Adult Social Care

John Pugh Excerpts

Thursday 8th March 2012 Commons Chamber

[Chris Skidmore (Kingswood) (Con)]

I start, like others, by congratulating my hon. Friend the Member for Truro and Falmouth (Sarah Newton) on securing this debate, bringing out the urgent need to tackle the issue of the future of social care, and ensuring that we face up to the responsibilities of looking after the elderly of today and tomorrow. We have heard humble messages from the Minister and the shadow Secretary of State about their willingness to work together. The spirit of cross-party agreement is encouraging.

As the right hon. Member for Leigh (Andy Burnham) said, these issues go right back to Beveridge in 1942, when the average life expectancy was 69 and social care was not an issue to be considered within the realms of the state. The right hon. Gentleman mentioned the “sixth giant”, and he is right that we need to revisit Beveridge for the 21st century and perhaps to look again at what Beveridge considered to be most important—the contributory principle. The contributory principle for social care will be all-important when we look at how to deliver social care reform.

As we know, reform is desperately needed. The arguments over the funding of our social care system are well practised, but let us rehearse some of the statistics, which are becoming more familiar with every debate we hold. The number of those aged over 85 will double by 2030, and during the course of this Parliament alone, more than 1.4 million people will turn 65—one in 10 of whom will have a long-term care need that will cost more than £100,000. We should also make it clear that this problem is not unique to the UK. Germany and Japan have recently taken radical action to reform their systems. However, the UK has a specific problem that makes finding a solution to the ever-growing problem of social care particularly difficult: most people simply do not understand the system. They do not understand that social care and the associated costs of getting older are not free, as the Minister stated, and nor have they ever been.

That point was made in the Dilnot report, and it cannot be stressed enough. I wish to highlight two of Dilnot’s recommendations. First, he states:

“To encourage people to plan ahead for their later life we recommend that the Government invests in an awareness campaign.”

Secondly:

“The Government should develop a major new information and advice strategy to help when care needs arise.”

The acknowledgement that more needs to be done to inform the public is welcome. In reality, until one is forced to interact with the system, there is a serious lack of information compounded by an assessment procedure that is often unrealistically complicated. For many elderly people, part of the shock that comes from being forced to sell their house to pay for care is the unexpected nature of that situation. In some respects, we are facing a problem of responsibility and of planning ahead. Although people are now accustomed to the idea of preparing for their old age with regard to pension provision, there remains an aversion to preparing for the eventuality of future frailty and ill health. Few of us wish to admit that we will grow old and frail and need help and support, before it is too late.

The solution to the funding crisis brought on by an ageing population will inevitably require individuals to pay more, and from an earlier age. Whatever we do to change the current system, it is absolutely essential that a much clearer picture of the relationship between contribution and entitlement—precisely as Beveridge set out—is at the heart of that.

Reform requires realism. Even if the Dilnot proposals are implemented in their entirety, they will not provide the full solution. Whatever cap on care costs is set, domiciliary care costs and annual living costs are not taken into account. A new system that is able to lever more private funding into the system will ensure that we can provide the best deal for the elderly, but it will require an understanding that we need to grow an insurance market to maturity that is then sustainable in the longer term. That will not happen overnight. This is a process that will take between 10 and 20 years.

The current Government have taken the first important steps to reforming the system. As hundreds of billions of pounds are being talked about in respect of the current euro crisis, it is easy to forget that the Government’s decision to give an additional £2 billion a year to social care in the 2010 comprehensive spending review was the greatest ever increase in social care funding, and will lead to a vast increase in resources. We are investing more than ever before in carers and respite care, recognising the huge contribution that they make to our country, selfless in their service to their partners, parents, families and relatives.

In addition, a greater focus on personalisation and individual budgets, combined with an increased use of resources such as tele-health, will put more control over care into the hands of individuals, ultimately allowing new providers to provide more tailored services, thereby driving down costs at the same time as improving quality. Placing the person at the heart of their care has the potential to transform social care services, which for too long have been led by inefficient monopolies.

The Prime Minister’s recent call for greater integration of health and social care is equally welcome. I am a member of the Health Committee, and we called for that in our recent report. If we fail to address the social care problem, the NHS will end up picking up the tab. Every unplanned hospital bed admission for the elderly is a mark of the failure of social care to prevent that from happening in the first place. We know that if we can reduce demand for hospital beds by just 10%, that could free up £1 billion that could then be redirected into community-based care services. We must recognise that hospital is not always the best place for care to take place and redirect resources to reflect that.

In preparing for the Committee’s social care report, we visited Torbay, and I was particularly struck by the experience of integrated care there. Torbay’s primary care trust and adult social services have been combined into Torbay Care Trust, following which five integrated health and social care teams were established. They seek to be proactive in managing patients and to work in partnership with GPs. In Torbay, a team was also introduced that was specifically charged with monitoring patients in hospital and discharging patients where there is pressure on beds—again, the team is working closely with clinical professionals. That has helped to cut out unnecessary lengthy hospital stays and delayed transfers of care. As a result, Torbay now has the lowest use of hospital bed days in the south-west region, as well as the best performance on the length of stay. The chief executive of the NHS, Sir David Nicholson, has said:

“I have seen the future and the future is Torbay”.

He did so because it is the elderly who will benefit most from integrated care. Complex long-term conditions complicated by age can be properly managed only with a collaborative approach.

[John Pugh (Southport) (LD)]

Torbay has, for some time, been a model of good practice and the fact that this good practice has not spread much further than the confines of Torbay is something of an enigma. Would the hon. Gentleman care to comment on that?

[Chris Skidmore]

Torbay was one of the sites for the pilots set up in alliance with Kaiser Permanente, which came over in 2003. Interestingly, it is instructive that one of the problems the NHS faces as an institution is that, although it creates fantastic pilots and the NHS innovation centre is working hard on rolling them out across a wider area, that process encounters significant delays. Good models of care should be spread out far more widely and far faster.

