National Health Service Funding

Joan Ryan Excerpts

Tuesday 22nd November 2016 Commons Chamber

[Jonathan Ashworth]

There will be a cash injection in Wales in 2017, whereas spending per head in the English NHS will be levelling out and then falling in 2018.

[Joan Ryan (Enfield North) (Lab)]

In Enfield we are short of 84 GPs going forward and we have just had a hospital crisis at the North Middlesex hospital, where there were not enough doctors for our A&E to be safe for patients, yet the only thing we hear about is the sustainability and transformation plan locally which, as far as we can see, is not only secret but about taking £22 billion out of the NHS.

[Jonathan Ashworth]

My right hon. Friend is right and she is a brilliant campaigner for the health service in Enfield. The points that she makes about the staffing crisis in the NHS are well made. I hope that the Secretary of State will respond to her.

Things are so bad for the Health Secretary that even the NHS chief executive told the Health Committee that

“2018-19 will be the most pressurised year for us…will have negative per-person NHS funding growth.”

Those were the chief executive’s words. Will the Health Secretary sit up and listen, and respond to the chief executive, or will we get what we saw in the Sunday newspapers—briefing against him? We heard that the Government are “gunning for” Mr Stevens and are going to “fix” him. I hope the Secretary of State will repudiate that briefing when he responds to the debate and distance himself from it.

The only people who do not appear to accept the need for more money for the NHS are the Prime Minister and the Secretary of State. We anticipate what the Secretary of State will tell us from the Dispatch Box. The right hon. Member for Chelmsford (Sir Simon Burns) alluded to it and I will now answer his question. The Secretary of State will not only tell us that we have a generous, munificent Conservative Government who have given the NHS the money it asked for, but persist with the fiction that the NHS is receiving an extra £10 billion. However, we all know—and I suspect that the Secretary of State knows, because he now distances himself from the figure when he does interviews—thanks to the Health Committee and others that this £10 billion claim is bogus. It is a claim universally derided and discredited, apart from in the drawing room of 10 Downing Street.

--- Later in debate ---

[Mr Hunt]

I have often from this Dispatch Box been prepared to praise some of the achievements of the last Labour Government. They did bring down waiting times, but they did not focus on the quality and safety of care.

What we now know from the CQC’s new regime, which has just finished its first round of inspections, is that 56% of our hospitals are good or outstanding. One could say that it is disappointing to know that 44% of hospitals are not, but to those who would use that as a political weapon I say this: we are the only country in the world brave enough to set up an independent inspection regime, and if we want to have the safest, highest quality care, the first thing we need to know is where it is good and where we need to improve it. I thank the chief inspector of hospitals, Professor Sir Mike Richards, for his outstanding work in raising quality.

[Joan Ryan]

The right hon. Gentleman talks about the inspection regime, but I think I am right in saying that it was not something he and his Government introduced. The Care Quality Commission was introduced by a Labour Government, as far as I am aware. As I know from North Middlesex hospital, hospitals end up in special measures because they are underfunded and under-supported, and cannot get the doctors they need.

North Middlesex University Hospital NHS Trust

Joan Ryan Excerpts

Tuesday 12th July 2016 Westminster Hall

[Joan Ryan (Enfield North) (Lab)]

I beg to move,

That this House has considered the performance of North Middlesex University Hospital NHS Trust.

It is a pleasure to serve under your chairmanship, Ms Vaz. North Middlesex University Hospital NHS Trust serves two thirds of my constituency and more than 350,000 people living in Enfield, Haringey and the surrounding areas. I am grateful for the opportunity to bring this important matter before the House.

The situation at the hospital is, frankly, a scandal. It operates the busiest emergency department in London, which is attended by more than 500 people a day, yet the Care Quality Commission has rated safety at the emergency department as inadequate. Medical care, including older people’s care, at the hospital also requires extensive and immediate improvement. The senior leadership team at the trust and the Government have serious questions to answer about how patient safety at North Mid has been allowed to have been put at grave risk.

What has been happening at the hospital has major implications for my constituents, for residents in north London and for health services across the capital and beyond. My speech will consider all those issues and the steps that need to be taken to ensure the safety of patients and the quality of care. I will call on the Government to give assurances that services at the hospital, including those provided by the accident and emergency department, will be protected and improved in the short and long term.

Before I get to the heart of the matter, I should make two important points. First, the many concerns and criticisms that I will raise about what has happened at the hospital are not directed at the front-line staff—the doctors, nurses and trainees who work there. They are overworked and under-resourced, and have been doing a challenging job in incredibly difficult circumstances. The CQC has made it clear that:

“Most staff were competent and endeavoured to provide good care and outcomes for patients.”

However, just like the patients, the front-line staff have been badly let down by poor management and a lack of leadership at the hospital, and by the Government’s health policies over the past six years, which have left the national health service on its knees.

My second point is one that I believe is shared by all London MPs whose constituents have been affected by the performance of the hospital. Although all of us have raised concerns about how North Mid has been operating, we were not made aware of the true extent of the crisis at the hospital until the CQC issued a warning notice at the beginning of June, requiring the trust significantly to improve the treatment of patients attending the A&E. That was almost two full months after its unannounced inspection of the hospital in April.

Many recent revelations about the chaos at North Mid have been exposed only because of the press via leaked documents, yet it appears that the terrible situation has been an open secret in health circles for a significant period of time.

[Mr David Lammy (Tottenham) (Lab)]

I hesitate to interrupt my right hon. Friend, who is laying out the story so comprehensively. Is she as concerned as I am that many health professionals knew what was going on, but that MPs in the three boroughs covered by the trust were kept in the dark?

[Joan Ryan]

That was exactly the case and I am very concerned. It is not an exaggeration to say we were kept in the dark. All of us across Enfield and Haringey have, over the past year, raised the issue of North Mid in the Chamber at a local level and with Ministers at various times. We received no information until a recent meeting with the Minister, who, I am pleased to say, is here today. Prior to that, there was almost no answer to the points that we raised, other than to brush them aside with answers such as how much better the NHS is doing now than ever before. The phrase “kept in the dark” absolutely covers the situation, with those in the know including the likes of NHS Improvement, NHS England, the General Medical Council, Health Education England and, no doubt, the Department of Health. However, but for the actions of the General Medical Council and Health Education England, the situation for patient safety could be even worse.

I have had a number of meetings with the senior leadership teams at North Mid and at the Enfield clinical commissioning group, and many of the problems I will discuss today were not thought noteworthy enough to bring to my attention. If they were brought to my attention, the exposure of those problems was minimal, such that they did not raise the alarm bells that they should have.

In May, the severity of the situation at the hospital was discussed at a high-risk summit, involving several north London hospital trusts, clinicians and other stakeholders. MPs were not even informed that the summit was happening, never mind informed of the outcomes. I would be interested to know whether the Minister thinks that that state of affairs is acceptable given that our constituents have to suffer the consequences of the failures at the hospital. Even as of today, despite numerous requests, we have received no minutes of the high-risk summit and no account of what was discussed in any detail whatever.

Would the Government be willing to bring in early warning measures to ensure that MPs and constituents are kept properly informed about impending healthcare crises in their communities, rather than being notified after the crisis has hit? To do our job on behalf of our constituents—to safeguard their safety and interests in the use of and access to one of the most important public services any of us can imagine—we need some kind of early warning system. It is clear that very many people knew about the situation, but nobody who is accountable to the public at a local level was properly informed. I look forward to the Minister’s response to that point.

I am pleased to see my hon. Friend the Member for Edmonton (Kate Osamor) in her place, as the hospital is just inside her constituency, although it serves a large number of my constituents and constituents from Hornsey and Wood Green. I think it also serves practically the whole of Tottenham—my right hon. Friend the Member for Tottenham (Mr Lammy) is in his place, as is the hon. Member for Enfield, Southgate (Mr Burrowes). I am pleased to say that we have been working cross-party on the issue. Frankly, I will work with anyone—other hon. Members involved would do the same—who is willing to put the hospital first.

The CQC’s damning report into North Mid was published on Wednesday 6 July, and its inspection of the emergency department and two medical wards at the hospital was in response to a

“number of serious incidents…which had raised concerns about the standards of care”.

Between March 2015 and March 2016, there were 22 cases at North Mid’s A&E department where patients experienced serious or permanent harm or alleged abuse, or where a service provision was threatened. The CQC found that people were waiting far too long to be assessed on first arriving at the hospital, to see a doctor and to be moved to specialist wards in the hospital. The main experience of anybody turning up at the hospital’s emergency department was to wait, wait and then wait again.

The report tells of a lack of respect and dignity in how patients were treated, including a time when there was only

“one commode available in the whole of the ED”—

emergency department—

“to serve over 100 patients.”

Most people reading this will find that shocking.

Resources had been so stretched that, by the time the CQC issued its warning notice to the hospital in June, only seven of 15 emergency department consultants were in post, and seven of 13 middle-grade emergency doctors. As a consequence, junior doctors and medical trainees have been left unsupported by senior staff in A&E at night, including in emergency paediatric care. Junior doctors have been asked to perform tasks for which they are not yet qualified, and there have even been reports of receptionists with no medical training being used to triage patients, at least to the extent of deciding whether they should go to urgent care or the emergency department.

In February, A&E staff were so overwhelmed that patients, many of whom had already been waiting for hours, were told that they should go home unless they thought their illness was life-threatening. How can anyone be expected to know how ill they are without seeing a doctor? We have self-service checkouts in our supermarkets, but self-service A&E? I think not.

