Adult Social Care

John Pugh Excerpts

Monday 16th July 2012 Commons Chamber

[John Pugh (Southport) (LD)]

I want to be constructive. I fear that this debate may take a different route from that taken in the recent consensual Back-Bench debate. We all recognise that the cost of adult social care is a problem not just for this country, but for every advanced society that we can think of. The outline is fairly familiar: funders, private and public, feel stretched and frightened by demographic change and the elderly are scared and anxious about mounting costs. Treasuries throughout the world are nervous whenever the issue crops up, and normally they vacillate. Last week, the Government were, in part, accused of that—of dragging their feet.

That is nothing new. Back in 2009, following the publication of the Green Paper, there was very much the same thing. The current Secretary of State, who was then the shadow Secretary of State, said:

“One debate always seems to roll into another with this Government. We need a decision, and we need serious, costed proposals to be the basis for that decision.”

The current shadow Secretary of State, then the Secretary of State, said:

“we are putting forward three broad options for the country to debate, and it would be wrong to force the pace of that debate.”

For the Liberal Democrats, my hon. Friend the Member for North Norfolk (Norman Lamb) said that the Green Paper

“comes 12 years too late. It is this Government’s shameful legacy that they will leave office having failed to reform a system that the Secretary of State”—

now the shadow Secretary of State—

“himself has described as a cruel lottery.”—[Official Report, 14 July 2009; Vol. 496, c. 160-62.]

When social care is viewed as a sustainable enterprise, Governments always see it as involving a big—and, worse still, an uncertain—sum, and that is why Treasuries usually baulk at it and we make very little progress. Governments are far happier in clarifying people’s rights and then passing the buck to local authorities. What paralyses Governments is the potential, not the identifiable, cost—what it is and how we are going to share it out —and that amounts to a huge political headache.

In order to resolve this, we need to do two things. First, obviously, we need to get a handle on the costs; but secondly, we need to work out a way of trying to defray them. Elderly people to whom I have spoken following our recent debates and last week’s statement have spoken in slightly different terms from how we speak here. They are sceptical about some of the Armageddon scenarios. They are resentful about their perceived lack of contribution to society—not in the past but currently. They do not see themselves, en bloc, as a drag on society.

We know that some people incur massive costs because they are frail, disabled, suffer with dementia and so on, and the social, personal and family costs are appreciable, but we also know of many pensioners who make a huge family and social commitment, and some who are even in employment. My predecessor, Lord Fearn, still has a delivery round of 500 copies of “Focus”, as does his wife, and they are both in their 80s. That shows the benefits of delivering “Focus”. We do not know enough, and need to know more, about how we get people into the category of the fit and keep them out of the category of the frail. We need to know why people end up in one category or the other and what the relative costs are of maintaining them there in terms of drugs, treatment and so on. We do not know whether by advocating an active, healthy old age we are deferring costs or eradicating them. The science of gerontology has an appreciable way to go. It is not clear to me, and probably not to many Members, how public health can move people into the better category of the fit and away from the category of the long-term frail.

My main point—to some extent it is not mine, as it was suggested to me by what the hon. Member for South Thanet (Laura Sandys) said in a previous debate—is that even if we accept that there is no way of avoiding the cost of the last years of life and the fact that as people get older their maintenance gets more expensive in terms of calls on the NHS, there is a case for considering whether we should do some serious number-crunching to re-engineer social care in order to sharpen up and prioritise interventions, as we have seen with dementia and arthritis. We do not know at this stage what the true benefits of that could be. I am not quite sure what I mean by re-engineering social care even as I say it, but we need to find out what it means and try to implement it in order to defray the costs.

Care and Support

John Pugh Excerpts

Wednesday 11th July 2012 Commons Chamber

[Mr Lansley]

First, it is ironic that the shadow Secretary of State said that local authorities would be aghast if they were asked to do extra things without resources given that we are providing those resources and that the Personal Care at Home Act was completely unfunded, which is why local government was desperate for us not to proceed with it. Andrew Dilnot and his colleagues are very clear, as are we, that there are, as I said in my statement, baseline funding pressures on local authorities in relation to social care. That will be addressed in the next spending review, as it was necessarily addressed in the previous spending review in direct response to recommendations that Andrew Dilnot gave us in 2010.

[John Pugh (Southport) (LD)]

I welcome the statement, which contains many good things, but without financial clarity we risk offering an unsustainable solution to an unsustainable problem. What can coalition Back Benchers do to get the Treasury to go further and faster?

NHS Annual Report and Care Objectives

John Pugh Excerpts

Wednesday 4th July 2012 Commons Chamber

[Mr Lansley]

As I made clear in my statement, according to the latest data 96.5% of patients in A and E are assessed, treated and discharged within four hours. The right hon. Member for Leigh (Andy Burnham) asked about the difference between a target and an outcome, but the point is that it is not enough to measure whether a patient has been seen and treated within four hours; the issue is the quality of treatment they receive, which is why our A and E quality indicators go further. The hon. Lady and I have had correspondence on this—I will be glad to look back and ensure that I have kept it up to date—so she knows that there has been a review of walk-in centres and that there is a need for people to have access not only to emergency departments, but to urgent care in a way that does not entail having to wait for a long time in A and E. I do not remember all the details, but I recall that some of the services offered in one walk-in centre in her constituency were being transferred to another that was adjacent to the A and E.

[John Pugh (Southport) (LD)]

I welcome the statement. In order fully to fulfil the NHS mandate, we need to raise NHS staff morale. What plans does the Secretary of State have for doing that?

[Mr Lansley]

I think that what most gives staff a sense of motivation and morale, in any organisation in any walk of life, is being more in control of the service they deliver. That is evidenced across many areas of economic and service activity. That is what we are doing for the NHS. Whether in foundation trusts or clinical commissioning groups, staff will feel that they have more control over the service they deliver. Consequently, I believe that as we see the figures improve it will be less a case of politicians interfering, or even trying to take credit, and much more a case of NHS staff taking credit for the services they deliver.

Cancer Treatments

John Pugh Excerpts

Tuesday 19th June 2012 Westminster Hall

[John Pugh (Southport) (LD)]

I thank all the people, from a variety of organisations, who made submissions before this debate in the hope that I could do justice to their thoughts and considerations. I may not succeed in doing so adequately, for which I apologise in advance, but other people in the Chamber, who are far better informed than me, can supplement any good, important or salient points that I fail to make.

It is a fact of the human condition that we are cell-replicating machines. I believe it is true—I am not totally certain, but I believe it is a truth—that none of the cells that were elected to this place in 2001 under the name of John Pugh are now here. They have all gradually been replaced, and some of them may actually be replaced during the course of the morning. That process goes on and on, and it is a very sophisticated one. When someone looks into the details of cellular biology, they are amazed that it occurs correctly as many times as it does. However, the longer we live, the more likely it is to go wrong, and when it goes wrong, we get the disease we know as cancer. It is a sad truth that the more we are saved from other diseases by progress in medical science, the more exposed we are to cancer.

Current stats show that, due to human longevity and the like, one in four of us are likely to die directly of cancer or a cancer-related condition. That will apply no matter what our success in investigating the environmental triggers for or the lifestyle causes of cancer.

We can all point to progress along those lines. We are no longer vulnerable to all the industrial causes of cancer, such as asbestos, and we took a momentous step forward in this place a few years ago when we backed the smoking ban, which remains the most useful thing I have done in Parliament, because it will undoubtedly reduce one of the major triggers for cancer. We now have to address other issues linked to cancer, such as obesity.

The disease is aggressive in youth and progresses slower with age, but, frankly, the longer we live, the more vulnerable we are to it. It is also true that many people will die with, but not of cancer. The challenge to any health system confronted with that crude biological fact is straightforward, and it is the same for any health system anywhere on the planet. I have divided the challenge under four headings. First, any health system needs to try to comprehend better the causes of cancer and initiate research. Secondly, any health system needs to try to prevent cancer and forfend its incidence. Thirdly, any health system—this is, of course, paramount—needs to cure people of cancer, where possible. Finally, any health and social system in any civilized society must help people living with cancer. Those four challenges are precisely the same for any health system anywhere, no matter how they are configured or delivered.

We have made substantial strides in the UK and our record should not be demeaned or lessened. During the passage through Parliament of the contentious Health and Social Care Bill, cancer stats were referred to and international comparisons were used to justify some of the changes. The oncology community had some misgivings about that, because its members felt that their real and substantive achievements were overlooked and that, for political purposes, people dwelled on what they had not achieved rather than on what they had.

The debate pack includes a good account of research by the King’s Fund and others on success in dealing with cancer. On European and international comparisons, an article in the pack states:

“While cancer deaths fell everywhere, England and Wales saw the biggest drop in mortality among males aged 15-74”—

that is, most males. The article continues:

“While mortality among women the same age declined by less, at 19%, that was the third biggest improvement”

in any civilised developed country in the world. We can, therefore, bank appreciable benefits and progress.

