Human Fertilisation and Embryology

Graham Stringer Excerpts

Tuesday 3rd February 2015 Commons Chamber

[Steve Baker (Wycombe) (Con)]

I approach this subject with a considerable degree of humility, for two reasons. First, I will never forget meeting a family in my constituency whose child suffers from mitochondrial disease; there was both a haunting sorrow in that family and the hope that if these regulations are passed they will be able to have a child without this problem. Secondly, I am very aware of my own shortcomings in relation to biological science. As a chartered engineer, I am perhaps more competent in the physical sciences, and I do not mind admitting that I had to look up at least a few of the words in the regulations in order to understand them.

As I have listened to this debate, not only today but previously, I have wondered whether we have really reflected on how science proceeds, because scientific truth is not established by authority or by democratic vote; it is established, as Karl Popper put it, through “conjecture and refutation”—trial and error. Someone who reads Thomas Kuhn’s “The Structure of Scientific Revolutions” will discover that it is possible for quite large bodies of knowledge to be developed with errors in them. When those errors are corrected, the paradigm shifts—that is a term we have all heard. That is how science proceeds, through trial and error. The reality is that there will always be uncertainty in any scientific procedure.

When the Commons Library summarised the Nuffield Council on Bioethics’ review, the second point mentioned was this:

“The knowledge about these techniques is uncertain and could remain so for several generations—their use could potentially harm future persons.”

The hon. Member for Liverpool, Wavertree (Luciana Berger), speaking from the Front Bench, made the point that, broadly, the question before us was whether there was a reason to withhold these techniques from people. If there is a reason, it is that they may do harm to future persons. I will not support the measure because this is inherently uncertain. That uncertainty is an inherent part of science, and it is no good appealing to authority to try to resolve the question, because different authorities will disagree and there is no way to resolve those disagreements apart from through empirical evidence, which we can obtain only by experimenting on humans.

[Graham Stringer (Blackley and Broughton) (Lab)]

The hon. Gentleman is making a typically thoughtful contribution to this important debate. Does he not have to balance that uncertainty, which he points out fairly, with the 100% certainty that the children of mothers with mitochondrial disease will suffer?

[Steve Baker]

The hon. Gentleman is absolutely right, which is why I began by expressing the humility I feel on this subject as a result of meeting and having had a lengthy conversation with a family who face just that issue. I remind myself, however, that we are dealing here not with a cure for those who have already been born, but with ensuring that those who are subsequently born do not suffer from that disease. If we were discussing a cure for those already living, perhaps the circumstances might be different.

Antibiotic Resistance

Graham Stringer Excerpts

Wednesday 15th October 2014 Westminster Hall

[Zac Goldsmith (Richmond Park) (Con)]

I am thrilled that despite my breaking two rules in a short time when I walked into the Chamber you are still allowing me to speak in the debate, Mr Chope. It is a pleasure to follow all the speeches, which have covered virtually all the angles. I am grateful to my hon. Friend the Member for York Outer (Julian Sturdy) for securing the debate, and for the speech he made.

There is a depressing but nevertheless welcome consensus that we are losing our antibiotics to resistance, and effectively losing modern medicine as we know it. Notwithstanding the threat of Ebola it is hard to imagine a bigger health threat. The World Health Organisation has described antibiotic resistance as a bigger crisis than the AIDS crisis of the 1980s. If we lose antibiotics we risk the return of a time when basic operations will be deadly. I used to wonder what it would take to wake up the British establishment to that appalling threat. For years virtually nothing seemed to be done to combat the extraordinary phenomenon of antibiotic resistance. I thought, naively, perhaps, that once the health establishment blew the whistle, everyone else would fall into line and, fortunately, the health establishment has been blowing the whistle very loudly. We have heard various quotations today of the apocalyptic language of the chief medical officer, Dame Sally Davies. I think she has even used the term “apocalypse”. She has said that if we do not take action, deaths will go up and up, and modern medicine will be lost.

That is of course already beginning to happen. It is not a futuristic scenario. In 2006 there were just five cases in which patients failed to respond even to last-resort antibiotics in this country. Last year the number was 600. I know that there has been some action and I do not mean to disparage that. In March last year the Cabinet Office confirmed that it would examine the question of resistance as a national security issue. In September of that year it released an outline UK five-year antimicrobial resistance strategy. The Government have since set up a high-level steering group, chaired by Dr Felicity Harvey, the director general, public health, to implement the strategy once it is released, which I think will be later this year. All that is good news, and it is possible that the strategy will match the urgency of the situation. However, I am afraid that there are worrying signs that it will not.

Yes, there will be renewed efforts to develop new drugs, which is crucial. I was thrilled to hear the Prime Minister’s response to a question on the subject, during Prime Minister’s questions, when he briefly outlined the Government’s commitment to supporting the development of new drugs. That is obviously a prerequisite to solving the problem. There is nothing in the pipeline at all, and, as existing drugs become ineffective, we clearly must hope for new developments and do all that we can to facilitate them. There will also be renewed efforts to limit the inappropriate use of antibiotics in human medicine. That subject has been covered and I shall not dwell on it today. However, so far, successive Governments, including the present one, have resolutely avoided confronting a part of the problem that is not only huge but avoidable.

It is worth repeating that from day one, when Alexander Fleming accepted his part of the Nobel prize, he issued a dire warning. We have heard the quotation and I will not repeat it. The simple reality is that we have completely ignored that warning, more or less from the day he issued it. Instead of treasuring that miracle cure, we have squandered it—not just in hospitals but on intensive farms, and not just to treat sick animals but to keep animals alive in conditions where they otherwise would struggle simply to survive. That is not just a niche concern; 50% or thereabouts of the antibiotics that we use in this country are used on farms and it is even more in the United States and some other countries. Overall use per animal on UK farms is 18% higher today than it was a decade ago. That is disproportionately true of those antibiotics that are critical to human health.

[Graham Stringer (Blackley and Broughton) (Lab)]

The hon. Gentleman is making an important point: since tetracycline and penicillin-based antibiotics have been banned as growth promoters for farm animals, the use of tetracyclines has up gone tenfold and the use of penicillins has gone up fivefold. This is not a party political point: there is something that the Government can do immediately about that situation, which is to monitor and study it with a view to reducing the excessive use of antibiotics on farms.

[Zac Goldsmith]

I absolutely agree with the hon. Gentleman, and will come on to that briefly—I am going to try to keep my remarks short. That is exactly the point. Many people felt that the ban on the use of growth promoters back in—actually, I forget the year, but I think it was 15 years ago, although I may have got that wrong and am happy to be corrected—

Regulatory Reform

Graham Stringer Excerpts

Tuesday 9th September 2014 Commons Chamber

[The Minister of State, Department of Health (Norman Lamb)]

I beg to move,

That the draft Legislative Reform (Clinical Commissioning Groups) order 2014, which was laid before this House on 13 March 2014, in the last Session of Parliament, be approved.

The draft legislative reform order seeks to amend the National Health Service Act 2006 in two ways. First, it will allow clinical commissioning groups to form a joint committee when exercising their commissioning functions jointly. The 2006 Act already allows two or more CCGs to exercise their commissioning functions jointly, but makes no provision for them to do so via a joint committee. Secondly, it will allow CCGs to exercise their commissioning functions jointly with NHS England and to form a joint committee when doing so. The Act already allows NHS England and CCGs jointly to exercise an NHS England function and to do so by way of a joint committee, but it makes no provision for them jointly to exercise a CCG function.

This draft order has already been scrutinised by the Regulatory Reform Committee, and I was pleased with its recommendation that it be approved under the affirmative resolution procedure.

I should say from the outset that the proposed arrangements are voluntary. One party cannot impose the arrangements on another. This allows CCGs to retain their autonomy and to continue to make decisions that are in the best interests of their local populations. They can decide whether to enter a joint committee arrangement with other CCGs. At the moment, the lack of provision for CCGs to form joint committees is placing a burden on CCGs and preventing them from working in the most effective and efficient way. Without the power to form joint committees, CCGs have had to find other means of reaching joint decisions that are binding. That means that they often end up seeking legal advice to ensure that they are on a firm footing, and that adds to cost and complexity without a proper process in place.

