirk rightly said that I was on record as saying that we have something to learn from where Scotland is in pharmacy. I will say it again: I think we have. We are doing our own review in England—the Murray review—of the services we want to see in pharmacies over the next few years. I have absolutely no hesitation or compunction in saying we could learn from Scotland. I do not take a “not invented here” view. A phrase I always used at work was “steal with pride”. If there are bits in the Scottish model that we can take and steal, we will.

On the direction of travel, the right hon. Member for Rother Valley chairs the APPG and he knows my view is that we need to move pharmacies away from predominantly dispensing and being paid for dispensing into a model with many more services in it. That is what we are determined to do. As we go through the process, that is what we will do. A fund of £300 million between now and 2020 has been set up. There is a lot of opportunity, and the hon. Member for Linlithgow and East Falkirk gave us some examples. We have announced two things already: the urgent medicine supply service and NHS 111. If someone is out of medicine, particularly if they have a long-term condition and have not had their prescription revalidated, NHS 111 has historically told them to go and see an out-of-hours GP or even an A&E service in order to meet a doctor to get the problem sorted. We are changing the script so that 200,000 calls a year will be directed to pharmacies, which will be empowered to make a judgment about the patient and will write the prescription and dispense the medicine. That is a big change and that is exactly where we need to go.

We heard from the hon. Member for Linlithgow and East Falkirk about the national minor ailments scheme. In England, we are now committed to rolling that out nationally by April 2018 so that the list of minor ailments that the hon. Member for Linlithgow and East Falkirk talked about will be treated in pharmacies in England. The pharmacist will be paid separately for the consultation and any dispensing that comes from it.

Another service-based activity in pharmacies was announced two weeks ago by Simon Stevens: the sore throat pilot. Pharmacists can do a test to determine whether someone’s sore throat is a bacterial or a viral issue. If it is bacterial, they will send someone to a doctor so that they can have antibiotics prescribed. If it is viral, they will not. As that service is rolled out nationally, it will save 800,000 GP consultations a year, but this all also relies on awareness and all that goes with that.

Diabetes self-care is a big area on which we can make progress. Diabetes is a growing problem and people will benefit greatly from individual care plans and social prescribing. We have changed the GP contract so that when GPs identify type 1 or type 2 diabetes, they put the person on a structured education course. GPs are now being paid for the numbers of people they get on to such courses. A big part of those education courses is explaining better to people how they can self-care.

I was going to talk about technology—I have probably spoken for long enough, but perhaps I will deal with some of the various points that were made. The right hon. Member for Rother Valley asked about the personal allowance in care homes, which he is right to say was not uprated. I will get back to him on the rationale for that. I suspect the reason is, as we know, that the care sector is under financial pressure. However, the money was not cut, but went to the rest of the adult social care budget. A judgment has to be made about what is adequate and where money is best spent, but I will write to him with a fuller answer to his question.

The right hon. Member for Rother Valley also talked about the need for a national strategy on self-care. I have been a Minister for about four months now. My general learning point would be that we need fewer strategies and more implementable plans, and I suspect the right hon. Gentleman would agree. We need to do things, and there are some things that are quite sensible. I have talked about some of them, but they need to happen. We need to go further and faster.

I agreed with much of what the hon. Member for Washington and Sunderland West said. She talked about a wholesale rethink, which is what we are trying to do with the STP process. The Opposition would do well to not necessarily oppose every part of that, but to act as critical friends, as all MPs must. She made good points about making every contact count. She talked a lot about common sense, which I completely agree with. I guess she will not be surprised to know that I am not going to talk to her about the autumn statement; all I will say on money is that the UK now spends more on health as a proportion of GDP than the OECD average. It is about one percentage point less than France and Germany; that is about where we are, and it is clearly critical that we look properly at every area of expenditure and maximise its value. I believe we did so with pharmacy, and we are trying to do it with the STPs, as regards the difference between secondary care and primary care.

The hon. Member for Linlithgow and East Falkirk made the point that in the thrust towards self-care—which is right—we must still be careful to say that people sometimes need to see a doctor. Sometimes there is something serious wrong. Too many people go to the doctor too often with trivial things; but on the other hand people do not always know when they have the initial symptom of something serious—it can be something that looks benign, or a lump or something. It is important to understand that GPs are there to look after such things. We need to be aware of that in the drive towards self-care. I thank the hon. Members who spoke in the debate.

Social Care

David Mowat Excerpts

Wednesday 16th November 2016 Commons Chamber

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

We have had a good debate, with a number of very good speeches from both sides of the House. I will try to respond to the points, or the themes of those points, that have been made.

First, I want to address the accusations, made by Labour Members, of criminal behaviour in relation to the minimum wage not being adhered to. If such evidence exists—I think the hon. Members for Sheffield Central (Paul Blomfield) and for Tooting (Dr Allin-Khan) raised this issue—please bring it to me. I will see that it goes to Her Majesty’s Revenue and Customs. Those involved will be named and shamed. Such behaviour is illegal and is not to be tolerated. I think the hon. Member for Tooting also said she had evidence that a care home or domiciliary supplier was forging attendance sheets. Again, if there is evidence of that I would like it to be brought forward. It should not just be bandied about here in a political way. We should investigate it and we will. If she brings that evidence to me, we will look at it.

One of the big themes in this debate, and one with which Members on both sides of the House can agree, is the importance of carers. The hon. Member for Worsley and Eccles South (Barbara Keeley) spoke about that and, rightly, about the need for a better career structure and clearer training requirements, a point the Cavendish report also addressed. Some 1.5 million people work in domiciliary and care homes, but—this is a very difficult statistic—the annual turnover is about 25%. That is caused not just by poor pay—I am proud to be part of a Government who have increased the pay of many of these people—but by a lack of career structure and, frankly, of regard, and we need to do more on that. She was right to raise it.

My right hon. Friend the Member for North East Bedfordshire (Alistair Burt) made the important point that, as well as the 1.5 million paid carers, there are 1.1 million unpaid carers. In many ways, these are the unsung heroes of the entire system, and we can all agree we need to do better by them. When he was doing my job, he kicked off the carers’ strategy, which we will be coming forward with. It is a cross-Government initiative and will result in concrete actions to make the 1.1 million-strong unpaid carer cohort better off.

Several people talked about finances and money. Of course they are tight. The Secretary of State made it clear that in the last Parliament, in order to respond to the situation we inherited, there were cuts to local government funding. During the course of this Parliament, there will be a real increase in the rate of adult care funding, but that is not to say we do not understand that the system is under pressure. We understand that, as Simon Stevens said, if more money was available, it would be good if it went into the social care system.