The difference between good and not-so-good policy is determined by the efficiency and effectiveness with which we approach the four fundamental tasks of comprehending the causes of cancer, curing people of cancer, trying to prevent cancer and trying to help people living with cancer, and by how intelligently we prioritise those tasks. An enormous amount of resources could be provided to address the problems presented by cancer, but such resources are not unlimited and we have to consider how we prioritise in every one of the four tasks. That applies to research, where people are continually examining how to prioritise the appreciable sums of money at their disposal in the most effective way. There are many debates about how we are to prioritise prevention and public health. Moreover, on prioritising treatment, recent discussions have centred on whether treatment for the elderly should be rationed or limited, because they may live longer with cancer but not actually die of it. There is also considerable debate, spearheaded by the likes of Macmillan Cancer Support, about the welfare provision for cancer patients.

I would like to turn briefly to public health, although it is not my main bone of contention. There has been a debate about how accurately we pitch our public health campaigns. Some have been excellent, particularly that on screening for bowel cancer, which I think has had an immediate and dramatic beneficial effect. My former colleague John Barrett is the former MP for Edinburgh West—he was elected in 2001—and he was diagnosed with bowel cancer through the screening programme shortly after leaving Parliament. He had absolutely no symptoms, but it is believed that it was caught in time. In fact, he was in Parliament recently and looked in pretty good shape to me. However, had the cancer not been detected—remember that he had no symptoms—it would have progressed as the years went by.

[Glyn Davies (Montgomeryshire) (Con)]

I thank the hon. Gentleman for giving way and allowing me to associate myself with the point that he is making. I am one of those whose cancer was found early, and I received treatment and survived. A younger friend of mine was diagnosed at the very same time, but his cancer was more advanced and he died aged 31. This is about catching it early and I want to emphasise the importance of screening, which saves a huge amount of lives. I have played a big part in driving forward the screening programme in Wales. Screening for bowel cancer is one of the best ways possible to save people’s lives.

[John Pugh]

I am sure that the hon. Gentleman is right and that he is also aware that there have been debates about screening for cervical cancer, breast cancer and so on, and about the age at which that should be done and the effect it would have. Although it is possible to screen everybody all of the time, that is not the most rational way to use resources, so any screening programme needs to be judged in the light of its subsequent evidence, which is very strong indeed for the bowel screening programme.

I was slightly, not amused, but distracted by the recent Department of Health advertisements—there were big adverts on buses—stating that anyone who has been coughing for three weeks should definitely go to see their doctor, because they might have lung cancer. When the advertising programme was launched, a horrible virus had gripped my office, the most lingering symptom of which was a cough that lasted for three to five weeks. Had we all trooped to our doctors’ surgeries saying that we might have cancer, a good deal of national health service time would have been wasted. Any campaign needs to be sophisticated and reviewed in the light of evidence. The one thing that we do not want a public health campaign to do is provoke alarm, because that would distract doctors from the things that we genuinely want them to address. People are not slow to be alarmed by any suspicion of cancer, which, I believe, after pornography and some other subjects, is one of the most researched topics on the internet. It is frequently referred to on various medical sites as a suspicion, rather than a diagnosis.

The academic community also has to prioritise. A lot of people leave substantial amounts of money for cancer research and it needs to be used as effectively as possible, as do welfare payments to cancer patients. Those issues need to be prioritised—Members may care to discuss that in the context of the Government’s ambitions for the outcomes framework.

I want to concentrate on the connection between treatment and health policy. The clinical armoury and tools available to medical science are pretty well known and can be put under four headings: chemotherapy, radiotherapy—possibly supplemented by more sophisticated treatments, such as proton beam therapy—drugs and surgery. A cocktail of those methods is used to treat cancer. All, in their place, can be extraordinarily useful and effective interventions, but the key thing that determines whether they have the maximum effect on and benefit for patients is whether they are used with skill—the right skill at the right time in the right place, and probably in the hands of the right doctor or consultant.

I learned relatively recently that, although we talk broadly about categories of cancer, there are sub-categories within those categories, and not every sub-category is responsive to the same treatment. Knowing which treatment is best tailored to which patient is a genuine art, because patients and their histories are all very different, as are the remedies that work with them.

Improved outcomes are to some extent determined not simply by having the tools but using them with better and greater skill. It is the skill or its absence that explains differential outcomes. There are differential outcomes across the UK. The chance of recovering from certain cancers in some areas is greater or less than in others. The chances of acquiring certain cancers appear to be greater in some areas than others. Genuine skill—knowing what to use on what person at what time—is in extraordinarily short supply. That sort of skill, the really effective intervention, is often allied with establishments that not just treat cancer, but research into cancer. Great skill is often, not unsurprisingly, aligned with a greater understanding of what is being dealt with. Treatment of cancer is not usually a journeyman matter or one of bog-standard clinical intervention and practice. That is why organisations such as the Christie hospital have such a well-established reputation.

I know the Government have put extra money into the drugs fund. Using the right drug in the right place at the right time is a fairly refined process. People can be given drugs that work with a cancer in general, but not for that particular patient or not at that stage in the disease, by organisations relatively unaware of the futility of the intervention. Therefore, we have all understandably come to the conclusion that we need clinical networks. We need to have people dealt with in the appropriate centres of excellence. There is a genuine readiness by patients to travel as far as they need to get the treatment. Most people in my constituency who contract any form of cancer travel across Liverpool, normally to Clatterbridge on the Wirral, generally without too much complaint, to get the treatment they want. The same group of constituents has been extremely angry and provoked by the need to travel 11 miles down the road for A and E assessment and triage.

[Mr John Leech (Manchester, Withington) (LD)]

My hon. Friend may not be aware that the Christie hospital has opened satellite centres in Oldham and Salford, so that patients do not necessarily have to go all the way to Christie, as they would have had to in the past. They still get Christie service, but in their local community in Salford or Oldham.

[John Pugh]

I think that is becoming the common pattern and could create some problems, given the way we intend to structure the NHS. However, it is a wholly desirable pattern. Clatterbridge is looking at a similar arrangement across Liverpool in collaboration with the Royal Liverpool University hospital. There is a sensible willingness on the part of the ordinary district general hospital to refer patients into an area where the maximum competence exists and where it is a matter of life and death. That is a totally laudable example of integrated service.

We can all accept there is a need to have an adequate clinical network, particularly for the more common cancers—lung, colorectal, prostate and breast cancer—in pretty well every area. That is a template that either is rolled out across the land or we wish to see rolled out around centres of excellence. We must always bear it in mind that, with cancer, a certain number of standard procedures can be done locally, without the full expertise of the top consultant.

There are certain cancers where that is not the case, for which we need national centres of excellence. To return briefly to the Liverpool Cancer Research UK Centre, that deals with pancreatic cancer almost as a speciality, with people there researching it very intensively. Its view is that there are probably about only two cases in the UK—and there may only ever be, given the relative distribution of that disease—where whatever treatment the patient gets can make a difference to outcomes, because the cancer is almost invariably fatal. It is necessary to vary the mix depending on the cancer in question. However, for the most common cancers, having a centre of excellence, having hubs around which standard procedures can take place and having a clinical network that works, is the way to go.

That sort of network does not happen by accident. Other hon. Members, apart from me, have asked how under the new regime it will be maintained and sustained. The construction of such networks in the past was the function, duty, mandate and overview of the strategic health authorities and they, of course, are to go. I saw in the notes that they would still be dealt with under the strategic health authority bundle within the NHS Commissioning Board. Clearly, “strategy” is the word to be used here. The hon. Member for Leicester West (Liz Kendall) was fond of saying that during the passage of the Health and Social Care Bill. The key point is that the strategy and the template are clear; the question is how to get them in place, sustained and maintained over time under the new regime. I would like the Minister to reassure me on that point.

It is not obvious how such a desirable template would emerge through simple market forces, or through bottom-up agreements by local commissioners. Even if those things could happen, it is not obvious that that would represent the most secure or quickest way to bring about the outcome. That is especially so when one acknowledges that the best treatment often occurs in environments where there is not only integration between providers, but research is taking place. I repeat the point that there is a need to deliver various levels of intervention and care in various settings. That will not happen by accident, or without some institutional resistance. One proposal in Liverpool is to move some of the activities currently conducted in Clatterbridge to the Royal hospital and get very substantial funding for that. That proposition, though supported by the bulk of people, is not supported by all. A certain amount of controversy may still arise about the level of care that could be delivered or result from such changes, which are not effortlessly brought about.