[Tulip Siddiq (Hampstead and Kilburn) (Lab)]

I thank my right hon. Friend for securing the debate. Even though the hospital is not in my constituency, much of what she describes happens in hospitals in my constituency and just outside it. At Central Middlesex hospital, which is just outside my constituency but serves many of my constituents, healthcare provision has also been affected by cuts. A recent inspection by the CQC similar to the one that she is describing highlighted a lack of experienced medics for seriously ill patients. Does she agree that such staff shortages threaten patient safety?

[Joan Ryan]

I do indeed, and I am grateful to my hon. Friend for that intervention. One point that I argue most strongly is that, although the MPs concerned are banding together to defend our hospital and fight for adequate and safe service, it is obvious that this is not just about North Mid—North Mid is just the first point where the crisis has hit. This is an issue around outer London, across London and probably nationally, particularly for district general hospitals.

[Andy Slaughter (Hammersmith) (Lab)]

I am delighted that my right hon. Friend has secured this debate, which resonates across London and probably outside it. We recognise the point about waiting, especially in ambulances outside hospitals. People are waiting for up to four hours and then being admitted just before the four-hour mark, so that it is not registered against the time limit, and then waiting again. That is happening even before the planned closures of accident and emergency departments. As one clinician said to me just today, there is no credible clinical evidence that out-of-hospital services can deliver on the scale necessary, but that is all we are being offered as an alternative.

[Joan Ryan]

I agree with my hon. Friend. Again, that demonstrates that this is not just about North Mid; it is just that North Mid has reached the crisis point before anywhere else.

The CQC has also raised concerns about the lack of equipment within the department, from missing monitors and missing leads for cardiac machines to trolleys in resuscitation rooms that are not fully equipped. I cannot imagine the distress of a patient with chest pains who is connected to a cardiac machine to monitor their progress, only to find that the staff member cannot connect it up to get an instant read-out because the leads are not there. Even a chute meant to carry specimens from the emergency department to the pathology unit was out of operation for six whole weeks. According to the CQC,

“this caused major delays to the speed in which results were returned to the department, thus slowing down the time in which some patients could be treated.”

That is unacceptable.

All those problems have been exacerbated by a lack of effective clinical leadership and a culture of bullying at the hospital, meaning that staff do not feel confident in raising concerns and have even

“stopped reporting incidents of staff shortage as management had not responded to them in the past”.

A quality visit report by Health Education England from March 2016 found that none of the medical trainees interviewed would recommend the emergency department to their family and friends for treatment, principally because they felt that the department was unsafe. The postgraduate trainee junior doctors at the hospital would not themselves recommend the hospital or the emergency department to their family and friends—what an indictment.

The General Medical Council, which oversees the standard of training for doctors, has threatened to ban North Mid from providing postgraduate training because standards have been so poor. The loss of junior doctors would leave the A&E so badly understaffed that it would effectively close. The future of North Mid’s emergency department is at risk.

I note that the chief inspector of hospitals—Professor Sir Mike Richards, whom a number of us are due to meet tomorrow—has said that since the CQC’s inspection in April, “some progress” has been made to improve the situation, although there is

“still much more that needs to be done.”

A new clinical leadership team has been put in place, and there have been moves to appoint more senior doctors. However, in almost every instance, the new appointments are short-term, with the doctors taken on loan from other hard-pressed local hospitals for up to six months. The situation is safe at the moment, given the number of doctors in the A&E, but the measures are only a sticking plaster, as many of the doctors are on a three to six-month loan. What measures are the Government willing to put in place to support North Mid and ensure that it has the consultants and doctors it requires on a permanent, long-term basis?

The CQC also states that North Middlesex University Hospital NHS Trust

“has supplied an action plan setting out the steps it will take to address the concerns identified in the Warning Notice and report.”

Does the Minister agree that the action plan should be published in full and updated regularly with the measures taken to improve patient safety at the hospital?

Tellingly, the CQC says that previous serious incident investigations and subsequent action plans at the hospital have not always been shared with staff in a timely manner, which has

“meant that in certain circumstances, reports were received when actions should already have been taken in order to mitigate against a future occurrence.”

Given the analysis of how things have been kept in the dark, which we have explored, and that statement from the CQC, the Minister will understand why I ask for a fully published action plan and regular reports on progress. This is about implementation and outcomes.

Surely the Minister will understand that without full transparency, many of my constituents and those of my colleagues who are here today will have little confidence that the required improvements have been made and are being sustained. As I said earlier, the trust’s shocking mismanagement and poor leadership have played a big part in creating the mess at North Mid, but the chief executive, who I understand is stepping down, is not solely responsible for what has happened. The Government cannot be let off the hook when they have done so much to undermine healthcare provision in Enfield.

The tipping point for the crisis at North Mid was the closure of the A& E department at Chase Farm hospital in my constituency. In 2007, the then Leader of the Opposition—the current Prime Minister, for now—posed outside Chase Farm hospital and promised to protect the emergency department on site. By 2013, his Conservative-led Government had ripped the heart out of the hospital, closing both the A&E unit and the maternity services. It went from a 480-bed hospital to one with 48 surgical beds. Those of us who campaigned against the closure at the time said that the decision would put huge pressure on North Middlesex hospital, Barnet hospital, our ambulance services and GP surgeries right across Enfield. We were right.

[Andy Slaughter]

My right hon. Friend describes exactly our experience in west London, where two A&E departments have closed and two more are intended to close, despite assurances having been given that they would not. We have heard nothing at all since February 2013 about what those plans will be. I was told just this week that the next report is not going to be in September, so until another report is done we will not know exactly what services there will be. People are waiting in limbo for years, and meanwhile there is a drain of staff and expertise from hospitals, so their closure becomes a self-fulfilling prophecy.

[Joan Ryan]

And that is exactly what happened at Chase Farm hospital. It was under threat for so long that it had no stability and it was no longer an attractive place for staff because they had no security. I hope I am wrong, but my fear is that in cases such as my hon. Friend outlines, no news is definitely not good news.

One year after the closure of Chase Farm’s A&E department, the CQC reported that services at North Mid were struggling with the additional workload. We know now that the hospital has had to manage an increase in A&E patients of between 20% and 25% as a result. That is unmanageable and unsustainable for an A&E department; many would bend, if not break, if put under such strain. The situation was so bad that by February 2016 only 67% of patients were seen and treated within the national four-hour target at North Mid, compared with an average of 88% across England.

Our local health services and the emergency department at North Mid would have been better placed to cope with the closure of Chase Farm’s A&E department if other promises to improve primary care had been fulfilled. In November 2013, the Prime Minister stood at the Dispatch Box and said:

“Enfield is…getting an increase in primary care funding. That is part of our plan of not cutting but expanding our NHS.”—[Official Report, 20 November 2013; Vol. 570, c. 1226.]

But many people in Enfield find it really hard to get a doctor’s appointment when they need one. Over the last six years, 12 doctors’ surgeries in Enfield have closed and only one new practice has opened. That is why, even though Enfield is now the fourth-biggest borough in London, we have fewer GPs per head than almost anywhere in the capital. That situation is not sustainable.

Will the Minister join me in calling for a proper plan for at least 84 more GPs in Enfield over the next four years, as recommended by the Royal College of General Practitioners? Will he support my calls to improve health funding across the board in Enfield? As he will know, Barnet, Enfield and Haringey Mental Health Trust anticipates a £13 million deficit by 2016-17; Enfield Council needs to deliver a saving of £24 million in adult social care by 2020 because of reductions in funding from central Government; and per capita spending on public health in Enfield is only £43 this year, far lower than the average across London and in England. Given that cutting preventive services piles pressure on hospitals, does he seriously believe that allowing the current situation to continue will take the strain off North Mid—or will it in fact do the exact opposite?

It should come as no surprise that I and many of my constituents have very little faith that the NHS is safe in the Government’s hands. The financial crisis in the NHS is a major reason why North Mid did not have enough equipment, consultants, doctors and nurses to cope with demand. The inability to recruit permanent staff has meant that many hospitals, including North Mid, have been forced to drain their resources on expensive agency workers and locums. One might have thought that, in the light of such circumstances, the Government would be bending over backwards to encourage people to join the medical profession—but no. Instead we are witnessing the sorry situation of a Government fighting with junior doctors over contracts and removing bursaries for nurses. What a slap in the face for the future front-line staff we so desperately need.

The Government also plan to make £22 billion of efficiency savings by 2020. I know that savings must be found, particularly in back-office services, but efficiencies on such a scale simply cannot be achieved without putting patient care at risk. I am also concerned that the Government’s methods to implement those cuts—described using woolly phrases like “the rationalisation of clinical facilities”, “the consolidation of trusts” or “the introduction of transformation and sustainability plans”—will result in takeovers, mergers and the downgrading of services. Even before the crisis at North Mid was revealed, plans were already afoot to launch an NHS pilot programme, involving the Royal Free London NHS Trust, to look at options to link hospitals including North Mid together and to merge clinical and support services. At the same time that it was announced that the chief executive of North Mid was going on leave, we learned that an acting chief executive was being appointed from the trust and that David Sloman, the trust’s chief executive—a very good chief executive, I might add—would be taking on the role of accountable officer on an interim basis. I fear for the future of service provision at North Mid as a consequence.

Local residents remember to their cost that the A&E and maternity units at Chase Farm were shut only a few months before the Royal Free London NHS Trust took over Barnet and Chase Farm hospitals in 2014. Chase Farm has been left as little more than a cottage hospital. North Mid cannot suffer the same fate; that would have terrible consequences for health services across North London. Think how much further people in Enfield would have to travel to get emergency hospital treatment, and how much pressure it would put on A&E departments at hospitals such as University College hospital in Euston, Barnet hospital and the Royal Free hospital in Hampstead.