Members on both sides of the House spoke about bed-blocking caused by a lack of money, and about delayed transfers of care, and it is true. Of course there is a correlation between the amount of money in the system and the number of delayed transfers of care, but one of the most extraordinary things about the numbers is that, between the best and worst 10% of local authorities, in terms of the number of DTOCs, the difference is a factor of 20 to 25. That is not just about budgets—budgets are not 20 to 25 times different—it is about leadership; about good people doing good work; about spreading best practice; about shared assessments, early discharge and discharge to assess; and about integration in the widest sense, as my right hon. Friend the Member for North East Bedfordshire said. Those councils, local authorities and health systems that have gone fastest and furthest with integration—the holy grail that the right hon. Member for Leigh (Andy Burnham) talked about—are those at the top end of the DTOC statistics. We should all think about that when we say, “We want more money.” We should all think about the reasons for that difference.

I would make another point about finance. An Opposition Member talked about the GDP equation getting worse in this Parliament. That is not true, but I would just make this point: in 2016, the OECD looked at the money spent on adult social care right across the major economies of Europe, and we in the UK spend about 20% to 25% more than other major industrialised countries such as Germany and France. That is not to say that the system is not under pressure in our country—it clearly is—but the facts are that other countries do a better job in terms of long-term saving, social insurance and some of those types of things. We clearly have an issue with this. Let me repeat that Germany and France, which in the round spend more on the entire health system than we do—about 1% more as a proportion of GDP—spend 25% to 30% less on adult social care. It is critical to spend what we can spend better.

[Andy Burnham]

I hear what the Minister says, but it seems to me that, in common with the Secretary of State, he is avoiding the main issue. The main issue is the urgent financial crisis that councils are facing. They have not got enough money to care for the people who need care. Will the Minister answer a direct question? Has he or the Secretary of State made a submission to the Treasury for more funding for social care as part of the autumn statement—yes or no?

[David Mowat]

We are not having the autumn statement today, and we are not going to give a commentary on what will come out of the autumn statement. We—the Secretary of State and I—have accepted that the care system is under pressure. I was just making the point that other countries spend less, and that we need to spend every penny we can as effectively and as well as we can. During the course of this Parliament, moreover, there will be a real increase in the amount of spending on social care.

[Several hon. Members rose—]

[David Mowat]

Let me make some progress, and I shall give way again later.

Another theme has been closure. Several Members have talked about contracts being handed back, and there is a bit of that going on in both domiciliary care and care homes. Let me put on record the fact that the number of bed places in care and nursing homes is broadly the same as it was five years ago. There has been no reduction. As for domiciliary care providers in the market, the number is now 47% higher than it was five years ago. There has been, rightly, a trend away from care homes to domiciliary care—and we should all welcome that, because people broadly want to spend more time in their own homes. I was asked a good question about the issue of 15 minutes of domiciliary care and what we are doing about the problem. When the CQC is doing its quality reviews, it has a specific question to ascertain whether 15 minutes is the norm, and if so, it would result in a poor quality assessment.

Members have raised broader issues of quality. Let me therefore say that 72% of care homes—a sector that is under a great deal of stress—are good or outstanding. This Government have been the first to do any kind of inspection to find that out. Of course some care homes are inadequate. As the Secretary of State said, inadequate care homes go into special measures and can be closed down after six months. That is the right thing to do, and we should be pleased and proud that that happens.

Also, users of care homes have been asked whether or not they are satisfied, and just under 70% said that they are either extremely satisfied or very satisfied with the level of care provided for them. Members of all parties should come together on this point and thank the people who work in these care homes for the dedicated care and the humanity that they provide.

The former Minister, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), who is no longer in his place, talked interestingly about the vanguards, the STPs and what we are doing to bring in leading-edge better care models. A lot of work is being done on the STPs, and I heard a couple of Opposition Members say favourable things about their STPs.

The hon. Member for Halton (Derek Twigg) asked me a number of specific questions about his STP. I will probably not have time to answer in detail, but I can say this. His STP and my STP are the same, and it is being published today—[Interruption.] It is certainly not secret, and we should have some dialogue about it. The hon. Gentleman made the point that his council was under pressure, and councils are under pressure. I think we should join together to congratulate both Halton and Warrington Councils on being two of the best performing councils in the country on delayed transfers of care and on increasing their budget.

I finish by—

Oral Answers to Questions

David Mowat Excerpts

Tuesday 15th November 2016 Commons Chamber

[Fiona Mactaggart (Slough) (Lab)]

4. What the average time taken is between referral and treatment for patients with (a) ovarian and (b) bowel cancer; and if he will make a statement.

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

The figures for times between referral and treatment are published against the standard whereby 85% of patients should begin treatment within 62 days of GP referral. The September 2016 figures were 69% for bowel cancer and 75% for ovarian cancer.

[Fiona Mactaggart]

Is it not the case that only skin cancer and breast cancer referrals are meeting that 62-day target? Is it not unsurprising that the survival rate over 10 years is 78% for breast cancer and 89% for skin cancer, whereas it is 35% for ovarian cancer and 57% for bowel cancer? How does the Minister feel about these excess deaths, and what is he going to do to ensure that people with these cancers are treated in time?

[David Mowat]

There are eight cancer standards for waiting times and we are consistently meeting seven of them, as we did in September. The right hon. Lady is right to say that the 62-day waiting time has been challenging, and that has an impact on bowel cancer and ovarian cancer. It is also true, though, that one-year, five-year and 10-year survival rates for bowel and ovarian cancer are improving significantly. However, we do need to go further. That is why all 96 recommendations of the Cancer Taskforce have been accepted—we are investing up to £300 million to make that happen—and there is going to be a new test whereby all patients will be either diagnosed or given the all-clear within 28 days.

[Simon Hoare (North Dorset) (Con)]

I refer to my entry in the register. Does my hon. Friend agree that research will defeat bowel and gastrointestinal tract cancer, and may I invite him to congratulate Bowel and Cancer Research on its fundraising and support for the cancer research community?

[David Mowat]

My hon. Friend is quite right: research, in the end, is the way we will beat cancer. This country is ahead of all countries in the world in terms of the number of trials going on, including the US. The voluntary sector, including the charity to which he refers, makes a big impact and I congratulate it.

[Tim Farron (Westmorland and Lonsdale) (LD)]

I lost my mum to ovarian cancer just a few years ago. She received outstanding treatment at the Rosemere centre in Preston. That is the centre that my constituents need to travel to for radiotherapy for all forms of cancer, but an average round trip to receive treatment takes about two hours. Does the Minister agree that that is not acceptable, and will he support the Rosemere centre in setting up a satellite unit at Kendal hospital, so that people in south Cumbria can get treatment quickly?

[David Mowat]

I certainly agree with the hon. Gentleman that two hours is a long time. His is a large constituency and I am very happy to look at his specific point and to revert to the House.

[Mr Peter Bone (Wellingborough) (Con)]

Like the hon. Member for Westmorland and Lonsdale (Tim Farron), I lost my mother to ovarian cancer. One of the reasons is late diagnosis and it has been suggested that cervical smear results should state that it is not a test for ovarian cancer. Will the excellent Minister update the House on his research on that proposal?