As an interim measure, therefore, some CCGs are forming committees in common whereby a number of CCGs may each appoint a representative to such a committee. Those representatives then meet, and any decisions reached are taken back to their respective CCGs for ratification. This leads to additional costs in terms of people’s time in sitting on multiple committees, administrative resources, and extra financial cost. Clearly, such arrangements are burdensome, particularly when compared with the simplicity of a joint committee. Primary care trusts, the predecessors of CCGs, were able to form joint committees at which all participating PCTs were bound by the decisions reached, subject to the terms of reference of that committee.

[Graham Stringer (Blackley and Broughton) (Lab)]

The Minister’s advice that all the members of a committee acting in common have to report back is at odds with the letter from the Department of Health to a committee dated 8 April 2014, where part of its case is that decisions have to be taken unanimously. That is quite different from having to report back, and it undermines his case about the administrative burden.

--- Later in debate ---

[Graham Stringer (Blackley and Broughton) (Lab)]

I rise to oppose the order for two primary reasons. I shall attempt to divide the House at the end of the debate.

My first reason relates to the Legislative and Regulatory Reform Act 2006. Right hon. and hon. Members may not be over-familiar with the Act, but its purpose was to allow regulatory burdens to be taken away if it was unlikely that Parliament would find time to debate the issues and if they were not controversial. It provides in the Act—this is why we are debating the order today—that if the Regulatory Reform Committee is not unanimous, there should be a debate on the Floor of the House. If there is a majority against the order, a longer debate in a different form would take place. The Committee did not unanimously support the order—I am not aware why one Member voted against it—and that has provided an opportunity to look at the process governed by the 2006 Act and assess whether the order complies with it.

In the simplest, most common-sense terms, an order would be passed if it would remove a burden and was non-controversial. I think that this order is controversial, and I do not think that it meets the conditions in the Act. Those conditions exist because, effectively, the process and the order concerned will relieve the House of the burden and responsibility of going through three Readings in this House and three Readings in the other place, so we have to be certain that this order is non-controversial.

First, there is the question of the consultation on the order. The report states that the Department consulted the better regulation unit, and was told that, as the order would remove only an administrative burden,

“it would be appropriate to conduct a targeted consultation rather than a full public consultation.”

I do not think that that is appropriate. Almost everything to do with the structure of the health service at the present time is controversial. My constituents and, certainly, Members of Parliament have views and concerns about that, but they were not directly involved or consulted about the process, and I think that that is a mistake in itself.

Then there is the claim that the order will remove an administrative burden. When I questioned the Minister earlier about the administrative burden, I tried to explain that, at present, clinical commissioning groups can organise themselves into committees, and can make decisions if those decisions are unanimous. They do not have to report back to anyone, so there is not an administrative burden there. There are other ways in which they can co-operate: they can reach legal agreements, or, indeed, they can report back, as in the example given by the Minister.

I do not believe that there is an administrative burden to be removed. However, I do think that there is the potential for repression of a clinical commissioning group. While it is voluntary to enter into these arrangements, if clinical commissioning groups entered into them in good faith and then encountered a more controversial issue, it would be difficult for them to move out; and if they could move out, that would return them to exactly the position in which they would have been had they been entering into a voluntary agreement with a committee in common, which means that there is no removal of an administrative burden. If that is the case, we do not need the order. If it is not the case, it is possible for a majority of clinical commissioning groups to overrule the interests of other CCGs.

In my view, the Regulatory Reform Committee and the Department have not followed the rules set down in the Legislative and Regulatory Reform Act 2006, and the House should reject the order on that basis alone.

I am not engaging in a theoretical discussion, and I am not going to ask the Minister to listen to a debate that would be exactly the same as our recent Westminster Hall debate about the proposals in Healthier Together. However, a consultation—a very flawed consultation—is currently taking place in Greater Manchester. The health trust that covers Wigan, Wrightington and Leigh in the west of Greater Manchester, and the one that covers south Manchester and Wythenshawe, fear that the proposals are unreasonable, and feel unable to support them at present. If the proposals were to go ahead, it would be possible for a majority of the 12 clinical commissioning groups that operate in Greater Manchester to make a decision that would impose changes on the hospitals in those clinical commissioning areas which are not wanted by the clinical commissioning groups.

As I said, the consultation is deeply flawed. It involves upgrading some hospitals to specialist hospital status and in effect downgrading other hospitals. Incidentally, three of the hospitals—those in north Manchester, Bury and Tameside—have not been consulted on the proposed changes in those hospitals.

The local healthwatch team said that the way in which our CCGs are operating is outside the law and that this proposal would put them inside the law. We can see the reason why: they want a majority decision, not a decision that would represent the areas of Wigan and south Manchester. I could talk a great deal about the rest of the Healthier Together proposals, but we debated those details in Westminster Hall. I do not think that the proposals are in the interests of the people of Greater Manchester. They try to jump the gun before the general election. It would be better for the decisions to be made by whichever Government are in power after the general election.

The consultation documents omit to mention the financial situation in which Greater Manchester finds itself—a £1 billion deficit is projected in the next two and a half to three years—and make proposals that could lead to the closure of hospitals, while pretending that they are only small decisions. The consultation paper wanders all over the place—through primary, secondary and tertiary care—but at the core of the consultation is the change in status of a number of hospitals in Greater Manchester. I worry that, if the CCGs work together and make majority decisions, the proposals in the Healthier Together consultation will be used as a blank cheque—health authorities in Greater Manchester will have carte blanche to do what they wish, without taking account of the views of the people of Greater Manchester.

--- Later in debate ---

[Richard Fuller (Bedford) (Con)]

It is truly a pleasure to listen to my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) and to follow him in the debate. I am a member of the Regulatory Reform Select Committee and it was my vote that enabled the House as a whole to debate this measure, which might, on paper, seem rather arcane. The hon. Member for Blackley and Broughton (Graham Stringer) asked why we are debating it in this way. We are doing so because the core dilemma in much health reform involves the tension between local decision making and common advance. For many people, there is a tension between the priority to localise decision making and the need, as seen by professionals such as the doctors and clinicians whom we trust, for some decisions to be made on a common basis in order to achieve overall advances in health care. It can be difficult to find the appropriate boundaries as we try to resolve that tension.

I felt that it was important to bring this matter to the House so that other hon. Members could have a chance to talk about the experience in their own localities. The issues in Greater Manchester have already been mentioned, and my hon. Friend the Member for Stafford (Jeremy Lefroy) has mentioned the issues in his own area. I also felt that it was important to herald one of the most important attributes of the reforms that my right hon. Friend the Member for South Cambridgeshire introduced, which was to enable, as far as possible, decision making on these issues to take place locally and to ensure that those local decisions were led not by politicians or bureaucrats but by doctors. A concern has been expressed that this change would somehow draw us away from those reforms.

The shadow Minister, the hon. Member for Leicester West (Liz Kendall), asked some extremely pertinent questions, although she perhaps got off to a bad start by taking the political apparatchik line and suggesting that certain problems were the result of the reforms. This is actually about one of the best parts of those reforms, which allows local people to make decisions. That was reflected in the widely quoted comments made by Anna Bradley, the chair of Healthwatch England. In her note, she said that

“we are concerned that the proposed reforms could create the conditions for CCG decision-making to become disconnected from the transparency and accountability mechanisms put in place by the Government’s health reforms”.

She recognises, as do many hon. Members, the importance of the tension. She also referred to it in a press release, in which she stated:

“We understand the benefits of commissioners working collaboratively but it remains crucial that local people are involved, asked what they want and understand how decisions will affect the way services are delivered in their area.”

In my own area in Bedfordshire, we have been having a collaborative exercise between two clinical commissioning groups, and they have done an extraordinarily good job of communicating and maintaining local decision making.

[Graham Stringer]

The House owes the hon. Gentleman a debt of gratitude for bringing the order before us today. Will he tell us whether, in the example he is giving, the order would help, hinder or be neutral?

[Richard Fuller]

I am not an expert, but in that particular instance I do not think I would fear the joint committee making a different recommendation from the current committee in common, although it has yet to come back with its report. The point is that the hon. Gentleman and others have aired important questions for the Minister to answer. He has answered some of them, and that has been the purpose of the debate today.