What most elderly people want from their health care system is simplicity. They do not want to be moved around constantly from pillar to post, waiting for specialists to see them; they do not want to see a host of different medical professionals, each of whom is unfamiliar with their case; and they do not want to languish in hospital beds when they could be more comfortable at home. The most important change must be a cultural one. There may have been a tendency in the past for health care to be reactive, responding to medical crises as they arise, but the future must be very different. To paraphrase John F. Kennedy, we do these things not because they are easy but because they are hard. We know that we face a challenge that will define the landscape of health and care for the decades to come—it is a challenge that all in this House cannot be willing to postpone.

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[John Pugh (Southport) (LD)]

I congratulate the hon. Member for Truro and Falmouth (Sarah Newton) on starting this debate. I shall be relatively brief because I sense that this is just the beginning of a debate that we will have throughout this Parliament and probably beyond. The whole issue represents a huge financial challenge to Government and a demographic challenge to the country and it will not go away. I suspect that many of the bad stories we have heard about poor care will, if anything, multiply over the years to come as finances are stretched further.

There are obvious things that the Government can do and that they mean to do, such as developing the public health agenda as well as ensuring that healthy old age is a possibility and that more healthy ageing takes place. I think that the Government are serious in their intent. Obviously, as has been suggested by many hon. Members, they can also join up health and social care a little better than they are at the moment. We want care to be integrated more and costs—and people—to be shunted around rather less. I cannot always follow how the Health and Social Care Bill advances that aim, because, after all, we will have a new set of commissioners with limited experience in interacting with local authorities and we will necessarily lose some established commissioners and some established arrangements will collapse. That will create a difficulty, albeit a temporary one; we will have it for a little while yet.

As I tried to point out in my intervention on the hon. Member for Kingswood (Chris Skidmore), there is no obvious mechanism for spreading good practice. How many times have we said that Torbay is an exemplar but then pointed to very few places that have followed that example? There is a real issue with how we spread good practice. I accept that the Bill gives the commissioners the right mandate to integrate social care and health care, but I question whether they will have the right capacity. I listened to the Minister, who put faith in the health and wellbeing boards being able to join things together or to force people to act together who might otherwise not do so, but the big issue staring us all in the face is the cost of care, followed by the quality of care.

In some respects, quality of care is the easier fix. We could have effective regulation and the Care Quality Commission could do a lot better and be less overloaded, but I suspect that it will not be short of work given some of the things it is asked to do by the Bill. Let me take this opportunity to pay tribute to the Minister, who has done a great deal in his time in Parliament to emphasise the need to treat people in care properly. In particular, he has campaigned for people to be respected in old age and for the elders—I think that is the word he used; it is a very nice word—to be defended. In terms of improving the quality of care, he is alive to the need to ensure there is portability so that, when someone goes from one place to another, the care does not decline but remains at a constant and expected standard. There is also a need, which we all recognise—again, the Minister has this well within his remit—to provide a proper legal framework in which people can understand their entitlements and secure them.

Then we come to funding, which is the big issue. I am relatively familiar with this issue because I have experience of being in a local authority with a large demographic bulge towards the top end that has had some difficulty with past Governments over this. Local authorities usually argue that they can provide only what they can—that provision is subject to whatever resources they have—and they try to ration what they deliver according to what they have in the kitty. They cannot always do what people feel they should, so they prefer to do what they can, but Governments are often quite explicit in telling them that regardless of what they have they need to deliver on the entitlements that people expect. I am very familiar with this because when I was the leader of a local authority, when Lord Boateng was in Richmond house, I was once summoned to be roundly told off because my local authority had just lost a celebrated case against Help the Aged. In that case, this problem was precisely the issue: we knew what we could justifiably afford but it was far less than what we needed to deliver what people expected. The previous Labour Government laid down in no uncertain terms that regardless of what we had got, we had to provide the service that was expected.

That tension between local authorities and central Government has always been there and is not going to go away. I accept the point that the Minister made—if we have an outcomes framework and greater transparency, it will be more obvious to people than it is now exactly what is going on and what quality of service is being delivered by individual local authorities—but at the heart of this issue is the local authority settlement. One can say many things about the local authority settlement, but one thing it is not is transparent. It is something that people argue over time and again. My borough has always found its resources severely stretched because we have a high percentage of elderly people and we have never felt that any Government have given us a fair deal in that respect. So the debate goes on, and in some ways it is going to become more critical because at some of the local authorities that have had to make quite severe cuts, including mine, the costs of adult care are going to swamp their budget completely. They are going to have to give up delivering other services in order to fund adult care. That is despite Government top-ups, which are welcome.

There is also the phenomenon of some sheltered housing providers, which have been affected by the refocusing of Supporting People budgets, giving up providing services that people expect as part and parcel of sheltered housing. There are also the local authorities being driven to be more efficient and switching providers but in the process completely hacking off the people who want continuous provision and do not see the case for doing that.

We need a solution to what is a huge financial problem. The solution needs to be affordable, sustainable, fair and, obviously, cross-party. I think we all regret what happened at the last general election, when the cross-party consensus broke down for political reasons. That is where Dilnot comes in. The Dilnot solution seems to be viable: it allows for individual responsibility but also caps costs. That deals with the two big problems I have always come across with this issue. From time to time, I get constituents saying to me how unfairly they are being treated when other people, who have blown all their money before retirement on cruises or whatever, seem to get provision—the free-rider problem. Dilnot recognised that and endeavoured to deal with it. The report also deals with the other, probably larger, problem that people fear that the cost of care will run away with their entire income and they will end up destitute. I personally know people who genuinely hope to die before the money runs out, and that is an unfortunate end to one’s time on this earth.