[David Mowat]

My hon. Friend is right to say that one of the big issues with ovarian cancer—we talked about this earlier—is that early diagnosis does not happen as quickly as it should. It is true that the cervical cancer test could raise awareness of ovarian cancer. We are looking at the issue and will revert to the House.

[Jim Shannon (Strangford) (DUP)]

Ovarian cancer accounts for some 12% of all new cases, and early diagnosis is critical. What discussions has the Minister had with the devolved Assemblies to co-ordinate and make available better treatment options, to provide a truly UK-wide NHS?

[David Mowat]

This is a reserved matter, but the hon. Gentleman is right to say that early diagnosis is the single most important thing that we need to do better in order to improve our cancer out-turn rates, and that dialogue continues.

[Michael Fabricant (Lichfield) (Con)]

Is it not rather unfair to compare outcome rates for skin cancer, with which I was diagnosed, with those for other types of cancer, because it is easier to diagnose skin cancer at an early stage, which means that the outcomes are usually very good?

[Michael Fabricant]

Yes, because it is easier to diagnose at an early stage—that is the point I am making. Compared with 2010, are we not seeing more than 26,000 extra outpatients a day?

[David Mowat]

Compared with 2010, we are referring an average of 800,000 more people urgently for cancer treatment. My hon. Friend is also right to say that both skin and lung cancer have more straightforward pathways than ovarian and bowel cancer, but that is not to say that we should not focus on continually improving in relation to the points made by the right hon. Member for Slough (Fiona Mactaggart).

[Stuart C. McDonald (Cumbernauld, Kilsyth and Kirkintilloch East) (SNP)]

5. What steps he is taking to implement his Department’s childhood obesity strategy.

--- Later in debate ---

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

The STPs are a collaborative local effort, involving providers and commissioners coming together with other stakeholders to produce place-based plans. The vast majority of plans have been developed jointly between the health sector and local authorities. Several plans have been led by local government.

[Ms Eagle]

Yesterday, the King’s Fund rightly characterised what is euphemistically called the sustainability and transformation project as being planned in secret, behind the backs of patients and the public. In Merseyside and Wirral, we know from leaks that the Government are going to cut £1 billion from our local national health service, which, despite rising demand, will close hospitals, downgrade many accident and emergency departments and possibly leave the whole of Wirral without an acute hospital. Will the Minister now come clean and publish these plans in full, and will he undertake to visit Wirral so that my constituents in Wallasey can come and have a word with him about his plans for their NHS?

[David Mowat]

To be clear, every single STP will be published by Christmas. About 12 have been published so far, and the Cheshire and Merseyside STP will be published tomorrow. When the hon. Lady has access to it, she will see that some of the statements she is making are just scaremongering. She mentioned the King’s Fund, so let me quote it:

“The King’s Fund continues to believe that STPs offer the best hope of delivering long term improvements to health and care services.”

That is what the King’s Fund says.

[Peter Heaton-Jones (North Devon) (Con)]

20. Will the Minister ensure that NHS managers undertaking the STP process affecting North Devon are fully aware of my constituents’ concerns, especially in relation to our geographical isolation? In particular, will he ensure that they are aware of their concerns in Ilfracombe, which has suffered from decades of health inequality because of its location?

[David Mowat]

It is vital that every STP engages with all stakeholders, and that includes North Devon. The public and, indeed, MPs should engage in the process as critical friends to try to make these plans better.

[Norman Lamb (North Norfolk) (LD)]

Despite reassurances, there are still concerns that mental health remains peripheral to STPs in many areas. Will the Minister provide some further reassurance, because unless the Government absolutely insist that mental health is central and that resources are focused on prevention in mental health, these plans will simply fail?

[David Mowat]

I give the right hon. Gentleman the categorical assurance that better mental health is a fundamental part of what the STPs are trying to achieve, as are better cancer outcomes and better integration of adult social care. If an STP does not include those things, it will have to continue to evolve until it does.

[Richard Fuller (Bedford) (Con)]

The Mayor of Bedford, Dave Hodgson, and I have a common approach to the STP in Bedford—it is ably led by Pauline Philip, the chief executive officer of Luton and Dunstable hospital—but he is frustrated that he is not being involved and that his voice is not being heard in the process. Will my hon. Friend ensure, when he reviews all the STPs, that he gets a guarantee in every single case that the local authorities have bought into the plan, and, if not, that they will not proceed?

[David Mowat]

I give my hon. Friend the categorical assurance that if local authorities and the NHS managers doing the planning work have not engaged properly, the plan will not be considered to be complete. That does not mean that every local authority has a veto on its STP.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

Following on from that point, the Minister has previously said that STPs will

“not go ahead if councils believe they have been marginalised.”

Given that seven councils in London and west Yorkshire have already rejected their STPs and, as we have heard, that council leaders from both main parties have expressed concerns about the Cheshire and Merseyside proposals, does the Minister have a plan B when it comes to rejected STPs?

[David Mowat]

In a previous answer, I made the point that every local authority should be engaging with its STP, and the NHS must ensure that that happens. That is not the same as saying that every local authority has a veto on the STP, which was the implication of the hon. Gentleman’s point.

[Tom Blenkinsop (Middlesbrough South and East Cleveland) (Lab)]

7. What assessment he has made of the effect of changes to local authority social care budgets on the level of delayed discharges from hospital.

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

The Government are giving councils access to a further £3.5 billion for social care by 2019, which will mean a real-terms increase over the lifetime of this Parliament. The causes of delayed transfers of care are complex and, frankly, vary considerably by local council.

[Tom Blenkinsop]

The Care Quality Commission has commented that social care is on the verge of collapse. The Government have had six years of warnings in relation to this matter, yet they have cut £4 billion from the social care budget. Will the Secretary of State for Health be talking to his colleague the Chancellor of the Exchequer to ensure that the £4 billion is replaced in the autumn statement?

[David Mowat]

The system is under pressure but we also know that the best way to achieve the best results is faster integration, and not just money. I will give the hon. Gentleman an example. There is a massive disparity between councils. The best 10% of councils have 20 times fewer delayed transfers of care than the worst 10%. It is not just about money, as the budgets are not 20 times different. Indeed, many councils have been able to increase their budgets, including Middlesbrough.

[Dr Sarah Wollaston (Totnes) (Con)]

The Minister is aware of the Health Committee’s concerns about the effect of underfunding of social care on the NHS. He may also be aware that there are particular concerns in my area and in the constituency of my hon. Friend the Member for Torbay (Kevin Foster) because of the recent Care Quality Commission rating of Mears Care as inadequate. Coming on the back of community hospital closures in Paignton, that gives grave concern to all our constituents. Will the Minister meet me and my hon. Friend the Member for Torbay to discuss this further?