What assurances will the Minister give my constituents, first that North Middlesex hospital will not be taken over by the Royal Free London NHS Trust by stealth, using this crisis as the back door to a merger; secondly, that constituents will be consulted fully on all future proposals for North Mid; and thirdly and most importantly, that its key services will be protected and improved in the short and long term? The performance of North Middlesex University Hospital NHS Trust must be a wake-up call for the Government. I urge the Minister to use every tool at his disposal to help North Mid make the immediate improvements required in the quality of care provided to patients. The Government must ensure that the hospital and our health services have the funding and support they need so that this situation never happens again. I look forward to the Minister’s response.

--- Later in debate ---

[Mr David Lammy (Tottenham) (Lab)]

I am grateful to have the opportunity to speak in this debate. The hospital serves almost the entirety of the constituency of Tottenham and has done ever since the closure of the Prince of Wales hospital in my constituency in the 1980s. It is important to emphasise that North Middlesex hospital is located in a strategically essential area. It serves not only the boroughs of Enfield and Haringey, but some of Barnet and Waltham Forest. Many years ago, when I was a Minister for Health, a neighbouring hospital, Whipps Cross, was a general hospital that on occasion struggled considerably with its emergency department, so I cannot emphasise enough that it is critical for the broader health economy of north-east London that the North Middlesex survives, flourishes and does well.

The concern that has been raised in this Chamber is really about how the situation has got to this stage over such a length of time, with so many Members of Parliament ringing alarm bells in a context where all of us have privately said, “We must tread carefully. We don’t want to talk down the hospital.” We say, “The chief exec seems to be…” as we whisper among ourselves. We do not want to talk down the hospital, but it has now got to the point at which we have to be absolutely frank about what has been happening at that trust, as we have heard, and we must ask some very hard questions about what has been going on.

I hope that the Minister will assist me on this point. There have been successive risk summits, meetings have been held, and the chief exec has asked for support, but I am not clear why support was not provided. In the old days, Members of Parliament would have been able to contact the strategic health authority and there would have been a clear line of leadership. We literally had two bodies to deal with: the strategic health authority and the chief executive of the trust. Frankly, chief executives went if they were not up to the job, and emergency teams were brought in to run the hospital. I did that as a Minister responsible for emergency care. I saw it happen in a range of trusts across the country as, under the Tony Blair Government, we pushed for the first targets of four-hour waits. I am struggling to understand how things have got to this level.

Life expectancy in a constituency such as mine is among the lowest in the country: men reach 74, six years behind the average life expectancy. We have homelessness and we have had two riots in a generation. The issues are clear, but what is not clear is who was in strategic charge? Why were meetings held in successive years? What is the role of NHS Improvement? Is it ever the case that anyone there would contact a Member of Parliament to say what they are doing to improve a trust? What is the role of NHS England’s London office? The individuals there are paid a hell of a lot of money—hundreds of thousands of pounds. Have they got a responsibility to contact a Member of Parliament to ask for a meeting or a conference call to speak to us about what is happening in the trust?

What is the role of Health Education England, which has been concerned about training and qualifications? We know the role of the General Medical Council, but has it been nobbled not to withdraw doctors by NHS England or any other body? What we have are numerous quangos. I have not even mentioned the clinical commissioning group. We have CCGs, HEE, NHS Improvement, NHS England London and the chief executive. The Government came into office determined to reduce the number of bureaucrats, but—my God!—each of us has at least 10 or 12. Then there are all the staff that work under them. Meetings have been held, but what has been done?

I have done the Minister’s job, so I feel for him. When I did his job, we did a lot of the running of the NHS from Whitehall. The Minister’s party came in and I understand why they said they could not run it from Whitehall, but we now have all these bodies and I am not clear what they have done. As a former Minister, I want to hear more of what they have been up to. I hope that the Minister will answer the question asked by my right hon. Friend the Member for Enfield North (Joan Ryan). Given that there have been CQC reports—the one that we had on the 6th is not the first—and risk summits, what is the obligation to inform Members of Parliament and therefore our constituents? At what point does that kick in? Or is it expected that that should be done solely by the trust? If it is, that is problematic if it is a failing trust in which the chief executive has been put on emergency leave. I have the CQC report before me and it says that safety at the hospital is inadequate, and so is responsiveness. As to whether it is well led—leadership is also inadequate, which is presumably why the chief executive has been put on emergency leave. Overall the hospital is inadequate. Under the headings of caring and effectiveness, it requires improvement. That is pretty damning. It does not get much worse than that.

Many hon. Members are concerned—and my right hon. Friend the Member for Enfield North, the hon. Member for Enfield, Southgate (Mr Burrowes) and I certainly are, having been around for a few years. We campaigned to get the PFI that put millions—I think it was £150 million—into building a brand new hospital. It is therefore deeply frustrating that we now have such an uphill struggle. Chase Farm has been mentioned and I will not discuss it again, but the Minister will recognise that we all rang alarm bells about the implications of closing emergency there. Money was put into the trust; yet it has got to its present situation.

I heard yesterday about the case of Mrs Alice Morfett, a 92-year-old lady who still went shopping in Morrisons. She had a heart operation in Barts and she was recuperating on the T3 ward. In the morning she told her daughter about her concern about a male nurse’s behaviour; she could not understand why he kept wanting to touch her chest. Her daughter said she did not believe Mrs Morfett and thought the anaesthetic had not worn off, but her mother complained about the nurse rubbing against her chest. After that Mrs Morfett was scared to ask for help. No one was summoned to help her. The next day, after an hour of asking for someone to take her to the toilet, Mrs Morfett tried to get out of bed herself and she fell. She ended up with huge open wounds; my constituent sent me a photo of the terrible wounds her mother suffered. Mrs Morfett died a couple of weeks later, and her daughter believes that she died as a result of her injuries. Mrs Morfett said to her daughter, “Please don’t let them get away with it; they have to pay for what they’ve done to me.” I do not lightly raise constituency case work in this way. I have used this letter because it is the latest one I have in a stream of letters from constituents about what is happening in the trust.

[Joan Ryan]

Such incidents are what the CQC calls “never” events because they should never happen: a patient dies, and it is not necessarily from medical issues or natural causes. I am sure that my right hon. Friend knows that the CQC report notes that one patient lay dead in a cubicle for four and a half hours last December because there were not enough doctors even to do the hourly rounds. It does not get much worse than that.

[Mr Lammy]

No, it does not, and that cuts to the critical issue of safety at the hospital. In fact, the problems at the hospital have been going on for well over two years. What happened to the hon. Member for Enfield, Southgate, who lay in the hospital with a burst appendix and who frankly would not be here but for a stroke of luck, says it all. How have we got to the situation where the local Member of Parliament is about to die of a medical emergency after waiting without being seen for 11 hours? He has been friendly—[Interruption.] Well, that is what happens with a burst appendix. The hon. Gentleman is looking well, but he is not that young. People die of a burst appendix if they are not treated.

--- Later in debate ---

[Ben Gummer]

Ideally, if things are going wrong and that has been noted within the hospital, the hospital chief executive or commissioners should inform local people, but in the past—and over the two and a half to three years since we instituted the special measures regime—it has taken a Care Quality Commission investigation to highlight poor standards of care so inadequate that the hospital needs to be placed under special measures. At that point, before the public are informed, Members of Parliament are informed by the CQC and what was Monitor and the Trust Development Authority, but is now NHS Improvement.

[Joan Ryan]

rose—

[Ben Gummer]

Before I take the right hon. Lady’s intervention, I will explain why Members were not informed, and it is by no means an excuse. The core problem around emergency medicine and paediatrics was to do with the training places and the relationship between the General Medical Council, which looks at and regulates the quality of training, Health Education England and NHS Improvement. Because this case did not go through the traditional special measures route, which is governed by the CQC and NHS Improvement, things did not happen at the pace I would have expected and nor were Members talked to when they should have been.

The first thing I want to ensure, once we have receipt of the review I asked for this morning, is that we have a similar standard approach, were this to happen again. We have to assume that it might, because things in a large system do go wrong. We need to learn from this scenario over the past year, where Members have been let down, and ensure that it does not happen again. We can move with greater celerity and ensure that Members are informed at the earliest possible opportunity.

--- Later in debate ---

[Joan Ryan]

I appreciate the Minister’s expression of regret and his acknowledgement that something went badly wrong, but I take issue. A CQC report in 2014 noted added pressures in A&E that we are all aware of. I only came back into Parliament in May 2015, and over the past year a number of Members, including me, have raised the issue several times in the Chamber. We were given no information. The CQC report is very welcome, but for it to take more than three months to be published means it is of no use as a warning note with any detail. [Interruption.]

[Valerie Vaz (in the Chair)]

Before the Minister responds, there is a Division.

NHS Spending

Joan Ryan Excerpts

Wednesday 6th July 2016 Commons Chamber

[Joan Ryan (Enfield North) (Lab)]

I am pleased to follow the hon. Member for Central Ayrshire (Dr Whitford) and agree with many of her points.

I share concerns expressed about the misleading statements made on the national health service during the EU referendum campaign. Many of my constituents who voted to leave were swayed by the pledge that a future outside the European Union could result in £350 million extra every week being invested in our NHS—and if not £350 million, then £120 million would do very nicely at the moment and make a big difference. Whether they voted leave or remain, people feel very disillusioned with such misleading statements.

