Mental Capacity (Amendment) Bill [Lords]

Jim Cunningham Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Tuesday 12th February 2019 Commons Chamber

[Chris Bryant]

My hon. Friend makes a very important point. I know the role she has played, in particular in the all-party group on the armed forces, and of course in the NATO Parliamentary Assembly. She is absolutely right, and there are sometimes coup and contrecoup elements of damage to the brain. There is also some evidence to suggest that some people diagnosed with post-traumatic stress disorder have actually been suffering from a brain injury.

Interestingly, the Ministry of Defence has done some of the most innovative work in relation to brain injuries—physical brain injuries, as it were—and it has been able to transfer some of the skills and research involved in that work to the wider population, which is all to the good. However, I think that the way in which the mind sits inside the brain and the brain sits inside the skull is one of the areas of research that is still underdeveloped, and we still need to do a great deal more about it.

Other causes include brain tumours and chronic traumatic encephalopathy, where somebody may have had a series of relatively minor concussions. There is a complete misunderstanding of what concussion actually involves, particularly in sport. This might be leading to some of the long-term sustained problems of, for example, people in my own constituency who played rugby for many years and had repeated concussions. They may suffer from dementia, depression and anxiety in later life, but have no understanding that that may relate to a brain injury, rather than to anything else.

[Mr Jim Cunningham (Coventry South) (Lab)]

While we are talking about sport, may I say that this does not involve only rugby players? There is now evidence that footballers, particularly those heading the ball, suffer sustained brain injuries. It used to be interpreted as dementia, but it is a lot more serious than that. Has my hon. Friend had any discussions with the Football League about that?

[Chris Bryant]

I have had lots of discussions, some of them more fruitful than others, with the Football Association.

It is wholly to be deprecated that FIFA still will not allow a full substitution for an assessment of brain injury during a match. Ten minutes are needed to do a proper assessment on the pitch, but at the moment only three minutes is available in a FIFA match. There can be no substitution, and it is not therefore in the team’s interests to take the person off the pitch. I think that this must change. If there is one thing that I hope Parliament will say to FIFA about this in the next few months, it is that this must change. People we talk of as heroes, such as Jeff Astle, have died because of heading the ball. If those who are heroes to our young people today end up suffering in later life because of what they sustained in their footballing career, we will have done them a terrible disservice.

Prostate Cancer

Jim Cunningham Excerpts

Wednesday 6th February 2019 Commons Chamber

[Simon Hoare]

I am grateful to my right hon. Friend. I think we both stand at roughly 5 feet 6 or 7 inches, although I might be slightly taller than him when he is in his stocking feet. I get his reference and it is delightful to see eye to eye with him.

[Mr Jim Cunningham (Coventry South) (Lab)]

I wonder what you two want out of the Minister, given that you are giving him so much praise. Having said that, I am sure the hon. Member for North Dorset (Simon Hoare) will agree that the National Institute for Health and Care Excellence has sometimes been slow in making progress on treatments, as we have seen with other health problems. I echo his words that, simply put, men just do not like to tell anybody when they are not well. When people tell me that they have an illness like prostate cancer, they often say, “But don’t tell anybody.” The big problem is getting men to realise that they have to do something early, and the person who finds the answer to that very difficult issue will have done a great service.

[Simon Hoare]

I agree. In answer to the first part of the hon. Gentleman’s intervention, which I presume was rhetorical, I just want the Minister to carry on with the excellent work he is doing. The hon. Gentleman is right to say that we need to blow away the cloak of secrecy and, sometimes, shame and embarrassment. No family represented in this House will not have heard an aunt or an uncle say, in slightly hushed tones and that silent mouthed way, best exemplified by Les Dawson, that they have the big C. It is as though they cannot quite bring themselves to annunciate the word, in case it brings a plague upon their house. We have to brush all that away.

I am absolutely determined to get on to the issue that I want the Minister to address, which is what I was trying to do about 16 interventions ago. I urge him to grasp the opportunity—provided not least by the additional funding—for efficient, cost-effective and easier diagnosis. I appreciate that there is a whole range of things in the marketplace, but during my research I have been particularly struck by the opportunities presented by the pre-biopsy multiparametric MRI scan. We have a problem, because while demand for MRI scans rose by 30% between 2013 and 2016, this country still has fewer MRI scanners per head of the population than other countries with comparable populations. The additional moneys available provide a golden opportunity to do something about that.

Of course, it is never just a question of cash and kit, so allied with that are the people who can use the kit. The workforce are key. In addressing the issue of money and the benefits it can provide, we should note that we will not realise its full potential if we are short on workforce. The 10% vacancy rate in the national health service cannot be allowed to become the norm. Prostate cancer patients need and would like more clinical nurse specialists, who have the empathy and expertise to provide comfort, hope and a guiding hand. It is difficult to recruit in any specialist nurse area, but that should not put us off the endeavour.

Likewise, we need a recruitment drive for more radiologists. Prostate Cancer UK estimates that an additional 23 to 31 radiologists are needed in the UK. The Royal College of Radiologists estimates that in the financial year 2016-17, a whopping £116 million was spent on the outsourcing and insourcing of radiological skills additional to core contracted hours. To put that in perspective, £116 million would buy about 1,300 full-time consultant radiologists.

As I have said, raising public awareness of prostate cancer—its signs, symptoms, diagnosis and treatment—is pivotal, but so too is the reinforcement of messages from the Department, NHS England and others to our general practitioners. We all know that there is a growing problem of finding people who are interested in and prepared to enter general practice. The myriad drugs that come on to market and myriad other conditions make the already demanding life of a GP ever more so.

I recently met Jim Davis, the chairman of the Dorset branch of the Prostate Cancer Support Organisation, a charity that covers Hampshire, Dorset and Sussex. It is run for men diagnosed with prostate cancer, by patients with prostate cancer. Last year, they held 23 free prostate-specific antigen testing events, which delivered those tests for 4,813 men. They have found that people are more inclined to go into that sort of environment than to their GP surgery. Their work involves—as a Hampshire Member of Parliament, the Minister may already know this—raising money, advertising the tests and hiring village halls and other places. Men then come and have the test, which is sent—in effect, the work is subcontracted—to the local hospital, which analyses it and sends back the results. I will not detain the Minister, but I could read out a whole legion of extracts from letters from grateful men who availed themselves of that opportunity and found their life chances and health much improved.