[David Mowat]

My hon. Friend is right that there was an inadequate CQC rating for that care home. It is therefore right that the care home must either improve or go out of business. That is what the CQC regulatory environment will ensure. She makes a point about the issue with the hospital in Paignton; that is out for consultation at the moment, and I would expect the local care situation to be part of that consultation.

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

The National Audit Office report “Discharging older patients from hospital” said that

“there are…far too many older people in hospitals who do not need to be there”.

Delayed discharges reached a record level in September. The Minister says that this is complex, but I can tell him that the main drivers for that increase were patients waiting for home care or for a nursing home place; those issues are both related to the underfunding of social care. Does he agree with NHS England chief executive Simon Stevens that any extra funding from Government should go into social care?

[David Mowat]

As I said earlier, we accept that the system is under pressure, but we also make the point that there is a massive disparity between different councils. Some 13% of local authorities cause 50% of the delayed transfers of care—DTOCs. The real point is that those local authorities that go furthest and fastest in integration, with trusted assessors, early discharge planning and discharge to assess, have the most success.

[Sir Hugo Swire (East Devon) (Con)]

Northern, Eastern and Western Devon clinical commissioning group is already consulting on the possible closure of community beds across Devon. The social care budget in East Devon, an area of elderly people, and the rest of the county is already under severe pressure. That pressure will inevitably increase if community beds are closed. Will the Secretary of State therefore commit to putting those points to the Chancellor of the Exchequer in the run-up to the autumn statement?

[David Mowat]

The Secretary of State has already made the point that we do not give a running commentary on the status of discussions with the Treasury, but I accept my right hon. Friend’s point about his local issue.

[Alan Brown (Kilmarnock and Loudoun) (SNP)]

9. What assessment he has made of the performance of NHS England in meeting A&E waiting time targets in the last 12 months.

--- Later in debate ---

[Jeff Smith (Manchester, Withington) (Lab)]

11. What assessment he has made of the effect of changes to local authority social care budgets on the demand for health services.

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

Social care plays a vital role in keeping people healthy and independent, which is why the Government are making a further £3.5 billion available by 2020—a real-terms increase over the lifetime of this Parliament. There is an overlap between care and health, which is why faster integration is our major priority.

[Jeff Smith]

The Secretary of State’s Conservative predecessor, Stephen Dorrell, has said this month that we are increasingly using our acute hospitals as “unbelievably expensive care homes”, and he described this as a “grotesque waste of resources”. Is it not the case that the Government have simply outsourced the hardest decisions on social care cuts to the hardest-pressed local authorities to ensure that councils get the blame, not the Government, and that ultimately it is the NHS that suffers?

[David Mowat]

As I said earlier, we agree that the social care system is under pressure, but we also make the point that there is a massive disparity between the performance of different parts of that system. For example, Manchester, the hon. Gentleman’s own patch, has a DTOC performance seven to eight times worse, per 10,000 patients, than Salford, in spite of the 15% increase in its budget this year.

[Caroline Ansell (Eastbourne) (Con)]

A small-scale study by Professor Peter Fleming has recently made the press. It links cardiorespiratory compromise in new-borns with sleeping in car seats for prolonged periods—over 30 minutes. Given that for many Eastbourne babies, one of their first life experiences is the journey home from Hastings hospital, which is longer than 30 minutes, will the Department look at these findings, consider whether further study is required and offer reassurance to parents rightly concerned by the research?

[David Mowat]

This is a very difficult case. The Department will look at the evidence and revert to the House.

[Mr Speaker]

That was very dextrous handling of a very broad interpretation of the question on the Order Paper, but I hope that honour has been served.

[Helen Jones (Warrington North) (Lab)]

14. The Cheshire and Merseyside sustainability and transformation plan relies heavily on more care in the community. Does the hon. Gentleman accept that this will not work while local authority social care is being cut to the bone, because it will merely send people back to their own homes, where their health will deteriorate?

[David Mowat]

The Cheshire and Merseyside STP will be published tomorrow, and we will all know better then what it says. The hon. Lady is right that there is an interaction between social care and health, but she and I, as Warrington MPs, must both be pleased that Warrington is one of the top performers in terms of delayed transfers of care, and on that we should congratulate our local authorities.

[Jason McCartney (Colne Valley) (Con)]

12. What discussions he has had with NHS England on the reconfiguration of A&E units.

--- Later in debate ---

[Henry Smith (Crawley) (Con)]

T7. The anti-coagulation service at the Furnace Green general practice was recently moved to Crawley hospital, which has caused concern to some local patients. Will a member of the health ministerial team agree to meet me to discuss that further?

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

I understand that the clinical commissioning group has provided an alternative which is no more than two miles away, but I should be happy to meet my hon. Friend to discuss the matter.

[Stuart Blair Donaldson (West Aberdeenshire and Kincardine) (SNP)]

Climbing obesity rates are expected to lead to increases in type 2 diabetes, cardiovascular disease and the need for joint replacements, which will put even greater pressure on the NHS. Given such threats to health, does the Secretary of State really think that now is the time for timidity and sucking up to business?

[Antoinette Sandbach (Eddisbury) (Con)]

T8. General practices in Winsford are being underfunded by 3.6% in terms of the formula that should apply to them because of the slow rate of change, while nearby Merseyside practices are being overfunded by 5%. That is resulting in a £30 million loss to my local surgeries. Will the Minister commit himself to looking into it and introducing a quicker rate of change, so that local residents can benefit from the funds that they should be receiving?

[David Mowat]

In 2016, the Government implemented a new formula for allocation, which means a better deal for underfunded areas such as Winsford. As my hon. Friend has noted, however, the extra money is being phased in over a few years to prevent distortions. This year her local CCG received an increase of more than 3%, and the funding will continue to catch up as a result of the new mechanism.

[Mr George Howarth (Knowsley) (Lab)]

The Minister rightly said that greater integration between health and social care was a prize worth striving for. Why do local government leaders on Merseyside feel that they have been excluded from discussions about the STP process? If we are to make progress, they need to be part of the solution.

[David Mowat]

As I said earlier, local engagement with all stakeholders is necessary. The STP for Cheshire and Merseyside will be published tomorrow. It is essential for local authorities to engage in it as it evolves, and it is essential for MPs to engage in it—as critical friends—to make the plans better.

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

T9. According to a report published recently by the British Lung Foundation, 1.2 million people are suffering from and have been diagnosed with chronic obstructive pulmonary disease, while many more sufferers have not been diagnosed. Will the Minister support the establishment of an independent respiratory taskforce to help diagnosis and improve lung health for everyone?

--- Later in debate ---

[Matt Warman (Boston and Skegness) (Con)]

Shared care allows GPs to provide complex prescriptions for drugs such as methotrexate, but in my constituency the Beacon surgery recently withdrew from those arrangements. Can the Secretary of State assure me that the Department will support not only patients who now face potentially longer round trips, but GPs themselves, so that they can continue to provide those vital services?