I guess that I am trying to say that ironing out the inequalities in cancer outcomes, ensuring there is the same provision and that each network is as good as any in every area, is possibly susceptible to a more dirigiste approach or Stalinist-like solution. I understand that the chief executive of the NHS was once a member of the Communist party—I hope I am not maligning him. That approach has its attractions. If the NHS Commissioning Board, which shelters the skeletal remains of the strategic health authorities, could play a dirigiste role, acting like the Politburo to impose the right template in every place, one could see how facilities could be aligned and personnel put in the right place. There would also be an opportunity to use central funding to effect. The Government have set up some central funding both for drugs and other purposes.

I have no issue with that way of doing things, provided it is rendered accountable. However, under the new dispensation, I can see problems in going down that particular road. Some of the provision we would want in place, for example, proton beam therapy, will require substantial capital investment. Under the new regime, if I understood what the Minister said during Health questions, substantial capital investment is primarily the responsibility of providers. So we have to hope that, in all places across the UK, all providers dealing with the common cancers feel obliged to make the same level of investment. I am not sure that there is an easy way to ensure that that happens. Clearly, the NHS Commissioning Board can commission clinical networks, just as it can commission any other piece of health provision. However, providing a substantial capital grant to a provider might create problems, particularly if it is contested by other providers. Providers may be reluctant to provide the kind of intensive capital resource that might be required when they have budgets to meet and control.

Last Tuesday, an hon. Member talked nostalgically about the days when we used to have fundraising for all kinds of scanners in hospitals. That does not seem to have taken place in the past decade or so because the money has been flowing a little more plentifully. However, we could be back in that territory if providers have difficulties in acquiring appropriate capital investment, or do not see a business case for doing so, without subsidy, by themselves.

I imagine that there are concerns about patterns of referrals within clinical networks, which, again, will test the new system. For example, dermatology providers that are unable to cope with cancer and oncology outcomes—there are such dermatology providers; I think they are now called Virgin Medical—will, under any willing provider, be one of the first ports of call for referrals, especially if they have partners in GP practices who are inclined to use them. At the same time, that may not be the right thing to do clinically, given its complexity. As incidences of melanoma have increased, it may be far better to refer people not to a dermatology provider that cannot do oncology, but to a dermatology provider that can—essentially, the existing hospital base. I can see that being a good thing clinically, but something that is contested in practice if it becomes a settled pattern.

I think we all know where we want to get to. I know that many other things need to be said and I hope other hon. Members will say them. My question is, given that there is a whole raft of agreements and evidence about the objectives and the point at which we want to end, how, under existing or future arrangements, will we ensure that the best outcome is delivered? In other words, how do we get the right clinical configuration to achieve the right clinical outcomes?

--- Later in debate ---

[John Pugh]

I am glad the hon. Gentleman mentioned that, because two close friends of mine died rapidly of pancreatic cancer. One point made by the people in Liverpool to whom I spoke was that, given the almost invariably fatal outcome from this cancer, it would not be a bad idea if some of the rules regarding drugs approval were relaxed a little bit, so that people could find out what worked, because in this case there is very little to lose.

[Jim Shannon]

I thank the hon. Gentleman for that valuable contribution and agree wholeheartedly. If it comes to the stage where people’s life expectancy is minimal or reduced, I believe that they would be quite happy to take advantage of new drugs, if those were available.

All hon. Members know that finances are finite in the health budget. That being so, we are grateful for the many charities that do such magnificent work, including Cancer Research UK, Macmillan Cancer Support and Marie Curie Cancer Care. However, we must get a handle on our treatment process and outcomes, which can only come through the correct use of funding. I hope that the Minister will tell us how that will happen.

In the NHS document, “Improving outcomes: a strategy for cancer”, published in January 2011, it is clear what the Minister regarded as the way forward:

“In order to achieve these principles we must also ensure that every possible penny of money the NHS has is spent improving the quality of care and outcomes that patients experience. The Government protected the NHS in the Spending Review settlement, with cash funding growth of £10.6 billion (over 10%) by 2014/15. Compared to many other government departments, that puts us in an incredibly privileged position but this is the toughest settlement the NHS has faced in a long time.

At the same time, we need to respond to the longer term pressures the NHS faces; of an ageing population and the new demands created by new treatments and technologies. That means that, as set out in the Spending Review and the 2011/12 Operating Framework, over the next four years the NHS will need to achieve up to £20 billion of efficiency savings. These savings will be reinvested back in continuing to give patients the care that they need.”

Will the Minister say whether we are on target to make those savings? If so, when will that money go back into the system?

The document contains many examples of cost-efficient care, such as people having certain treatments as day procedures and then care at home, which makes a lot of people feel more secure as well as being cost effective. We understand the reasons and the thinking behind that: it is essential that the patient is at the heart of any decision made and any strategy must incorporate this.

I am not an argumentative person—far from it, I try to get on with most people in this world—but the hon. Member for Southport commented on the advertising campaign “Have you had a cough for three weeks or more?” We do not know how successful it was. The campaign has a role to play, and those who have had a cough for more than three weeks might well have a problem. We do not know how many people went to see their doctor and, as a result, have been made aware of problems. That is perhaps a different opinion from that expressed by the hon. Gentleman.

[John Pugh]

I said that all those things need to be reviewed in the light of evidence, that there were good campaigns and bad campaigns, and that evidence decided which category they fell into.

--- Later in debate ---

[The Minister of State, Department of Health (Paul Burstow)]

I congratulate my hon. Friend the Member for Southport (John Pugh) on securing the debate and on setting out—as he always does so admirably—the terrain that he wished us to traverse. Other hon. Members have done just that, and it is helpful to have this opportunity to mention the progress that has been made since the publication of the Government’s cancer outcome strategy in 2011. The annual report that we published last December set out that strategy in greater detail than I fear I will be able to provide in the time available today, and I commend it to Members.

Interestingly, one common theme in this debate has been touched on, quite rightly, by most of those who have contributed. Health inequality has been raised in the context of patient experience surveys—with which the Government will continue—and of age. The Government take health inequality so seriously that we have placed for the first time clear duties on commissioners and other parts of the NHS to act to reduce it, and we will say more about that soon when we publish the draft mandate for the NHS Commissioning Board.

The hon. Member for Leicester West (Liz Kendall) referred to age and the differences in outcomes from cancer services for older people. I approved funding for a joint piece of work by Macmillan Cancer Support and Age UK to explore some of the obstacles and barriers that may prevent people from taking up cancer treatment or accessing it in the first place. We recently visited Barts Health NHS trust, which is taking part in that pilot programme, and we are looking at issues such as comorbidity and services in the community. We will report accordingly and take action to ensure that lessons are learned. The hon. Lady was right to raise the issue, and the Government have decided to implement provisions on age with regard to goods and services in the NHS and social services. On taking office, one of my first responsibilities was to take the necessary decisions to ensure that no part of the NHS would be exempt from those provisions, and key decisions needed to be taken to make it clear that age can be used only on an objective basis in health care and social care decision making.

I will say something about the NHS outcomes framework, and then respond to as many of the points that have been raised as I can in the time remaining. Recognising that many people have more than one medical condition, we have deliberately taken a generic approach to the NHS outcomes framework, rather than focusing on specific diseases. We recognise, however, that cancer is a big killer, and we have said repeatedly that improving health outcomes for cancer patients is a priority for the Government. We have aimed to reflect that in the framework by including seven specific indicators on cancer. Those include the under-75 mortality rate from cancer, and the one and five-year survival rates for the three major cancers, to which other hon. Members have referred: colorectal, breast, and lung. In addition, two overarching indicators include data on cancer: potential years of life lost from causes considered amenable to health care; and life expectancy at 75.

The indicator “under 75 mortality rate from cancer” is shared with the public health outcomes framework. By having that shared indicator, with joint accountability for delivery, Public Health England and the NHS Commissioning Board will have the incentive to work together to improve cancer mortality and survival. That relates to the question about the commissioning of public awareness campaigns. I can confirm to the hon. Member for Leicester West that Public Health England and the NHS Commissioning Board will have a joint responsibility, and a clear obligation, to commission in that regard.

[John Pugh]

On the point about indicators, a clear theme throughout the debate has been late diagnosis. Late diagnosis is not the same as late treatment. With GPs probably under more pressure than ever before not to make unnecessary referrals to secondary health settings of one kind or another, do the Government keep or have they any intention of keeping statistics on whether, where people are diagnosed late, the cause of the late diagnosis was that they presented far too late or that the GP and whoever they saw figured out what was wrong with them far too late?

[Paul Burstow]

I am coming to that. It relates to the point raised by my hon. Friend the Member for Basildon and Billericay (Mr Baron), who chairs the all-party group, about staging data. I will say more about that in a minute.

Outcomes for cancer patients and survivors will also be covered by other areas of the NHS outcomes framework. For example, we will measure patients’ experience of the NHS by looking at different patient surveys. We have been talking about that in this debate.

In addition to the indicators in the outcomes frameworks, the cancer outcomes strategy sets out a commitment to improve cancer survival rates generally and—we have heard the figure—to save an additional 5,000 lives a year by 2014-15. The strategy is supported by more than £750 million of investment for implementation during this spending review period.