Underpinning all this is the fact—whose importance I hope the Minister will emphasise in his response—that people want important health decisions to be taken locally. They can be persuaded of, and they can understand, the issue of common advance, but they want to know that a decision is being taken locally. I think that the Minister dealt with this in his response to the shadow Minister, but I would be grateful if he answered these points quite specifically. First, am I right in thinking that he said that decisions on the part of commissioning groups to go into joint committees were voluntary, rather than compulsory, and that it would therefore remain possible for them to continue to set up committees in common if they so wished? My second question—

Mitochondrial Replacement (Public Safety)

Graham Stringer Excerpts

Monday 1st September 2014 Commons Chamber

[Dr Julian Huppert (Cambridge) (LD)]

It is pleasure to speak in this debate, and I pay tribute to the work of so many, but particularly the Lily Foundation and the Wellcome Trust which have done a huge amount to prepare for this debate, to educate the public, to support Members of Parliament and to support some of the research.

I do not know, Mr Deputy Speaker, if you or others in this House have met people with serious mitochondrial disorders, but those disorders are absolutely awful. Cells fail to function, and people can get seizures, strokes, blindness, deafness, heart failure, lung failure and liver failure. Most of the people afflicted will not survive to adulthood. There is no treatment and no cure, and about 1 in 6,500 babies born will suffer from something like this. I would hope everybody in this House would want to stop that, and I simply do not understand how opponents of this can argue that they want to continue to inflict that sort of suffering on so many children, because that is the consequence of not finding a way to treat these disorders.

The hon. Member for Congleton (Fiona Bruce) expressed concern that there may be consequences for people who are helped in this way. Her first example was, I think—I am sure she will correct me if I am wrong—lower fertility. Now, that is possible—we will not know until we try it on people—but if I had a choice between a hideous disease that was likely to kill me before adulthood or the possibility of lower fertility, I know which one I would choose.

We also heard the comparison to eugenics. This is fundamentally different. Mitochondrial DNA is very different from nuclear DNA. It has a very different history, and it is a fascinating history—I used to work on mitochondrial DNA and other nucleic acids so I have some interest in this. This is not the same as eugenics, as the right hon. Member for Havant (Mr Willetts) explained well—it is good to have him in the Chamber, even if he is not in his former place.

We have heard arguments about multiple parents and the idea that this approach means that somehow there are three parents, but there are clearly two parents. I have not heard people say that if someone is given an organ donation and they have someone else’s organ inside them, they then have four parents because they have a lot of different DNA inside them which could interact. I think—I would hope—that all of us support organ donation, because it has saved many, many lives. Why should we not allow what is, in effect, mitochondrial donation?

We have heard the view that we should wait for there to be much greater safety. My mother had breast cancer a couple of years ago and she wanted to choose which of the two most modern treatments she should have. She wanted to know what the life expectancy was and whether she would live for 15 more years with either treatment. The answer was, of course, that we do not know, because with the most modern treatments we have not waited 15 years to find out. But I do not think any of us would say that we should not use any single cancer treatment that has been used this century because we do not know whether someone will live for 15 years after having it.

[Graham Stringer (Blackley and Broughton) (Lab)]

I agree completely with what the hon. Gentleman is saying. Does he agree that the motion would be better if it was asking for these enabling regulations to be hurried up? They will take into account, as much as one can, all the safety issues, and by delaying them we may be condemning more children to horrible diseases that could be prevented if we hurried this process up.

[Dr Huppert]

The hon. Gentleman is absolutely right, but I would improve the motion in a number of ways. I would not try to characterise Lord Winston’s position as being fundamentally different from what it is. I would also say that we need to have these regulations so that the tests can be done and so that we can go ahead with clinical trials and find out what happens in humans. I hope that the Government will introduce the regulations promptly. It has been useful to have this airing of views, but it will be helpful when we have the regulations before us to have that debate. This House will then be able to vote on whether or not to adopt the regulations.

Healthier Together Programme (Greater Manchester)

Graham Stringer Excerpts

Tuesday 22nd July 2014 Westminster Hall

[Mrs Linda Riordan (in the Chair)]

Before the debate starts, I should say that I will allow gentlemen to remove their jackets.

[Graham Stringer (Blackley and Broughton) (Lab)]

Although it is the last day of term, it is still a pleasure to serve under your chairmanship, Mrs Riordan.

I am going to be critical of the Healthier Together programme, but one facility that it does have, of which I was unaware until about half an hour ago, is the gift of prophecy. It has just put out a press release in response to what I am about to say, which is particularly clever because I have not yet fully decided what to say. Although the programme has failed in many ways, it clearly has attributes that most of us do not have.

As it stands, the Healthier Together programme is both a shambles and a charade. I shall start by talking about the shambles. So far, more than £4 million has been spent on the process leading up to the consultation. Some of that money has gone on producing 200,000 leaflets for the consultation, which started two weeks ago. Unfortunately, as far as I am aware not a single one of those leaflets is yet in a public library—there were certainly none in the library near my office in north Manchester when I checked an hour or so ago, and I cannot believe that that library has been discriminated against. That is a failing of organisation.

That is not the only such failing. The website is complex and not easy to navigate. If someone can find the consultation document, they can download it, and they will find that at the end it says, “Please fill in the questionnaire opposite”. But there is no questionnaire opposite; it is elsewhere. If someone can continue to struggle through the website they can find it, but it is not where it is supposed to be.

I am not the only person who is critical of the consultation. The University Hospital of South Manchester wrote to me to say that the proposed changes are incomprehensible and full of NHS jargon. That is an improvement on the previous document that was produced, which was totally and completely incomprehensible. The more recent document varies between NHS jargon and “Janet and John” talk, which is almost as meaningless. There are phrases in speech bubbles saying:

“Knowing the council and the NHS will work together to look after mum.”

There is no reasoning or line of thought, just nice ideas about things that we would all hope the NHS would do. The University Hospital of South Manchester also criticised the fact that the consultation meetings—the proposed engagements, some of which may have already happened—all take place during the day. That means that the vast majority of people of working age cannot attend.

It is not only me and other members of the public who are greatly concerned about the proposals; as far as I can see, there is little clinical support for them. The chief executive of Wrightington, Wigan and Leigh NHS Foundation Trust, Andrew Foster, said that there is

“a lack of widespread support for the consultation process”,

and he went on to say stronger things as well. I have been sent information from a GP survey showing that almost 50% of GPs are concerned about the process and certainly do not support it in its current form. The University Hospital of South Manchester says that the process is “flawed and misleading”, and

“not an integrated care consultation…but rather a consultation on changes to a small number of acute providers”.

Healthwatch England has been very critical of the process, because until March this year all meetings took place in secret. It has been allowed to attend meetings since March, but, as I will explain later, many decisions had already been taken by that point. I would be interested to hear the Minister’s response to a more worrying point: according to Healthwatch England, the Healthier Together body—the combined committee of the commissioning groups—has no power to spend until the draft Legislative Reform (Clinical Commissioning Groups) Order 2014 is passed, and that has not yet been passed by either House. I would be interested to hear whether there will be a power to spend or to go ahead with the proposals, although I would be surprised if the proposals were not challenged.

There is not only the problem that legally, perhaps, the £4 million should not have been spent; the consultation document also refers time and again to hospitals co-operating with each other. However, the competition authorities ruled that the attempt by the Royal Bournemouth and Christchurch hospital and Poole hospital to work together was unlawful. If, after the consultation, it is decided that the proposals will go ahead—I hope that it is not—will they be lawful? Behind all that, £4 million may have been spent unlawfully, and could have been better spent on nurses, doctors and the health of people in Greater Manchester.

I turn to the charade aspect of the Healthier Together programme. It is a charade in many different ways. Who is conducting the consultation? The document contains statements from the chair of the Association of Greater Manchester Authorities, Lord Peter Smith, and from a number of doctors on the clinical commissioning groups, but if one looks deeper, one finds that a large multinational corporation called Mott MacDonald is involved but not declared. It has all sorts of consultancy interests in areas ranging from engineering to private and public health care. Why were we not told?

Part of the charade is that we are not told who is conducting the consultation, but the real charade is that a number of decisions have already been taken before the consultation has gone out to the public. The document itself does not show to the public the configuration of health services as they currently are in Greater Manchester; it presents a number of decisions that have already been taken without any form of consultation. I will return to that point later.

It is also unclear what the consultation is about. The University Hospital of South Manchester said that it thinks it is about the reorganisation of acute care in hospitals. I do not think that it is. It is not clear—it is muddled—but it could be about primary care, because there is talk of more GPs and more access to primary care services. There is no financial plan for that and it is not clear how it would happen, which is not a bad thing in itself, but it is mentioned in the consultation document without it being clear what anyone is expected to say about it, apart from their wanting better care for their relatives, mother, sons, daughters, wives or anyone else.