[David Mowat]

The arrangement my hon. Friend describes is a special relationship whereby a GP agrees with a hospital consultant to prescribe complex drugs which are normally only hospital-prescribed. This is not part of the standard GP contract and they cannot be required to provide this service. On the specific issue raised, we have asked NHS England to determine whether there are alternatives and I will revert to my hon. Friend on that.

[John Cryer (Leyton and Wanstead) (Lab)]

Is the Minister satisfied that the National Institute for Health and Care Excellence procedures for the approval of anti-cancer drugs are sufficiently speedy, because the waiting times for approvals can be months or even years, and there is a widespread feeling that that is too slow?

Leaving the EU: NHS Funding

David Mowat Excerpts

Tuesday 15th November 2016 Commons Chamber

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

I congratulate the hon. Member for Streatham (Mr Umunna) on securing the debate, and on the points that he made. Like him, I voted and campaigned for the remain side, and, like him, I accept the result. I am now part of a Government who are responsible for delivering what was democratically decided by the British people. I should say at the outset, however, that I am speaking today for the Government and not for the leave campaign. If the hon. Gentleman feels that he is taking part in the wrong debate, I apologise for that in advance.

I will, however, address some of the points that have been made about the impact of Brexit on the NHS, because valid points were made about staff morale, the level of funding and the exchange rate. All those are variables, and I think it is good for us to spend a bit of time talking about them this evening. I will also talk about what stage I think we have reached on the pledge and the amount of money that we will no longer be giving to the European Union when we leave—although, as the hon. Gentleman knows, that depends on how we leave, and on the nature of the agreement that we eventually reach.

Let us begin by agreeing on one point. The single most important thing that the NHS needs to be properly funded is a strong economy. To the extent that Brexit may have positives and negatives, that fact is relevant, but the NHS is properly funded at the moment. We have heard some stuff about budgets and all the rest of it, but let me tell the hon. Gentleman that the OECD’s analysis of health and social care spending in every OECD country shows that we are now above average, although that has not always been the case. We are possibly 1% lower than the best of class, including France and Germany. That figure was for 2014, and the gap is likely to have been filled because this year we gave an increase to NHS spending of three times the rate of inflation and we have pledged that NHS England’s budget will increase in real terms by £10 billion between now and 2021. I do not believe Brexit will make any difference to that; indeed it is a commitment and priority of this Government that it will not.

We do know, however, that there are issues in how that money is allocated within the NHS. We are broadly at the average point of the OECD, and we do and could spend that money more efficiently and effectively. We could spend more on primary care, cancer and mental health than we do, and those are Government priorities, and we hope the sustainability and transformation plan process will help to deliver that because at the moment we spend too much on acute care.

Of course we can find efficiencies, too. Agency staffing is too high and we need to address that. There is a lot we can do on procurement—Carter and new care models and all that go with that.

[Stella Creasy]

The Minister could also work to renegotiate the private finance initiative loans that are crippling our NHS, and not use PF2 to do that. In order to do that, we need money in the NHS to be able to renegotiate. Surely the £350 million would help get us to that place; it would help us to renegotiate our debt, get our constituents back into work and get our NHS fit for purpose in the 21st century?

[David Mowat]

Nobody in this House would be more pleased than me if we did not have the PFI millstone around our neck. The hon. Lady talks of renegotiation; this is real money, and these are real contracts that were signed more or less entirely by the last Labour Government. There is no magic wand that enables us just to set those PFI contracts aside, although I wish there was; that is not how the commercial world works.

[Mr Umunna]

I am sure the Minister will be aware that the £10 billion figure for increased funding he has just cited is rejected by the cross-party Select Committee on Health. It is also very well him referring to what he alleges are increases in NHS funding, but the other cuts his Government have made over the last five to six years, in particular to local authority budgets, have put huge pressure on social care, which has led to a knock-on impact on the NHS and its funding.

[David Mowat]

The hon. Gentleman mentions social care, and that is fair. It is funded separately to the NHS, and the budgets are separate. During the course of this Parliament the social care budget will increase in real terms. I do accept that the social care system is under pressure, but there is a massive disparity in performance in social care between councils. The top 10% of councils are about 20 to 25 times better in terms of outcomes for delayed transfers of care and so forth than the bottom 10%. There are many facets to this, therefore, but I accept the basic point. I think that, all other things being equal, Members on both sides of the House would like the NHS to have more money; let us agree on that and see how we make progress on it.

Brexit introduced a number of variables that may not have been there before. What will be the impact of Brexit on our economy? Our GDP in three or four years could be higher, but also could be lower, because of Brexit. The truth is that neither the hon. Gentleman nor I knows the answer to that. There are different views on that in this House, too, although some with other views may not be here today. This is important and relevant because if the economy were to have a significant difficulty, that could impact on spending commitments.

The second variable is a very substantive one and was mentioned earlier: the exchange rate. Our exchange rate went down about 15%, principally, it would seem reasonable to say, as a consequence of Brexit. That is a good and a bad thing for the economy. Many countries in the world are trying to get their exchange rate down. I represent a constituency in the north of our country where we have a more manufacturing-based economy. Frankly, a lower exchange rate will help the economy there. That may not be the case in other parts of the country and in the City.

The exchange rate has an impact on the NHS. In fact, it has two impacts. As the hon. Member for Nottingham South (Lilian Greenwood) mentioned, it will be more expensive to import products such as scanners and, potentially, to import drugs. She asked what the figure was, but I cannot give her an exact figure. My understanding is that it is considerably less than 5% of the total NHS expenditure of about £100 billion. Nevertheless, this is a relevant factor and it makes a difference.

The other impact of the exchange rate, which the hon. Lady did not mention, is that it will affect the attractiveness to overseas workers of the UK economy in general and the NHS in particular. If someone comes in from the EU to work in our economy and the value of the pound is 15% lower than it was a year ago, they will be earning 15% less in their home currency. That will have an impact on the margin in relation to staffing, and that is an issue that we need to manage.

The third variable is the one that we have spent so much time talking about—namely, the payment that we make to the EU. I am not going to get bogged down in the numbers, but I believe that we pay the EU about £20 billion a year, of which we get roughly £10 billion back. Leaving the EU would therefore create a bonus. The hon. Member for Streatham mentioned a letter. Even if that bonus were to materialise, as I expect it to, it will not happen until after we have left the EU, so his writing a letter to the Chancellor now strikes me as somewhat symbolic.

[Mr Umunna]

To be absolutely clear to the Minister, the ask was that the Chancellor should set out the path for achieving this payment after we have left. I want to ask the Minister two questions. First, given his view that the pledge to make a payment to the NHS was made not by the Government but by the campaign, would he say that it was wrong for people to go around giving the impression that the Government would dish out that money? Secondly, for the record, is he saying that this Government will not meet that pledge?