Although the national health service says that any man over 50 is entitled to a free PSA test, evidence suggests that some GPs—I stress the word “some”, but one is too many—are either unaware of that entitlement or express and demonstrate an unwillingness to refer. Last May, David Radbourne, the director of commissioning operations at NHS England South East, wrote in response to a letter from Jim, who had produced a list of affected patients:

“If there are individuals who feel they are being refused legitimate access to this test…please ask them to file a complaint through the appropriate NHS complaints process.”

I say to my hon. Friend the Minister that in those circumstances, people should not be forced to go through an NHS complaints process. Like other campaigners, I see a lacuna, or an information gap—call it what you will—among certain GPs, and I urge the Department to consider ways in which to plug it. That issue needs to be addressed quickly. The official in the Box is waving a piece of paper and the Parliamentary Private Secretary, my hon. Friend the Member for Erewash (Maggie Throup), is up on her feet with alacrity, as always.

The Public Health England advisory note, “Advising well men aged 50 and over about the PSA test for prostate cancer”, needs to be reviewed and updated. It states:

“GPs should use their clinical judgement”.

That is a pejorative term—it is an open term—so perhaps that language should be revisited. The approach needs to be a little more robust.

Appropriate ME Treatment

Jim Cunningham Excerpts

Thursday 24th January 2019 Commons Chamber

[Carol Monaghan (Glasgow North West) (SNP)]

This debate is long overdue and much anticipated, and I thank the Members who have remained in the House on a Thursday afternoon to contribute to it.

There have been previous debates on ME, including one called by the then Member of Parliament for Great Yarmouth, Anthony Wright. That debate took place 20 years ago, and in 20 years little has changed for those living with ME. There is currently no cure, and many with the condition experience inadequate care and support. An estimated quarter of a million people in the UK suffer from it, and we are letting those people down. Many adults with ME cannot maintain employment or relationships, while children frequently fall behind at school. The ignorance surrounding the condition makes it harder for people to access benefits, and assessors from the Department for Work and Pensions often decide that sufferers are fit for work.

ME has specific characteristics—severe fatigue, debilitating muscle and joint pain, and extreme sensitivity to light and sound—but an important marker for the condition is that mental and physical activities can make the symptoms more acute. Some people with severe ME spend their days in darkened rooms, unable even to watch TV or listen to music. Touch is intolerable. Many are tube fed. For these individuals, ME is a life sentence, but it is a life spent existing, not living.

[Mr Jim Cunningham (Coventry South) (Lab)]

Will the hon. Lady give way?

[Carol Monaghan]

Very briefly.

[Mr Cunningham]

I fully support the motion, because it alludes to some of the complaints that ME sufferers have brought to my surgeries. This is a timely debate, and what the hon. Lady has said so far is quite right.

[Carol Monaghan]

I thank the hon. Gentleman.

This condition is largely unknown, because those affected are often hidden away. I commend the ME community for lobbying so successfully to ensure so many Members are here this afternoon. Ultimately, what that community wants is better treatment and care for people with ME.

Healthcare (International Arrangements) Bill

Jim Cunningham Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Monday 21st January 2019 Commons Chamber

[Justin Madders]

We want to ensure that there are appropriate safeguards with regard to costs, not least because the Bill currently gives the Secretary of State authority not only to facilitate a continuation of existing arrangements, but to enter into any number of bilateral agreements with individual member states, with very little opportunity for parliamentary scrutiny. It also provides the authority to strengthen existing reciprocal healthcare agreements with countries outside the EU, or to implement new ones across the globe, in line with the Government’s aspiration to develop trading arrangements with countries beyond the EU. There is therefore a potential for the establishment of multiple complex agreements.

New clause 1 addresses the important point that the Bill before us is rightly intended to provide for all reciprocal healthcare arrangements in the future, and to provide for all eventualities. As we know, a no-deal Brexit could lead to a multitude of new bilateral agreements within the EU27, let alone the rest of the world. At this stage, none of us can be clear about how many of those agreements will come into being. We cannot assess their likely cost or impact, and, indeed, the Government’s own impact assessment is inadequate in that regard. It suggests that the cost will be similar to, or lower than, the current £630 million per year.

[Mr Jim Cunningham (Coventry South) (Lab)]

My hon. Friend has mentioned potential bilateral agreements with different countries. Does he agree that there could be a problem if our citizens are not covered when travelling to those countries for a variety of purposes, and insurance companies send premiums through the roof? That is always a big factor, even with the current arrangements in Europe.

[Justin Madders]

It is true that there is some concern in the insurance industry about our potential failure to secure bilateral agreements. I think it inevitable that unless those agreements are secured, premiums will rise. That is why the Opposition support the thrust of the Bill.

It is impossible to provide reliable estimates of the costs of the new agreements in advance without knowing who they would be with or what they would cover. The British Medical Association has said that any prediction of costs is likely to be unreliable, and we cannot afford to give the Government carte blanche.

New clause 1 proposes a sensible and very reasonable requirement for the Government to report back to Parliament annually. It would require the Government to provide details of all payments made by the UK Government for all healthcare provided outside the UK to British citizens. It would also stipulate a requirement to provide details of all payments received by the UK Government as reimbursement for healthcare provided by the UK to all non-British citizens. It would also write into law a requirement for the Government to set out any outstanding payments owed to, or by, the UK Government. This would provide an important opportunity to monitor efficiency in this area and may provide an incentive to address some of the concerns raised by the Public Accounts Committee in its 2017 report, “NHS treatment for overseas patients”, which stated that

“the NHS has been recovering much less than it should”,

and

“The systems for cost recovery appear chaotic.”