If Dilnot or something like it is to work, insurance companies will have to develop the right products, as other hon. Members have emphasised. If one has discussions with insurance companies, one will find that they are of varied minds and that some of the products that Dilnot expects that they will offer are not the ones that they would ideally wish to provide or that they think they should provide, so there will be quite a debate there.

Another problem with Dilnot, which I think we can all see, is that in so far as it caps the overall costs, it presumably represents some sort of bail-out for the fabulously wealthy. People might see fairness in that, but they do not see that it should necessarily be the Government’s first priority in the current circumstances.

Then, lingering behind everything, the Treasury is simply worrying what it is all going to cost at the end of the day and wants some financial certainty, for quite good reasons. It is difficult for anyone to provide that, so all this is going to provide a rich menu for a future debate, and we are grateful to the hon. Member for Truro and Falmouth for initiating it.

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[Laura Sandys (South Thanet) (Con)]

It is a great pleasure to follow my hon. Friend the Member for Congleton (Fiona Bruce).

My hon. Friend the Member for Truro and Falmouth (Sarah Newton) has been very important in instigating this debate about future policy on long-term care and ensuring that other such discussions are going on around the House. If it is the case that we come into Parliament because of certain issues, then reviewing and reforming long-term care would be one of the reasons that I find myself in this place. I am not sure that anything is more important for Government, Opposition and this House to resolve, and I give a huge amount of support to the cross-party debate that is going on.

However, we must realise that, unlike in other parts of NHS reform, there is not one person in the country who does not have a view on this subject and does not understand what long-term care means to them. They will look at it, and present it, through the prism of their parents or elderly relatives, and in their heart they will be thinking, “That is what my future will look like.” The shadow Secretary of State said that this debate needs to go beyond this House and to engage the public. I welcome that comment. As my hon. Friend the Member for Kingswood (Chris Skidmore) said, this is about a contract. We are entering into a discussion that will end up as a settlement between the country—the hon. Member for Luton North (Kelvin Hopkins) thinks that a little more funding might be needed—and the public, whose responsibility meets that of the state halfway, or perhaps more.

The public know that the system is broken. Its funding has been squeezed and there has been very little reform or innovation—other than in Torbay, which as we all know is the place to move to as one gets older. When people talk about care packages, it sometimes seems as though the patient is the package and it is hard to understand where the care kicks in. I believe that Dilnot has produced something useful and important, but perhaps it is a little pre-emptive. Until we can be explicit about what this care looks like and feels like, and what people’s experiences of it will be, it is difficult to talk to people about how we expect them to pay for it. I do not believe that the public are prepared to fund the current system, so we must first look at changing it.

I have been a carer myself. I cared for my father when he had a stroke when I was 17, and I saw my mother age by 15 years over a five-year period of caring for him. I have seen it first hand, and I understand some of the key issues that people face. I have also worked professionally in the areas of incontinence—not a charming subject, but one that is exceptionally important in this respect— epilepsy and motor neurone disease, so I have seen this from the end user’s perspective.

What could the new system look like? I believe that the system should be re-engineered around the principle of early intervention. The deceleration of the impact of ageing could be achieved by co-ordinating non-clinical services to keep people fitter and out of the care system. The things that social care delivers must change; it needs a total refit. I believe that that could be guided by four key principles. The first is about keeping the new old young. The second is about keeping people out of care, rather than talking about funding them in care. The third is about caring for carers; we need a whole stream of wraparound policy to support those people who are making that ultimate sacrifice—well, not the ultimate sacrifice, but a significant one. The fourth is about the need for top-quality care for those who do end up in residential care.

I hope that we will be able to keep the new old young. Members will be thrilled to hear that most of us have already started the process of ageing. Everything that we do now will have an impact on us in our 60s and 70s, and beyond. Why are we not introducing, through our GPs, human MOTs to look at any challenges to mobility? Owing to distributing far too many leaflets, both my arches have collapsed and I now have insoles in my shoes. That could have become a major problem as I got older. Why are we not looking at people in their 40s and 50s and taking steps to intervene and decelerate the ageing process?

[John Pugh]

Does the hon. Lady not recognise that delivering leaflets is one of the finest ways of keeping the old young?

[Laura Sandys]

I totally agree.

The acceleration of ageing starts to happen before we get old, and we must look at the public health opportunities to engage with and pre-empt some of the issues that we might face as we get older. That leads me on to keeping people out of care. The three biggest reasons for people going into care are dementia, incontinence and accidents, such as falls. Are we looking at those three factors in enough detail? This morning, on the radio, we heard about a drug that could help people to stay more able despite their dementia, and I hope that it will become more widely available.

I said earlier that I had worked in the area of incontinence. It is one of the most easily managed conditions, so why is it not properly supported? Why are so many people referring their family members to residential care for that reason, when the condition can be addressed easily and extremely cheaply? We are not addressing the condition, and we need to look at it in a lot more detail to ensure that more people can keep their relatives at home. I also mentioned falls. Why do we wait until someone breaks their pelvis before going into their house to see whether they have a handrail, whether their lights are working or whether the ramp is in the right place? None of this is rocket science, folks. It is perfectly straightforward, and I do not understand why such interventions are not being made much earlier.

We have a system that is broken, but we are not doing the necessary pre-emptive work. Instead, the system rewards acute services. It finds installing handrails or wet-rooms less thrilling than ambulances and broken hips. That makes no financial sense, and no human sense. The public know where the system is going wrong, and they can see that earlier intervention would make a difference to their loved ones. Many people have spoken about carers today, and we need to do as much as possible for them. They are at the heart of keeping people out of the care sector.

If we re-engineer our care system, making prevention and pre-emption the gold standard, we must look at a re-engineered funding mechanism, too. I believe that there is a policy framework that is a little like the green deal: for those who support people out of care, there is a bonus and an incentive, rather than the current financial model that rewards hospitalisation and pays far too little for those in home support.

I welcome the comments of hon. Members about how little care workers in homes are paid. My word, if we look at the value we get from that particular care intervention in comparison with extreme nurses in hospitals, we should start to understand that we have a very unbalanced system.