[David Mowat]

Just for the record, I am not saying that this Government will not meet it. All I can say is that this Government have yet to decide how they will spend any bonus that comes from any rebate we get. This will all depend on the precise negotiations that take place and the precise type of exit that we make from the EU. Nobody in this Chamber knows the answers to those questions. For example, we could get a Norwegian-type deal that could entail paying money to the EU. I am not a member of the Department for Exiting the European Union and I do not know where the current thinking is on that, but this is of course a variable.

[Mr Umunna]

Given what the Minister is saying, does he believe that it was wrong to go around giving people the impression that all they needed to do was vote to leave the European Union in order for £350 million a week to be dished out to the NHS?

[David Mowat]

Had I been writing something on the side of the bus, and had I been campaigning on that cause in the referendum, I might have been more circumspect. I might have said that £350 million could become available and could be spent on whatever the Government’s priorities were, one of which was very likely to be the NHS. I hope that that satisfies the hon. Gentleman.

[Mr Stewart Jackson (Peterborough) (Con)]

I regret that I seem to have stumbled into a sort of elongated primal scream therapy session involving refighting last June’s referendum. The hon. Member for Streatham (Mr Umunna) would have a more persuasive and cogent argument if he saw the other side of the equation. Yes, EU workers have a massive impact on and are committed to the NHS, but unrestricted EU migration over a number of years has put massive strains on the delivery of our health services. He has never conceded that point.

[Mr Umunna]

That is not what I am talking about.

[David Mowat]

I want to make some progress in the debate, although I understand that I have until 7.30.

We have mentioned the payments to the EU, and there is also the point about staff. Another point that has not been mentioned—I shall mention it for completeness—is that there will be an impact on EU institutions. For example, the European Medicines Agency is located in London, which is of benefit to our pharmaceuticals industry. Where it ends up should be an issue for the people negotiating this deal, because of the potential impact involved. From my point of view, we talk too often about the conditions in relation to the EU for the City of London and passporting and all that goes with it, but not enough about other world-class industries, one of which is pharmaceuticals. I hope that those responsible will listen to that.

We have talked about the economy, which is a big variable. To be frank, neither I nor the hon. Member for Streatham knows whether the economy will be better or worse as consequence of leaving the EU, but it is true that the 15% fall in the value of the pound is helping manufacturing firms in the north and will have an effect on GDP, but it will also have some effect on imports of, for example, scanners, accelerators and drugs.

The NHS is hugely reliant on staff from the EU. Some 58,000 people from EU countries work in the NHS, and another 90,000 work in social care. I want to take this opportunity to reiterate the Government’s position that we understand that massive contribution and know that it is important to our NHS that it continues. The Secretary of State said exactly that to the Health Committee and the Prime Minister has said that she hopes and expects citizens from the EU to stay in our vital services. I would like—perhaps the hon. Gentleman and the group he is speaking for today can help with this—some of our EU colleagues and friends to make a similar commitment about people from this country who are working in EU countries, because that has not yet happened.

[Mr Umunna]

I speak for my constituents above all others whenever I speak on such issues in this House. On that specific point, will the Minister explain why the Government do not simply guarantee the right to stay of EU citizens working in our health service? I understand the demand for the reciprocal right to be given to UK citizens living in other EU countries, but they should not be used as a bargaining chip. When the Immigration Minister appeared before the Home Affairs Committee, he admitted that we do not know where most of the EU citizens are in this country or who they are, so if we were not to deliver on the promise to guarantee them the right to stay we would have no way of removing them.

[David Mowat]

It is not for me to make that specific guarantee. The Prime Minister clearly said that she hopes and expects them to remain. It is disappointing that a similarly strong statement has not been made by any Head of State in any other European country.

It is also right that we do more to train more of our own nurses and doctors—not because we need to replace people from the EU, but because it is the right thing to do. We should try to become self-sufficient in these matters, and that will happen.

We have knocked around this point quite a lot during the debate and have talked about variables such as the exchange rate, GDP and the EU bonus or payment that we will get, but there is one thing that is not a variable and it is probably the single most important constant: the extent to which this Government give priority to the health service in their spending commitments. That constant is absolutely clear. The previous Prime Minister treated the NHS as his No. 1 commitment, as does the current Prime Minister. Many of the points we have discussed this evening are things that should properly form part of the negotiation that we are going to have after we trigger article 50, as we hope to do by the end of March, and I am certain that that will be the case. What is not negotiable is that our commitments to NHS funding and social care funding are unmoved by any of these things; this is the No. 1 priority for this Government.

[Mr Jackson]

Is it not the case that in the future dispensation after Brexit we might have a fairer system of recruitment and retention of NHS staff? In all our constituencies, we have staff from outside the EU—my constituency has Nigerian, Ghanaian and, in particular, Filipino nursing staff—who have hitherto been discriminated against inadvertently vis-à-vis those from the European Union, and we will have a much fairer system in reaching out and getting the brightest and best to work in our NHS in the future.

[David Mowat]

My hon. Friend uses the word “fairer”, and of course we do have staff from other parts of the world. I will be honest and say that part of me has difficulty with this country taking large numbers of doctors and nurses from places such as Nigeria and others parts of Africa that need them more than we do. So it is right that we try to train more of the people that we need in these vital public services, but it is also right that we make it absolutely clear how important the people who currently work in our NHS and in social care are—those from the EU and from outside it, as my hon. Friend reminded us. That is important.

I make the point again, because I will not go on until 7.30 pm, that the NHS is this Government’s No.1 spending priority and it will continue to be so.

Question put and agreed to.

Community Pharmacies

David Mowat Excerpts

Wednesday 2nd November 2016 Commons Chamber

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

I beg to move an amendment, to leave out from “NHS services” to the end of the Question and add:

“welcomes the Government’s proposals to further integrate community pharmacy into the NHS, including through the Pharmacy Integration Fund, and make better use of pharmacists’ clinical expertise, including investing £112 million to deliver a further 1,500 pharmacists in general practice by 2020; supports the need to reform the funding system to ensure better value for the taxpayer; and welcomes the establishment of a Pharmacy Access Scheme which will ensure all patients in all parts of the country continue to enjoy good access to a local community pharmacy.”.

I welcome the opportunity to set out again the Government’s approach to pharmacy in general and community pharmacy in particular over the next few years. I will also address some of the points that we just heard, which were, frankly, alarmist scare-mongering.

The proposals I announced two weeks ago are directed at four main areas: first, the need to better integrate pharmacy with GPs, primary care and the NHS more widely; secondly, the need for the existing community pharmacy network to move from a dispensing-based model to a value-added services-based model; thirdly, the need to continue to work with NHS England to ensure value for every penny we spend on the NHS; and fourthly, the need to ensure that, as we undertake these reforms, everybody in the country continues to have ready access to a community pharmacy.