Our aspiration is to have cancer survival rates as good as the best in Europe, but we have to stage progress to that goal. Our ambition during this spending review period is to halve the gap between England’s survival rates and those of the best in Europe. The estimate, based on the latest figures available, is that that would save an extra 5,000 lives. To deliver on that ambition, we must tackle survival rates for all cancers. To realise our goal, we are taking action to achieve earlier diagnosis of cancer, to extend existing screening programmes for breast and bowel cancer and to improve access to radiotherapy.

Let me deal specifically with early diagnosis. My hon. Friend the Member for Southport referred to the recent lung cancer awareness campaign—the “coughing” campaign as I think he described it. Obviously that campaign has not just dropped out of thin air into the broadcasts of our media around the country. It is the product of a detailed process of testing, trialling and evaluation. Indeed, the original idea came from a local campaign in Doncaster. Then there was a series of regional pilots to see how it would affect behaviour and what benefits would arise from that. I will be more than happy to send my hon. Friend the details of that and, as we evaluate the national programme, how that is going as well.

Early diagnosis is central to our strategy. It is one of the areas to which our international benchmarking has pointed us. By diagnosing cancer earlier, we will improve patients’ chances of being successfully treated, as other hon. Members have said. Through the national awareness and early diagnosis initiative, we have worked with the NHS and other stakeholders to run a number of campaigns to raise awareness. That is about getting people to talk about things that they would not necessarily normally want to discuss—getting them to overcome embarrassment, because embarrassment never killed anyone, but not turning up at the GP’s and asking key questions about particular cancers certainly does.

The hon. Member for Leicester West asked about support for GPs. A range of support is available to help GPs assess when it is appropriate to refer patients for investigation of suspected cancer. Obviously, there are the National Institute for Health and Clinical Excellence referral guidelines. However, we need to do more and we are investing in better GP access to diagnostic tests. I will say a little more about that in a moment. The national cancer action team, Cancer Research UK and Macmillan Cancer Support are working together to develop a broader GP support programme for the coming years. That includes working with the Royal College of General Practitioners.

The hon. Member for Strangford (Jim Shannon) raised the issue of pancreatic cancer. We are working closely with Pancreatic Cancer UK. In fact, we will be working through many of the issues of early diagnosis in a workshop specifically on pancreatic cancer next week. I will be speaking at that event.

We know from the latest diagnostic waiting times and activity figures that despite increasing demand, the proportion of people waiting more than six weeks for an endoscopy has decreased during 2011-12. I hope that hon. Members will join me in congratulating the NHS on the way in which it went about preparing for and dealing with the increased work load that arose from the bowel cancer symptoms awareness campaign that ran between January and March this year.

The Department is working with partners to support the NHS to improve the management of diagnostic demand. There are a couple of things that we are doing in particular. We are promoting the uptake and spread of efficient and productive service models. Some places have no problem in utilising the capacity that they have. Other trusts have struggled, and we are using NHS Improvement to target the trusts where the highest waits have occurred. We are also providing a variety of tools and information to support commissioners. Data are a key component in driving improvements, and we have a new data set for diagnostics, which is providing a wealth of new information.

In our cancer outcomes strategy, we said that access to appropriate treatment, delivered to a high standard, was critical to improving outcomes. That is why we have made available £150 million more over the spending review period. In April 2012, we confirmed plans to develop proton beam therapy services in Manchester and London by the end of 2017. Those services will have the capacity to treat up to 1,500 people a year. Much has been achieved with regard to access to radiotherapy in recent years. Radiotherapy waiting times are now within the 31-day operational standard for both first definitive and subsequent radiotherapy. Modelling shows that that improvement saves 2,500 lives annually in comparison with waiting times in 2007. Data are playing their part, and there are other issues around that.

I want to touch on investment. In answer to a question last week, I said that the first and foremost responsibility for maintaining equipment and identifying when it needs to be replaced does, of course, sit with the provider that uses that equipment. However, in March 2012, we announced the establishment of a £300 million fund, to be operated by NHS Supply Chain, to bulk-purchase medical equipment to achieve better prices for the NHS and to encourage trusts to keep their equipment up to date. It is therefore a combination of responsibilities, but we certainly see the foremost responsibility sitting clearly with providers in that regard.

About 1.8 million people living in England have had a diagnosis of cancer, and the number is growing. We know that we can do more to improve their quality of life, which is why we have been working in partnership with Macmillan Cancer Support on the national cancer survivorship initiative. The use of patient surveys has been a key aspect of that. We will publish a full analysis of the detailed work that we have undertaken jointly this autumn.

We have committed to the next cancer patient experience survey in 2012. We find those data invaluable. The shock to the system when a provider finds itself at the bottom of the tables is very powerful indeed and is leading to significant improvements.

The hon. Member for Ealing, Southall (Mr Sharma) talked about the limited scope of existing indicators. I can tell him and other hon. Members that we are considering how we can make progress on bringing a number of indicators together. My officials are working with the information centre to consider the resource implications of substituting existing indicators and whether it would be appropriate for a composite indicator to replace some of the individual survival rate indicators. Ensuring that we cover more cancers was a concern that several hon. Members raised in the debate.

On funding cancer networks, my right hon. Friend the Secretary of State has made the position clear. We have provided funding for the remaining year for which the Department is responsible. Indicative figures have been set out. A review is going on of clinical networks and how they are governed. That will ultimately determine precisely how much resource is allocated. There is no final figure at this stage.

Regretfully, I shall conclude now, as I am about to run out of time. There is much going on in respect of cancer. I will write to the hon. Members who took part in the debate so that they can see what I would have said if I had more time. However, the cancer outcomes strategy remains the guiding light for the Government to deliver the world-class cancer care that people deserve in this country.

Mental Health

John Pugh Excerpts

Thursday 14th June 2012 Commons Chamber

[Nicky Morgan]

I entirely agree with the hon. Gentleman. The Centre for Mental Health has shown that for a person who has a physical and a mental health condition, the costs of treatment are increased by 45%. Those are additional costs around mental health problems, which are often untreated initially and then have to be treated at a later stage, so the hon. Gentleman is absolutely right.

According to the Centre for Mental Health, only a quarter of people with mental health conditions—children as well as adults—receive any treatment. I have no reason to doubt that statistic, and I find it shocking that three quarters of people with mental health conditions are not being treated. We should ask ourselves why that is.

Recent figures have shown that depression alone is costing the economy £10 billion a year. As we all know, we do not have a lot of money to spend, so we should be working as hard as we can on preventive measures. One in every eight pounds spent on dealing with long-term conditions is linked to poor mental health, which equates to between £8 billion and £13 billion of NHS spending each year.

I welcome the Health and Social Care Act 2012. I hope that today’s debate will be conducted on pretty non-partisan terms, but I realise that that may strike Opposition Members as a controversial comment. I welcome the opportunities that the Act offers for the commissioning of mental health services. I spoke in the Third Reading debate, and I especially welcomed the Government’s acceptance of an amendment tabled in the other place to ensure parity between physical and mental health. Although those are only words in a Bill, they are very important words, and they send a very clear signal not only to sufferers from mental health conditions and their families, but to those working in the NHS. I hope that, in his annual mandate to the national commissioning board, the Secretary of State will insist that the board prioritise mental health.

How are we to achieve parity between physical and mental health conditions? The question is about money, certainly, but it is also about awareness. Confessing to having a mental health condition carries far too much stigma. That is part of the reason for our wish to hold a debate on the Floor of the House. If we do not start to talk about mental health in this place, and encourage others to talk about it, how can we expect to de-stigmatise mental health conditions and enable people to confront their problems?

I find it interesting that, when I was preparing for the debate, a few people who had initially said to me “Yes, go ahead, mention my name” came back after thinking about it for a couple of days and said “Actually, I would rather you didn’t, because I have not told my employer,” or “I have not told all my friends and my family.” It is clear that mental health conditions still carry a considerable stigma. Admitting to having been sectioned is traumatic, especially when the information appears on Criminal Records Bureau checks connected with job applications.

I welcome the work of Time to Change, which has been funded partly by the Department of Health as well as by Comic Relief. I also welcome the Sunday Express campaign on mental health. However, the de-stigmatisation of mental health conditions is down to all of us, and it is especially important for those of us who are employers not to discriminate against people who may be working for us and who tell us that they have a mental health condition. I hope that today’s debate will constitute another firm step on the path to ensuring that mental health conditions are de-stigmatised, because I think that without that de-stigmatisation, successful treatment will be very hard for a person to achieve.