In conclusion, if we have a vision for decent and dignified care, the public will enter into a contract with the Government. They might even do so more than the Government think; they might even pay more than we are currently asking them to contribute. However, they will do that only if they see a re-engineered system that places the foremost priority on delivering care—quality care—that they can trust, rely on and understand.

Veterans (Mental Health)

John Pugh Excerpts

Wednesday 7th March 2012 Westminster Hall

[John Pugh (Southport) (LD)]

I congratulate the hon. Member for York Outer (Julian Sturdy) on opening this important debate.

I must admit that I am not a natural when it comes to defence-orientated debates. I do not come from a garrison town and I have no experience of the forces—I suspect I am naturally too insubordinate to fit into them. However, I have a genuine interest in this issue. It is spurred not so much by constituency cases, although a soldier came to see me who was severely traumatised by the conflict he had endured, and the atrocities he had seen, in Aden. It was an awfully long time ago, but it had scarred his whole life, traumatising him, driving him to alcoholism and creating huge mental health issues. I also dealt with a case in which a gentleman who had been advised by the Ministry of Defence to assist it with research at Porton Down on the common cold subsequently had a lot of worries that were quite unrelated to his exposure to the common cold.

What really sparked my interest, however, was my experience on the Public Accounts Committee, which produced a series of interesting reports on and around this area that showed up some quite distinctive and worrying issues. The report I want to dwell on was called “Ministry of Defence: Treating injury and illness arising on military operations”. It showed quite categorically that the forces were excellent at dealing with people’s physical ailments in the theatre of war and subsequently—the profile and the results were good, and the medical treatment was exemplary. When it came to mental health, however, there were some very odd results. For example, it appeared that American and British soldiers exiting the same theatres of war had widely disparate experiences in terms of their mental health, with more Americans reporting themselves, or being reported, as having mental health problems by a considerable margin.

Even more strangely, the figures coming out of the British forces for mental health problems showed soldiers were experiencing no real anxiety at all; in fact, they showed that troops were in just as good mental health as the ordinary population, which was odd. During the PAC inquiry, I told Sir Bill Jeffrey, who was permanent under-secretary at the time:

“I think we would all accept that war is extremely stressful and people see some horrid, fearsome things that would disrupt the psychology of almost anybody. What surprises me”—

then and now—

“is that the referral of the Forces appears to be lower than the referral rate of the population as a whole.”

I put it to him that that was intrinsically implausible:

“You would have thought there would be more mental health issues amongst a population of people who see quite traumatic scenes than amongst those who do not.”

More brutally, I said the rate of referrals

“is actually lower than the population at large. In other words, it would appear…that in the confines of Committee Room 15”,

where the PAC was meeting,

“we are far more vulnerable to mental health stress than people in the operational theatre of war.”

It can be pretty torrid in the PAC at times, but I suggest that result shows that something is going awry in the forces’ reading of troops’ mental health post-war.

Equally puzzling was the disparity between people coming out of the Iraq and Afghanistan theatres of war. Lieutenant-General Baxter, who was then the deputy Chief of the Defence Staff, explained:

“I think you have to look at the nature of combat…When you are being shot at and you can shoot back, it is a lot less stressful than when you are being bombed or suffering indirect fire.”

I do not know whether that is true, but it invites serious questions about the level and quality of screening when people are discharged.

Other reports that the PAC produced at the time were equally troubling. They showed, for example, that squaddies were far less well prepared for the outside world than they could have been when they were discharged. There were also troubling statistics, with which we are all familiar, about high rates of alcohol problems, imprisonment and homelessness among people leaving the forces.

That is all very troubling, and the causes are fairly complex, but one thing is absolutely clear: the screening of soldiers exiting the theatre of war was very poor in the British forces. Often, it was done simply through self-completed questionnaires, but people do not ordinarily volunteer any deep psychological problems they may think they have in such a questionnaire.

There was also evidence in the PAC report that I quoted that support for people in the theatre of war was relatively poor. The most that they seemed to get out there most of the time was three community nurses, along with one consultant psychiatrist every three months. If people showed up with problems in the theatre of war, those problems were unlikely to be fielded especially well. There are particular issues here, and we must be prepared to face up to them. One, although I have only anecdote to go on, is that some people enter the forces because the structure that they provide is exactly what their personality needs. When they leave the forces, however, that structure simply disappears. Often, their homes will have gone, and their families will sometimes have gone, too, so they find themselves in difficult territory.

A second suggestion is that there is necessarily a culture of mental toughness in the forces, so people are slow to own up to whatever problems they may have. Those problems might therefore go unrecognised and be submerged for quite some time, and that is at the root of some of the problems that were so well analysed by the hon. Member for York Outer.

We in this place have clocked these problems, and quite a lot has been done about them. Since 2010, when the PAC report I quoted was produced, there has been a surprising amount of really good progress. On 6 April 2010, the previous Government committed themselves to providing £2 million of new funding. They can be credited with increasing the number of helplines and endeavouring to increase the education and training of GPs. We also pay tribute to the Murrison report, which represented excellent progress. Before that, the Ministry of Defence even did some research, which helped everything along. There is strong cross-party commitment to recognising these problems and doing something about them. In a sense, therefore, Parliament can justifiably credit itself with having done something about a very real and clearly identified problem.

I would like to conclude by thinking about where we go from here. My concern is that most of the solutions that were proposed following the previous Government’s deliberations and the Murrison report involved something along the lines of specialist health service commissioning. I do not want to talk about the difficulties of the legislation currently going through Parliament, but such specialist commissioning is an issue. The hon. Member for Hexham (Guy Opperman) has advocated as a solution getting round specialist commissioning to some extent by means of an agency that is a one-stop, catch-all arrangement. Creditable though that suggestion is, it will not get us out of the business of specialist commissioning, because the problems will show up locally in many diverse settings. I wonder whether the Minister will say something about that.