The breathtaking speed with which prominent figures from the leave campaign have backtracked on that promise shows how hollow their words really were. People on both sides of the debate are upset and angry about what has happened. They understand that our hospitals, doctors and nurses need better support and more investment. I therefore fully support the motion.

[Andrea Jenkyns]

I completely agree with the right hon. Lady that we need more investment, but does she agree that the Government are right to point out that we have invested an extra £8 billion in the NHS already?

[Joan Ryan]

If the hon. Lady looks at my constituency she will see a perfect storm when it comes to health funding. We are underfunded in public health, in social care, in primary care and in acute care. She can come up with whatever figure she likes, but the experience on the ground is that we are suffering very badly.

I will come on to talk about the Care Quality Commission report, out today, on our hospital. I do not know whether the hon. Lady has seen it, but if she wants to talk about increased spending, I suggest she look at that report. What it says about what is going on in an acute care hospital is unprecedented.

[Mr Jamie Reed]

Two of the prominent leave campaigners who endorsed the £350 million figure are now running to be leader of the Conservative party and our future Prime Minister. Does my right hon. Friend agree that those two people should be brought to this House and made to explain to the country just where they will get the £350 million from?

[Joan Ryan]

I absolutely agree. Nothing makes the public feel more disillusioned and separated from the political and democratic process than to be given promises by politicians who, once the public have given their vote to them, walk away from those promises. That is not acceptable.

[Karin Smyth (Bristol South) (Lab)]

Does my right hon. Friend accept that as well as the £350 million promise, the issue of access to GP primary care appointments caused a lot of anxiety in many communities? That is the fault not only of the funding situation but of the way in which primary care has been run down in the past six years.

[Joan Ryan]

The lack of primary care—particularly in London but also elsewhere—is a key factor behind the huge pressures on our accident and emergency departments and urgent care. No wonder people go there when they cannot get an appointment.

[Philip Boswell (Coatbridge, Chryston and Bellshill) (SNP)]

It takes four years to train a nurse and five years to train a doctor, but the divorce proceedings triggered by article 50 will be done in two years. It clearly presents a critical problem for NHS funding if staff leave when the UK leaves the EU.

[Joan Ryan]

As we have heard, Brexit will present us with many problems, particularly with health care provision. Not only are we not getting large sums of money, but we will actually be worse off. We will face many challenges because of that decision, and if the promise of £350 million led people to vote in a particular way that will undermine the funding we receive, that is a desperate state of affairs.

People feel badly let down by the leave campaign’s empty pledges on the NHS over the past few months, and residents in Enfield are deeply disenchanted by the Government’s failure to fulfil their recent promises to our local health service. Before the 2010 general election, the then Leader of the Opposition—actually, he was then Prime Minister of the coalition Government—stood outside Chase Farm hospital in my constituency and vowed to protect its A&E and maternity units. By 2013, his Government had shut both departments. Many of us warned at the time that closing Chase Farm’s A&E department would put huge strain on other local health services, including North Middlesex University Hospital NHS Trust, which is the subject of the CQC report that I referred to earlier. We were right, and almost three years since the decision to close Chase Farm’s emergency department, the NHS in Enfield has reached breaking point.

Earlier today the Care Quality Commission published its report into the standard of care at North Middlesex hospital, following a spot check by its inspection team in early April. It found that the closure of Chase Farm’s A&E has led to significant increases in patient numbers attending the emergency department at North Mid. Despite being one of the busiest A&E departments in the country, North Mid’s urgent and emergency services have been graded as “inadequate”, and patient safety has been compromised. Patients who arrive at the emergency department are not seen quickly enough by clinical staff, and they are waiting too long to be seen by a doctor. Some blue-light patients are being brought in, and hard-pressed nurses are dealing with them because no doctor is free to treat them.

[Mr Gareth Thomas]

My right hon. Friend is making a strong case for her constituents and their hospital. Does she recognise that although the situation she describes at North Middlesex hospital is particularly bad, such things have also been witnessed in many other parts of London, not least in north-west London where the London North West Healthcare NHS Trust has shut an accident and emergency department at Central Middlesex hospital? As a result, there has been a big increase in pressure at Northwick Park hospital, which serves my constituents.

[Joan Ryan]

Absolutely. North Middlesex is just the first hospital to reach absolute crisis point, but I am well aware that other hospitals, particularly in outer London, are heading down a similar path and facing real difficulties. If we consider A&E waiting times, we see that hospitals are sliding into that difficult scenario.

Junior doctors and trainees have been left unsupervised in North Middlesex hospital’s A&E department at night, without competent senior support—in fact, no consultant has been available from 11 o’clock onwards. My hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott) referred to such cases. In one instance, one commode was available for 100 patients in the whole of the emergency department. Staff raised concerns about the lack of vital medical equipment, including missing leads for cardiac machines so they could not get an instant read-out. Trolleys in the resuscitation area lacked vital equipment. There was an oppressive, overbearing culture at the hospital that meant staff did not feel confident in raising concerns, and they even stopped reporting incidents of staff shortages, as management had not responded to them in the past.

The CQC report reinforces the findings of Health Education England and the General Medical Council. At a high-risk summit in May, the GMC threatened to withdraw junior doctor post-graduate trainees if the numbers of A&E staff and middle-ranking doctors and consultants were not increased. That would effectively close the busiest emergency department in London. This is an unprecedented situation. The future of North Mid A&E has been put at risk. Even medical trainees at the hospital are not prepared to recommend the A&E for treatment to their friends and family. In interviews with Health Education England, they said that that was

“because they felt the department was unsafe.”

My constituents have had to suffer the consequences of shocking mismanagement and a lack of leadership at North Mid. The chief executive is now on leave and I understand she is stepping down. Although there is a lack of leadership, she cannot be held solely responsible for what has happened. The Prime Minister and the Health Secretary have told us repeatedly that the NHS is safe in their hands, yet huge pressures have been placed upon North Mid due to a lack of central Government funding. Patient care has suffered further as a direct result of the hospital not having enough equipment, consultants, doctors and nurses. It has had to spend large parts of its budget on locums and agency nurses.

What is the Government’s solution to ensuring that hospital departments, such as those at North Mid, do not remain dangerously understaffed? Is it to divert a large amount of funding to help to solve this situation and put patients first? No: they decide to go to war with junior doctors over their contracts and abolish NHS bursaries for student nurses, while we have hospitals going abroad to try to recruit staff. That is an insult to dedicated professionals who deserve our admiration, respect and support. The Government’s actions will discourage the future frontline staff we so desperately need.

The NHS is facing a huge financial challenge, so a commitment to spend an extra £350 million a week, or even £120 million a week, on the NHS in lieu of our EU membership was clearly a very attractive offer to our constituents. NHS England needs to plug a funding gap of £30 billion a year by 2021 and a few months ago it was revealed that nearly every hospital in the country was in deficit. We are obviously not going to get £350 million or £120 million a week and I think that that was always known by the leave campaigners. In fact, the Government are seeking to suck out £5 billion in savings through the sustainability and transformation programme. I know that savings and efficiencies, particularly in back-office services, can and must be found, but not at the expense of patient safety.

My hon. Friend the Member for Lewisham East (Heidi Alexander), the former shadow Health Secretary, warned that the scale of savings required could

“not be delivered without putting patient care at risk… These ‘efficiencies’ will mean cuts to staff, cuts to pay, rationing of treatments. And it will be patients who suffer.”

Her analysis is spot on. We have witnessed the disastrous effects of this course of action in Enfield. We need more investment in North Middlesex University hospital, and in the NHS in general, not less. I join my parliamentary colleagues on the Labour Benches in calling on the Government to increase spending on our NHS. It is most regrettable that, given the urgent need for more funding and the very real and justifiable concerns of people in Enfield, they should have been led to believe Brexit could possibly mean major new funding for the NHS.

In closing, I think I corrected myself wrongly. In the run-in to the 2010 general election, the current Prime Minister was, of course, the Leader of the Opposition, and he made a promise to keep our hospital open, which, when he became Prime Minister, he then closed. That kind of behaviour is very similar to what the leave campaigners did in promising money that does not really exist. It is hoodwinking the voter and it is not acceptable. It desperately undermines the voters’ faith in politics and democratic processes.

--- Later in debate ---

[Mr Gareth Thomas (Harrow West) (Lab/Co-op)]

It is a pleasure to follow my hon. Friend the Member for Bristol South (Karin Smyth). I will be unashamedly parochial and pursue the point that I made in an intervention on the Secretary of State about the future finances of the Harrow clinical commissioning group and the London North West Healthcare NHS Trust. It includes Northwick Park hospital, which serves my constituents. I should declare an interest in that I have been operated on and indeed members of my family have been born at Northwick Park hospital, with which I therefore have a particular affinity, as do my constituents.

[Joan Ryan]

My hon. Friend is right to remain parochial and focused on his hospital. One of the scandals of North Middlesex is that all the local MPs have been kept in the dark about all the serious faults that were known to the hospital and to NHS officials. None of that was shared with the local MPs.

[Mr Thomas]

My right hon. Friend made a very powerful speech about North Middlesex hospital. I am pleased to say that I have a positive relationship with the managers at North West London Hospitals Trust as they have always made themselves open and available to answer my questions. I hope that they will read Hansard and see my right hon. Friend’s warning in relation to the difficulties that she has had with previous managers at North Middlesex hospital and will do even more to provide transparency in our area.