Even with the Government’s recent funding announcements, the NHS continues to struggle. I am sure that the Minister would not want to see funds destined for patient care swallowed up by the additional administrative burden created by the introduction of a range of complex charging arrangements and a failure to recover the costs that have been incurred. It is imperative that hospital trusts are not required to shoulder additional financial burdens because of the costs of administering the collection of charges. That is why if the Government are, as the Minister said in Committee, committed to transparency and parliamentary scrutiny, new clause 1 should be supported.

Turning briefly to the amendment that I tabled, we have discussed previously widely held concerns about the scope of this Bill that are exacerbated by the fact that the powers contained within it to create regulations will, in many cases, be subject only to the negative procedure. The Delegated Powers and Regulatory Reform Committee in the other place set out very clearly the potential impact of this Bill should my amendment not be accepted today. It said:

“If…the Secretary of State wished to fund wholly or entirely the cost of all mental health provision in the state of Arizona, or the cost of all hip replacements in Australia, the regulations would only be subject to the negative procedure.”

It added:

“Of course, these examples will not be priorities for any Secretary of State in this country”.

I am sure that is the case, but we must consider how the powers could be used, not just how we would expect and hope them to be used.

There is always merit when examining legislation in considering all potential scenarios as well as the stated intentions of the Government at the time, and in such an unprecedented period of uncertainty it is prudent to consider all eventualities. As the Government have included these powers in the legislation we cannot simply consider the world as it is now, nor how it might be in a year or two—indeed, if anyone knows what the world will be like in two or three weeks’ time I will be very impressed. We need to look at what the world might be like in many years’ time and how the powers in the Bill can be used.

If we require further persuasion about the need for caution, the Committee set out in its report a devastating list of reasons why the negative procedure is inappropriate. It said:

“There is no limit to the amount of the payments. There is no limit to who can be funded world-wide. There is no limit to the types of healthcare being funded. The regulations can confer functions (that is, powers and duties, including discretions) on anyone anywhere. The regulations can delegate functions to anyone anywhere.”

The Committee concluded:

“In our view, the powers in clause 2(1) are inappropriately wide and have not been adequately justified by the Department. It is particularly unsatisfactory that exceedingly wide powers should be subject only to the negative procedure.”

Just for good measure, it went on to describe the powers sought in the Bill as “breath-taking”.

Parliament is not alone in having concerns about the scope of the clause and the lack of clarity about how the powers might be used. In the Committee evidence session, Raj Jethwa, director of policy at the British Medical Association said:

“We would like to see much more emphasis on scrutiny of all the discussions in the arrangements going forward.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 6, Q14.]

Picking up on the Committee’s comments, despite the Government having ample opportunity both on Second Reading and in Committee to justify the need for these exceedingly wide powers, I believe that the arguments that they advanced during the passage of the Bill have not only failed to do so, but have strengthened the case for greater scrutiny. The Minister conceded in Committee:

“The Bill also provides flexibility to fund healthcare even where there is no bilateral agreement, which we might explore using in exceptional circumstances to secure healthcare for certain groups of people.”

That is the nub of it: we know the well-rehearsed and necessary reasons why the Bill is required to secure the continuation of arrangements as we leave the EU, but it is on the record that the Bill can potentially do far more than that. We do not know what those exceptional circumstances are, and we do not know who those groups of people might be, and even if the Minister were able to set out here and now what he was referring to in that statement, he cannot bind a successor to that. The Bill gives the Secretary of State what I might describe as Martini powers: any time, any place, anywhere. If he is to have such wide powers they must at the very least be subject to the affirmative procedure.

The Minister also said in Committee that not only would the Bill encapsulate existing healthcare agreements but that it

“will potentially add to their number as part of future health and trade policy.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 29 November 2018; c. 23-24.]

That is also a concern. I do not know whether the Minister intended it to come across as it did, but it sounded very much to me as if the Government were intending to couple trade negotiations with access to healthcare. I hope that that is not the case.

Many people have expressed concern over a number of years that the Government appear willing to open up the NHS to American private healthcare companies as part of trade negotiations, but I am not sure that many people imagined that the Government also had designs on opening up the NHS to patients around the world as part of a strategy to secure trade deals with other nations. Perhaps I am wrong about that, but it is clear that the Bill can be used in that way, which is why any arrangements ratified under it need proper scrutiny.

We also to consider the impact of new arrangements on the NHS. Alastair Henderson, chief executive of the Academy of Medical Royal Colleges, said in the Committee evidence session:

“Both clinicians and health organisations are concerned that we could end up with a system that is both administration-intensive and time-intensive.”––[Official Report, Healthcare (International Arrangements) Public Bill Committee, 27 November 2018; c. 3, Q4.]

We went through some of the implications of that when discussing new clause 1.

Finally, there is a practical element to this. As we know, under the negative procedure, once an instrument is laid in draft it cannot be made law if the draft is disapproved within 40 days. This would be done via a prayer against, usually by way of an early-day motion. If that is not invoked then the legislation is passed. Under the negative procedure, that is still a 40-day process in the best-case scenario, and if we leave without a deal the Secretary of State in the next three weeks will have to reach agreement with each of the 30-plus other countries, sign those agreements, draft statutory instruments and lay them before Parliament so they are with us no later than Friday 15 February, the last date on which they could be laid in order for them to be passed by 29 March—and that is assuming they are not prayed against.

If we assume this Bill completes Third Reading today, that gives the Lords about three weeks to complete their consideration—and the Minister will no doubt be crossing his fingers that they do not table any amendments. That seems to be a tall order, and given the Committee’s comments on this amendment the Lords may well be minded to send the measure back to us, but in either case it all seems rather a tight, if not unrealistic, timetable. I therefore urge the Minister to think through the practicalities of this; the affirmative procedure could be significantly quicker than the negative one, and it has the advantage of being far more transparent.