[Derek Twigg (Halton) (Lab)]

When I was the Defence Minister with responsibility for such matters, we set up pilot schemes with the NHS, with which Combat Stress was involved. Delivery issues are important, because in most respects the treatment is exactly the same whether the patient is a civilian or not, but some members or former members of the armed forces would prefer to talk to someone with experience in the armed forces. That is why we involved such people in the pilots.

On the other hand, other people from the armed forces did not want to see someone who had also been in the armed forces, because as far as they were concerned that life had finished, or they wanted to move on, or they had had a bad experience. It is a difficult issue to come to terms with, and that is why there is a need to mix and match support and clinical help. It is important for people to have that choice.

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[John Pugh]

I defer to the hon. Gentleman’s experience, and he is probably right in advocating that solution. The question is who will secure that proper mix.

[The Minister of State, Department of Health (Mr Simon Burns)]

Will the hon. Gentleman give way?

[John Pugh]

The Minister is going to tell us.

[Mr Burns]

I am grateful to the hon. Gentleman. Given that I will not have very much time to speak, can I deal with the question of who will commission veterans’ mental health services? It will be the responsibility of the NHS Commissioning Board.

[John Pugh]

I am relieved that it is placed within an appropriate body, although the board has an awful lot else to do.

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[Andrew Percy]

I entirely endorse what my hon. Friend says. We have probably all seen examples in our surgeries of military service sometimes leading to breakdowns, which are then presented at our constituency surgery for assistance. I am reminded of the old saying: while the physical wounds may heal, the mental scars never quite go away. So I endorse what has been said by other Members today.

[John Pugh]

One of the themes in the debate today has been whether we do or do not have a veterans agency. Somebody said that the veterans agency is an American model, but the Americans do not have our GP system. Even with the existence of a veterans agency, is there not a problem with how that then interacts with the GP, who will often be the first port of call when problems occur?

[Andrew Percy]

That is exactly the point that the hon. Member for Hexham (Guy Opperman) accepted. In creating anything, there will always be interaction problems. We all know where we want to be; how we get there is probably a bit more difficult. Now that the shadow Minister and the Minister will have a little more time, I am sure that they will expertly plot a course forward to deal with these issues.

NHS Risk Register

John Pugh Excerpts

Wednesday 22nd February 2012 Commons Chamber

[Mr Lansley]

I have met Bliss—I just said so—and we discussed exactly those kind of issues. I would happily do so again.

The objective of the NHS—this is precisely what we have set out in our focus on outcomes—is to ensure that we seek a continuously improving quality of service for patients. I have many times been on specialist neo-natal intensive care units precisely to understand that. I remember having a long discussion just last year with the staff, including the neo-natal staff, at my local hospital, Addenbrooke’s, and hearing of the importance to them of recruiting an additional neo-natal nursing complement to ensure that they provide the right service. That is nothing to do with the Bill. It is about focusing in the service on delivering quality. That is why we are getting resources into the front line.

The third reason is that the publication of a risk register could take away directly or distract from policy development—the process that it is intended to support. Departmental officials and Ministers should work directly to deliver the policy rather than react to the risks associated with the development of policy before the policy has been agreed.

[John Pugh (Southport) (LD)]

Will the Secretary of State give way?

[Mr Lansley]

I will give way in a moment.

Fourthly, the publication of the risk register would distort rather than enhance public debate. We should remember that a risk register does not express the risks of not pursuing the policy—[Interruption.] Hon. Members should think about it. A risk register does not include the risks of not pursuing a policy and ignores the benefits of a policy—it presents only one side of the cost-benefit equation and is deliberately negative. Effectively, it is a “devil’s advocate” document, not a balanced one.

What is the balanced document associated the Bill? The impact assessment. I have with me a summary of the impact assessment, but there are hundreds more pages. We incorporate all relevant information in the impact assessment because it not only captures the same risks, but puts them alongside the benefits, costs and impacts, including the impact of not taking action.

The impact assessment is the proper evidential and informative basis for parliamentary and public debate. If any hon. Member is in any doubt about the public interest served by not releasing the risk register, I remind them of the advice received by the House nearly five years ago from the shadow Secretary of State. The argument that he put was precisely the argument that we are now putting.

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[Gareth Johnson]

My hon. Friend makes a valid and correct point. Governments need such registers to function efficiently and to cover every eventuality. As he pointed out, a risk register is a mechanism by which civil servants can candidly present a worst-case scenario to Ministers. It is not about what is expected to happen, but about what is the worst that can happen. Risk registers are therefore not Government policy, but preparatory documents.

[John Pugh]

Would the hon. Gentleman be surprised to know that I have here a national risk register that was published by a Department in 2012?

[Gareth Johnson]

Yes, I would be surprised if that had happened.

It would be wrong for there to be routine publication of risk registers without any kind of control. The beauty of risk registers is that they enable civil servants to think the unthinkable.

The hon. Member for St Ives (Andrew George), who is no longer in his place, made the point that there is a difference between the approaches of the Government and the Opposition. If we are honest with ourselves, we must recognise that every Opposition in this place has been guilty of some scaremongering. There is no doubt about that, so let us be mature about it. Whether it has been my party, the Labour party or the Liberal Democrats, we have all been guilty of a certain amount of scaremongering. Presenting a pessimistic view as a real likelihood is part of the game of political football. However, there is a huge danger that information from the risk register could end up misleading the public and giving them inaccurate information.

--- Later in debate ---

[John Pugh (Southport) (LD)]

Another day, another health Bill debate: it is a groundhog day, déjà vu experience for many of us. On these occasions, I often find myself sounding like that irritating little man with the flat cap and glasses who was in Harry Enfield’s programmes and went around all the time saying, “You don’t want to do that.” It is a matter of record that I have described the Health and Social Care Bill as a huge strategic mistake and that I have from the start publicly and privately—but, I hope, politely—tried to discourage the Government from progressing with it. Even though it is Ash Wednesday today, I do not intend to repent of my ways, although I do agree with the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) that the onus is now on critics to come up with a viable alternative to what the Government propose to implement.