There is an absence of financial information in every part of the document, not just the primary care part. So is it about money? It is indicated and implied that there is not sufficient money. The background document makes it clear that, within two-and-a-half to three years, there will be a £1 billion, or 16%, black hole in Greater Manchester’s health budget of £6 billion. Is the consultation about that—it certainly is not clear—or is it a south Manchester thing? Is it about hospital reorganisation? If it is about hospital reorganisation, creating more specialist hospitals and downgrading some hospitals, why were we not consulted?

Fairfield hospital in Bury, Tameside hospital and North Manchester hospital have been downgraded to so-called community general hospitals, but that is not in the consultation. We are told that we are going to get almost immediate access to GPs, but there is no mention of what has been happening in the health service in Greater Manchester over the past few years. Fifty per cent. of the walk-in centres in Greater Manchester have been closed down, and they gave people immediate access to a GP. They have closed, but the Government are talking about improvements.

The Government are talking about improving care in the community, and specialist nurses would certainly help to keep people out of hospital and reduce costs in the long term, yet when I put in a freedom of information request to Tameside metropolitan borough council, half a Parkinson’s nurse was available for the whole of Tameside, which is shocking. One can go through the other specialist nursing services and find the same. Why have we not been told the proposals for those specialist nursing services, which are vital for keeping people out of A and E and out of long-term care within hospitals?

The proposals are a charade. In the original consultation, and when the Healthier Together people had a meeting with Greater Manchester MPs, we were told there was a guarantee that no hospitals or A and E departments would close. Why is that missing from the consultation document? Why is it not still a commitment? When the commitment was given, I did not believe it because I do not believe, when there is a looming financial crisis in the NHS in Greater Manchester and across the country, that any group of medics or health bureaucrats can guarantee that hospitals will stay open. A 16% gap is looming in the care and health service budget, and the gap might get bigger. That is equivalent to two or three hospitals in financial terms. We were given that guarantee yet, arrogantly, three hospitals have been downgraded without any consultation.

A similar guarantee was given when maternity provision was taken out of Hope hospital during a review five or six years ago. It was guaranteed that a midwife-led maternity service would continue in Hope hospital, but there is currently a consultation on removing that service. Those of us who have been discussing, debating and arguing with the health service for some time about the provision of services are sceptical about all guarantees.

There is also an ongoing trauma review in relation to Wythenshawe hospital, yet Wythenshawe hospital is being downgraded. It is an extraordinary decision to say, “We will have this discussion, but we have already taken some decisions. We want to know what should happen to these hospitals but, although two other major service reviews are ongoing, we will completely ignore them and not mention them at all in the consultation document.”

I am sure my hon. Friend the Member for Wythenshawe and Sale East (Mike Kane) will want to mention Wythenshawe hospital, so I will not steal his speech. I am an ex-chair of Manchester airport, and downgrading Wythenshawe hospital from its grade 1 status is appalling because it has the nearest A and E unit to Manchester airport. If there was an unfortunate air crash, people would want to go to the nearest hospital. The downgrading of Wythenshawe hospital is another extraordinary decision.

We have been here before with such consultations. At the moment, the Healthier Together people are saying that there is 98% support on Twitter for the proposals. They are in a feedback loop in which they are twittering to themselves, and we know what the Prime Minister thinks two twitters make. We were in exactly that position on the congestion charge. When the people running the scheme ran opinion polls and consultations, they all showed huge support for the congestion charge—anyone who talked to anybody in Greater Manchester would have found that support unbelievable—and of course when it came to putting crosses in boxes in the referendum, 80% were against the congestion charge. That is exactly the position we are in at the moment. There is an unreality about the people who are doing this, and they are trying to fiddle things. This is a scandalous fiddle.

At the end of the debate, I do not want to be accused of pretending that there are no real problems—there are. I have mentioned the financial problems, and there are also the differences between Greater Manchester hospitals. Given the survival rates for similar operations, people are clearly better off in some hospitals at certain times of the week. People are clearly better off in other parts of the country than in some Greater Manchester hospitals. That needs to be put right, but the consultation will not do that. We need to consider why there are problems—it is not just about recruitment, although recruitment is part of the problem—and try to solve those problems, rather than wishing them away with yet another reorganisation of the health service.

I could give more examples, but time is limited. The current booking system in Greater Manchester must waste many millions of pounds a year. The NHS authorities regularly criticise patients who do not turn up for appointments, but they do not criticise themselves when they fail to organise appointments properly. From the past 12 months I can give five examples from my close family, and from my constituency casework, of where the booking system has been appalling. I know of people who have been sent to closed service centres in hospitals and people who have been told that the plaster on their arm would be examined to see whether it has set when, in fact, the plaster should have been taken off. I could go on about the booking system’s failings. Addressing those failings would save millions.

Cleanliness is not a cost issue directly, but it is a health issue, and there is a massive difference in cleanliness levels both within hospitals and between hospitals, which could be addressed. There could be improvements in other areas. There are big decisions to be made on hospital configuration, finances, how much money should be put into primary care and the structure of the health service. Those questions will not be addressed by the current process. There are genuine differences between the Labour and Conservative parties on how those issues will be resolved, and those differences will be resolved at the general election.

The process is trying to do two things. First, it is trying to usurp the political process at the general election, when those big decisions will be taken. Secondly, it is asking for a blank cheque. If the Government put out such a rubbish consultation document that people do not know whether it is about primary care, secondary care or hospital reorganisation, and if Healthier Together is already saying that it has 98% support, what do they want to do? They are asking for a blank cheque to do whatever they want, and it should not be given to them.

I will finish with another quote from University Hospital of South Manchester, which I completely agree with, although I would add other things to it:

“Wait until the trauma review is finished and do the consultation properly.”

In other words, withdraw this consultation, do it properly, wait until the review of maternity and trauma services is in, wait for the general election and then we can have a serious, proper and grown-up discussion about how we can make health services in Greater Manchester better.

--- Later in debate ---

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

I thank my hon. Friend the Member for Blackley and Broughton (Graham Stringer) for securing the debate. It is particularly useful that we can express our views before the summer recess. I do not want to speak for too long. I will echo my colleagues’ sentiments about the quality of the consultation process, but I want to give a view from the eastern part of the conurbation, Tameside, and make a couple of additional observations.

A lot is going on with the NHS and health care in Greater Manchester at the moment, so the timing is not very conducive to running such a consultation. The changes to Trafford A and E have already been mentioned. Passenger transport has been privatised from the NHS ambulance service to Arriva. Most of the walk-in centres that I am aware of have gone. I do not know about the situation in other constituencies, but in mine GP access is a huge issue—people regularly wait a fortnight for access to a GP in Stalybridge. Of course, in Tameside there are particular challenges because of the Keogh review in Tameside hospital. All the Tameside MPs warmly welcome that. It has been a positive process enabling a light to be shone on many of the things that we have been discussing for several years. However, when all the factors I have mentioned are added together, it is a difficult time to carry out a consultation on any part of the NHS and particularly on hospitals, because the public are most sensitive about them in many ways.

I understand the need for specialisation. I echo the remarks of my hon. Friend the Member for Stretford and Urmston (Kate Green). Even if we had substantially greater resources, it would be difficult to recruit the people we would need to meet the standards now required for hospitals in the conurbation. With the financial modelling that has been done in Tameside, we are perhaps a little more advanced in our forward projection work than some other boroughs, and I think that we are in a perfect storm. We have had to spend a lot of money at the hospital to try to meet the higher standards that people should expect by correcting some of the processes that the Keogh review highlighted as wrong. On top of that, the council was always one of the leanest in the country, let alone in Greater Manchester, so it suffered the worst from the severe reductions made by the coalition in northern local authorities. Our clinical commissioning group is in a relatively good position, but clearly it is not to anyone’s benefit simply to use that financial picture to prop up other parts of the system that are not working so well.

History will be hard on the coalition for prioritising such a big ideological reorganisation at a time when the figures show that the situation I have described is the challenge that incoming Health Ministers should have concentrated on. The promise that no A and E departments in our hospitals will close is welcome news, but I wonder whether the scale of the rhetoric around Healthier Together justifies or validates that promise. Either we shall not produce the results that have been promised, or that promise on the long-term future of hospitals and A and Es may not be honoured in the way we expect.

[Graham Stringer]

My hon. Friend is right to say that that commitment was given when we met the Healthier Together people and in some background documents. Does he agree that it is worrying that it is not in the consultation document, whatever credibility we give to the commitment itself?