The Minister tried to reassure me in Committee that there would be adequate scrutiny by virtue of the Constitutional Reform and Governance Act 2010, but I am afraid that that just does not cut the mustard. Under that Act, there is a specified process enabling Parliament to object to a treaty being ratified within 21 days, but that does not automatically lead to a debate and a thorough examination of the issues of concern. The Act simply says that in the event of an objection the Government must issue a statement setting out why they still want to ratify; this process could apparently be repeated ad infinitum, and crucially under the Act there is no requirement for a debate. It would be open to either Government or Opposition to set aside some of their allotted time to facilitate a debate, but there is no requirement to do so. In addition, there are exceptions that enable the Government to ratify treaties outside the Act—for example, if there are “exceptional circumstances”, which of course is a judgment that is within Government’s gift. The measure does not cover memorandums of understanding either, and some of the older reciprocal healthcare arrangements fall within that description.

Putting new agreements into force in these extraordinary circumstances is necessary, but we simply cannot accept the clause as it stands. No matter how well-intentioned everyone might be now, once that power has been given away it is not easily taken back. Do Members want us to fund hip replacements in Arizona? Are Members comfortable with access to the NHS being used as a bargaining chip in trade deals? Of course they are not, so why do they not vote for the amendment tonight?

Mental Capacity (Amendment) Bill [Lords]

Jim Cunningham Excerpts

2nd reading: House of Commons & Money resolution: House of Commons & Programme motion: House of Commons & Ways and Means resolution: House of Commons
Tuesday 18th December 2018 Commons Chamber

[Matt Hancock]

The resource question is an important one, and so too is the process. The question of resources and the question of what the process is go hand in hand. There has been an increase in the amount of resources given to local authorities to enable them to deliver in this area, but the question will undoubtedly arise again as we run up to the spending review.

[Mr Jim Cunningham (Coventry South) (Lab)]

I visited a police station a couple of weeks ago, and I found that the police lacked adequate training to deal with some of the cases that they were coming across. Has the Minister had any discussions with the Home Secretary about that?

[Matt Hancock]

Yes, I have. This is an incredibly important point. The deprivation of people’s liberty in a police cell when there is a lack of mental capacity—or, in certain circumstances, when there is a serious mental illness—happens far too often. The purpose of police cells is to detain criminals. Providing a system in which such people do not have to be held in police cells is absolutely critical and part of our plan.

Diabetes: Artificial Pancreas

Jim Cunningham Excerpts

Wednesday 12th December 2018 Commons Chamber

[Mr Howarth]

There are centres where people can access a lot of services in one place in a similar way to what the hon. Gentleman describes as happening in Northern Ireland.

I attended an interesting conference in Vancouver three or four years ago. I found out—the Minister or one of her colleagues might want to investigate this a bit further—that some of the smaller island states tend to provide all the services in one place because they do not have the capacity or resources to do anything else. It is an accident of geography that they are forced to do that, but it seems to work very well, particularly in some of the Pacific island areas, where there is a massive problem with type 2 diabetes.

[Mr Jim Cunningham (Coventry South) (Lab)]

I apologise for coming to the debate a bit late. My right hon. Friend may have touched on this; the issue affects not only families, but schools, which need to have a bigger appreciation of the difficulties that kids experience not only with diabetes, but in other areas. I had a private Member’s Bill some years ago that proposed a cluster of schools having a specialist who could spot early problems with children, including diabetes and all sorts of mental health problems. Does he agree that would be helpful?

[Mr Howarth]

My hon. Friend may have been late, but he is never behind. Of course I agree with him.

In October, I tabled a written parliamentary question to the Secretary of State for Health and Social Care, asking how many patients with type 1 diabetes had been referred for psychological support, psychiatric support, and treatment for an eating disorder or diabulimia in the last 12 months. I was told that the information is not held centrally. I then took the matter up with Knowsley clinical commissioning group, but it turns out that it does not hold that information either.

The lack of psychological support for adults and young people with type 1 diabetes is a real and important issue. It was one of the key points in the national service framework for diabetes when that was first brought into being. Most patients on Merseyside, which is my part of the world, still cannot get the support that they need.

Diabulimia, which is a syndrome, rather than a condition, is an eating disorder present among those with type 1 diabetes. It involves the omission of insulin doses, which leads to high blood glucose levels and the body’s cells being deprived of oxygen and energy. The available research suggests that around 40% of females between the ages of 15 and 30 with type 1 diabetes deliberately induce hyperglycaemia and diabetic ketoacidosis in order to bring about weight loss. Anyone can go on the internet and quite easily find out that if they omit to use their insulin, they can probably lose half a stone in a week, but of course the risks in involved in doing so, including damage to vital organs, should not be taken at all.

According to the charity Diabetics with Eating Disorders, 60% of all females with type 1 diabetes will have experienced a clinically diagnosable eating disorder by the age of 25, and new research suggests that 11% of adolescent males also engage in insulin omission for weight loss. I just want to pause at this point and say a word: although I am describing something that affects type 1 diabetics, it is all part of a wider problem of body image and an obsession with a particular type of weight range. Although diabetics, because of their condition, have a different means of achieving that weight loss, it is an issue that has to be addressed nationally. I know that the fashion industry, for example, has started to make some moves in that direction, but it is a national problem, particularly for many young women who feel that they have to look a certain way to be acceptable. That is, of course, nonsensical, but, nevertheless, it is the way that some of them feel.

Sandie Atkinson, a PhD candidate at Liverpool John Moores University, believes that there is a lot more that clinics can do to reduce the psychological impact of type 1 diabetes and, as a consequence, reduce the prevalence of diabulimia. She says:

“By being empathetic to the issues that impact blood glucose level outside of the realm of an individual’s ability to manage and having realistic expectations of them in light of these uncontrollable factors, individuals might feel less inclined to hide their true condition from Healthcare Professionals.  The likelihood of them being more open would undoubtedly be in the best interest of the patients and the NHS at large.”

While conducting her research, those whom Sandie spoke to described the problems that they had in accessing support in clinics. One participant said:

“Eating disorders thrive on secrecy and yet people feel with diabetes they can’t be honest about the expectations of where they are with control so there’s two lots of secrecy there that really does a lot more damage”.