Let me talk now about my concerns about the finances at Northwick Park. Back in 2014-15, North West London Hospitals Trust had a deficit of some £55.9 million. That had risen to £100 million by the beginning of this financial year. The trust management board is optimistic that it can get that deficit down over the course of the next financial year to just over £88 million, which is an enormous sum in its own right and will, if that figure is achieved, still be without question one of the biggest deficits in the NHS in England. To achieve that target, it has committed to axe 140 posts. My concern, and the concern of many of my constituents, is that services at Northwick Park and indeed in other parts of the trust will be affected despite the intentions of the management.

The situation at Northwick Park has been compounded by the decision to close a number of accident and emergency departments in north-west London in recent years. In particular, the decision to close Central Middlesex hospital has undoubtedly had an impact, increasing the pressure on the services at Northwick Park hospital. Although it was great to see some new investment at Northwick Park—we now have an upgraded accident and emergency department—no extra beds were created in the hospital, which is a major concern.

I recognise that time is a concern, so let me underline my last point, which is about the funding of Harrow clinical commissioning group. In the past three years for which parliamentary figures were available, it has received the lowest funding of any London CCG. The Secretary of State was very generous in offering to go away and review that situation. I ask the Minister who is due to reply to this debate whether he would be willing to receive a deputation of local general practitioners and me to discuss the funding of Harrow CCG, which is one of the causes of the difficult financial situation at Northwick Park hospital that serves my constituents.

World Autism Awareness Week

Joan Ryan Excerpts

Thursday 28th April 2016 Commons Chamber

[Jon Cruddas (Dagenham and Rainham) (Lab)]

Last Saturday, anticipating today’s debate, and in his customary elegant way, Guardian columnist John Harris wrote an excellent summation of some of the issues around autism. He ended his piece with these words:

“Our culture still too often couches autism in terms of pity or fear as an essentially Victorian sensibility lingers on. But we are moving towards a new world in which autistic people and their families advocate for themselves. For them, the current noise about autism perhaps highlights an inevitable phase of any struggle against ignorance: the point at which you know you’ve come a long way but still have light years to go.”

When we consider the debates and the legislation passed in this House regarding autism, we understand that we, too, have come a long way, and a significant reason for that has been the work of the right hon. Member for Chesham and Amersham (Mrs Gillan). I therefore congratulate her on securing this debate and on all her work over many years in this area, not least as chair of the all-party parliamentary group on autism.

In my short contribution I will focus on a few issues. The first is that of diagnosis delay, something that every Member in this House will have countless examples of. It is the focus of the National Autistic Society’s brilliant campaign and is flagged up in the motion. As we have heard, for children the average diagnosis time is now some three and a half years. In my experience, from talking to parents, carers and experts, that is partly down to insufficient training among NHS people and cost pressures within the system. The reality for parents is that if they do not know where to turn and are without a diagnosis, there is not much that they can access.

Secondly, I will focus on what appears to me to be the biggest single problem, which is that people have to deal with a system of immense complexity, which is buckling under the cuts and has no single point of contact marked “autism”. For many, the system is simply bewildering and often very scary.

Finally, I want to highlight the campaign work being done by amazing people at local level, including my constituent Fay Hough, who only last week led a large demonstration outside Havering town hall demanding better services and support for autistic people and their families.

I will also make a couple of points about the nature of research into autism in the UK and how it might be developed, to help both our overall awareness and, most importantly, autistic citizens and their families. Recent figures suggest that roughly 1% of the UK population has an autism spectrum condition, a twentyfold increase in the 50 years since the first epidemiological study. Given that, we need more and better research.

We can detect a dramatic expansion in autism research, especially in the US. For example, the 2006 Combating Autism Act authorised some $950 million for autism research over a five-year period to develop screening, early diagnosis and children’s intervention strategies. It has been estimated that in 2010 alone, investment in autism research in the US exceeded $400 million.

Here in the UK, research from the Centre for Research in Autism and Education at University College London suggests that public and private funding organisations invested some £21 million into autism research between 2007 and 2011, amounting to a significant increase. The question is whether that research is focused on the correct issues and whether it tallies with the needs of autistic people and their families.

I refer to an article in Autism, “What should autism research focus upon?”, which suggested that

“research activity should be broadened to reflect the priorities of the UK autism community, focusing in particular on research that helps people live with autism.”

It would appear obvious that research should maximise its impact on the life experiences of those affected—our constituents—so why might this apparently self-evident objective not be the case?

When we look at the debate about autism research, there appears to be a tension between two types of project. On the one hand, there are projects that focus on what we might call the basic science of autism—on neural and cognitive systems, genetics and other risk factors. On the other hand, there is research focused on the understanding and promotion of how families function and the services those families need. Evidence suggests that that tension has been identified in the US and that as a result there is a growing diversity in research funding, to the direct benefit of autistic citizens and their families.

In contrast, evidence from the Centre for Research in Autism and Education suggests that that diversification of funding has not occurred in the UK, and that projects in the areas of biology, the brain and cognition outstrip all other areas of autism research by a vast margin, in terms of both the numbers of projects and the total research grant. The effect is that very little research funding is directed into identifying effective services for autistic people and their families—that is, research on services, treatments, intervention and education.

Obviously, that is not just an academic issue, but relates directly to all the questions about autism awareness discussed this afternoon. Research by the Centre for Research in Autism and Education suggested that the families of autistic people value research into the underlying causes of autism, but need a more balanced distribution that redirects attention on to their daily lives, their needs and the services afforded to them.

[Joan Ryan (Enfield North) (Lab)]

I congratulate the right hon. Member for Chesham and Amersham (Mrs Gillan) on securing this debate, and my hon. Friend the Member for Dagenham and Rainham (Jon Cruddas) on his powerful speech. Durants school is a secondary school for young people with autism in my constituency. Its governing body has written to me to express concerns that with the Government consultation on changes to the national school funding formula—including that for high needs—there will be a levelling down and funds will be drawn away from those schools, which would be very damaging.

[Jon Cruddas]

The issues that some of us planned to raise in the debate that was cancelled on Monday evening concerned precisely some of the pressures on the system, especially for special needs children. That takes us back to a point that I wished to raise about problems with diagnosis, entry points into the system, and the cuts that are being experienced. Those things are all linked to the research base around autism and effective public policy making, and to the concrete problems of commissioning services, the decision-making of front-line staff, and the dilemmas facing autistic people and their families—it is basically the existing evidence base for decisions on autism and public service provision.

I look forward to a reorientation of the research priorities for autism to balance out research funding and projects, as appears to have been achieved in the US. We need to balance scientific research with under- standing the needs of the most effective support offered to autistic citizens and their families, as well as greater co-ordination with autistic research, which again appears to have been achieved through strategic oversight in the US. Finally, we need the involvement of autistic people and their families in those strategic decisions—basic issues of democracy are involved in this debate.

It is great that we are having this debate today, and another sign of progress. To return to the words of my friend John Harris, whose family have tried to navigate through this system for many years, we appear to be at a point at which we know we have come a long way, but we still have light years to go.

Junior Doctors Contracts

Joan Ryan Excerpts

Monday 25th April 2016 Commons Chamber

[Mr Hunt]

Regrettably, there has not been only one occasion. In the October before the election, the junior doctors committee walked out of talks after extensive efforts to negotiate a new contract. We then had the independent pay review body process. Then—this was the most shocking thing of all—we had the decision of the committee to ballot for strike action before it had even been prepared to sit down and talk to me about what the new contract involved. That has been at the heart of so many misunderstandings about this contract and has led to so much disappointment on all sides. If the committee had sat down and talked to us, it would have discovered that we all want the same thing: a safer, seven-day NHS.

[Joan Ryan (Enfield North) (Lab)]

The Secretary of State tells us he has spent over three years on this matter—three years, and he has brought us to this unprecedented state of affairs. May I gently suggest to him that it is not the junior doctors who are the problem, but him? My constituents—hundreds of whom have written to me—overwhelmingly feel that he has been irresponsible and intransigent. He needs to get back to the negotiating table, lift the imposition and put the people who need A&E—in the next few days and beyond —first.

[Mr Hunt]

If the right hon. Lady is asking whether I will compromise in my pursuit of a safer NHS for her constituents and my constituents, the answer is I will not. I am the Health Secretary who had to deal with Mid Staffs and with a huge number of hospitals up and down the country that the Labour party, when in power, did nothing to turn around. We dealt with that. We put 27 hospitals into special measures. We have dramatically increased the number of doctors and nurses in our hospital wards because we care about a safer NHS. When there are issues about weekend care, the right thing to do is to address those issues, not to duck them.

Mental Health Taskforce

Joan Ryan Excerpts

Tuesday 23rd February 2016 Commons Chamber

[Alistair Burt]

Absolutely. Attention is now being paid to crisis care in A&E, which recognises the fact that people who need urgent treatment will go to A&E. The Government are determined to ensure that there is emergency access 24/7 by placing more psychiatric liaison teams in hospitals and by improving crisis care in the community. My hon. Friend is right to recognise the problem. A number of syndromes and issues have particular qualities associated with them that need individual care, and he is right to raise his concerns about those who suffer from Tourette’s.

[Joan Ryan (Enfield North) (Lab)]

The taskforce emphasises the importance of supported housing for people with mental health problems. I think it is right to say that the Minister’s Department made no representations to the Treasury before the changes to housing benefit for tenants in supported housing were announced. It had made no official representations to other Departments as recently as three weeks ago. Will the Minister now make the case to his colleagues in the Departments for Communities and Local Government and for Work and Pensions on the need to exempt vulnerable people from the changes in housing benefit?