We asked for today’s debate to be kept deliberately general, so that Members in all parts of the House could raise many different issues on behalf of their constituents and, perhaps, themselves or their families as well as looking at the mental health policy landscape. Mental ill health is no respecter of age or background. It can strike anyone, often very unexpectedly. That includes people in senior positions such as Members of Parliament, company directors and school governors. I am sure that my hon. Friend the Member for Croydon Central (Gavin Barwell) will refer to the private Member’s Bill that he will be presenting, which would end discrimination against people in such positions who have mental health conditions.

I expect that during today’s debate we shall hear about new mums with post-natal depression. For them, a time of life that should be one of the happiest is often one of the most difficult. I welcome the recent Government announcement that health visitors will be properly trained to recognise signs of post-natal depression, which I think was long overdue. I expect that we shall also hear about veterans from our armed forces who suffer from mental health conditions, and about older people who suffer from dementia. Particular issues affect our black and ethnic minority communities, as well as those who find themselves in the criminal justice system. I am sure that we shall hear from the Minister abut the Government’s widely welcomed framework document “No health without mental health”, which was published last year. We now await the detailed implementation plan on which the Department of Health is working alongside leading mental health charities.

I want to talk, very briefly—I have noted Mr Speaker’s strictures about time limits—about three specific matters: listening to patients, integrated care, and the wider mental health well-being landscape. We made it clear during the passage of the Health and Social Care Act that one of the developments that we wanted to see, as a Government, was “No decision about me without me.” That means patients having a voice in their care. It seems to me from my discussions with those in the mental health system who have been sufferers that once the initial crisis has been dealt with, they tend to want choice and involvement in their treatment. They are facing a lifetime condition. They will have to self-medicate, look after themselves and identify the point at which they may be deteriorating or potentially reaching crisis point for years and years to come. They want a voice. They want to be heard by the health care professionals, and I think that it is up to us as a Government to help them to achieve that.

[John Pugh (Southport) (LD)]

The hon. Lady has just said that people who suffer from mental health problems have a lifelong condition. I think that many people have an occasional mental health problem.

[Nicky Morgan]

I am not sure that I entirely agree with the hon. Gentleman. I agree with him that people often enter the system at a time of crisis and experience a single episode, but others who experience episodes will get better. For years they may have no problems at all. The hon. Gentleman shakes his head, but I can tell him on the basis of the experience of constituents and family members that it is possible to go in and out of the system. One of the hardest things for people to accept when they are diagnosed with a mental health condition is that they will be on drugs for years and years. That is often difficult for people to admit, particularly when they are striking up a new relationship or working for a new employer. I think that that is why people want to have a voice in the way in which they are treated.

According to Mind, people are three times as likely to be satisfied with their treatment if they are presented with a choice of treatments, and failure to stay on medication is the main cause of relapses, when people often have to re-enter the system at a time of crisis. There is a need to work with and trust health professionals. According to a recent study by the university of Kent,

“Low levels of trust between mental health patients and professionals can lead to poor communication which generates negative outcomes for patients, including a further undermining of trust”,

and

“trust can play a significant role in facilitating service users’ initial and ongoing engagement with services, the openness of their communication, and the level of co-operation with, and outcomes from, treatment or medication.”

In 2009, a mental heath in-patient survey by the Care Quality Commission revealed that in some mental health trusts as few as 40% of people diagnosed with schizophrenia felt that they were involved as much as they wanted to be in decisions about their care and treatment. I am no health professional—I hope that some Members who are health professionals will speak later this afternoon—but what people have said to me suggests that medication is not always the answer, at least in the long term. Research by Platform 51 has found that a quarter of women have been on anti-depressants for 10 years or more, that half of women on anti-depressants were not offered alternatives at the time of prescription, and that a quarter of women on antidepressants have waited a year or more for a review of their medication

I welcome the Government’s investment of £400 million in treatments under the improving access to psychological therapies programme. I should add, to be fair, that that builds on announcements made by the last Government. I also commend the report by the Centre for Social Justice on talking therapies, which calls for a broadening of therapies. Every patient is different, and patients will respond differently to different medications and therapies. Mental health patients must have real choice, and I think that Any Qualified Provider and Payment by Results must be extended to them in the way in which they are being extended to patients with physical health conditions. We must also ensure that patients’ voices are heard within the management structures of both clinical commissioning groups and health and wellbeing boards, whose job it is to hold services to account for the care that they are giving.

I expect that Members will refer to integrated care: the need for all services to work together. Poor mental health has an impact on every area of Government policy: health care, benefits, housing and debt, social exclusion, business and employment, criminal justice and education, to name but a few. One person with a mental health condition may need help from many different agencies, but too often care is not joined up, and each agency deals with its own bit and passes the person on. Sometimes there is no follow-up, and the person is lost in the system.

In a 2011 survey, 45% of people contacted by Mind said that they had been given eight or more assessments by different agencies in a single year. YoungMinds, which campaigns on behalf of children and young people with mental health conditions, has called for one worker to be allotted to each child needing support for a mental health condition, so that children can avoid multiple assessments and need not re-tell their story each time they see a new person in the system. However, there must be a clear care pathway, whatever the point at which access is gained to the mental health system.

The other thing patients are calling for is the ability to self-refer. We need to do all we can to prevent people from reaching crisis point, and often it is patients themselves who are best able to tell when they are about to reach that point. My West Leicestershire clinical commissioning group is developing an acute care pathway in partnership with Leicestershire Partnership NHS Trust. It plans to replace the many and varied access routes to secondary care and mental health services with a single access point, in order to provide speedy access at times of greatest need. That move has come out of both patient and GP feedback.

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[Andy Burnham (Leigh) (Lab)]

I begin by giving my apologies to the hon. Member for Loughborough (Nicky Morgan) for missing the beginning of her speech, and by congratulating the Minister on his excellent and thoughtful speech, to which I can hopefully add something.

I have high hopes for the debate. I hope it will help us to confront a major paradox: how can a subject that is so central to the big public policy challenges we face as a country—the challenges are not just of public health provision, but of worklessness, benefits, the criminal justice system and addiction—still exist on the fringes of our national debate, getting so little airtime and attention? As other hon. Members have acknowledged, the House, sadly, rarely applies itself to mental health. Perhaps that reflects our national stiff-upper-lip tendency not to talk openly about mental health, which in turn might help to explain why our public services are designed for the 20th century rather than the 21st.

[John Pugh]

The right hon. Gentleman seems to be forgetting that we had appreciable mental health legislation in the last Parliament—the Mental Health Act 2007.

[Andy Burnham]

I am proud of the improvements we made in the last Parliament, but I did not come here today to say that everything the previous Government did was right and wonderful. I will talk a little about those improvements, but given my failure to sing about Labour achievements, I am grateful to the hon. Gentleman for doing so.

We are reticent to talk about mental health as much as we should. There is a complacency in the public debate—that is not to make a political point, because it involves hon. Members on both sides of the House. The complacency goes throughout the civil service and the Government. To reflect on my time in government—not just in the Department of Health, but in the Treasury and the Home Office—it is remarkable how few submissions or meetings I had relating to mental health, given that it underlies the spending of hundreds of millions of pounds of public money. Indeed, £105 billion is the estimated cost of the full burden of mental health to this country.

That complacency is not shared by everybody and I congratulate the hon. Lady on introducing this debate. We have heard two unbelievably powerful speeches, from my hon. Friend the Member for North Durham (Mr Jones) and the hon. Member for Broxbourne (Mr Walker), to which I will turn at the end of my remarks. My hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott), who leads on these matters for the shadow health team, has rightly pointed out how mental health lies under the whole public health challenge. We will soon introduce Labour’s public health review.

We are beginning to wake up from our complacency. I am leading the debate for the Opposition to show that that comes from the top. We see the mental health challenge as central to health policy. Indeed, I made a point of making my first speech on returning as shadow Health Secretary on the subject of rethinking mental health in the 21st century at the Centre for Social Justice.

I must be honest: I shared the complacency about the mental health debate, or perhaps did not give it enough attention, but two things changed that when I was a Health Minister. First, I spent a day work-shadowing an assertive outreach team in Easington. I will never forget what one of the team told me about the early ’90s, when the mines closed and GP referrals for support were piling up on clinic desks, but there simply was no support to offer people. She said that that lay behind the social collapse in those mining communities. People facing difficult times were given no help.

A second thing made me think differently. When I became Health Secretary in June 2009, I inherited Lord Bradley’s report into mental health problems and learning disabilities in the criminal justice system. I will never forget sitting in my office at Richmond house reading that about 70% of young people in the criminal justice system have an undiagnosed or untreated mental health problem. If that is not truly shocking to every Member and does not make us do something, frankly nothing will. That was the moment that changed how I thought, and I have tried to follow it through ever since.

I mentioned that we had a public service designed for the 20th century, rather than the 21st century, and I want to illustrate that point with reference to my own constituency. The world that gave birth to the NHS was a very different place. When the NHS was set up, Leigh, like Easington, was a physically dangerous place to live and work in. Working underground exposed people to coal dust, explosions and accidents, and people had no choice but to lock arms, look out for each other and face the dangers together—that is how it was—and that spirit of solidarity was carried over into the streets above.