A second interviewee said:

“There’s something about the way that we treat diabetes and I don’t know if it’s maybe because there is some internal stigma, but there’s something needs to be done…I just kind of feel like we’ve got it all wrong…right from the off you should have a psychologist…at least for the first year. I mean the research is all there, suicide risk goes up, self-harm risk goes up, mental health declines…We know this but we’re like, ‘oh yeah, we’ll see you in six months’ time’.”

To progress towards artificial pancreas systems, there are a number of things that the Government must do. The NHS needs to establish a new national framework that encourages innovation. The framework could include some of the following elements: first, a national strategy, with allocated funding, for diabetes technology, allowing all people with type 1 diabetes to self-manage their condition by considering individual medical need and the potential to improve quality of life and psychological aspects of care.

NHS Reorganisation

Jim Cunningham Excerpts

Wednesday 12th December 2018 Westminster Hall

[Faisal Rashid (Warrington South) (Lab)]

I beg to move,

That this House has considered NHS reorganisation.

It is an honour to serve under your chairmanship, Mr Gapes. It is my pleasure to open this debate on our NHS as we near the end of the year marking its 70th birthday. In debating its reorganisation, we should not lose sight of what a great credit the NHS and its staff are to our country. Its foundation represents arguably the greatest achievement of this House. It is for precisely that reason that its reorganisation matters so greatly.

Let me set the context. Eight years of cuts and the biggest financial squeeze in its history have pushed the NHS to the brink. On all key performance measures, it is struggling to keep up with demand—A&E performance hit a record low this year, more than 4 million people are stuck on a waiting list, and cancer targets are repeatedly missed. In a speech last year, the chief executive of NHS England warned:

“On the current funding outlook, the NHS waiting list will rise to 5 million people by 2021. That is an extra 1 million people on the waiting list. One in 10 of us waiting for an operation. The highest number ever.”

As the NHS is pressurised to do more with less, it is imperative that Parliament properly scrutinises the ongoing process of its reorganisation. We should not allow the Government’s shambolic handling of the Brexit negotiations to distract us from reforms that are critical to the livelihoods of millions in this country.

I acknowledge that this subject is wide-ranging and complex, so I intend to focus on a few key issues: clinical commissioning groups; sustainability and transformation plans and partnerships; integrated care partnerships; health and social care integration; and healthcare infrastructure.

Let me start with the Health and Social Care Act 2012 and CCGs. Six years on from the coalition Government’s top-down reorganisation of the NHS, it is clear that that initiative has been as much of a disaster as Labour warned it would be. My hon. Friend the Member for Ellesmere Port and Neston (Justin Madders) rightly described those reforms as having put in place

“a siloed, market-based approach that created statutory barriers to integration.”—[Official Report, 6 September 2018; Vol. 646, c. 176WH.]

The 2012 Act removed regional health planning by abolishing strategic health authorities and creating a complex and fragmented system of clinical commissioning groups. Strategic health authorities helped co-ordinate the provision of healthcare across an area. Subsequent NHS reorganisations have often felt like partial attempts to reverse the damage done by the 2012 Act. It is therefore unsurprising that little effort has been made to keep the public informed of those changes.

[Mr Jim Cunningham (Coventry South) (Lab)]

I congratulate my hon. Friend on securing the debate. He touches on the reorganisation way back in 2012. Clinical commissioning groups were created, but they are not accountable to the public—we have problems trying to find out what their budgets are and so forth. We have the same problem with NHS England, which is another very difficult organisation to deal with. As a result of all this reorganisation, we have organisations that are not really accountable to the public, and the public do not get their voices heard.

My hon. Friend touched on staff salaries. If we worked it out, we would probably find that they have had an 8% real-terms cut in wages over the past seven or eight years, on top of which they have to pay car parking charges for the privilege of serving the public. Does he agree that that cannot be right?

[Mike Gapes (in the Chair)]

Order. Can I just request that interventions are not long speeches?

--- Later in debate ---

[Mr Jim Cunningham]

My hon. Friend is quite right. One of the things that would help, particularly among women, is reintroducing the education maintenance allowance so we can bring forward student nurses and so forth. I will give a very quick example—I know you have been a bit lenient, Mr Gapes. In Coventry, a certain facility is starting to be moved to Birmingham. That is 16 miles away, so people are going to have to travel quite a distance. We still have difficulties getting through to NHS England, which arbitrarily comes along and says, “This is going to happen.” It looks as though it might happen unless we can find some alternative. Does my hon. Friend agree that that is no way to run a national health service?

[Mike Gapes (in the Chair)]

Order. I remind hon. Members that they should not make lengthy speeches in interventions. I would be grateful if all Members bear that in mind in future. I will not be very kind if I get the sense that we are getting three or four speeches from one Member.

Nursing: Higher Education Investment

Jim Cunningham Excerpts

Wednesday 21st November 2018 Westminster Hall

[Eleanor Smith (Wolverhampton South West) (Lab)]

I beg to move,

That this House has considered investing in nursing higher education in England.

It is a pleasure to serve under your chairmanship, Mr Davies.

I am proud to speak on an issue close to my heart. Before I entered Parliament, I was privileged to work as a nurse for almost 40 years, and last year my daughter graduated as a nurse. Nursing is an incredible profession, a fulfilling career and full of opportunities for those who choose that rewarding path. Nurses are the most trusted profession in Britain, a position they have held for years, with 96% of the public trusting nurses to tell them the truth. It may come as little surprise to hon. Members that politicians are the least trusted. Let all of us in this House show political leadership now and listen to what nursing students and nurses are telling us. They are telling us what must happen to meet the needs of communities across England.

Everywhere there are people, there are nurses, but they are not necessarily doing what we might think they are doing. Yes, nurses connect with patients and families to understand what people need, but they are also diagnosing, prescribing, performing surgery, creating care plans, delivering treatment, overseeing clinics, managing hospitals, working as chief executives and designing primary care services.

