Local Government and Social Care Funding

Debate between Jim Cunningham and Philippa Whitford

Wednesday 24th April 2019 Commons Chamber

[Dr Whitford]

I utterly agree and, obviously, the Department’s name was changed to the Department of Health and Social Care to reflect that need for integration, yet that is not the discussion we are hearing.

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

The hon. Lady is making a valuable contribution. One of the big problems in social care is the lack of social workers, which local authorities cannot fund because of the gigantic cuts conducted over the years by this Government. It is about time we faced up to the fact that austerity has gone on far longer than the second world war and, quite frankly, rationing.

[Dr Whitford]

The hon. Gentleman talks about the workforce, but in both the NHS funding settlement and the forward plan we see a big injection into NHS England, but no extra funding for Health Education England or for public health. Preventing illness is the cheapest thing we can do yet, for decades, Governments of all colours in all places have failed to do that. Unfortunately, the long-term plan does not do it, either.

Age UK talks about 1.5 million people being left without sufficient care and support at home, and it describes the number of people needing elderly social care increasing by almost 50% since 2010, but local authority-funded patients in England are down by a quarter over that time. A third of patients depend on family support, but 2 million carers are over 65 themselves, and 400,000 of them are over 80. Look at the burden we are putting on elderly people to care for their elderly partners, often without respite or support.

NHS Whistleblowers

Debate between Jim Cunningham and Philippa Whitford

Wednesday 18th July 2018 Westminster Hall

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

I beg to move,

That this House has considered NHS whistleblowers and the Public Interest Disclosure Act 1998.

It is an honour to serve under your chairmanship, Mr Davies. Gosport, Morecambe Bay, Mid Staffordshire and Bristol Royal Infirmary are NHS scandals that all have quite a few things in common: they went on for a long time and often whistleblowers who might have brought the issue to an end and saved lives were punished or ignored. They were certainly intimidated. The anaesthetist who raised the issue of baby cardiac surgery at Bristol Royal Infirmary ended up in Australia.

The term “whistleblower” suggests a pressure cooker—a build-up of pressure to the point where someone cannot resist it any longer and feels the need to come forward. We are trying to decompress some of that impression by having audit of patient safety through such systems as Datix, where staff get used to reporting every little aspect that does not go smoothly, which therefore creates the habit of coming forward. We still have issues. They often relate to the whole system, the trust or perhaps the behaviour of certain medical or clinical staff. There is no easy way to come forward, and the people seeing that behaviour take a long time to be listened to or to step up.

In the investigation into Mid Staffordshire, which was the worst NHS scandal, Sir Robert Francis’s report spoke about developing a “freedom to speak up” culture, to make doing so normal. Sir Robert suggested only minor changes to the Public Interest Disclosure Act 1998 but, as I will come on to later, I think it needs major change because it underwrites everything else.

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

I congratulate the hon. Lady on securing this timely debate. I had two cases in Coventry, going back 10 or 15 years, in which consultants were suspended for whistleblowing. On the one hand, the Government encourage whistleblowers, but on the other the national health service seems to have a different definition of whistleblowers. One of those cases ended up in court. I do not know the exact figure, but it cost between £3 million and £4 million, and went on for at least 10 years. Meanwhile, back at the ranch, the individual was losing their skills. What does she think about that?

[Dr Whitford]

Obviously, I am unaware of the individual case and the rights and wrongs of it. However, a review of the cost of whistleblowing as it stands shows that having an effective system and effective law would save us money overall.

Sir Robert Francis envisaged “freedom to speak up” guardians in each trust, to whom whistleblowers could go informally to seek advice and support. Such guardians are in all trusts across England. They include a wide range of people, and the appointment system is not altogether clear or transparent. We will have to look at what kinds of staff work best, whether appointments have been appropriate, and whether whistleblower guardians can recognise, if they are clinicians—which many of them are—that there might be a conflict of interest, because the issue might be in their department. The national guardian has been in place since 2016, but her position is non-statutory and sits inside the Care Quality Commission. Her role is described on the website as “leading cultural change” rather than deciding individual cases.

Through all the publicity, there has been quite a change in atmosphere and tone. The whole issue has had a significant airing. In Scotland, we have an alert and advice line run by Public Concern at Work. It is interesting to see the changes from the second half of 2016 to the first half of 2017. The number of concerns that the hospital, or the health board as it is in Scotland, admitted immediately were valid—instead of their having to be proved, or their being put off—went from 0% to 14%. The number of those that were ignored or denied dropped by 30%, and those reported to a manager or a senior manager went up by 30%. That suggests quite a difference in practice. The numbers are quite small, but they suggest a pattern. The data showed that, naturally, the most common group to report is nurses—they are the biggest employed group within the NHS—and the most common reason was still patient safety.