[Jonathan Reynolds]

I do agree. That is a matter of extreme concern to me. My understanding is that we have been given a cast-iron pledge that there will be no hospital or A and E closures as part of Healthier Together. The problem with all hospital reconfigurations anywhere—it happened with the maternity services consultation—is that they always appear to people to be about cuts. It is hard to get across the argument that they are about improving services. There is some mixed messaging about the primary outcome of such a process.

My principal problem with specialisation is the one that arises with specialisation in any field. Greater Manchester’s geography makes it hard to get from one borough to another. Public transport and the railway system are not configured to operate in that way. I should love the opposite to be true—if we had the resources and local autonomy to make public transport work differently. That will come one day, I think, but it is not true at the minute. I did not by any measure expect to become an MP in the 2010 general election, and my daughter was booked in to be born at St. Mary’s, because I worked in the centre of the city and it was easier to have appointments there than to get back to Tameside for them. Frankly, we were concerned about the possibility of labour starting in Tameside at the wrong time, because of the journey to get to St Mary’s and what that might mean. I think that that would be the same for many people, whatever the health issue: the journey is not easy in a car, but by public transport it is almost untenable. That would be people’s primary concern when they thought about the outcome of such a consultation

--- Later in debate ---

[Norman Lamb]

To be fair, when I indicated earlier that the issue is about process, the hon. Lady came back at me—as is her right—to say that it is not just about process but about the model of separating specialisms from general hospitals. I therefore quoted what the shadow Secretary of State for Health had said in that regard.

I turn to the specific case raised by the hon. Member for Blackley and Broughton in this debate. Healthier Together was launched by the NHS in Manchester in February 2012 and is part of the Greater Manchester programme for health and social care reform, which seeks to improve outcomes for all Greater Manchester residents. The scheme is substantial, involving 12 CCGs and 12 hospital sites across Greater Manchester. As the consultation sets out, the case for change aims to improve access to integrated care and primary care, community-based care and in-hospital care services, including urgent and emergency care, acute medicine, general surgery and children’s and women’s services.

The House should appreciate that although those are the services being looked at, there are interdependencies with the core in-hospital services, including anaesthetics, critical care, neonatal services and clinical support such as diagnostic services. Changes in one area might have consequential effects elsewhere, as hon. Members have pointed out, and those effects have to be fully understood.

I should also repeat that the proposed changes are not a top-down restructuring. They are led by local clinicians who know the needs of their patients better than anyone. They believe that the clinical case for change—

[Graham Stringer]

Will the Minister give way?

[Norman Lamb]

I am conscious that I have only three minutes left. I have tried to be generous.

Local clinicians estimate that across Greater Manchester around 1,500 lives could be saved over five years as a result of implementing the proposed changes; that is not my assessment, but that of local clinicians. That would be an impressive improvement in health care, touching and affecting the lives of thousands of ordinary people—not only the individuals concerned, but their families and friends. It is because of the area’s current performance: if all trusts in Greater Manchester achieved the lowest mortality rates in the country, the CCGs believe that the number of deaths in Manchester could reduce by some 300 per year, equating to saving 1,500 lives over five years. That is an objective that we should all sign up to.

I am sure hon. Members will agree that it is not an unrealistic aim for hospitals in Greater Manchester to want to be the very best in the country. I am also sure all hon. Members want the very best for their constituents. Greater Manchester has some of the best hospitals in the country. However, not all patients experience the best care all of the time. In particular, the consultation sets out evidence that suggests that for the sickest patients who need emergency general surgery, the risk of dying at some Greater Manchester hospitals might be twice that at the best hospitals. That is simply not acceptable.

There is a shortage of the most experienced doctors in services such as A and E and general surgery, leaving some hospitals without enough staff. Only a third of Greater Manchester hospitals can ensure a consultant surgeon operates on the sickest patients every time; similarly, only a third can ensure a consultant is present in A and E 16 hours a day, seven days a week.

Healthier Together aims to ensure that all patients receive reliable and effective care every time. The programme is endorsed by the independent National Clinical Advisory Team, which offered strong support for the programme’s ambition, vision and scope, as well as its impressive public and clinician engagement. The NCAT felt that the programme’s approach was an exemplar of how the NHS should try to improve safety, value and sustainability.

I have not had time to say everything that I wanted to. I am conscious that hon. Members raised specific issues that I should respond to and am happy to write to all Members who have taken part in the debate. I hope my remarks have been of some help.

Rare Diseases

Graham Stringer Excerpts

Tuesday 17th December 2013 Westminster Hall

[Jim Shannon (Strangford) (DUP)]

It is a pleasure to be called to speak in this debate, Mr Bayley, which I have sought for some time. It all goes back to a meeting that I had with a number of people from Northern Ireland back in June. They outlined their concerns about the funding and resources for rare diseases, and about strategy.

In this debate, we have an opportunity to look back. Governments in Westminster and the regions, and particularly in Northern Ireland, which I represent, are responding to a UK strategy. The timing of this debate is more appropriate than it would have been had we had it in September, or July last year, because we now have the chance to discuss where we go with the strategy, and how we tie it in throughout the United Kingdom. I appreciate the attendance of Members to discuss rare diseases. It is a pleasure to have so many in the Chamber—to make a contribution, I hope.

Some of the stories that I have heard about rare diseases would break your heart, Mr Bayley. That is where I am coming from, because my cases are those of constituents who came to me with their problems and asked me to portray or reflect on them in the House of Commons and, we hope, find a way forward. It is abundantly clear to me and to everyone in the Chamber that we need to be proactive, making changes that will give the people affected in our nation a better quality of life.

Let me set the scene with a few facts. One in 17 people in the United Kingdom will be affected by a rare disease at some point in their life, which equates to 3.5 million people; 75% of rare diseases affect children; and 30% of patients with rare diseases will die before their fifth birthday. The Teenage Cancer Trust has given me some facts. There are more than 6,000 recognised rare conditions, 80% of which have a genetic cause.

In June 2009, the UK adopted the Council of the European Union’s “Recommendation on an action in the field of rare diseases”. It recommends that member states

“Establish and implement plans or strategies for rare diseases”,

which should be adopted

“as soon as possible, preferably by the end of 2013 at the latest”.

We will not make that deadline, but I hope that we will make the deadline of February 2014, when all the regions will come together under the captaincy of the NHS and the Minister in attendance, who will push things forward.

In November 2013, a UK strategy for rare diseases was issued by Ministers from the four UK Health Departments, including our Northern Ireland Minister, Edwin Poots. The recommendation contains 51 commitments, which all four countries of the UK are committed to delivering by 2020. The commitments are UK-wide and will be implemented in country-specific plans for England, Scotland, Wales and Northern Ireland. Time prevents me from going into all 51 commitments, but I have been contacted by many groups, and I wish to raise at least some of the issues that they highlighted for me.

[Graham Stringer (Blackley and Broughton) (Lab)]

Before the hon. Gentleman gets into a long list, does he agree that the changes in the structure of the NHS have made achieving a strategy more difficult, because it is often not clear where the responsibility for dealing with rare diseases lies between the commissioning groups and NHS England?

[Jim Shannon]

The hon. Gentleman has outlined an issue that is of concern to us, and I hope that the Minister will respond to it in this debate. With great respect to the Minister, he always tries hard to respond to the issues that we ask him about; I do not mean to put up too high a pedestal, but we have high expectations of his response.

The Teenage Cancer Trust contacted me, and its correspondence included some of the figures I gave earlier, which indicate how important the subject is. The trust told me that seven young people per day between the ages of 13 and 24 are diagnosed with cancer. The trust has 27 cancer units operating throughout the United Kingdom and Ireland. There are around 1,200 new cases of cancer among teenagers and young adults in the UK every year, which is a significant number for a rare disease, as defined by the specialised services. Cancer, however, remains the most common cause of non-accidental death in young people, and the five-year survival rates are lower among teenagers for some cancer types than among children. I repeat that, according to the trust, 30% of rare-disease patients will die before their fifth birthday. It is a cruel fact that some children will not enjoy life beyond the age of five.

The trust has proposed recommendations. It believes that it is critical that the service model continues to be secure in the NHS, as part of a standard cancer care; in other words, diagnosis and care must be delivered at an early stage. It welcomed the setting up of the teenage and young adult clinical reference group in NHS England, and called on NHS England to continue to work with the group to focus development on the services.