Regardless of the merits of the Bill, the politics of it have turned into an absolute nightmare, to the extent that there are now two clearly defined schools of thought in Parliament. There are two opposed camps: those who think that the Bill is very problematic and that we should drop it, and those who think that it is problematic but that we are stuck with it. All that is despite the good intentions of Ministers, the constructive amendments of both Houses and the work of the NHS Future Forum. I essentially agree with Tim Montgomerie, who publicly acknowledged what some Cabinet Members privately acknowledge: it is toxifying for the Tories and detrimental to the Liberal Democrats, which is sad.

Over the past 20 months, I have tried—possibly ineptly—to get that message across. I even e-mailed the Prime Minister’s adviser on strategy, Andrew Cooper, a man for whom I have appreciable respect. On 14 April last year I wrote to him saying that over the previous 10 months I had

“watched the coalition in terms of health policy cheerfully prepare to be driven over the cliff by the”

Department of Health. On 4 May of the same year I told him that the Government risked ending up in a no-win situation, and on 6 September that the Bill was unnecessary and would create uncertainty, divide the coalition, lower morale and harm Government ratings—which it has. There are no happy endings, I said.

I get no satisfaction from being proved right. After all, nobody welcomes a know-all. However, nobody likes gigantic Government schemes that do not come off—especially not, as the right hon. Member for Wentworth and Dearne (John Healey) said, in the Department of Health. That is why it would have helped so much to have had a gateway review of Connecting for Health, the Government IT project. That was not published by the Blair Government, and blew £12 billion of taxpayers’ money. A review was demanded by my hon. Friend the Member for South Norfolk (Mr Bacon), but Blair decided to press on bravely through the signals of danger, aided and abetted by a report from McKinsey. I was relieved to find out that the Government do not rely on advisers to the extent mooted in the press, at any rate, because their advice has not always been solid or sensible.

Would not we all have really liked, however, to see a gateway review of Connecting for Health, and would it not have saved the country an appreciable amount of money? Why did we have to wait nine years—and spend £12 billion—before the NHS essentially settled on the position mapped out by my hon. Friend the Member for South Norfolk in a paper in 2006? Should we not have seen the review? Perhaps Labour should adopt an “I’ll show you mine if you show me yours” policy as the best way forward, for in truth there are not many good arguments against transparency in the case of this NHS risk register—and I have heard some pretty bad arguments, both today and in recent days.

One particularly poor argument has been that Members should not support this call because that would endorse the Labour party’s position. I think that is called political tribalism, which is not attractive and which poisons this place. It is always wiser to agree with people when they are right and to disagree with them if they are wrong, regardless of party. Another bad argument that has been made several times this afternoon is that the Labour Government did the same thing and refused to publish risk registers. That is a pretty weak argument in terms of its general logic. Just because the Labour Government fought an illegal war in Iraq, that would not justify the coalition’s fighting another war in a country of its choosing. Then there is the weak argument that publishing the register would create a precedent, but what is the precedent? Surely, it is that risk registers may be released when the Information Commissioner—a role that was set up by our legislation—so decrees when interpreting our legislation. It appears that most of the arguments that were presented quite cogently by the Secretary of State were attended to by the Information Commissioner at the time.

Some risk registers are voluntarily released, but it has been suggested, including in the other place, that the risk register might unduly alarm the unwitting public, who apparently cannot understand risk, or the difference between the unlikely and the probable. That rather patronising view is hard to square with the fact that risk registers are already published on many subjects, including on more alarming subjects than NHS reorganisation. I am talking not just about local risk registers such as that for NHS London. I have here the risk register on civil emergencies published by the Cabinet Office in 2012. It is not bland or anodyne, as has previously been suggested, and one can download it from the internet. It tells of the possibility of catastrophic terrorist incidents, major pandemics, volcanic eruptions, cyber attacks, floods, pestilence, and even the dangers of rabies and cosmic rays. I think it also gives the probability of all such events occurring. I cannot help thinking that if the public can already find out the chances of being blasted with cosmic rays, they can cope with knowing about the marginally disruptive effects of the abolition of strategic health authorities. I cannot help thinking that if the public have already grappled with the possibilities of being buried under volcanic ash or bitten by rabid dogs, they will not be too hysterical about the potential consequences of setting up health and wellbeing boards.

There is a virtue to transparency, which the Government accept. They have made substantial progress on this issue and it is unfortunate that this episode is going to blot the copybook. I am reminded of the futile attempts that were made by the previous Speaker to block the commissioner regarding our expenses. We risk a replay of that, and I urge all Members, before they troop into the Lobby tonight, to consider what they will say in 10 days’ time when the Government either win or, more probably, lose their appeal.

[Several hon. Members]

rose—

Oral Answers to Questions

John Pugh Excerpts

Tuesday 21st February 2012 Commons Chamber

[Mr Lansley]

I gave the hon. Lady the figure: £67 billion of debt. Seven NHS trusts and foundation trusts are clearly unviable because of the debt that was left them by the Labour Government.

[John Pugh (Southport) (LD)]

Is the Secretary of State confident that subsidising hospitals burdened with PFI will not be deemed anti-competitive under forthcoming legislation, or state aid under EU legislation? Has he taken appropriate legal advice?

[Mr Lansley]

I always act on advice, and I am absolutely clear that the support we have set out for NHS trusts and foundation trusts will not fall foul of anti-competitive procedures.

Alcohol Strategy

John Pugh Excerpts

Tuesday 7th February 2012 Westminster Hall

[Dr Wollaston]

That is an excellent point, and I thank the hon. Lady for making it. Certainly, many young women drinkers would be deterred if they realised what the calorie content is for some of the popular alcohol mixer drinks. That might help to stem the rise in vodka mixer drinking among young women.