The problem is that that is all still legally underpinned by the Public Interest Disclosure Act, which was passed in 1998. It was a private Member’s Bill very similar to one that had been introduced a few months before. It therefore did not have a Second Reading, and it had only one day in Committee. At the time, it definitely was ahead of what was going on elsewhere, and was a recognition of the importance of whistleblowers, but that was 20 years ago. It really is time for change.

--- Later in debate ---

[Dr Whitford]

I thank the hon. Gentleman, who has set up an all-party group on whistleblowing and on the Public Interest Disclosure Act 1998. I welcome that, but one of my concerns is the issue of bounties.

It is important that we have a new PIDA law and an independent, statutory body that is equal to other bodies and can take on the NHS, NHS Improvement and the CQC. It must not be a department in one of those regulators; it must be separate from the NHS to ensure real independence, and it must investigate and act on concerns. If a local investigation has failed or is failing, there should be a mechanism to report that to an independent body. If we get to the point where there is simply a slanging match within a trust, there will never be a satisfactory resolution, so arbitration needs to come in and look at the cold facts and the original facts of the disclosure. Often, what is looked at is the process, but not whether the whistleblower was actually right to raise an issue in the first place.

It is critical that whistleblowers are protected from detriment from the moment of speaking up. They should be protected during the investigation, and they must not be picked on either subtly, as the hon. Member for Strangford (Jim Shannon) said, or blatantly—they must not lose their jobs. It is important that legal penalties for reprisals against whistleblowers can actually be enforced.

There should be a system of redress for whistleblowers that does not involve litigation. Litigation is expensive for the NHS and the whistleblower, and is utterly confrontational. That means that, at the end of the process, even when a whistleblower has been proven to be right and genuine, there has often been such a breakdown in relationships that it is not possible for them to go back to their previous role.

[Mr Jim Cunningham]

I thank the hon. Lady for giving way once again. The case I outlined actually ended up in the courts, and the hospital was told to take the individual back. Well, it never took him back. There was a long, drawn-out process over a number of years, and it was eventually settled through litigation. That individual—Dr Mattu—was a well-known consultant.

Some of the older Members will remember the case, going back 10 or 15 years. We had debates and got the support of Mr Speaker. The hospital tried to use letters I sent to it, in which I raised issues that had been raised with me, in the courts, and the judge ruled it out of order. The hon. Lady is right that we need an independent body, but where it finds that the hospital is guilty, as it were, and that the whistleblower was doing their job, it should have the power to order reinstatement—that is the nub of the matter—to ensure they are not victimised.

[Dr Whitford]

I agree that there should be protection to ensure that whistleblowers are not victimised, but the problem is that if the relationships have been allowed to break down because the system is so confrontational, often even the whistleblower does not consider it possible to go back. That is a tragedy, because it often means losing someone talented, particularly at a time when we are so short of staff in all four NHS systems in the UK.

The body obviously needs to be statutory so it has enforcement powers, but it should also be responsible for developing standards and training to show hospital trusts, health boards and hospitals, regardless of the system, what good looks like. Setting up, speaking up for and reporting on a body structure for the NHS will be for all four nations, because health is devolved, but PIDA still sits above that. It needs to be the underpinning statutory law that gives the body force.

In Scotland, we are still working on our system. Obviously, the Francis report looked at the system in England. We have whistleblower champions in our health boards, but we are working on setting up the independent national whistleblowers office. The difference between that and the national guardian in England is that it will be statutory and independent of NHS Scotland. It will sit in the office of the Scottish public services ombudsman, so it is utterly outside the NHS and clearly sends a message of independence. It will be able to adjudicate in individual cases. Normally, that will be when all local processes have been exhausted, but provision is being considered to allow an earlier referral when the local system has simply broken down and the concern about patients has been lost in the conflict-driven system.

Standards are being developed for all health boards so there is a consistent approach. The standards that sit above everything else are that whistleblowers will be listened to, that their concerns will be acted on and that they will be supported. The former Secretary of State, who is now away to sunnier climes or travelling the world, used to keep saying in the Chamber that whistleblowers are central to patient safety. I have to say that I slightly disagree.

When someone is forced to blow the whistle, it is because the patient safety systems have failed. In Scotland, we have a national patient safety programme, which is the first in the world that is right across the system. People cannot pick and choose whether they do the huddle at the start of an operating list or whether they do the World Health Organisation checks before operating on somebody. It looks at the frontline to try to reduce errors, but we know that there will still be situations that are not ideal, so someone will need to come forward. That is the thing: whistleblowers are a backstop. The patient safety system, the Datix system or the auditing may need to be improved, but whistleblowers provide a backstop to prevent us from going over the cliff, to prevent more people from dying and to allow timely action.