I refer to NHS England, even though I am an MP for Northern Ireland and health is a devolved matter, because there has to be a driver on rare diseases, and NHS England is the driver to take all the regions forward together. When I refer to NHS England, I am referring to something to which we can all contribute, including those in our part of Northern Ireland.

The Teenage Cancer Trust also referred to the fact that there are different cancer biologies, treatment protocols and responses to treatment. All the issues need to be brought together, which underlines what the hon. Member for Blackley and Broughton (Graham Stringer) said. There has to be better co-ordination. The trust also recommended more trials relating to teenagers and young adults with cancer, and challenging the arbitrary age criteria that are often set for trials. It also recommended ensuring a mechanism for action on new drugs, so that they can be tested by different groups. In other words, it wants early diagnosis, a focus on the issue and, by releasing financial and regulatory burdens safely, to encourage more research development for teenagers and young adults.

Another trust recommendation was for a system that alerted GPs when they had seen a patient three times with unresolved cancer symptoms. That would help them to identify and manage those cases. That is to say, with cancer, when someone has had three strikes, it is time for the case to be looked at intensely, so that we can ascertain exactly what is wrong. The trust has put forward those ideas, which are important to what we are trying to do.

There are more than 60 different types of muscular dystrophy and related neuromuscular conditions. Approximately 1,000 children and adults for every 1 million of the UK population are affected by muscle-wasting neuromuscular diseases. It is therefore estimated that some 70,000 people are affected by a neuromuscular condition in the UK. A constituent I met in June, Dr Amy Jayne McKnight, chair of the Muscular Dystrophy Campaign in Northern Ireland, is a director of the Northern Ireland Rare Disease Partnership; she sent me the following quotation through the Muscular Dystrophy Campaign, with which I have contact:

“There is an urgent need to establish multidisciplinary support for people with neuromuscular conditions in Northern Ireland. The lack of a register of affected individuals makes clinical care particularly challenging due to a lack of planned services. My father, who has spinal muscular atrophy, experienced very sporadic clinical support and was only offered respiratory care after he ended up in intensive care—putting his health at risk. Individuals in Northern Ireland deserve the same care and support as those living in England; international standards of care guidelines exist for several neuromuscular disorders including NICE accredited guidelines for Duchenne and the forthcoming NICE guidelines for uncommon neuromuscular disorders. We need to build on existing expertise in Belfast, alongside support from Centres of Excellence in the rest of the UK, to enable an effective network of specialist services to be developed in Northern Ireland.”

That is a lengthy comment, but it puts in perspective what the partnership is seeking, and what the House should be doing in the strategy that we develop.

I have raised this issue with the Minister who has responsibility for health in Northern Ireland, Edwin Poots, but if all four UK countries are to fulfil their part of the deal, the United Kingdom Government must soon provide additional, ring-fenced funding to each region. Only then will people receive the care that they need. It is all very well to have a strategy, but we must have resources and finance in place to make it happen. The four regions need to work together to make it happen; that is what we should be trying to do.

[Graham Stringer]

The hon. Gentleman has raised some profound points about networks and information. I am not so familiar with the situation in Northern Ireland, but clinical reference groups are vital. He has talked about Duchenne muscular dystrophy. In England, patients suffering from neuromuscular diseases are often directed to a clinical reference group for generic neurological diseases, which is obviously inappropriate. Is that his experience in Northern Ireland, and does he believe that we should do something about the situation in England?

[Jim Shannon]

I cannot speak about other places, but I do not believe that that has been the case in Northern Ireland—I am not aware of it. In my area, there are young people with Duchenne muscular dystrophy, and I met some young people with Duchenne at an event held every year in the Methodist centre across the way. I have been to the past couple of events, and there has been only one person from Northern Ireland there. With my background information, I would say that what the hon. Gentleman describes does not happen in Northern Ireland, but he says that it does in England, and that needs to be addressed. I hope that the Minister will take that point on board when responding.

The United Kingdom Primary Immunodeficiency Network, or UKPIN, is a professional organisation for all doctors, nurses and scientists working in this field, and it covers six rare diseases. UKPIN—I need to be careful how I say that, because UKIP has no role in this matter whatever—has stated that its aims are the registration and accreditation of specialist immunology centres for primary immunodeficiency, or PID; the development of a national patient registry, to which the Government have given a commitment in the rare diseases strategy; and the development and dissemination of guidelines and standards for best clinical practice. The UK PID registry has been supported by the Healthcare Quality Improvement Partnership, and has engaged the participation of 95% of UK centres since its establishment in 2008. To date, nearly 3,000 patients have been registered, making it the second largest patient registry in Europe, after the long-established French registry.

The figures for Northern Ireland suggest that PID is as common as cystic fibrosis. A first report on the matter is at the presses, and we will soon have the opportunity to read it. Perhaps the most pressing point that has been raised is that there is a need for meaningful national and international collaboration on both research and development of clinical practice to ensure maximum benefit for patients. Let us not disregard international collaboration: if something good is being done in France or Germany, it would be good to exchange expertise, so that we can all improve and move forward. Groups such as UKPIN can take the lead in some of these matters. The UK has already led in the development of novel treatments—for example, with gene therapy—and in implementing novel technologies such as next-generation sequencing. It is crucial that there is ongoing investment to maintain that research.

Rare Disease UK has welcomed the promise of greater co-ordination of care for people with rare diseases. As we hear all too often, patients and families have nobody to co-ordinate the multiple elements of care and treatment that their condition necessitates. How often have we heard that, when it comes to health care? It is not just about care for rare diseases. Members here today all regularly contribute to our discussions on health issues in the House, and all too often we hear of people who do not know where to go or who to speak to, and are not quite sure who they need to be in touch with to help them. That is a key issue; if we could address that, it would be helpful.

--- Later in debate ---

[Charles Hendry]

I think that is absolutely true and there is a role that the Department can perhaps play in bringing people together, when they have similar goals, and if they can combine their force and strength, the overall gain may be bigger than the sum of the parts. Perhaps that is something to which the Minister could respond when he replies to the debate.

My second point relates to the university work that is being done in this area. When I left the Government in September last year, one thing that gave me the most joy was to be invited by the university of Edinburgh to become a visiting professor. I have been incredibly impressed by the work that is being done in this area—not in the part in which I am involved, which is the business school—particularly by the medical faculty. Work is being done to look comprehensively at the patient experience and at how to bring together all the issues that affect patients who often are being affected by rare diseases and how they can combine the necessary research into that as well.

The issue is not only about the role of world-class research, which I think Edinburgh has in abundance, but about how that is tied in with the role of benefactors, because the work of the university of Edinburgh has been made possible by a small number of extraordinarily important contributions. The Euan MacDonald centre for motor neurone disease research is funded by an immense donation by the family of Euan MacDonald, but that in turn led to an even bigger donation by J. K. Rowling for the Anne Rowling regenerative neurology clinic. It is through the work of the university—of examining how it can bring together its extraordinary genius in looking at the challenges that have been presented by these rare diseases—and tying that in to extraordinarily generous benefactors that offers us a really great way to address some of the issues. The work being done in Edinburgh is of course being done in many other universities in this country as well, but if we can help, through the Government, to try and co-ordinate that better, we will see real progress.

I remember hearing former President Jimmy Carter talking about what it meant to him, in his lifetime, to have played a leading role in the eradication of a single disease—river blindness. What an extraordinary, unbelievable ambition, and it is a magnificent thing to have been achieved, just as Bill Gates is achieving similar things in different sectors. The more that we can co-ordinate that work, expertise and genius in our universities with the good will of so many people outside it, the more, as a succession of Governments, we will be able to say that what we have done has led to the eradication of some of these diseases.

[Graham Stringer]

The hon. Gentleman is making very serious points about the excellent research that happens in the university of Edinburgh and in many of our other medical schools up and down the country, but he has not referred to a problem, which is that an excellent drug, or one that is likely to be excellent, can be developed, but because of the nature of rare diseases—that very few people suffer from them—it is very difficult to get it through the trials process, because that is designed to see whether the drug works on large numbers of people, quite sensibly. Does he agree with me that NICE should have different rules for drugs related to rare diseases?

[Charles Hendry]

I agree with the hon. Gentleman. A constituent has written to me just this week about meningitis and a drug that has gone through the trials process. It has been approved, essentially, but is only being made available to people who can pay for it at the moment. It seems to me that when treatments could be made available, expediting the process of approval and then ensuring that they are generally available as soon as possible, to as many people as possible, should be an objective of its own. I absolutely agree with what he said in that respect.