Like many places in this country, then, Leigh in the ’50s was a physically dangerous place but emotionally secure, because people pulled together. In the 21st century, however, that has completely reversed. We now live in a physically safe society—our work does not generally expose us to dangers—but it is emotionally far less secure than it was for most of the last century. The 21st century has changed the modern condition. We are all living longer, more stressful and isolated lives, and have to learn to cope with huge and constant change. Twentieth-century living demands levels of emotional and mental resilience that our parents and grandparents never needed, yet the NHS does not reflect that new reality; essentially, it remains a post-war production-line model focused on episodic physical care—the stroke, the hip replacement, the cataract—rather than the whole person. That is the issue to confront.

The demands of this society and the ageing society require a change in how we provide health and social care. We need a whole-person approach that combines not only the physical but the mental and social, if we are to give people the quality of life that we desire for our own families. That one in four people will experience a serious mental health problem makes this an issue for all families and people in the country. It also means that mental health must move from the margins to the centre of the NHS.

I shall say a couple of things about that necessary culture change. How can it be that an issue that causes so much suffering and costs our society so much still accounts for only a fraction of the NHS budget? It cannot be right. We also have to consider the separateness of mental health within the NHS. This has deep social roots—the asylum, the separate place where people with mental health problems were treated, the accompanying stigma and suspicion about what went on behind those four walls. Essentially, we still have the same system in the NHS, with separate organisations—mental health trusts—providing services on separate premises. That maintains the sense of a divide between the two systems and raises a huge health inequalities issue.

The wonderful briefing that Mind, Rethink and others have prepared for this debate contains this startling statistic: on average, people with severe mental health problems die 20 years earlier than those without. What an unbelievable statistic! Why is that? It is partly—not completely—explained by the separateness within our system. If someone is labelled a mental health patient, they are treated in the mental health system, and consequently their physical health needs are neglected.

--- Later in debate ---

[John Pugh (Southport) (LD)]

Let me begin by commending those who have spoken about their own problems today. I assure them that they have done their prospects no harm whatsoever. They have risen appreciably in the esteem of the House, although whether that is the key to promotion I do not know.

[Mr Kevan Jones]

I am grateful to the hon. Gentleman, but the use of language is very important when it comes to mental health. I do not consider it to be a problem. My own experience has made me stronger. I think we should be careful about how we use language: we should not describe mental health as a problem, because it is not.

[John Pugh]

I think that the expression used nowadays is “issue”.

[Sir Peter Bottomley]

The hon. Gentleman and I would probably agree that it is an experience.

[John Pugh]

We will settle for “experience”, then.

I congratulate the hon. Member for Loughborough (Nicky Morgan) on introducing the debate, although she omitted to mention the Mental Health Act 2007, over which the House laboured long and hard to, I hope, some good effect.

In the 18th century, it was possible to cross the river to Bedlam and gawp at people gesticulating, ranting, performing odd rituals, talking to no one in particular, exhibiting delusory beliefs in their own power, or expressing paranoid fears about their foes. The nearest 21st-century equivalent is probably Prime Minister’s Question Time. [Laughter.] That is not an entirely facetious point. The dividing line between robust mental health and mental illness is, in fact, a fine one. Statistics show that the bulk of people of working age who either report or are diagnosed with mental health problems are not, in general, those who suffer from the terrible scourge of schizophrenia. The hallucinations and delusions often associated with that disease currently affect less than 1% of the population, and are treated more benignly and more effectively than ever before. Moreover, numbers are not substantially on the increase.

Most mental health problems occur when the anxieties, the fears, the stresses and the dark moods to which we are all prone become insupportable, prolonged and disabling, and the individual is no longer able to cope in any ordinary sense but breaks down and loses control, social capacity and, sometimes, insight into his or her condition. That is on the increase: it is the major mental health challenge that we face.

Mental health is a genuine continuum. The mentally ill do not have viruses, germs, cellular patterns or physical impairments that the well do not have. They have the same gamut of emotions that we all have—often exaggerated, accentuated or uncontrollable, but in no way unique or uncommon. We all possess a shared vulnerability to mental health issues which could be described as a tendency to neurosis, managed with differing degrees of success at different times in our lives. That is why I took issue with some of the comments made by the hon. Member for Loughborough.

There is a nugget of truth in the American belief that we could all benefit from an element of psychiatry. As I have said, we share a common vulnerability, and for a variety of reasons—fairly complex in many cases—one in four, or one in six, citizens falls victim to that vulnerability. We have learned not to be too judgmental about those who do, and not to stigmatise them. We recognise that the vulnerability they display is often a product of circumstance, and that it is as frequently related to desirable traits—empathy and sensitivity, for instance—as to undesirable ones such as self-obsession or lack of self-control. However, although that recognition is now widespread, it does not eradicate stigma, nor does calling everybody “service users” as if they are some kind of consumer, and nor does saying mental illness is just the same as physical illness, because it is not.

The big problem for those with a record of mental health issues—particularly, perhaps, in respect of the workplace or getting off benefits and back into the workplace—is the bias of the wider world in favour of those who have not illustrated our common vulnerability. That bias is rather like having a—rational—preference for people with a stronger immune system. There are other vitiating factors at play, of course. People who suffer from mental illness often suffer from a lack of confidence, for example. There is also the fact, which has not so far been acknowledged, that a mental health diagnosis can sometimes be misused for employment and benefit reasons. The big problem is this bias and discrimination, however.

There are only two real remedies for that. One is better public education about what mental health actually is and what mental illness and frailty actually are. I would put more faith in the second remedy, however: having a public mental health campaign that is geared in positive directions, as described by the hon. Member for Loughborough. Having said that, we must acknowledge that the active pursuit of mental well-being is a bigger and more significant task than we currently recognise. Corporate Britain, business Britain and every public service in Britain needs to be seriously engaged with the Layard agenda and to accept that we need to promote well-being at work—including here in Parliament. We must create a wholesome workplace, and therefore bother about the happiness of the workplace and the individuals in it.

We may need to tackle a huge fallacy, however: the idea that we either have mental health or we do not, so we are either employable or we are not. That ignores the fact that many people in employment—in senior jobs, even—have mental health issues, some of which might not always be diagnosed. Sometimes they work them out in the office and the workplace in a wholly unsatisfactory way, and sometimes to the detriment of their colleagues—although not always, in certain professions, to the detriment of customers and profits. Sometimes people mask their symptoms and problems through alcoholic self-medication.

There was a time when employers would have walked away from considering issues such as personal safety at work, and there was a time when they would have walked away from issues of employment legislation and the rights of people at work. Nowadays, however, most employers are keen to stick “Investors in People” logos on their notepaper to show that they are a good employer in that respect. The next, and most obvious, stage is the pursuit of the wholesome workplace, in a move beyond the “Investors in People” initiative. That must be encouraged by public health bodies and by large public and corporate organisations. Indeed, to some extent it already is encouraged: 41% of large companies now have a mental health policy. That represents appreciable progress.

For most of us, work is where we spend most of our time, and it is where our feelings of self-worth are either confirmed or demolished—that is certainly true of this place. It is where people find meaning to their lives—although we do not always succeed in doing that here. Indeed, we in Parliament cannot honestly say our working environment is wholly conducive to good mental health.

Let me conclude by reiterating my key point: we cannot help people with mental health issues without making it manifestly clear that in everyday work and everyday life mental health is everybody’s issue.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 12th June 2012 Commons Chamber

[Mr Lansley]

Yes, I do—in the same way as, for example, we are not including doctors and dentists in the same market-facing proposals. The reason why is that they do not work in what are essentially local labour markets; rather, they work in national labour markets.

[John Pugh (Southport) (LD)]

The most recent available statistics show that 50% of public sector jobs outside London were vacant for more than eight weeks, compared with 13% in the private sector. How will lower regional pay improve that situation?

[Mr Lansley]

I simply reiterate to my hon. Friend the point that I have already made. We are not proposing to cut anybody’s pay; we are proposing to give NHS organisations a greater mechanism through the “Agenda for Change” framework so that they can secure the recruitment and retention of staff. That is precisely the issue. Whatever their needs may be in terms of the recruitment and retention of staff, their pay should be better able to adjust to that.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 27th March 2012 Commons Chamber

[Mr Lansley]

We have made it very clear that GPs should not be using 0844 numbers for that purpose and charging patients for them. One of the benefits of NHS 111 is that it will be a free service for patients, and will give them an opportunity to gain access to integrated urgent care wherever they are in the country. That is why we want to roll it out as soon as we can.

[John Pugh (Southport) (LD)]

Given the importance of 111 contracts, should we not delay assigning them until the clinical commissioning groups are properly in place?