The problem is that, although doctors have a duty of candour laid on us by the General Medical Council, we also see the landscape littered with people’s careers and jobs, as the hon. Member for Strangford said earlier. For an individual, that is really difficult. They think, “If I speak up and step forward, it may be the end of my career. I may be out of a job. I may be out of this hospital.” For patients’ sake, we need a change, we need to get it right, and we need a new public interest disclosure law. We should start work on that now.

Health Service Medical Supplies (Costs) Bill

Debate between Jim Cunningham and Philippa Whitford

Tuesday 25th April 2017 Commons Chamber

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

Like the hon. Member for Ellesmere Port and Neston (Justin Madders), this will be my last time speaking in the Chamber before Dissolution, and as a newbie I also want to pay tribute to the staff of the House, who made coming here much easier than we had expected it to be. I am also glad that my final speech before Dissolution is on a Bill that, despite some of our disagreements, we have worked on on a cross-party basis to produce a piece of work that we all agreed needed to be done.

I, too, welcome Government amendment (b), although I would have laid out the three paragraphs the other way around, because the whole point of the NHS, and the whole reason we are discussing this, is patient access: that is the No. 1 concern. I would have put patients first, not third. The fear of not getting access to drugs is a great issue for patients. As the hon. Gentleman mentioned, we have a significant delay that is measurable in comparison with other countries. For certain types of cancer, our performance in relation to patients with early disease is as good as anywhere, but we fall down in dealing with people with difficult or advanced disease. That is because of the delay.

I want briefly to mention the interaction of the budget impact assessment with our no longer being part of the European Medicines Agency. I am not talking about the United Kingdom losing the agency itself; I am talking about our no longer being part of the scheme. We know that there is a danger that drugs are presented for licensing in the United Kingdom at a later date than in the United States and the European Union, which are major markets. It is likely that we could also be behind Japan. I am not suggesting that we should simply hand over any amount of money, but if we were also seen as a hostile market in which there was an expected delay of three years for expensive drugs, there would be a danger that international pharma would simply say, “You know what? We’ll license everywhere else, then we’ll come back to the UK in a few years.” That could result in significant delayed access for our patients.

We need to think about how all this feeds into trials and research, and into the life sciences system. If we are not using what is considered to be the gold standard drug at the time of a new international trial, we will not be able to take part in the comparison of the gold standard with the new drug. The UK has led the EU research network, which is the biggest research network in the world. We have been a major player in that, and it is important to realise how building in this delay from NHS England could undermine that. Surely this should be part of the NICE process. It should be clear to pharma, when it comes with a drug at a price, what process it will have to go through, what evidence it will have to bring forward and how it will have to negotiate a price. I fear that there will be delays in drugs being licensed.

This will affect us in Scotland even though NICE decisions do not apply to us. If a drug were simply not licensed here, it would be irrelevant that the Scottish Medicines Consortium chose to fund it—as it did the other week with Kadcyla—because it would still be an unlicensed medicine. We need to look at how the loss of the European Medicines Agency will work in this regard. There should not be a separate procedure after NICE that could suddenly hit pharma with another barrier to jump over. This will hit new cancer drugs, because they are expensive. It will particularly hit drugs for rare diseases, which the EMA has led on, because they are bespoke and therefore inevitably expensive. The £20 million limit would mean that if someone came up with a fabulous cure for dementia, for example, a budget impact assessment would be triggered.

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

I agree with what the hon. Lady says about the European Medicines Agency. I have had a lot of letters from people who are very concerned about that issue. There is another factor involved in the delays that can occur in the Government agreeing a price. I think that the drugs companies often take the Government to the cleaners.

[Dr Whitford]

I thank the hon. Gentleman for his intervention. That is obviously why the Government are introducing the Bill. They are trying to achieve a degree of control and to prevent runaway drugs costs. Of course we agree with that objective, which is visible in the Bill. The Government are trying to establish a predictable system of licensing in the UK, so that a pharmaceutical company knows what it has to bring to the table. That might mean a bit more flexibility during the NICE process, because we could appear hostile if a drug goes through that process and is defined as cost- effective, only to be hit with another, less predictable, barrier. The danger is that that will affect Scotland just as much as England, regardless of our drug funding decisions, because licensing is a reserved matter. The Government need to take that into account, because patients come third in the order set out in the amendment, and I believe that they should come first.