Oral Answers to Questions

Graham Stringer Excerpts

Tuesday 27th November 2012 Commons Chamber

[The Minister of State, Department of Health (Norman Lamb)]

I thank my hon. Friend for that question. The NHS outcomes framework includes an indicator on the quality of end-of-life care as it is experienced by patients and carers, which is based on the VOICES survey of bereaved relatives. The proposals for reform to the NHS constitution include a right for patients and families to be involved fully in discussions, including at the end of life.

[Graham Stringer (Blackley and Broughton) (Lab)]

T3. What action does the Minister intend to take to reduce the number of unplanned emergency admissions to hospital by sufferers of muscular dystrophy and other neuromuscular conditions?

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

I thank the hon. Gentleman for that question and for his concern about this matter. One of the key challenges for the NHS is to ensure that we deliver better care in the community, deliver more preventive care and provide better support to people with long-term conditions, such as muscular dystrophy and diabetes, in their own homes. A key part of the reforms is to make sure that a lot of services are commissioned from the community by the local commissioning groups. We have already seen that that has reduced inappropriate admissions. For example, in my part of the world in Suffolk, they have been reduced by 15% for older people.

Musculoskeletal Diseases

Graham Stringer Excerpts

Monday 4th July 2011 Commons Chamber

[Graham Stringer (Blackley and Broughton) (Lab)]

The genesis of this debate was four reports into musculoskeletal disorders from about two years ago. The first was from the National Audit Office, one was the King’s college report, there was another from the umbrella organisation, the Arthritis and Musculoskeletal Alliance, and the final one was the clinical advice from the National Institute for Health and Clinical Excellence. Those four reports led to an excellent debate in Westminster Hall on 19 January 2010 at column 1WH of the Official Report. I advise the Minister to take a look at that hour and a half debate in which many more points were made than—[Interruption.]

[Mr Speaker]

Order. I apologise for interrupting. There are Members behind the Chair making a frightful racket and it should not happen. They should leave the Chamber and show some courtesy to the Member who is developing his speech. I apologise to the hon. Gentleman who should now resume.

[Graham Stringer]

Thank you, Mr Speaker.

Many more points were made in that debate than it is possible to make in a half hour debate in this Chamber. What the then Government were essentially being asked was to take action to ensure better clinical outcomes for the money being spent on musculoskeletal disorders. The real ask from the community was for a clinical director or so-called tsar. In a sense, however, the most important ask is not that, but that there is an outcome strategy that improves the outcome for people suffering from musculoskeletal disorders. In many ways, in spite of those four reports and the debates that have taken place since, the situation nationally remains much the same. The statistics are worth going through in some detail. The amount of money spent on musculoskeletal disorders is large—£4.76 billion, which is the fourth-largest category spend within the NHS. That money is spent on 25% of the population as one in four people have a musculoskeletal disorder. That is 9.6 million adults and 12,000 children. Many people think that arthritis and rheumatism affect only older people, but that is not true. They can affect people of any age, as is perfectly illustrated by the fact that 12,000 children suffer from it. In terms of costs, the magnitude of the issue is that one visit in every four to a general practitioner concerns musculoskeletal disorders and 10.8 million working days are lost because of such disorders.

Those are the statistics. The problem is that there is no equality of outcome and no sense that when money is put into the system outcomes improve. About two years ago, partly in response to the reports, the previous Government put £600 million more into the system, but there was no noticeable improvement in outcomes. The NHS atlas of variation shows a threefold difference in spending in different parts of the country, but it does not relate to differences in incidence, prevalence or severity of the problem; nor does it necessarily relate to better outcomes. Although there is a threefold difference generally, the difference for rheumatoid arthritis is five times, for hip replacements 14 times, cemented hips 16 times and for uncemented hips it is 30 times. Clearly something unusual is happening in that area of the service and it requires examination.

Quite simply, current services do not ensure swift treatment of arthritis, which in many cases is vital. I shall give an example from one category of disorder: rheumatoid arthritis. People think it is the same as any other arthritis but it is not; it is an auto-immune disease and few people suffer from it. Many GPs see only one new case every year or so, which is surprising but true. Because GPs do not see such cases regularly, patients often have to visit their GP about three times before they receive treatment, but early treatment is vital. The time before treatment means not only pain but also that the rheumatoid arthritis is not cured. Since a third generation of drugs—the biologics—has been developed, the disease is curable in a large number of cases if treatment is given quickly enough. Even if the disease is not curable, what matters is getting the patient to a multidisciplinary team of physiotherapists, consultant surgeons, doctors and community nurses as quickly as possible.

[Nic Dakin (Scunthorpe) (Lab)]

My hon. Friend is setting out his stall powerfully. It is a difficult subject. Does he agree that early intervention is good not only for the patient, because they can recover faster or get to grips with the condition, but also for the economy, because the person is more likely to be able to continue active employment, and for the health service because early intervention is likely to cost less in the longer term?

[Graham Stringer]

Precisely. I mentioned the total number of lost days. In the vast majority of cases of rheumatoid arthritis, people stop working two years after diagnosis, but if diagnosis and treatment are earlier it is most likely that even if the person is not cured they could continue working for longer.

The Arthritis and Musculoskeletal Alliance—ARMA—is calling for a number of things, but before I put its case I note the following points. The fact that there are unsatisfactory differences in inputs and outcomes is not completely an accident. By and large, the services have not had the attention they deserve. I am not making a party political point; the situation has been going on for a number of years and unfortunately it continues. The quality and outcomes framework contains no indicator for musculoskeletal conditions. Why not? The musculoskeletal services framework of 2006 lacked leadership and was largely ignored by the centre in the NHS, GP training in musculoskeletal conditions remains poor, despite the evidence I have just given about the importance of GPs recognising precisely what form of musculoskeletal disorder a patient has, and only two of the NICE policy standards announced so far relate to musculoskeletal conditions—for hip fractures and osteoarthritis—out of the vast range of some 200 conditions covered by this generic term.

ARMA is calling for an outcomes strategy as a vital first step in addressing the current failures in provision of treatment and care for people with these disorders. What would that strategy look like? It would cover a number of areas, including outcomes, demonstrating how high-quality musculoskeletal services can deliver improvements in the outcomes measured in the NHS outcomes framework, particularly gaining independence and returning to work, as my hon. Friend the Member for Scunthorpe (Nic Dakin) pointed out.

The useful slogan, “no decision about me without me”, should also be a guiding factor, enabling patient involvement and shared decision making at all points in the patient pathway and, in particular, encouraging better self-management and at the same time improving general public awareness of musculoskeletal conditions. The information revolution is also relevant for setting out and making public the key sources of data on the performance of and expenditure on musculoskeletal services and improving our understanding of outcomes beyond hip and knee replacements, which account for only 20% of expenditure. There must be co-ordinated service delivery, joining up delivery across the NHS and social care services. Commissioning should describe the measures of success that will be used to assess clinical commissioning groups and set out the support that will be provided to commissioners. Training for GPs in musculoskeletal medicine is also important. We must enhance the currently small component in training to support GPs in providing effective and timely treatment and care to patients, as well as informing their commissioning decisions.

ARMA’s request of 18 months ago for a direct musculoskeletal service was reasonable. Even if there is to be no service director, ARMA’s requests are quite reasonable, because surely the Minister cannot be satisfied with how services are being delivered across the country, with different inputs and massively different outputs.

I finish by quoting Professor Emery of Leeds university. He was talking about rheumatoid arthritis, but this applies to any of these conditions. He said that it is the “most common treatable disability”. Essentially, it is not treated as well as it should be and the disability could be removed. I look forward to the Minister’s response, and hopefully he will respond positively to what should be a reasonable way forward.

Private Finance Initiative Hospitals

Graham Stringer Excerpts

Wednesday 4th May 2011 Westminster Hall

[Derek Twigg]

I will say more about the St Helens and Knowsley Teaching Hospitals NHS Trust a little later, but I have a lifelong relationship with the Whiston hospital, which is used by many thousands of my constituents. As I said, my right hon. Friend the Member for Knowsley, my hon. Friend the Member for St Helens North and I work very closely on issues relating to it, as neighbouring MPs.