First, on integration with the NHS, especially in general practice, over the weekend Simon Stevens, the NHS England chief executive, again reiterated the importance of that and why he supports this process. We know we need to expand the number of GPs, and by 2020 we will have a further 5,000 doctors working in this area, but as well as recruiting and retaining more doctors, we need to provide them with further support. The “General Practice Forward View”, published by NHS England, has set out fully costed plans to recruit a further 1,500 clinical pharmacists into GP practices by 2020. By then there will be one pharmacist working within a GP practice for every 30,000 of population. Most of these will be prescribing pharmacists, and all will have a role in performing medicine reviews and leveraging GP time. This is a major investment and it is already happening.

[Huw Merriman]

The point I wanted to make when trying to intervene on the hon. Member for Leicester South (Jonathan Ashworth) was that I recently went to a pharmacy in my town of Bexhill, and it is making deliveries to every single customer who asks for a delivery, not just the vulnerable and the elderly. It does so because if it did not Lloyds would put it out of business. Does the Minister agree that that shows that there are efficiencies to be made, and the fact that those efficiencies are recycled in the health service has got to be good for all our constituents?

[David Mowat]

It does show that. This is a competitive business. My hon. Friend mentions Lloyds; it is one of the two big players in this industry, in which two players own 30% of all pharmacies.

[Graham Jones (Hyndburn) (Lab)]

The Minister talks about moving away from a dispensing model to a value-added model. I shall say something about healthy living if I get the opportunity to speak in the debate, but in relation to that shift, what is his view on warehouse pharmacies?

[David Mowat]

Our view on the structure of the industry is that it is up to individual companies within the sector to organise themselves and to provide their services as efficiently as possible. It is true that 70% of all pharmacies are either chains, multiples or public companies, and I will address that point later.

[Several hon. Members rose—]

[David Mowat]

I want to make some progress.

Secondly, we want to see an enhanced role for the community pharmacy network in providing value-added services. This is an aspiration that we share with the network and its representatives. To that end, NHS England has commissioned Richard Murray of the King’s Fund to produce an evidence-based report to determine which types of primary care services are best done by pharmacists over the next two or three years. The report, which will be published later this year, will inform NHS England’s decisions on how to use the integration fund of £42 million that I announced two weeks ago. There are many candidate areas, including long-term conditions, minor ailments, better care home support and more medicine reviews, as well as the work that pharmacists do in public health.

[Maria Eagle]

Many of the pharmacies in my constituency already provide such services, but they are now threatened by the Government’s proposals. Does the Minister not realise that, according to research carried out by Pharmacy Voice, in a constituency such as mine, which is No. 20 on the list of deprived areas, four in five people who cannot see a pharmacist will end up going to their GP? Does he not agree that that will achieve exactly the opposite of what he wants?

[David Mowat]

The impact review, which was published at the same time as my statement two weeks ago, estimated that the amount of extra time that people would have to spend going to a pharmacy would be a matter of seconds, even if we had, say, 100 closures. The impact review sets that out in some detail. Did someone sitting behind me wish to intervene?

[Mr Speaker]

Perhaps the hon. Member for Plymouth, Sutton and Devonport (Oliver Colvile) could detach himself from his device for a matter of seconds. It is very good of him to drop in on us and to take a continuing interest in our proceedings. They certainly interested him greatly a few seconds ago.

[Oliver Colvile]

Thank you, Mr Speaker. I was just trying to find something that was going to inform my intervention. Is my hon. Friend the Minister aware that in Devon, about £5.5 million is wasted on unused medicines? We need to do something about that.

[David Mowat]

I do realise that, and I mentioned the fact that the King’s Fund is looking into medicine reviews.

As I have said before in the Chamber, the model that is adopted for pharmacies in Scotland has a lot to commend it, even though we might not adopt it in its entirety. I hope that we will get a chance to discuss that later.

[Several hon. Members rose—]

[David Mowat]

Before I give way, I should like to quote the chief pharmacist himself. Dr Keith Ridge has confirmed that the review

“will support community pharmacy to develop new clinical pharmacy services, working practices and online support to meet the public’s expectations for a modern NHS.”

Two weeks ago, I announced two initiatives that will proceed in advance of the King’s Fund report. From 1 December, phone calls made to NHS 111 for urgent repeat prescriptions will be directed not to an out-of-hours GP service as at present but to a community pharmacy. This will amount to some 200,000 calls a year, resulting in further revenue streams, for the consultations and for supplying the medicine. NHS England has also committed to encouraging national coverage of a locally commissioned NHS minor ailments service. Some areas, including West Yorkshire, already do this, and we will roll it out to the whole country by April 2018. Both those initiatives will relieve pressure on surgeries and emergency care centres. Both will result in additional incremental revenue for pharmacies, but they are very much only the start.

[Norman Lamb (North Norfolk) (LD)]

Does the Minister accept the view expressed in the impact assessment that independent pharmacies, which are often micro-businesses, and small chains of up to 20 pharmacies will be at a higher risk of closure than the larger chains?

[David Mowat]

In terms of these proposals, we have to be blind to the ownership of pharmacies. The fact is that the average pharmacy sells for something like £750,000. I do not accept that the proposals will cause closures in those segments, if that was the thrust of the right hon. Gentleman’s question.

[Several hon. Members rose—]

--- Later in debate ---

[David Mowat]

I want to continue.

The third area I wish to address is value for money, and I make no apology for doing this. According to recent OECD analysis, the UK now spends above the OECD average on healthcare, but however much money we spend, every penny needs to be spent as efficiently as possible. If that does not happen, waiting lists can become too long, treatments can be denied to patients and drugs might not be available. We also know that efficiency savings are required of every part of the NHS, and community pharmacy must play a role in contributing to the £22 billion of savings that we need to find. I do not apologise for that.

[Dr Murrison]

I certainly support the amendment on the Order Paper today, but does the Minister agree that, in relation to efficiencies, the issue of category M clawback is an important one? I tried to extract an answer to that question from the hon. Member for Leicester South (Jonathan Ashworth) earlier. Also, I ask the Minister to think again about the ownership-blind point that he just made. There is not an equal playing field at the moment, and there is a real risk that small independent pharmacies will continue to be done in.

[David Mowat]

I do accept that point. We are working on the category M clawback, and I hope to be able to make some progress on that matter soon.

[Claire Perry (Devizes) (Con)]

If anybody can square this circle, it is the Minister, given his extensive experience in this area. I genuinely believe that we have to sort out this issue. I am not happy to subsidise large private companies through the system—some of the chains have already been mentioned—so it is right to look at where the clusters occur. The Minister is well aware of the Kennet pharmacy in my constituency, and we all have really value-added pharmacies that are doing very valuable work. How can we help him, over the review period, to identify and support the services that those pharmacies provide? They must not be allowed to close as a result of this policy.