[Mr Lansley]

My hon. Friend will recall from my first answer that I am looking to discuss the timing of the roll-out with clinical commissioning groups. I do not want that to be unduly delayed, because there are clear benefits to patients in the 111 system in that it gives them a more integrated single point of access to the NHS.

Health and Social Care Bill

John Pugh Excerpts

Tuesday 20th March 2012 Commons Chamber

[Tony Baldry (Banbury) (Con)]

I start by apologising to the House for making what I suspect may sound like a slightly portentous speech. It is not meant to sound portentous, but if it does I apologise.

Because of the effluxion of time, there are not many former Ministers on the Government Benches are, but there is, irrespective of the topic, an important point that needs to be made in the context of today’s debate. I urge every right hon. and hon. Member, before they vote at the end of this debate, to get a copy of House of Lords Hansard for yesterday’s debate, where this matter was debated. There are, in that Lords Hansard, two speeches that hon. Members would do well to read: those of Lord Wilson of Dinton and Lord Armstrong of Ilminster, both former heads of the civil service.

Lord Wilson was head of the civil service during the time of a Labour Government, and both he and Lord Armstrong made it very clear in their speeches yesterday that to release the risk register would be extremely bad news for the relationship between the civil service and Ministers generally. Irrespective of this issue, irrespective of the topic, if risk registers were to be released, officials would needlessly be politicised and thus be concerned about the advice that they gave to Ministers. Ministers would then find themselves being given verbal advice, fewer people would be involved and that would not help the machinery of government.

[John Pugh (Southport) (LD)]

Will the hon. Gentleman give way?

[Tony Baldry]

May I just make some progress?

--- Later in debate ---

[Tony Baldry]

I understand that point, but they are very different registers. The register to which the right hon. Lady refers is meant to be publicised. The two are of an entirely different nature, and that point has been explained to the House by my right hon. and hon. Friends on the Treasury Bench on a number of occasions.

We are discussing departmental risk registers and the advice that civil servants give to Ministers. All I am saying is that right hon. and hon. colleagues, before they vote, should at least take care to consider the advice of former heads of the civil service on the effect that publication would have on the relationship between civil servants and Ministers.

[John Pugh]

If what the hon. Gentleman says is true, why has the Cabinet Office released the register on civil emergencies and put it on the internet?

--- Later in debate ---

[John Pugh (Southport) (LD)]

It is a sure sign of a deranged mind when one starts to repeat oneself. I have said previously that the Bill is a huge mistake, that not releasing the risk register merely creates further alarm, and that abandoning the Bill could be the safer option. I have also said that the Secretary of State’s intentions are noble and that the Opposition’s objections are—in part, at any rate—considered and compelling. However, I have clearly failed to persuade many of my parliamentary colleagues to share that point of view, as last night’s voting showed.

[Karl Turner]

I am grateful to the hon. Gentleman for giving way. He says that he has been opposed to the Bill from the outset. As he knows, I served on the Public Bill Committee with him. Why did he not vote against it? He had ample opportunity to make the Government drop the Bill.

[John Pugh]

If the hon. Gentleman checks Hansard carefully, he will find that there were occasions when I did. We must all agree, whether sadly or happily, that the vote in the Lords last night was conclusive, even if some, like Baroness Williams, were voting for legislation that they said they did not particularly like. That is in part because of the modifying genius—I put it as strongly as that—of Earl Howe.

There are risks attached to the legislation. The risks that I face are small in comparison with those faced by the Secretary of State. I risk being found out for having fears that are misplaced. I risk having my forebodings exposed. He risks a great deal more than that. The House does not need a risk register to find out what those risks are. If he proceeds rapidly at a time of huge upheaval in the NHS, he will actually promote that upheaval. If he goes ahead, he will be doing so at a time of austerity, in the teeth of wholesale professional opposition and in a climate of genuine legal uncertainty, with legislation that has, in part, been cobbled together. We will soon find out what has been scaremongering and what is plain scary. Crucial to mitigating the risks will be the pace and the extent of enactment and implementation. There will be a mopping-up phase. It will be crucial for the Government to woo back professional opinion. The risk register would have told us, to some extent, how easy or difficult that will be.

Already we hear that the Government are struggling with the central plank of the legislation: GP commissioning. We wait with interest to see the regulations on that. It is hard to see how GPs can commission basic out-of-hospital services in primary care, which is a central thrust of the Government’s legislation, and not be seen, as small businesses or associations of undertakings, to be benefiting themselves with public money. In the legislation, we have made the biggest provider the biggest commissioner as well. GPs will have no problem commissioning hospital services without any legal obstacle, but they will lack the expertise to do so. That is what primary care trusts found when they did the commissioning. The risk is that we will end up with GPs not being able to commission what they do understand, and being asked to commission what they do not understand. We therefore await the regulations with considerable interest.

I suggest that although Cabinet members have been banging the table today, they may well be banging their heads against the wall in the years to come.

--- Later in debate ---

[Dr Wollaston]

The equivalent of that is actually the impact assessment. However, as I have said, I would be prepared to allow the publication of the register, because, in this internet age, the misrepresentation of the Bill, and the extrapolation out of all proportion to the risks, has been a complete disgrace.

[John Pugh]

Does the hon. Lady recall saying that the absence of an intermediary body between small GP commissioning and the National Commissioning Board was a serious flaw in the Bill? Clearly that flaw is still there.

[Dr Wollaston]

I believe that by the time of the next election, our patients will still be going to see GPs. They will still be referred to the hospitals of their choice, that referral will still be free at the point of use, and it will still be based on their needs and not on their ability to pay. The only thing that will be missing will be an apology from the Labour party.

Health and Social Care Bill

John Pugh Excerpts

Tuesday 20th March 2012 Commons Chamber

[Nicky Morgan (Loughborough) (Con)]

I will speak very briefly. Let me begin by pointing out to the hon. Member for Leicester West (Liz Kendall), who said that we did not have enough time to consider all the amendments, that if we had not spent an hour and a half discussing the risk register yet again, we would have had more time to discuss the amendments.

I congratulate the Government on accepting Lords amendment 1, which relates to parity of esteem between physical and mental health. As the Minister said, genuine parity cannot be laid down in legislation, and the mental health framework will be very important to the achievement of it. However, research findings published by the Centre for Mental Health, which I mentioned to the Minister during health questions recently, show the link between physical and mental health conditions. As I am sure we all know from our constituency casework, when someone presents with a physical health condition, it may be clear that there is an underlying mental health condition which has been either undiagnosed or untreated, and which is therefore hampering the person’s physical health recovery.

The Minister spoke of the “symbolic significance” of including a reference to mental health. He is right, but I think that on a day when we have seen Her Majesty the Queen address Parliament, we should recognise that there is sometimes a place for symbolism, particularly when it comes to something that is as cherished on the Government Benches as the NHS. I know that the Opposition claim ownership of the NHS, but in fact it is cherished by all of us, and by our constituents.

I also thank the Government for accepting Lords amendments 19, 32 and 33, which concern the duty of commissioners and commissioning groups to provide patient-focused care—the “No decision about me without me” duty. My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) rightly spoke of the importance of mental health care in that regard. I have certainly found, when listening to patients in the mental health system, that they want their doctors, consultants and everyone else in the system to ensure that they are involved in their own care. I am glad that the clinical commissioning groups will be given guidance on that, but I do not expect the very best CCGs and GPs to need to follow it. They are likely to know that treatment is more likely to succeed if patients are involved in it.

Having spent 10 weeks on the Public Bill Committee, and having been present during all the debates on the Floor of the House, I am especially pleased to be able to welcome the amendments.

[John Pugh (Southport) (LD)]

Let me begin by paying tribute to my colleagues in the House of Lords, who have improved the Bill significantly.

I want to raise two issues relating to conflicts of interest. Subsection (1) of the new section proposed in the amendment tabled by Baroness Barker states:

“Each clinical commissioning group must maintain one or more registers of the interests of—

(a) the members of the group,

(b) the members of its governing body,

(c) the members of its committees or sub-committees or of committees or sub-committees of its governing body, and

(d) its employees.”

I looked in vain for a paragraph (e) specifying “parties with which it is contracted for commissioning support”. I think that that is a live issue. There will be commissioning support organisations—some of which will be private institutions, and some of which will be allied with organisations that provide the clinical services that are commissioned—and there may be occasions when those advising the commissioners make recommendations that benefit some parties with which they are contracted. That model, involving the influence of the executive, will be fairly familiar to those who have been members of local authorities. Councillors, like doctors, are often very busy. They rely heavily on expert advice provided by officers, and they generally follow it.

The issue was raised in the House of Lords—I believe that it was raised by Lady Barker—but, when I read the report of that debate, I could not help feeling that it had been glossed over. I should welcome any enlightenment from the Minister on how such a quandary can be dealt with. Clearly it must be dealt with, because otherwise it will create general anxiety about how commissioning will proceed.