[Mr Jim Cunningham (Coventry South) (Lab)]

My hon. Friend mentioned that nurses are valued, but if the Government really valued them, they would give them a decent wage increase and restore the education maintenance grants and, if necessary, bursaries as well. Does she agree that that would demonstrate how nurses are really valued in this country?

[Eleanor Smith]

I do agree, and my hon. Friend will hear me refer in my speech to what he has just said.

Healthcare (International Arrangements) Bill

Jim Cunningham Excerpts

Wednesday 14th November 2018 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

I will be supporting the Bill today. I am only sorry it is necessary. There is no version of Brexit that will benefit people who rely on the NHS, social care, scientific research or public health; there are only varying degrees of harm. The Bill seeks to address one of those harms, and that is around our reciprocal healthcare arrangements, which have made such a difference to people’s lives both here and across the EU. As the hon. Member for Linlithgow and East Falkirk (Martyn Day) pointed out, 190,000 UK expats live in the EU and 27 million people hold an active European health insurance card, which covers about a quarter of a million treatments every year, but we are also talking about British citizens who travel or live in the EU to work and the 1,300 people who benefit from planned medical treatments in the EU under the S2 route.

I will turn first to the 190,000 British expatriates, mostly pensioners, living in the EU. Incidentally, 90% of them live in Ireland, Spain, France and Cyprus. They face a desperately worrying future. In the event of a deal, they will be covered by transitional arrangements until 2020, but in the event of a chaotic exit, with no deal and no transition, in just 135 days they could be left stranded, many of them with access only to very basic medical care. Some of them will be uninsurable and many will have no easy path to return to the UK.

The Minister will know that, as I mentioned to my hon. Friend the Member for Poole (Sir Robert Syms), 75%—£468 million of the total £630 million in 2016-17—of the cost of our reciprocal healthcare arrangement relates to pensioners. When he sums up, will the Minister please respond to the updated estimated cost of those pensioners having to return to the UK and the net effect on the NHS? The Health and Social Care Select Committee heard that the current average cost of treating a UK pensioner in Spain was €3,500, but the average cost of treating pensioners in the UK was £4,500, and again the discrepancy between the pounds and euros makes that even greater.

In the future, the costs associated with EHIC— £156 million—and the S2 route for planned medical treatments will be borne directly by the 50 million UK nationals who visit the EU every year, but those costs will not be distributed evenly. The costs will fall disproportionately on those with pre-existing medical conditions. They will be exceptionally hard hit. As we heard from the hon. Member for Ellesmere Port and Neston (Justin Madders), many individuals will be effectively uninsurable and unable to travel. Will the Minister tell us what clear advice the Government are giving to people with pre-existing medical conditions who are thinking of making travel arrangements after 29 March? Is he being explicit with them, and telling them that they need to check now whether they may find themselves left stranded without medical insurance in the event of our crashing out in a chaotic exit with no deal whatsoever?

I recognise and welcome the fact that the Bill gives the Minister power to put in place an equivalent scheme, but that scheme will have to involve a dispute resolution process. In the deal that is about to be published, has the Minister seen what that process would be? Another thing that he needs to be very clear about when he sums up the debate is that if we crash out with no deal and no transition, we will not be making these reciprocal arrangements with a single body; we will be making them with 27 different European states, three European economic area states, and Switzerland. Is it even conceivable that we could complete negotiations on that scale with 135 days to go? We need to be really clear with Members throughout the House, and to the public, about what that means, so that people can make plans accordingly. May I also ask whether the Minister is setting aside, within the contingency fund, a sum of money that we could use to assist British nationals who find themselves in difficulties on the wrong side of the channel in the event of no deal and no transition? Those are all important points about which we must be very clear with people.

Does the Minister agree that during the referendum campaign there were very many different versions of Brexit? The Brexit reality with which we are about to be presented is very different from the fantasy version that was presented during the campaign. People will remember the “easiest deal in history” and the “financial bonanza” for the NHS, but the Brexit reality is that there will be a significant Brexit penalty, from the most damaging form of Brexit in particular. We are looking at effects across the entire health, care and research system. Yesterday I met representatives of the Royal College of Nursing to discuss their grave concern about the future workforce. While the overall number of registrants has increased, there has been a very worrying decrease in the number of joiners in the past year. The number of joiners from EEA countries has dropped by nearly 20%.

[Mr Jim Cunningham (Coventry South) (Lab)]

The Royal College of Nursing has been on to me as well, expressing serious concern about what will happen after we leave the European Union. The hon. Lady should add to her earlier question, “What will happen after 2022 in relation to medical care for expats in Europe in particular?”

[Dr Wollaston]

That is, indeed, a question that I have been addressing. What will happen to expats in Europe? What we absolutely must focus on, however, is what will happen 135 days from now if we do not have a deal and people are left high and dry. It is a very worrying situation.

The issue of the workforce does not just affect nursing staff. We should bear in mind that 5% of members of the regulated nursing profession, 16% of dentists, 5% of allied health professionals and 9% of doctors are EEA nationals. We cannot afford to lose any more of that workforce, or to demoralise them further. I think it shames us all that the Health and Social Care Committee heard from nursing staff from across the European Union some of whom were in tears when reporting that they no longer felt welcome here. That is a terrible Brexit penalty, and no one voted for it when they went to the polls.

This does not just affect the workforce either. The Brexit penalty applies to the entire supply chain of medicines and medical devices, from research and development to clinical trials, to the safety testing of batches of medicines, and right through to the pharmacy shelf and the hospital. There are many unanswered questions about the issue of stockpiling, and about contingency plans for products that may require refrigeration, or products with very short shelf lives that cannot be stockpiled. There may also be brand-switching issues: for people who suffer from conditions such as epilepsy, switching brands is not easy.

I am sorry, Madam Deputy Speaker. I will bring my remarks to a close shortly. [Interruption.] I understand that you were merely coughing, Madam Deputy Speaker, so I will continue.