[John Pugh (Southport) (LD)]

Is the hon. Lady aware that there is a problem with EU legislation in terms of putting the calorific amount on the bottle?

[Dr Wollaston]

I thank the hon. Gentleman for making that point. EU legislation is getting in the way of an awful lot of the measures I would like to be introduced.

Returning to why education should not be in the hands of the drinks industry, I would like to draw hon. Members’ attention to a problem that arose when the Drinkaware Trust introduced its safe drinking recommendations. It presented those recommendations not as a safe upper limit but a recommended daily amount, as if it were marketing them as a vitamin intake. There is a clear conflict of interest in having the drinks industry controlling education. Although I welcome much of the Drinkaware Trust’s work, I do not see the need for the drinks industry to be on the board and would like the Minister to comment on that if possible. Following the report of the Select Committee on Science and Technology, the clear message should be that people should take at least two alcohol-free days a week to protect themselves.

Turning to the health service, relatively few hospitals have a dedicated alcohol service. It is a shame that only 5.7% of dependent or harmful drinkers are able to access treatment compared with 67% of dependent or harmful drug users. There is a clear case for changing that. One third of people who are admitted to hospital with acute liver disease die immediately, and the mortality rate for that has remained unchanged for 15 years. They die without being able to be aware that they even had a problem in the first place.

I would like to make the case for having much better services for screening and early intervention because such an approach works. Some 12% of people who are given brief advice and are informed that they are developing harmful or hazardous drinking traits will significantly cut down or stop drinking. Such a scheme is highly cost-effective, and I would like it to be rolled out, particularly in casualty departments. All hospitals should have a seven-day acute nurse specialist to give brief advice and intervention. That approach should be rolled out further to GP surgeries through the quality and outcomes framework and should also be available in community pharmacies, so that we can let people have clear information and advice. As I say, we should do that, principally, because such a scheme is evidence based and works.

Regarding people who already have a problem, it is time for all hospitals to have a dedicated alcohol specialist team and an assertive outreach team, particularly to help those revolving-door patients who come in and out of hospital repeatedly. They often have complex mental health needs and issues surrounding homelessness. Again, such an approach has a very strong evidence base and is cost-effective.

The law and order challenge for our police force is vast. May I pay tribute to the people who are at the sharp end of all this? Police officers, street pastors, casualty workers and ambulance staff bear the brunt of the problem. The police are making progress. I pay tribute to Devon and Cornwall police for their work. In my area, people who are picked up by the police can choose between a fixed penalty notice of £80 or attending a course run by Druglink. For those people who attend those courses, there is only a 2% offending rate. That is an example of something very positive that we should be moving forward with.

We should also carefully consider what has been happening in South Dakota in the USA, where they have introduced mandatory breath testing for those convicted of an alcohol-related offence. That has significantly reduced the prison population and has had an effect on domestic violence rates. It would be sensible to at least pilot that in this country to establish whether such a model could work here.

There is a strong case for reducing the drink-drive limit from 80 mg per 100 ml of blood to 50 mg, if for no other reason than for the sake of the 380 people who are killed every year on our roads and the more than 11,900 who are injured. Of course, we also need to give the police greater powers to breath test people.

What about the industry’s role? There is a role for industry in reducing product strength and I welcome those who have already taken action along that line. Crucially, business models should be changed, so that they are based on quality not quantity. The opinion is that that is what has had the greatest effect on the continent, where there have been significant falls in drinking levels because of the move away from drinking vast quantities of plonk towards drinking smaller quantities of quality product. That is something we could do here. I would like to see further work on the use of responsible locations in supermarket aisles and, as I have said, further progress on labelling.

I repeat that it is not the place or the responsibility of the drinks industry to define public health policy. There is a clear conflict of interest. It is time for us to follow an evidence-based approach built on medical advice and for there to be far less involvement with the drinks industry in dictating policy.

I have already been fortunate to lead a debate on alcohol taxation, so I will not repeat the points I made then. I hope that other hon. Members will give us advice on why the introduction of minimum pricing is compatible with EU legislation. I know that the hon. Member for Brighton, Pavilion (Caroline Lucas) will do so. The fact that price influences behaviour is, beyond doubt, completely undeniable. There has recently been further evidence from British Columbia about the impact of minimum pricing, based on 20 years of experience. There has also been evidence from Scotland, where the change in pricing policies, particularly those inhibiting multi-buys, have caused a 14% fall in beer sales. I will conclude and allow other Members to contribute by saying that there is no such thing as a cheap drink, but we are all paying a very heavy price.

--- Later in debate ---

[John Pugh (Southport) (LD)]

I congratulate my hon. Friend the Member for Totnes (Dr Wollaston) on securing this important debate. I should like to take a slightly different track and speak briefly about alcoholism. I am motivated to do so because a friend of mine died recently of alcoholism. I surveyed his circumstances and wondered what conceivably could have been done to prevent his early death—he died at a younger age than I am now.

I looked back at my friend’s history in some depth, trying to find out how it all started. It started, as it does for many people who take to drink, with other psychological problems: a lack of self-esteem, to some extent prompted by his family upbringing. It was accentuated by losing his job as a civil servant—he took early retirement—and then by the loss of his marriage due to the strain induced by alcoholism. I followed his whole history from that stage on. There were periods of abstinence, where he thought he had licked the problem. There were periods of very aberrant behaviour that sometimes involved the police, but often strange and gratuitous acts of mad generosity. There were periods of treatment when he went in for detox, somewhat ineffectively, and came out and resumed previous behaviour.