[Alistair Burt]

I understand the right hon. Lady’s point. I know that such issues are being considered extremely carefully by those who are responsible for developing the policy, but I will ensure that her further concerns are noted and that the Departments recognise them.

IVF: Welfare of Women

Joan Ryan Excerpts

Wednesday 20th January 2016 Westminster Hall

[Siobhain McDonagh (Mitcham and Morden) (Lab)]

I beg to move,

That this House has considered the welfare of women undergoing IVF treatment.

I want to draw attention to the Human Fertilisation and Embryology Act 1990, which is also known as the HFE Act. It contains worrying failures that are endangering women’s lives and long-term health. As a result of the failures, it is time for Parliament to take action to protect the welfare of women undergoing IVF treatment. IVF is a huge industry, estimated to be worth some £500 million, with most treatment taking place in the private sector.

The Human Fertilisation and Embryology Authority code of practice, which follows from the 26-year-old HFE Act, rightly requires clinics to take into account the welfare of the child before providing IVF treatment, but the HFEA’s narrow interpretation means that women’s welfare is not considered. IVF treatment works by stimulating the ovaries of a woman to grow multiple follicles through the use of a drug identical to the natural stimulating hormone called follicle stimulating hormone or FSH. In turn, the growth of such follicles causes a rise in oestrogen in a woman’s bloodstream.

However, if levels become too high, there can be a profound and adverse effect on a woman’s health. Indeed, extensive research has shown that the high stimulation given to women during IVF can significantly compromise their health. The most common adverse effect following the use of such hormones during IVF is ovarian hyperstimulation syndrome or OHSS, which can be mild, moderate or severe. Mild OHSS can occur in up to 33% of IVF cycles, while 3% to 8% of IVF cycles are complicated by moderate to severe OHSS. Women with severe OHSS are hospitalised, some in intensive care, needing intravenous infusions and drugs to save their lives. In its most severe form, OHSS can be fatal and women have died in the UK as a result of the complication.

[Joan Ryan (Enfield North) (Lab)]

Given the serious health risks that can arise from women being treated with too much hormone medication during IVF, does my hon. Friend agree that the HFEA must collect and publish information on the type and amount of drugs given to women so that they can make a more informed choice about the treatment they may receive?

[Siobhain McDonagh]

I wholeheartedly agree with my right hon. Friend and hope to expand on that point in my speech.

Care Homes: England

Joan Ryan Excerpts

Wednesday 13th January 2016 Westminster Hall

[Joan Ryan (Enfield North) (Lab)]

It is a pleasure to follow the hon. Member for Bexhill and Battle (Huw Merriman). I echo what he said about some of the excellent care that we see in care homes.

I congratulate my hon. Friend the Member for Hove (Peter Kyle) on securing an important and timely debate. He highlighted many of the key concerns of care providers in the UK. One is the current funding crisis in social care. Over the past five years we have seen social care budgets across the country cut by almost 11%. In Enfield, the local authority has had to deliver net savings in its adult social care budget of 16% over the past four years, and by 2019, the savings requirement that the council will need to initiate will further reduce the budget by £19.8 million, from £80.8 million this year to £61 million. That is equivalent to another 25% reduction in the net budget. How do the Government seriously expect local authorities such as Enfield to cope with a cut of that level?

[Andrea Jenkyns (Morley and Outwood) (Con)]

I have been a councillor, so I know that budgets have been quite tight in local authorities over the years. A care home in my constituency, Siegen Manor, is possibly due to close. Does the right hon. Lady agree that we need to look at the way councils spend money? In my new city council, there is a lot of wastage. We need to look at how councils spend their money, because I could give a lot of examples of how they could—

[Mrs Anne Main (in the Chair)]

Order. I call Joan Ryan.

[Joan Ryan]

It is always important that we have a weather eye on how any public authority is spending its money and that we get the best value for money; that goes without saying. However, I think—I do not believe the hon. Member for Morley and Outwood (Andrea Jenkyns) was disagreeing with me on this—that we need to hear from the Government how local authorities can be expected to cope with the size of cut that has been happening and is continuing to come their way. I thank the hon. Lady for her intervention.

Spending reductions of the size that my local authority is facing will almost inevitably result in cuts to the services that Enfield delivers to some of the most vulnerable people in the borough. Given the huge pressures on shrinking resources, I commend Enfield Council for its nationally recognised standards of best practice and the gold accreditation that it has received for its safeguarding work. Enfield has a wide range of care homes, which provide support to older and disabled people not only from the local area but from other areas. However, the deep cuts from central Government have already seen care homes close, and a significant increase in the number of people placed in the borough by other councils has meant that nursing home provision, particularly for people with dementia, is under severe strain. As a result, an ever increasing burden has been placed on our local NHS services and family carers. In those circumstances, it can be no great surprise that there is difficulty in recruiting and retaining staff to work as care providers.

Front-line care workers are all too often grossly undervalued. They offer vital support to people with ever more complex conditions, yet in return they often receive very poor wages. So although I welcome the introduction of the national living wage of £7.20 from April 2016, that figure is nowhere near the current London living wage of £9.40. Many care workers working in Enfield and elsewhere in London need that hourly rate just to get by. However, the Government have yet to explain how the care sector will be able to cope with the increased pressures on payrolls when funding has been so drastically cut. It is estimated that the introduction of the national living wage will add at least 5% to payrolls from 2016-17 and a further 7% every year until 2020. That will drive even more front-line care providers out of business and make a bad situation even worse.

I would like to draw to the Minister’s attention a letter I received from the Enfield Carers Centre in August last year. It read:

“Dear Joan Ryan

I am writing to you on behalf of Enfield Carers Centre to ask if you will support us in an urgent call that we are issuing to the Chancellor George Osborne in advance of the 2015 Spending Review.

In the Summer Budget, the Chancellor announced that, as of 2016, there will be a new compulsory National Living Wage of £7.20 per hour. We welcome support for care workers who deserve decent pay. However since we are dependent on local authorities paying us enough to pass this on to our valued care workers this increase therefore has to be reflected in the hourly rate paid by local authorities for care and support.

A report by the UK Homecare Association (UKHCA) has found that councils are going to need an additional £753 million to ensure their local care providers can meet these new pay requirements. Without that funding, care services risk closing down entirely…Care services have been badly affected over recent years by cuts and this is a financial stretch which we cannot meet. Quite simply the home care market, is at risk of collapse.”

I do not think that the Enfield Carers Centre got the answer it was looking for from the Chancellor, and I hope that it will hear some better news today from the Minister. I agree with the National Care Association when it states:

“UK Care Services are an irreplaceable part of the fabric of the NHS. There should be no doubt that what is under threat is a UK support service which is essential to local government and NHS care provision.”

I would like to know how the Minister will address those concerns and what steps the Government intend to put in place to provide a transparent and sustainable funding settlement for social care. The older and disabled people who rely on the service, their families and the all too often unsung heroes who work in it deserve no less.

--- Later in debate ---

[Rachael Maskell (York Central) (Lab/Co-op)]

It is a pleasure to serve under your chairmanship, Mrs Main. I thank my hon. Friend the Member for Hove (Peter Kyle) for securing today’s timely and important debate. As a country, we need to give deep thought to the importance we place on social care. We have heard in this debate that constrained finances are skewing the opportunity to do that. I have always said that we can judge a country by the way it treats its older people, and I wonder how we really think we are doing against that test. Those who have served our country in so many different ways deserve the very best care, and I am not sure that our system is built on that model. In fact, the model is now built more on minimal provision as opposed to optimal provision. I wrestle with that approach, and I believe that we really need to think about the direction in which we are going.

The current black hole in state funding for care has been made more challenging as the years have gone on by local authority cuts. We have heard clearly about the impact of a 10.7% budget cut over five years, and the fact that care providers have to pay more has added further challenge. I really welcome an uplift in the pay of care staff, because they are paid a ridiculously low amount of money. They are also faced with pension uplifts, and they have had to wrestle with the rise in national insurance and steep rises in the cost of energy, food and other services. That has all happened at the same time as they face the increasing demands of a challenging and changing demographic, including people with multiple needs, and tighter budgets. What we are seeing is unrealistic: the demand is greater, but the money is less.

[Joan Ryan]

Will my hon. Friend add to that list the fact that the CQC rates more than 50% of nursing homes as inadequate and needing improvement? The people living in those homes are therefore living in inadequate situations. How will that change, given the circumstances she outlines?

[Rachael Maskell]

My right hon. Friend makes a really pertinent point. There has to be a debate about safety and about providing good, secure homes for individuals. If people are living in substandard conditions, that is simply unacceptable. If there are not the resources to put that right, we obviously fear for the future.

Another thing we know is that the pressure being put on so many care organisations will make older people far more vulnerable. As we have heard, tens of thousands of beds could be lost. If people do not have security in later life, it can have a real impact on their wellbeing.

As others right across the Chamber have said in the debate, the autumn statement has left many question marks, and one of the issues we are going to see as a result is inequality. Some of the communities with the most demand for investment in social care will get the least money from the precept the Chancellor set out. Taken with the further cuts that local authorities will experience, that will have a cumulative negative impact on the provision of social care. That is happening at the same time as the NHS is really struggling with discharges, because the provision is not there in the community. In my constituency of York Central, some of the transitional beds will be lost because of a care home closure programme, which I will return to.

Cuts to support services for the elderly, such as day care placements, are happening because of the cuts to local authorities, and they are having a detrimental impact. The little things that local authorities could provide that kept people safe in their homes and connected in their communities are now very much part of history, as opposed to part of the solution. We keep hearing that finances are tight, but we must remember that it was not the people in our care homes who caused the financial crash—but, my, how they are paying for it.