Refrigerated warehousing and special air freight do not come cheap. The companies whom we met, represented by the Association of the British Pharmaceutical Industry, made it clear that they were already having to spend hundreds of millions of pounds on contingency planning. The Government have said that they intend to reimburse companies, but the smaller companies need to know how quickly they will be reimbursed, because they may have cash-flow issues. They need to know the details of how the scheme will work, but they simply do not have the information that would enable them to make plans for the future. I hope that the Minister will be very mindful of that.

As I said earlier, the simple truth is that the many versions of Brexit have very different implications for the NHS, for social care, for public health and for research. Once this deal is published, we will have an opportunity to set out what this means, but, most important, to set all the risks and benefits of the deal that is on offer for the NHS and social care. The Minister will be aware of the important principle of informed consent in healthcare. No one would dream of going into an operating theatre and having an operation without someone telling them what is involved and setting out the risks and benefits so that they could weigh them up for themselves. That is called informed consent, and without informed consent, there is no valid consent.

Let me say to the Minister that we are all being wheeled into the operating theatre for major constitutional, economic and social surgery without informed consent, and let me ask him please to consider how things will be 136 days from now, after we crash out with no deal and when the serious consequences of that start to unfold and unravel and hit real people’s lives. What will he be saying to his constituents and the House if we have proceeded without informed consent?

Budget Resolutions

Jim Cunningham Excerpts

Tuesday 30th October 2018 Commons Chamber

[John McDonnell]

My hon. Friend is right. Yesterday we needed serious action to address the bias against high streets, which has led to so many empty shops. Instead we got legislation that will help turn shops into flats.

We then had a huge media presentation about an online tax being introduced: it was said that £400 million will be found from this online tax in a few years’ time. At the weekend the Tax Justice Network said the top five tech companies have avoided £5 billion-worth of tax.

My second concern about the austerity debate is that if we understand and appreciate what people have been forced to go through with austerity, only callous complacency could drive us to inflict those policies on people. Yesterday the Chancellor’s speech, with references to “Labour’s recession,” demonstrated that he is trapped in a time warp of a political propaganda exercise by the Tories of a decade ago. [Interruption.] I thought they would like that one. Let us be clear: the financial crash was the result of greed and speculation, and a lack of regulation that goes right back to the 1980s. Austerity was always a bad idea.

[Mr Jim Cunningham (Coventry South) (Lab)]

Like my right hon. Friend, I heard the Chancellor try to blame the last Labour Government for the recession, but in actual fact the previous Chancellor said a couple of months ago that it was not the Labour Government’s fault; it was the whole system’s fault, starting with Lehman Brothers in America. We should get the facts right.

[John McDonnell]

I always said George Osborne would get it right one day.

The consensus among economists, and the evidence of recent history, is absolutely clear. The worst possible response to a recession is for a Government to cut their own spending. In a recession, the Government should be there to support businesses and households. Instead, at the moment when Government support was most needed to help people back on their feet, Conservative Chancellors chose to impose the most severe spending cuts in generations. They did not have to, and they should not have done.

The Tories were warned that austerity would lead to slower growth and lower wages, and it has. The economic experts the Tories chose to ignore were proved right. Growth since the financial crisis, under Conservative Chancellors, has been the slowest after any recession in modern times. Real weekly average earnings are still lower today than they were in 2010. The Resolution Foundation reports this morning that real wages will not have fully recovered until 2024.

Ten years after the crash, we should be clear about the causes of the financial crisis. The Chancellor seemed confused on that point yesterday. It was not the deficit that caused the crisis; it was the crisis that caused the deficit. It was a crisis—[Interruption.] They don’t like to hear the truth. It was a crisis that resulted from the casino economy that the Tories helped construct right from the 1980s and supported every step of the way.

--- Later in debate ---

[Victoria Prentis]

No, I do not agree, but I was able to take my local PCC’s issues up with the Chief Secretary to the Treasury directly in the last fortnight, and I encourage the hon. Gentleman to go to the Treasury with specifics; I think he will find that Treasury Ministers are listening.

We have £30 million extra to improve security and decency across the prison estate, which I feel very passionately about. We also have a whole new prison, Glen Parva, which was due to be a private finance initiative project, but the Treasury has now agreed to fund it. No specifics on the finances have been given in the Budget because it has to go out to tender and there will be all sorts of legal issues, but that is a very big commitment from the Treasury, and I for one am very proud of it. We need to put decent conditions in place for criminals so we can rehabilitate them before they are put back into society.

I also welcome the £21.5 million to be invested in the wider justice system. I feel very strongly that justice is not free; it does not just happen. The rule of law is not automatic, as we can see from the world we live in: it is a world in which people are poisoned in Salisbury, and in which the Chinese have a definition of the rule of law that does not coincide with the norms of modern international law since the second world war. I feel very strongly that we need to stand up for British justice values, and this does not happen automatically or cheaply.

We have had real difficulties in the prison service.

[Mr Jim Cunningham]

Will the hon. Lady give way?

[Victoria Prentis]

No, I will not; I am sorry, but I need to make progress, and I feel very strongly about this subject. We have had real difficulties in the prison service under successive Governments which we know can only be resolved if we can recruit more staff. The prisons Minister and the Lord Chancellor, whom I am happy to see in his place, are both working extremely hard on staff recruitment, and real progress has been made. We can see that this is making a day-to-day difference on the coalface, if you like, in prisons. People are being treated more appropriately.

However, there are other areas of justice spend that are harder to justify and even to talk about in this place. We have a crisis of judicial recruitment, for example, and it is tied up with the provision of suitable judicial pensions. The quality of court buildings also matters for morale, and it is therefore important for the recruitment of the people that we need to provide justice in a way that we all too often take for granted. The justice system stands or falls as one. What we do for the most lowly magistrates court is just as important as what we do for the Supreme Court. The system must be joined up, and if we are proud of the rule of law and the separation of powers that we talk about so often, we must be careful to fund the system as an entirety.