I congratulate the hospital on delivering the PFI six months ahead of time and to an excellent standard. The chief executive, the board and the staff have done an outstanding job. The many medical staff, support staff and ancillary staff do an amazing job, and the hospital has the highest reputation, but I will talk specifically about the hospital in more detail later.

It is important to understand the use of PFIs, what was required and what was achieved. In 1997, after 18 years of Conservative disinvestment in the NHS, the service was in crisis: 1 million people were on waiting lists, hospitals were in disrepair, staff felt undervalued and buildings had been neglected. As my hon. Friends will confirm, people regularly complained to us in 1997 and thereafter—my right hon. Friend will say that they were complaining before then—about waiting more than two years to have an operation or even to be seen by a specialist in some instances. It is important to make that point.

The Labour Government made a firm commitment to improve, support and protect the NHS. In government, we did what was necessary to turn it from an organisation that was struggling for survival into the world-class and world-leading service it is today. It is important to make that point about the improvements made under the previous Labour Government, which included achieving the lowest waiting times, the highest public satisfaction, a two-week turnaround to see a specialist, a massive decrease in the number of those dying early from heart disease and cancer, and improved facilities. In the context of PFI, investment in the NHS is important.

As my hon. Friend said, 114 new hospitals were built over Labour’s 13 years in government to replace the existing ageing and neglected infrastructure. In 1997, half the NHS estate dated from before 1948; in 2010, that figure was down to about 20%. That rapid modernisation was unprecedented, but vital to the regeneration of the NHS, and PFIs played an important part in making that possible. They made possible the move from the previous workhouse-style provision of health care to a modern, technically advanced health care system for the 21st century. [Interruption.] The Minister tuts, but an old workhouse building was still being used on the Whiston site at the time. In fact, back in the 19th century, one of my distant relatives died in that building when it was still a workhouse, so it was a workhouse and it was used for health care. Now, we have a modern hospital to replace it. It is important to make that contrast, as my hon. Friend did.

[Graham Stringer (Blackley and Broughton) (Lab)]

Even with the massive investment and improvement under the previous Labour Government, my local hospital is still 60% a Victorian workhouse, and we need more. [Laughter.] The Minister laughs, but I mean that we need more investment, not more workhouses. Does the shadow Minister agree that although PFI was incredibly valuable in bringing that expansion about, it had two fundamental flaws? In a pragmatic way, it relied on the private sector being more efficient than the public sector to recover the higher borrowing costs, but that has not happened in many cases, because of the strict configuration of the contracts. Secondly, when the private sector is involved—I am not totally against that—we have the secrecy that my hon. Friend the Member for St Helens North (Mr Watts) mentioned. There are commercial interests, which is bad when public money is being used for the public good, because we cannot find out what is going on.

[Derek Twigg]

I totally understand my hon. Friend’s concerns. As regards his local hospital, he will realise that I never said that every hospital was modernised and improved. The issue now is how they will be modernised and improved under this Government, and I will return to that because we need to know from the Minister today what the Secretary of State’s and the Prime Minister’s plans are for modernising our NHS estate. The massive improvement under the previous Labour Government was unprecedented, but my hon. Friend is right that there were concerns. Not everybody supported PFIs, and there were issues, which I will come to later. My hon. Friend raises an important point.

It should be remembered that PFIs were also used under the previous Conservative Government. As noted in the Public Accounts Committee report entitled “PFI in Housing and Hospitals”, which was published on 18 January,

“PFI has delivered many new hospitals and homes which might otherwise not have been delivered”.

It is also important to note that the report’s summary says that hospitals are mostly

“receiving the services expected at the point contracts were signed and are generally being well managed.”

Again, I accept there were some problems, but the Public Accounts Committee recognised that they were generally well managed. Labour not only invested in the NHS, we invested in protecting its future. The contracted maintenance of buildings under the PFI agreements will ensure that the standard of NHS buildings will be as high in 30 years as it is today. The present generation is only the custodian of the NHS. Future generations are its owners, and PFI agreements will ensure that they are served by the same exceptional standard of facilities as today. That is an important point.

The system is not perfect, but at least it guarantees the maintenance of the buildings over a 30 to 35 year contract period. We all know that, with financial pressures, funding was cut for maintenance. Rather than being a one-off, that became a regular occurrence. That is why we found hospitals in the state they were in 1997—for which we, too, had some responsibility, as we had been in government for various periods before then. The fact was that there was massive under-investment, which was exacerbated by the Thatcher Government.

Under Labour, PFIs gave private sector partners responsibility for the completion of large infrastructure projects. A crucial point—of importance to my hon. Friend the Member for Blackley and Broughton (Graham Stringer)—is that accountability for services and the satisfactory completion of such projects remained in the public sector. That meant that the Government were still accountable to the people and Parliament for improving services to patients.

The PFI arrangement is a tool; it is a method that can be used badly or well. It would be disingenuous, as I said to my hon. Friend, to suggest that we were all in favour of PFIs when we were in government. It is important to be frank and honest and acknowledge that. There are strong views opposed to PFIs—it would be wrong to suggest otherwise with regard to some schemes. What we can be sure of is that, under Labour, the PFIs formed part of a carefully managed NHS in which the private sector could play a limited role. Sadly, under the Government’s current reforms, that will no longer be the case. The Government continue to rush through their NHS reorganisation; despite the so-called pause, work is still going on, without sufficient evidence or consultation on its true effect. Pressure has been relentlessly piled on to the NHS and foundation trusts, with insufficient consideration for the future. Through these costly, unwise and unwarranted reforms, spending cuts and efficiency savings, the Government are showing once again that they cannot be trusted on the NHS.

My hon. Friend the Member for St Helens North and my right hon. Friend the Member for Knowsley highlighted the issues surrounding the St Helens and Knowsley Teaching Hospitals NHS Trust, with which they have had a long association. However, it is important to repeat some of the things they said. This trust has a strong track record of high performance, achieving three stars and consecutive double excellent ratings from the Care Quality Commission. That high standard of care has been maintained: in 2010, it was the only acute trust in the country to perform above the national average in every indicator of quality of services and care in the CQC assessment. Therefore, I believe it could be described as the nation’s top-performing hospital. In addition, the trust achieved the maximum overall score in the auditors’ local evaluation for the use of its resources, for the fourth year running, acknowledging the trust’s excellent financial management.

Therefore, the trust performs to an excellent standard, not only in services and hygiene, but in financial management. The benefits of the PFI scheme for the hospital have been tremendous—more than 80% of the accommodation is new build on two sites, to which my right hon. and hon. Friends have referred; there has been capital investment of £350 million, with a 35-year concessionary period; radiology imaging equipment through a managed equipment services has been provided by GE Medical Systems; and hard and soft facilities management services, including catering, domestic estates, grounds, gardens and so on, have been provided. An important point for the Minister is that there is also 50% single room provision, with en suite facilities, as per Department of Health guidance. That is important in meeting both what we wanted and what the Government have said in respect of single-sex wards.

In 2009, the Secretary of State for Health, who was then the shadow Secretary of State, said this in an interview on Mumsnet about the pledge regarding single-sex rooms:

“This pledge will be delivered as part of our plans to provide 45,000 more single rooms in the NHS.”

Funnily enough, that pledge was dropped, and we have heard no more about it. I am interested to know, in the context of any PFI plans or hospital building programmes that the Minister has to comment on, whether there are plans to increase the number of single rooms, which is an important part of improvements in the NHS. I look forward to hearing any details that the Minister might give us.

My hon. Friend the Member for St Helens North, backed up by my right hon. Friend the Member for Knowsley, made some important points about secret documents. One has now been put into the public domain, though not officially, but we have not been able to see the other one. The Minister must answer who suggested as an option that a private sector provider could be brought in to manage this specific trust, and perhaps other trusts. Who suggested that that was the case? I understand that the trust board rejected that option and would only deal with it if directed to do so by the NHS, whether that involved the strategic health authority or the Department. I understand that that was the case. Will the Minister clarify that important point? I understand that one reason why the trust board would not accept the option of voluntarily considering a private sector provider coming to run it was a concern for patient safety. The cuts it was being asked to make to get to foundation trust status were too great and, in its opinion, were threatening patient safety. Will the Minister tell us whether that was the case?

What part of the NHS would suggest that option for a hospital that has achieved a double excellent rating, that has excellent financial management, that has been well run for years, that has a brilliant chief executive and management board, that has a committed staff and that has the support of the community? What person in their right mind would suggest a private sector provider? How could a private sector provider run it better than a double excellent rating?