A care provider in my constituency has highlighted the challenges of the new minimum wage rate and asked how on earth they are going to pay it. They already have staff who are engaged on zero-hours contracts. They tell me they cannot pay for staff to travel between visits. I obviously question that, and I support paying staff proper wages, but I really worry about how providers will deal with these issues in the future and how they will survive. I have written to the Government to raise those concerns.

The issues I have outlined are particularly challenging in a city such as York, which has a high cost of living and high housing costs. When those are combined with low wages, it is virtually impossible to recruit care staff, and that adds to the sector’s challenges. As a result, the care model we have does not really address people’s needs. That has had a real impact on discharges from the NHS and on being able to give individuals timely care in the community. We are now seeing the cumulative impact of these things, as the care home closure programme across York means that fewer beds are available.

The problem we have is that care is seen as a zero-hours, minimum wage, low-esteem industry, when it should be regarded as a high-skilled, professional service and the funding should match that. Those who have the means can afford to pay for what they get—only just, but they can. However, for the rest, care packages are being driven to the absolute minimum. It would therefore be appropriate for us all to agree that current provision is totally unacceptable. We need to draw a line under that and to have a real debate about what needs to be done. After all, who are we talking about? Who are we providing care for? It is our mums and dads. It is the most vulnerable in our society—those with multiple disabilities, those with learning challenges, those with mental health challenges and those whose bodies are not quite working as they once did. One day, it will be us.

Who do we expect to care for those individuals? It is highly trained professionals—the very best—who are rewarded appropriately, motivated and driven to learn more and deliver more. Like everybody else, I have met care workers right across the sector—in fact, I spent time doing care work myself—and I know the passion they have for providing the optimum care for individuals, but if they are not given the time to care, how can they deliver that service?

The Kingsmill review “Taking Care”, which Labour brought forward before the last general election, set out a clear programme for improving care standards and providing training and remuneration. It also dealt with the important issue of registration. It is really important that care workers are state-registered to ensure public safety. The steps the review set out show how we can secure high standards in care and safeguard service users.

We then need to think about how and where care needs to be provided. Of course people have different needs, including physical needs. In my own clinical practice as a state-registered physiotherapist, I would often get people’s confidence up and get them back on their feet, only for them to go home and lose the support and stimulation they had had, because support was not available continually in the community. Falls prevention work, which really puts in investment upstream and provides care, means that individuals avoid things such as a fractured neck of femur, which is so expensive to treat, putting more pressure on the health service. Little steps can make such a difference in the community and in care homes, keeping people well and addressing their physical needs.

Likewise, we know that so many people have mental health challenges in later life—two thirds of the occupants of care homes experience some form of mental health challenge. It is really important that the setting individuals are placed in appropriately addresses those needs. We need to start thinking big on these issues. The Dutch—I hope I say this right—Hogeweyk dementia care village is a fantastic scheme. It is about state provision. We need that kind of investment and that imaginative, big thinking around how we provide care in our country.

The issues I have mentioned are exacerbated by some of the most prevalent diseases in our country—loneliness and isolation, and the social and emotional health of the most vulnerable in our society. The tightening of budgets is having a major impact on the wellbeing of old people. Investment in the issue can mitigate the worst aspects. I am totally passionate about that. It is heart-breaking that older people are just given 15-minute appointments, often with a stranger, as opposed to a full support network and a real life. Our goal should be helping people to live, not preparing them to die.

On the challenges we face, we need to take a step back and think about what we want from care provision in future. These are political choices and are possible if somebody believes they can deliver them. I talk to carers who share the vision I have outlined and who want the very best for the people they serve. I also talk to people in residential care, who want hope in their future. Those people would give momentum to a Government who would dare to grasp the nettle to make sure that we provide appropriate care in future.

I want quickly to set out the situation we have in York. I have had many conversations with the residents of care homes, their families and the staff. We are going through a transition. That has already resulted in two care homes closing, and a further two—Oakhaven and Grove House—are set to close early this year. Residents and their families are distraught about the fragmentation that that is causing. Residents are being moved to placements across the city and away from their families. Some placements are on the other side of the city from where their families live, so family members can no longer just pop in to see mum as they do at the moment. Residents are being moved away from their friends in the care home—for some, these are the only friends they have in the world. Staff are also being moved away from their homes. Residents feel that they have not been listened to and that they have been ignored, which is unacceptable.

The council has put its plans ahead of the support that it purports to want to deliver. It is remodelling social care. I very much support the last Labour Administration’s vision for that. However, the sequencing of the changes is detrimental. It is about putting money before people’s needs. We need to hold back on the transition that is taking place, to make sure that there is investment upstream, as opposed to making people fit the system and sacrifice some of the only bonds that they have.

We have gone badly wrong in many areas of social care, and do not currently place the value on care users and staff that we should. As I have said, this is about political choices and political priorities. I ask the Minister whether there could be any greater priority than getting this right. I urge Parliament from today to take the debate forward. I want all those who have participated in today’s debate to make sure that we prioritise social care so that it is seen as an urgent need to be addressed by the Government in this term, so that we do not have to face challenges and struggles we face at the moment of questioning the finances and the value we put on social care. The question is whether the Government are willing.

Adult Skills Budgets: Enfield

Joan Ryan Excerpts

Friday 20th November 2015 Commons Chamber

[Joan Ryan (Enfield North) (Lab)]

I am grateful for this opportunity to discuss the important matter of adult skills budgets in Enfield.

First, I want to put on record my gratitude to the further education colleges in the borough for the excellent services that they deliver. The College of Haringey, Enfield and North East London—known as CONEL—Barnet and Southgate college and Capel Manor college have a proud history of providing essential technical and vocational skills training. The training, confidence and qualifications that students have gained from those institutions have been of tremendous benefit to their career prospects as well as to the economy in Enfield, London and beyond.

I am sure that the Minister will want to join me in paying tribute to FE colleges providing adult skills training in Enfield, as they need and deserve our wholehearted support. I hope that the Minister also agrees with the statement made by the University and College Union that

“further and adult education is a crucial part of our society and economy and that it should be invested in properly.”

However, a consideration of current Government policy indicates that genuine support for that statement is less than forthcoming. FE colleges have seen their adult skills budgets hit with unprecedented cuts. According to the University and College Union, the adult skills budget for those students aged 19 and over has fallen by almost 40% since 2009. While apprenticeship funding will be protected, there has been a 23% real-terms cut in non-protected adult skills budgets since 2014.

The effects have been felt particularly keenly in further education colleges serving Enfield. In 2008-09, the newly combined college of Haringey, Enfield and North East London had an annual income of £52 million. By 2014-15, the figure had fallen to £36 million—a drop of 31% in six years. Its income for this coming year is budgeted at £31 million, which is a further 13% cut. At Capel Manor college, adult education and training funding has been cut by 28% this year alone. This comprises a 24% cut when its funding allocations were made in February, followed by a sudden 3.9% cut announced in July. This was after the college had finished for the summer break and the governors had signed off the budgets.

What assurances is the Minister prepared to give today that no further cuts to adult skills budgets will be announced in the spending review next week? Does he understand that announcements of sudden cuts, such as those that we witnessed over the summer, undermine colleges’ ability to make strategic decisions, and damage their ability to respond to the needs of employers, students, the local community and the wider economy?

The consequences of the cuts to adult skills budgets are jeopardising colleges’ ability to support adult learners. In a letter to London Members of Parliament, Dr Stephen Dowbiggin, the principal of Capel Manor college, said:

“The reductions in funding between 2013-2015 mean we have had to turn away over 700 students—the majority of which have, in the past, gained employment or set themselves up in business.”

CONEL made 42 teaching posts redundant earlier this year. It has also suffered greatly from the complete withdrawal of ESOL—English for speakers of other languages—mandation funding for English courses. As David Hughes, the chief executive of the National Institute of Adult Continuing Education, has said, this cut will

“hit people who are working hard to gain the language skills they need to participate in work and in our society.”

CONEL is working on plans to deal with additional cuts. That is likely to have a major impact on staffing levels at the college and the scope of the curriculum on offer.

It is clear that the Government’s policy has a huge impact on the provision of courses. The Association of Colleges has said that up to 190,000 adult education places across the country could be lost in 2015-16. It warns that

“Adult education and training in England will not exist by 2020 if the Government continues with its swathe of cuts to the adult skills budget”.

Its research has shown that the squeeze on adult education and training funding in recent years has seen the number of adult students participating in level 3 courses fall by almost 18% since 2012. According to the Government’s own statistics, participation in adult further education courses has fallen by more than 500,000 since 2011.

I am sure that the Minister will be aware of the report, “The economic impact of further education colleges”, by a consortium of FE colleges, the 157 Group. Its research found that the approximate average impact of a college on the regional economy is £550 million. In addition, its study shows that

“Learners receive an average 11.2 per cent return on their investment in terms of higher future earnings…Society receives an average 12.6 per cent return on its investment in terms of an expanded tax base and reduced social costs…The taxpayer receives a 12.3 per cent return on its investment in terms of returns to the exchequer.”

Bearing the report by the 157 Group in mind, how can the Government’s cuts be anything other than bad for learners, bad for society and bad for the taxpayer? The assault on the adult skills budgets is a deeply misguided decision. The UK desperately needs to improve its productivity and competitiveness. FE colleges serving Enfield and elsewhere should be at the forefront of training, educating and reskilling our workforce.