[David Mowat]

I agree with my hon. Friend. I have set out the work that we are doing, and the fact that we are providing more money for services, over and above all the money involved in the cuts and efficiency savings that we have had to make, will help that process.

[Dr Sarah Wollaston (Totnes) (Con)]

Further to that point, the Minister knows that our pharmacists are a highly skilled and professional resource that has long been underused in the NHS. He has mentioned the ongoing Murray review, and a sustainability and transformation plan process is also going on around the country. My concern is that the closures will come about in a random way, rather than through a planned process based on identifying skills in particular areas. Will he consider delaying them until we have all the reports in place and we can consider the matter on an area-by-area basis?

[David Mowat]

The access scheme is the device that will ensure that pharmacies are not closed in a random way. I want to address the point about closures head on. It is my belief that there will be a minimal number of closures. The impact analysis talks about 100 and it models 100. The average pharmacy has a margin of 15%, and the amount of efficiency savings that we are asking pharmacies to make over two years is 7%. In addition, the average pharmacy is trading for £750,000 when it closes or merges, even after we announced these efficiency savings a year ago. That value is being retained.

[Jonathan Ashworth]

The previous Minister put a figure on this. Will the hon. Gentleman tell us what he means by a “minimal” number of closures? What is the number?

[David Mowat]

These are private businesses, each with a different business model and a different amount of income from the NHS, from other retail activities and from services. Each is financed in a different way. Indeed, 30% of them are owned by two public companies, and 70% of them are multiples.

[Victoria Borwick (Kensington) (Con)]

Can reassurance be given that local pharmacies are the frontline of primary care? Will the Minister extend the work and responsibility of those local pharmacies, particularly in deprived areas, and reassure us that that is the focus of this debate?

[David Mowat]

I spoke to 500 pharmacists this morning and gave them that precise reassurance. The changes that we are making to transform the sector into a service-based, not dispensing-based, economy will do just that. That is where pharmacies need to go and it is where they want to go. Frankly, it has taken too long.

[Several hon. Members rose—]

[David Mowat]

I need to make some progress. I will give way in a moment.

At present, the average pharmacy receives NHS income of £220,000 a year, which is based on throughput of £1 million from the NHS. That translates into a value of the order of £750,000 for each pharmacy. When pharmacies merge or are sold, that is what they are traded for and the changes will not make a significant difference.

Returning to an earlier point, 40% of all pharmacies are located within a 10-minute walk of at least two others. Instances exist of a dozen or more pharmacies located within half a mile of each other. As I noted earlier, each one will most likely be receiving £25,000 a year just for being there.

[Jonathan Ashworth]

Has the Minister been to Leicester?

[David Mowat]

I was brought up on the outskirts of Leicester, so I am delighted to tell the hon. Gentleman that I have indeed been there. Giving all these clusters £25,000 of national health service money is not the best way to spend precious resources.

In addition, the extra services that pharmacies will choose to provide, such as winter flu jabs and public health services, are commissioned separately and will be unaffected by the reset. For example, 600,000 flu jabs have been given in community pharmacies this year—more than all of last winter.

[Several hon. Members rose—]

--- Later in debate ---

[David Mowat]

I need to make progress.

[Mr Speaker]

Order. I think it is fair to say that the Minister is being what I would call—if it does not sound a contradiction in terms—courteously harangued to give way, but it is perfectly evident to me that he is not giving way at the moment. Members will therefore have to exercise their judgment as to the frequency with which they make further attempts.

[David Mowat]

I will continue to make some progress and then give way towards the end of my remarks.

I do not want to downplay the impact of the change on the private businesses that own and operate the network. The pharmacy sector is a mixed economy with 70% of the market made up of multiples and chains and 30% owned by independents. It is hard to accurately predict the impact of the changes on those individual business models. What I can say, however, is that the savings we are making will be entirely recycled back into the NHS. Every penny of the efficiency savings that we are asking of community pharmacies will be spent on better patient care, better drugs and better GP access.

[Norman Lamb]

I am grateful to the Minister for giving way. I totally understand the importance of trying to get as much bang for your buck from pharmacy services, but does this not actually amount to a significant cut in spending on preventive services? That seems completely counter to the Government’s aim.

[David Mowat]

When one takes into account the £112 million that we are spending on getting more pharmacists into GP practices, the right hon. Gentleman’s point is incorrect.

[Luciana Berger]

Will the Minister give way?

[David Mowat]

I will give way to the hon. Lady in a moment.

Finally, I want to talk about the work that we are doing to ensure that everyone in the country has access to a community pharmacy. We have developed a scheme with two components. First, all pharmacies that are more than 1 mile from another pharmacy will be eligible for additional funding, which will almost entirely mitigate the impact of the changes. That component is specifically designed to protect areas where current provision is quite spread out. In total, it will apply to around 1,400 locations—roughly half urban and half rural. Pharmacies that are in the highest 25% by prescription volume, and therefore most profitable, will not be eligible for the scheme. Secondly, there is a near-miss scheme under which pharmacies that are located up to 0.8 miles from each other and in the 20% most deprived areas in the country can apply to be reviewed by NHS England as a special case. The final safeguard is that NHS England has a continuing duty to ensure the adequate provision of services. Its role is to commission a new pharmacy in any area where it believes access is inadequate. That duty will continue.

[Luciana Berger]

I thank the Minister for very kindly giving way. Will he correct the record on something? Pharmacies are not all private enterprises. Many co-operatives across our country provide community pharmacies, often in rural and isolated areas. For the purposes of this debate, will he clarify his understanding of the distinction between a community pharmacy and a GP pharmacy? That has not been clear in his remarks so far.

[David Mowat]

The distinction is that a community pharmacy is part of a privately owned business that dispenses and is paid in that way. The ones that we are hiring into GP practices will leverage GP time and do medicine reviews, and I expect them to enable the pharmacy network in an area to work more cohesively. It is a welcome and, frankly, overdue step forward.

[Several hon. Members rose—]

[David Mowat]

I need to continue.

Taken as a whole, I am confident that the three measures I have talked about for protecting access will ensure that everyone has access to a community pharmacy in much the same way as they do at present. The future for pharmacy is bright. The change we are implementing of a 7.4% efficiency requirement over two years is proportionate and will continue to orientate the profession towards services and—for the first time—quality and away from a remuneration model based on dispensing.

I will finish by again quoting the chief pharmacist, who said:

“The public can be reassured that while efficiencies are being asked of community pharmacy just as they are of other parts of the NHS, there is still sufficient funding to ensure there are accessible and convenient local NHS pharmacy services across England. The NHS is committed to a positive future for pharmacists and community pharmacy.”

Every penny that we save as a result of the efficiency reviews will be spent within the NHS on better care, better drugs and on quicker treatment. I urge Members to support the amendment later today.