The second issue is a bigger one. I think that it is of particular interest to us all, because it affects the general position of the commissioning consortia themselves. There is a view that PCTs are more or less in the same legal boat as GP or clinical commissioning consortia would be. I disagree with what the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) said about that. The PCT, as a unit, is not built around general practices, which, as we have said several times in this place, are small businesses. It is possible to view a clinical commissioning consortium as an association of undertakings, which creates serious issues as to how it is able to use public money. If it used public money to benefit itself, that would obviously become a big issue immediately.

[Mr Simon Burns]

No.

[John Pugh]

The Minister says “No”, but I tabled a question recently in which I asked him whether he had taken advice from the European Commission. He told me that he had not. [Interruption.] We are talking about European law—

[Madam Deputy Speaker (Dawn Primarolo)]

Order. This is not just a conversation between the Government Front Bench and its supporters and the hon. Gentleman. If Members want to intervene to disagree with the hon. Gentleman, they should do so, rather than shouting at him while he is speaking.

[John Pugh]

The Minister could undoubtedly answer my query and deal with my anxiety. A significant regulatory issue is involved in the provision of regulations that will work for commissioners in the Department of Health, and he knows that that is the case. It is not a question of what we intend to do; it is a question of what those in the European legal system will make of the function and the nature of what we have set up. If they interpret it as an association of undertakings, that is exactly how they will treat it, regardless of what the Bill says or of what the Minister says at the Dispatch Box. This is a matter of concern that has been raised by people who are more knowledgeable about such matters than I am, and it genuinely needs to be addressed.

Lords amendment agreed to.

Lords amendments 2 to 10 and 13 to 30 agreed to, with Commons financial privileges waived in respect of Lords amendments 7 and 21.

Amendment (a) proposed to Lords amendment 3(1)—(Andy Burnham).

Question put, That the amendment be made.

Health and Social Care Bill

John Pugh Excerpts

Tuesday 13th March 2012 Commons Chamber

[Mr Lansley]

There is absolutely nothing in the Bill that promotes or permits the transfer of NHS activities to the private sector. Of course, NHS trusts are technically able to do any amount of private activity at the moment, with no constraint. The Bill will make absolutely clear the safeguard that foundation trusts’ governors must consent if trusts are to increase their private income by more than 5% in the course of one year, and that they must always demonstrate in their annual plan and their annual reporting how that private activity supports their principal legal purpose, which is to provide services to NHS patients.

Labour sought to oppose the Bill in another place, but its motion was defeated by 134 votes. We have reached a stage at which the Labour party, and the right hon. Member for Leigh in particular, having embraced opposition —for which they are well suited—now oppose everything. They even oppose the policies on which Labour stood at the election. Labour’s manifesto stated that

“to safeguard the NHS in tougher fiscal times, we need sustained reform.”

The trade unions have got hold of the Labour party in opposition, and it is now against reform. Its manifesto also stated that

“we will deliver up to £20bn of efficiencies in the frontline NHS, ensuring that every pound is reinvested in frontline care”.

I remind Labour Members, who are all wandering around their constituencies telling the public that there are to be £20 billion of cuts to the NHS, that that £20 billion was in their manifesto. Now they are talking about it as if it were cuts; it is not. We are the ones who are doing it, and they are the ones who are now opposing it. They scare people by talking of cuts—[Interruption.] They do not like to hear this. Actually, this year, the NHS has an increased budget of £3 billion compared with last year, and in the financial year starting this April there will be another increase of £3 billion compared with this year. The Labour manifesto also stated:

“Foundation Trusts will be given the freedom to expand their provision into primary and community care, and to increase their private services”.

[John Pugh (Southport) (LD)]

The right hon. Gentleman has just mentioned reform. In 2009, he said in this place:

“Organisational upheaval and reform do not seem to correlate well.”—[Official Report, 19 November 2009; Vol. 501, c. 225.]

What did he mean by that?

[Mr Lansley]

We know that it is necessary for us to reform in order to deliver the improvements that the NHS needs, as well as the sustainability that it needs. We are not even speculating about this; we can demonstrate that it is happening. This is in contrast to what the right hon. Member for Leigh said. He said that he was not scaremongering, then he got up and did just that. He scaremongered all over again. He went to a completely different set of data on the four-hour A and E provision, for example. He went to the faulty monitoring data, which are completely different from the ones that we have always used in the past—namely, the hospital episodes statistics data, which demonstrate that we are continuing to meet the 95% target.

When we look across the range of NHS performance measures, we can see that we have improved performance while maintaining financial control. The monitoring data from the NHS make that absolutely clear, and that is in contrast to what happened when the right hon. Gentleman was a Minister in the Department, when Labour increased the NHS budget and lost financial control. That happened when the hon. Member for Leicester West (Liz Kendall) was a special adviser in the Department. Now, we have financial control across the NHS and we have the NHS in financial surplus.

Let me return to the Labour manifesto—[Interruption.] Labour Members do not like to hear this. It stated:

“Patients requiring elective care will have the right, in law, to choose from any provider who meets NHS standards of quality at NHS costs.”

Yes—choice and any qualified provider are in the Labour manifesto. We are doing what Labour said should be done in its manifesto—and it is now opposing it.

Let us find out what it is that the right hon. Member for Leigh opposes in the Bill. I did not find that out in his speech; I heard generalised distortions, but I genuinely want to know. Let us take some examples. Is it the Secretary of State’s duty in clause 1 to promote a comprehensive health service free of charge, as now? No, he cannot possibly be against that. Is it that the Bill incorporates for the first time a duty on the Secretary of State to act to secure continuous improvement in quality—not just access to an NHS service, but putting quality at the heart of the NHS? Is he against that? No, surely not. Anyway, that approach began with Ara Darzi, and we have strengthened it.

--- Later in debate ---

[John Pugh (Southport) (LD)]

I was cut off when I previously spoke on the subject. Perhaps that was welcome, because I was quoting a strangely prophetic entry in Chris Mullin’s diary. It was a conversation with a Labour Member, whom he describes as a “mild-mannered” Yorkshireman—surely an oxymoron—who said in 2005:

“I think we will lose the next election. The Tories will come to some sort of understanding with the Lib Dems and we’ll find we’ve opened the door to the market in health and in education. And when we protest they will reply, ‘But this is your policy; you started it.’”

That is the story of our debate.

Critics of the Bill often fail to realise how far Labour had exposed the NHS to all sorts of market forces such as EU competition law, encouraged and subsidised the private sector, and imposed “any willing provider” in all sorts of places where it might not have been appropriate. Essentially, Labour set up the building blocks for a market system.

The Bill continues that process. To put it bluntly, no one in this House regards the Bill as anything but risky. Even the Whips, who are normally the most cheerful about legislation, can barely summon a smile when dragooning Members into voting for it. Why? There is a simple explanation. It is the combination of the biggest ever organisational upheaval and the biggest ever financial pressure: the £20 billion Nicholson challenge.

The Bill is also considered risky because the confidence of staff and the public is low, concern is justifiably high, and, to quote Donald Rumsfeld, there are too many “known unknowns”—about the interaction with EU law, how GPs can commission themselves legally, and what the law actually means. Nigel Crisp, the former chief executive of the NHS, recently described the Bill as “confused and confusing”.

There is also a lack of trust. To some, the thrust of the Bill seems essentially unchanged. As the Secretary of State warned us in 2009—I repeat his words in case people missed them in the earlier intervention:

“Organisational upheaval and reform do not seem to correlate well.”—[Official Report, 19 November 2009; Vol. 501, c. 225.]

The Bill also represents a significant generator of future over-regulation and, to some extent, a perpetuation of micro-management. There is no essential difference between a Government imposing AWP and telling everyone what to commission and when, regardless of local circumstances, and instructing everyone to have a Darzi clinic, as the Labour party did.

We are considering a strange spectacle—a sort of paradox. We genuinely have gradual improvement of legislation, but simultaneously there is increasing professional detachment and disillusionment. That is possibly because people view the Bill as big government; as a centralising measure. The right hon. Member for South Shields (David Miliband) was right to point out that a huge quango had been set up— “the biggest quango in the land”, in the words of my hon. Friend the Member for North Norfolk (Norman Lamb), who is now a Minister.

There are alternatives. Life without the Bill is possible. However, with or without it, the gap between professional and political opinion is fatal. The gap between ideology and evidence is fatal. The gap between what the Prime Minister thinks he needs—not to look weak—and what the NHS needs, which is a two-way dialogue, is also fatal. We must find some way of bridging those gaps. My hon. Friend the Member for St Ives (Andrew George) has tried to find a particular way.

Spin and propaganda will not get any of us out of this. The reality will be played out in the next year and the subsequent year in hospitals, surgeries and homes. Spin will not help because, across the land, reality will kick in—and reality has a horrible habit of trumping spin.