Colleges serving Enfield have other particular issues that I want to address. Enfield boasts the fourth highest population figure of all London boroughs. According to the last census, Enfield’s population increased by more than 14% in one decade. If we see the same growth in the next 10 years, with many more adults coming into the borough, common sense suggests that there will be even greater demand for adult skills training, and increased demand for adults to retrain and upskill. Can the Minister tell me how they would be able to do that if the rate of cuts to adult skills budgets continues at its current pace?

Enfield has employers such as Chase Farm and North Middlesex University Hospitals, Siemens, Kelvin Hughes, Johnson Matthey and others who are heavily involved in health and life sciences, digital skills and the engineering sector. They are always on the look-out for skilled recruits. Given the uncertainty over adult skills budgets, how can the Minister expect FE colleges to invest in the necessary equipment and facilities required to deliver high-quality training in these areas?

The college of Haringey, Enfield and North East London has been particularly exposed to cuts in adult funding, as London attracts a greater proportion of adults from the rest of the UK and from overseas. Less money for the college means fewer members of staff, fewer courses available and fewer opportunities to help those most in need. I welcome the Government’s proposal to increase the number of apprenticeships on offer. However, they should not and must not be a substitute for sustainable funding for other forms of adult skills training. As Andy Forbes, the principal and chief executive of the college of Haringey, Enfield and North East London has said:

“The problem is that many of our students are nowhere near ready to undertake an apprenticeship and often have significant barriers—such as childcare responsibilities—which prevent them from working the 30 hours a week needed to be an apprentice.”

The college has a great deal of high-quality vocational training at level 2 and below for adults for whom apprenticeships are not appropriate. It also has a lot of ESOL provision.

Both of those reflect the demographics of Enfield, which has diverse communities and high levels of need. What measures is the Minister willing to put in place to ensure that the most vulnerable adults—those most in need of further education—are not excluded from opportunities to train, learn and thrive?

I recognise the importance of ensuring that investment in adult skills funding is as effective as possible. It is, therefore, important to ensure that certain FE colleges offering specialist provision are given due care and attention when funding decisions are made. Capel Manor college is one such institution. It is London’s only specialist land-based college. It provides education and training for adults, not only in Enfield, but at four other centres across London, in land-based and related areas, including horticulture, animal management and conservation. I commend the work of Dr Dowbiggin who, in over three decades of service, has overseen the development of Capel Manor college from 130 students to more than 3,000 students today.

The college has an excellent reputation. As a regional college with centres across London, Capel Manor is helping to address a key skills shortage in the capital. In the latest research, almost 50% of employers in the vocational areas that Capel Manor college serves said that no one living in London applying for a recent vacancy had the necessary skills. I hope the Minister will agree that we should be backing colleges such as Capel Manor, and that the Government should be encouraging as many adult students as possible to acquire the skills necessary to support a sector which is vital to Enfield and to London as a whole.

I am sure the Minister will recognise that the land-based sector is made up mostly of micro-businesses and voluntary and charitable organisations. It is an ideal industry for adults who want to set themselves up in business—for example, as gardeners, florists and landscapers—or who want to work, often unpaid, in animal shelters, conservation groups and the like. But I am sure the Minister understands that these are areas in which apprenticeships cannot really work or there are too few opportunities on offer.

I know that the Minister will be following closely the work of the Public Accounts Committee as it conducts its inquiry into financial sustainability in the further education sector. During oral evidence last month the specific case of Capel Manor college was raised. The Chair of the Committee, my hon. Friend the Member for Hackney South and Shoreditch (Meg Hillier), said in reference to Capel Manor:

“For their balance of budget to work for the sort of students they have, more adult skills and slightly fewer apprenticeships would work, but they are getting more apprenticeships and fewer adult skills—a big cut in the adult skills budget.”

Peter Lauener, chief executive of the Skills Funding Agency and Education Funding Agency, acknowledged that

“some kinds of education do not fit quite as well in the apprenticeship world.”

I am interested to know what the Minister has to say in relation to Capel Manor college.

Over the summer, the Department for Business, Innovation and Skills announced a national review of post-16 education and training. I very much hope that FE colleges offering training opportunities for adults will also play an important part in the review’s considerations. That is important because FE colleges offering education for students aged 16 and over in Enfield and elsewhere also offer training and opportunities to adults aged 19 and over. It would be problematic to divorce the two.

I also urge the Minister to ensure that, when the area review process is conducted, suitable allowances are made for FE colleges with campuses in different local authorities, such as those that operate in Enfield. In the case of Capel Manor college, can the Minister provide an assurance that it will be considered as a regional specialist provider in the area review, instead of having to take part in five separate reviews—where each of its centres is looked at separately—or to be restricted to one local review where its head office is based in Enfield?

The purpose of the Department’s review is to

“provide an opportunity for institutions and localities to restructure their provision to ensure it is tailored to the changing context and designed to achieve maximum impact.”

It is vital, therefore, that this process is not so locally focused as to prejudice successful organisations such as Capel Manor, which, as I have said, is a truly regional college.

I believe that the Government’s current policy on adult skills budgets is wrong and short-sighted. I urge the Minister to come to Enfield, to visit the fantastic FE colleges serving the borough and beyond, and to see for himself the great work they do, in very difficult circumstances, to provide high-quality adult skills training. I look forward to the Minister’s response.

--- Later in debate ---

[Joan Ryan]

rose—

[George Freeman]

We are very short of time. Perhaps I can undertake to take away the right hon. Lady’s points and get back to her on the detail in writing, but I will take one quick intervention and then I must wrap up.

[Joan Ryan]

May I just reiterate my offer to the Minister to visit us in Enfield to see the good work for himself and talk to our principals, staff and students about these issues?

[George Freeman]

That is an incredibly kind invitation. Perhaps I may pass it on to the Minister for Skills—he has responsibility for further education—who I know will appreciate it. If I am ever passing nearby, I will gladly come and have a look.

I will take away and address the right hon. Lady’s specific points. I hope that there will be some good news through the area reviews. We will see how we may be able to help post the comprehensive spending review.

Question put and agreed to.

Junior Doctors’ Contracts

Joan Ryan Excerpts

Wednesday 28th October 2015 Commons Chamber

[Joan Ryan (Enfield North) (Lab)]

I congratulate my hon. Friend the Member for Lewisham East (Heidi Alexander) on securing this important debate and on her powerful opening speech. As she will know, health services in my constituency have already suffered greatly at the hands of the Conservatives. Two years ago they downgraded Chase Farm hospital, axing both our accident and emergency and maternity services and breaking every promise they made to local people.

Now they are seeking to implement changes to contracts that I believe are unfair on doctors and pose significant risks to patients, both in Enfield and across the country. That view has been reinforced by the number of doctors from Enfield North who have contacted me to express their serious concerns. Dr Irene Gafson is one of my constituents and has been a junior doctor for eight years. She took part in the march in London earlier this month and carried a sign bearing Nye Bevan’s famous words that the NHS

“will last as long as there are folk left with the faith to fight for it.”

Many Members may have seen the thought-provoking and insightful article she wrote for The Daily Telegraph after the event. Two things in particular struck me when I read her piece. The first was the deep sense of privilege she and her colleagues feel about being doctors. It is not just a job, but a vocation. These are hard-working, dedicated professionals who care passionately about what they do.

[Paula Sherriff (Dewsbury) (Lab)]

I spent some time in a busy city hospital last week with doctors who told me that many junior doctors now feel so demoralised that there has been a flood of applications to receive the certification to go and work overseas, so much so that the department that deals with that process has had to take on extra staff just to deal with the number of applications. Does my right hon. Friend agree that that is very worrying indeed?

[Joan Ryan]

Absolutely.

The second point Dr Gafson highlighted was the level of disillusionment in the medical profession with the Government’s plans. She said:

“Whilst the sense of solidarity and unity amongst junior doctors”

on the march

“was tangible to all, there was a much sadder force underpinning our mood...People who have invested years of passion into their work are feeling demoralised. This unique day that brought so many doctors together in one place really served to illustrate how dangerously low levels of morale amongst junior doctors have sunk.”

Dr Gafson voiced her strongest criticism for the way in which these contracts had not been negotiated with doctors and how the proposals threatened the safeguards on working hours. Significantly, she voted for the Conservatives at the last election:

“I trusted them with the NHS and I feel let down. I actually feel embarrassed”.

Dr Gafson is not the only one. Another local doctor who does not wish to be named contacted me to express her grave concerns at how the changes could impact on the NHS as a whole. She said that in a meeting last week a significant number of her colleagues were discussing alternative career plans and many were considering a move abroad to practise in another country. She said:

“If these reforms go through then the frontline specialties such as Accident and Emergency, General Practice and acute medicine will be hardest hit, and these areas are already undersubscribed”.

She went on to say:

“I am gravely concerned that if these changes go through they will signify the start of the dismantlement of the NHS.”

The Secretary of State should heed those words. They are an indictment of how the entire situation has been handled. If what is being offered is a “good and fair deal”, as he has described it previously, how does he account for the upset and concern the offer has caused? Is he willing to publish in full the financial models being used to calculate the proposed changes to contracts so that doctors can know exactly what they can expect to be paid? If he is not willing to do that, junior doctors working evenings and weekends have every right to be concerned that they face a possible pay cut.

Finally, is he willing to accept that removing the safeguards that penalise hospitals that force junior doctors to work in excess of their contract hours has the potential to overburden doctors and compromise patient safety?

I therefore urge the Secretary of State to stop his continued and unwarranted attacks on the BMA and to get back to the negotiating table and offer a deal that is fair to doctors and safe for patients in the context of talks without preconditions.