I am glad that the Lord Chancellor has been here to listen to this. I commend him for what he is doing. I also commend the Chancellor of the Exchequer for what he is doing for the justice system. The subject does not often get talked about in the House, and it was not talked about a great deal yesterday, but the detail in the Red Book has pleased me. Thank you for your patience, Madam Deputy Speaker.

--- Later in debate ---

[Jeremy Lefroy (Stafford) (Con)]

Our country faces some immense challenges and this Budget—from a fine Chancellor, who I hope stays for many more Budgets—does good work in tackling a number of them, but there are several others that I want to address and that some colleagues have touched on.

The first challenge to which the Chancellor and the Prime Minister have risen is the need to fund healthcare properly. A number of Members across the House have regularly made the case for an increase of about £20 billion a year to bring our spending in line with German or French levels, and this is happening. But I agree with the point made yesterday by the hon. Member for Bassetlaw (John Mann)—that is, that we need to pay for this. It should not just come from additional borrowing, and we should continue to look at using hypothecated or other forms of revenue, particularly when it comes to social care.

A second challenge that the Chancellor has met—as, indeed, have employers up and down the country—is the need to increase and maintain employment, and to reduce unemployment to the lowest level in decades. The unemployment rate has fallen from 8% to 4%. In many constituencies, including mine, it has fallen much further than that, but every person out of work is still one too many. It is also welcome that on the whole jobs are gradually becoming better paid.

The third area in which the challenge is being met is defence and our global role, particularly in international development. The UK is one of the only major countries in the world—if not the only one—to maintain both the 2% defence commitment under NATO and the 0.7% official development assistance, and I welcome that. In difficult times, we can be proud that the UK will meet our international commitments as well as the commitments to our own people on safety and security.

Now, what about the challenges? The big and immediate one is clearly exiting the EU. It is absolutely essential that we reach a deal. I am a member of the Exiting the European Union Committee, and the more I hear of the consequences of no deal, the more apparent it is just how damaging it would be to the EU and to the UK. The Chancellor recognises this, and I sincerely hope that he does not have to come to the House with his alternative Budget. But this is not just about exiting the EU; it is about the future of the economy.

My hon. Friends the Members for Mid Norfolk (George Freeman) and for The Cotswolds (Sir Geoffrey Clifton-Brown) have mentioned the challenges we face and the future opportunities. The right hon. Member for Birmingham, Hodge Hill (Liam Byrne) and I recently produced a book on the future of work, looking at countries around the world that are meeting these challenges, including South Korea, Singapore and Argentina. Lots of people across the country are trying to meet these challenges, but they also exist globally.

It is an honour to follow the hon. Member for Makerfield (Yvonne Fovargue), who was right about funding for 16 to 18-year-olds. The years from 16 to 18 are a critical time, and funding dropping off at that stage poses some severe challenges to colleges and schools.

[Mr Jim Cunningham]

Like me, the hon. Gentleman is a west midlands MP, and knows that the west midlands economy is very important to the country. I am not sure whether the Government have clarified whether there will be more money for further education. Further education is the backbone of things such as apprenticeships, and we need more apprenticeships. Does the hon. Gentleman agree that we should be focusing on this important area?

[Jeremy Lefroy]

Indeed, and I think I just mentioned that. In my constituency, Newcastle-under-Lyme College and Stafford College do excellent work, as does South Staffordshire College, but they are underfunded, particularly at that level.

A further challenge is balancing the Budget. The OBR report refers to the Chancellor in terms of St Augustine, as it describes the Budget as Augustinian—“make me chaste, but not yet.” I believe that it is nearly 20 years since the UK has run a Budget surplus, and we are now pushing that back by a further two years. This is not the way to go. We have to look carefully at how we can return to a balanced Budget or a surplus, which can only come from growth, more efficiency or allowing tax rates to rise—we have some of the lowest revenues as a percentage of GDP in the G7—but that has not happened this time. If we are to maintain a sound fiscal policy, it will have to happen soon. The country needs to build up assets in better times to meet the challenges of hard times, and one of those assets is a surplus Budget and a reducing deficit.

Local government finance has been mentioned today. This is a great challenge because I believe, as do pretty much all colleagues in this House, in the importance of devolution and making decisions locally. However, the Government are placing more and more pressures on local government, without giving it the means to deal with them. Local authorities, including Staffordshire, have done excellent work to reduce spending while maintaining services over the last eight years. That cannot go on. Local government has reached the bottom. I welcome the additional money, but we need to see more, particularly in terms of loosening up the requirements for referendums.

The right hon. Member for Enfield North (Joan Ryan) rightly said that the Office for Budget Responsibility report talked about the low savings rate and rising personal debt. That incredibly important area has not been focused on, and I am extremely concerned about it. We need to help households rebuild their balance sheets. People cannot always look to Government to support them in times of difficulty. Personal assets are vital, and I urge the Chancellor to look at ways of encouraging saving, difficult though that is—including efficient lifetime savings accounts that people can draw on in times of difficulty, financial education in schools and further support for credit unions.

We have the biggest current account deficit in the G7—from memory, it is about 3.8%. That is down from 5.1%, but it is still too much. We are too dependent on resources from other countries, and we need to build up our network of foreign assets, from which we receive income. At the same time, we need to reduce our balance of trade deficit.

Finally, we have the challenge of supporting people on the lowest incomes who are long-term sick or disabled. At a time when many people in this country are seeing their incomes continue to rise and are living in prosperity, which I welcome, we need to meet the needs of those who suffer from disability, sickness or low income. I welcome the changes to universal credit, but it still does not work for everyone. I welcome the additional money, but we have to make sure that nobody loses out in the transfer to universal credit, most particularly disabled people. Others, including my hon. Friend the Member for South Cambridgeshire (Heidi Allen) and the right hon. Member for Birkenhead (Frank Field) yesterday, have spoken about how that could be done.

This Budget is a chance to tackle long-term challenges in difficult circumstances, with the coming exit from the EU. The Chancellor has seized the chance to address some of those areas, on which I congratulate him. I believe that, but for this challenge of exiting the EU, he would have tackled other areas, too, but the challenges that remain cannot be put off for ever.