Community Pharmacies

Debate between Jim Cunningham and Philippa Whitford

Wednesday 2nd November 2016 Commons Chamber

[Dr Whitford]

Scotland actually has both. We do have pharmacists who are in a consulting room within a practice, and our Government have put £85 million into taking on an additional 140 pharmacists who work in primary care with GPs. We are not, as has been done in the past, saying, “Everyone on drug A must change to drug B because it is cheaper,” without giving any thought to how that affects the patient. We are consulting patients, who are often on 10 or 15 medications, all of which interact and have different side effects, and then rationalising that and giving the patient advice. We are therefore providing a clinical service rather than just a changeover service.

Our community pharmacy system has been running for 10 years, so it is quite mature. Patients register with a pharmacist in the same way as they register with a GP. The aim is for all people to be registered with whomever they consider their local pharmacist to be, as that means that they can access minor ailment treatment. It also means that people who are on chronic medication have a chronic medication service, with their prescription sent electronically to the pharmacy, which then keeps track of when it is due and therefore ensures that patients do not run out of medication. The pharmacies also provide an acute medication service for people who have not signed up to the other service but suddenly find they have no tablets, as they had not thought to re-order them with their GP. If they are regulars at the pharmacy, a single round of drugs can be prescribed for them there so that they do not have a gap in their treatment. The important thing is that our vision is to have all our pharmacists as prescribers by 2023, and to have our public registered with pharmacists by 2020.

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

The hon. Lady makes two important points: this move is cuts-led, rather than well planned; and just as communities rely on their doctor, they rely on the facilities at their pharmacy. That is particularly true of elderly people and those with disabilities, who may have to travel miles, depending on where the pharmacy is.

[Dr Whitford]

It is crucial that the service covers all areas, including those that are deprived and those that do not have good public transport. Distance is not everything; this is also about how people travel that distance. In many places, the distance involved might not be that great, but there simply may not be a bus going in the required direction.

Junior Doctors’ Contracts

Debate between Jim Cunningham and Philippa Whitford

Wednesday 28th October 2015 Commons Chamber

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

The hon. Member for Lewisham East (Heidi Alexander) described what a junior doctor is, and that is really important. Many people think that being a junior doctor is just for the first couple of years, and isn’t it character-forming to work a bit hard and not have a lot of money? However, in the NHS, which is quite a hierarchical beast, a junior doctor is a junior doctor all the way until they are not a junior doctor and they become a senior doctor: either a consultant, as I was for the past 19 years, or a GP. That means we are talking about people who might be in their 30s, with children, families and mortgages. They are not youngsters who are able to move around flexibly and have very few financial commitments. It is important that we remember that.

It is obviously quite some time since I started as a junior doctor. More than 30 years ago, in 1982, we had absolutely no limits on hours. My light week was 57 hours; my heavy week was 132 hours. You just had no idea what your name was by the end of a weekend. It took more than 10 years of my career before the first new deal started to come in, in the early 1990s, and trusts or hospitals had to pay an additional premium to junior staff if they worked excessive hours. The definition of excessive hours at that time was still pretty lax, but it was the first step. It was tightened up in 2003, when the European working time directive came in. The Secretary of State talks about taking away those safeguards, but that he will replace them with something else. But with what? They have served us well. When trusts are in financial difficulties, the pressure on them to save money is likely to outweigh completely any little safeguard. The 48-hour working time directive does not come with punitive safeguards, and the financial one was important.

It is important to remember that the basic pay is already for 7 o’clock in the morning to 7 o’clock at night, Monday to Friday. That is a pretty long day for most people. It is proposed that the time covered by basic pay should be extended to 7 o’clock in the morning to 10 o’clock at night and include Saturday. What many people do not know is that a junior doctor starts at under £23,000 a year—below the benefit cap we have been arguing about. The salary is made up largely of out-of-hours.

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

Does the hon. Lady not agree that in any other walk of life that would be intolerable, yet we put up with this situation in the national health service? Secondly, does she agree we still have not seen the £8 billion the Government promised, during the general election, to put into the NHS?

[Dr Whitford]

I totally agree with that.

As mentioned on both sides of the House, people do not work in an NHS hospital to make a lot of money. It is not high up the list of ways for the smartest people in our country to make money; it is a vocation, which means we have a responsibility not to exploit them. The Secretary of State says that no one will lose money, but what will happen to the people who start next August? After the first hours change, when I started my surgical career in Belfast, the “two in three” rota—every third evening off and no weekends off for a year—was no longer legal, and the hospital henceforth considered extra hours to be voluntary service. The NHS is a hierarchical organisation, bullying exists within it, and the junior doctor is in a weak position. These safeguards have worked well for a long time, and I would be reluctant to see them go.