There was a period when my friend found that Librium worked in discouraging him from drinking, but he could not be given the amount he needed, so I made an arrangement with his doctor to provide him with the drug. For the first time in my life, I became a drug dealer. He could not receive it himself, simply because it was feared that he would take an overdose. Then there were periods of real sickness when he was losing weight rapidly. He was hospitalised frequently. He had blood transfusions and other forms of hospital treatment for a disease that I fundamentally believed to be, at root, of a mental rather than physical kind. Throughout it all, there were long periods of solitary drinking, punctuated by phone conversations to his friends. Those conversations were not always welcome; any drunken conversation tends to be very repetitive and goes nowhere. Ultimately, this was followed by a phone call saying that he had been found dead alone in his flat.

I reflected on this. I believe that, at root, the cause is psychological, but I had seen my friend struggling when applying for NHS services to get any psychological treatment, because most psychiatrists do not want to mess around with alcoholics. They regard them as a complete waste of time. In some cases, their criteria for treating people exclude alcoholics. I was a member of the Public Bill Committee that considered the Mental Health Act 2007, when it was expressly stated that people could not be sectioned for alcoholism—it was not regarded as the kind of disease that fell under that banner.

My friend phoned me on many occasions and pleaded with me to find some sort of mechanism so that he could be sectioned, because he knew that he could not stop himself drinking. Towards the end of the time when I was trying to help him, I found something that I thought might work. It was a treatment that other alcoholics I had known had benefited from. It was a process of very robust detoxification, followed by rehab, and was clearly producing results. It took place outside the primary care trust area in which he lived and was going to cost £10,000. However, I am sure that the total cost to the NHS of his treatment in all those years was much more than £10,000. I could not, in all honestly, believe that the PCT would respond very positively, given its other priorities, to a case that stated, “This man has had a lifetime’s history of alcoholism. Now, will you spend £10,000 in getting him out of this fix?”

I am concerned about what we do for alcoholics under the current regime. Having had to look into it, I found that a lot of them go through procedures that are, in a sense, futile—they do not actually take things a great deal further. They detox people and turn them around again, so they go back to the habits that they had before. Unless there is detox plus rehab, this is not a workable solution. This is a big problem for many families and communities, so it is surprising that so many organisations out there take so much money out of the NHS to so little effect. The NHS needs to drill down and support only those therapies that genuinely work. In the short term, they may be very expensive, but in the long term, they will repay the investment.

On the voluntary consumption of alcohol, there are a couple of factors that can precipitate people along the route that my friend followed: a cultural permissiveness about excessive drinking and a mishandling of how, culturally, we deal with alcohol. At root, that is our problem. Recent licensing law reforms have been an ineffectual attempt to change the culture into a French or continental system where we can manage our alcohol a little better. Certainly, one of the bedevilling features that impact on how society handles alcohol is its cheap and plentiful supply.

Frankly, I am agnostic—I am not sure whether my hon. Friend is right. Doctors are arguing very forcibly for minimum pricing, and I think that the Government are committed to banning below-cost pricing. Both are helpful, but probably neither are sufficient because in themselves neither will guarantee cultural change. As a former teacher, I am agnostic about what education can do. Asking 14-year-olds to forswear a life of alcoholic indulgence is not an easy task, particularly as most of them have not really engaged much in that direction.

We have to accept that alcohol consumption is always regulated in some form or other, but its long history shows that we do not always get it correct and that no system is flawless. We need to look at good practice and at what works—my hon. Friend the Member for St Austell and Newquay (Stephen Gilbert) has some good examples—and roll them out right across the piece. We do not have many good models to imitate in the control of either alcohol or alcoholism, but evidence-led policy is clearly the way forward.

--- Later in debate ---

[Philip Davies (Shipley) (Con)]

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

As a libertarian and a believer in individual freedoms, I had hoped that the country had escaped from the nanny-state health police with the end of the previous Labour Government but, sadly, I was clearly naive in that thought. A great many people in the House seem to want to do nothing else but ban everyone else from doing all the things that they do not happen to like themselves, and I was certainly not brought into politics to do that. I urge the Minister not to be seduced by the reasonableness of my hon. Friend the Member for Totnes (Dr Wollaston), because I assure her that, were she to implement everything that my hon. Friend asked for today, my hon. Friend and the health zealots would still return with another list of things that they want the Minister to do. Such people will never be appeased or satisfied until alcohol has been banned altogether.

I want to focus on two points—the futile proposal on minimum pricing, and advertising and marketing. The very principle of minimum pricing goes against all my Conservative instincts and beliefs—the free market and freedom of choice. The process of setting a minimum price is predicated on the assumption that raising the price of alcohol will make those who misuse alcohol behave differently. However, that is an incredibly simplistic belief. It is worrying that people in the Chamber think that, by increasing the price of a bottle of wine by 30p or 40p, or of a can of beer by 40p, all the problems associated with drinking would at a stroke disappear. People who think that minimum pricing will stop young people going into town centres on Friday and Saturday nights with the intention of getting bladdered, or whatever the current term is, are living in cloud cuckoo land.

[John Pugh]

Will the hon. Gentleman give way?

[Philip Davies]

I will not give way, because plenty of other people want to speak and time is pressing. I will happily debate with the hon. Gentleman in the Tea Room or at some other point, although I am the only one arguing from this perspective, I suspect.

The Centre for Economics and Business Research conducted research on minimum pricing and concluded that the heaviest drinkers are the least responsive to higher prices. For example, at a minimum unit price of 40p, the CEBR found that harmful drinkers, which the policy is supposed to be targeting, would reduce their weekly consumption by only 1.7 units per week, which at the end of the day is less than one pint of weak beer. A report by Sheffield university found that a minimum price of 45p per unit would trigger a 6% fall in overall alcohol consumption and 60 fewer deaths in the first year alone. Yet the Government figures for 2009-10 show that overall alcohol consumption fell by 7%, while alcohol-related deaths rose by 36. Clearly, there is no link between the two.

Minimum pricing treats all drinkers the same, and penalises—financially and practically—the overwhelming majority of adults, all those people who drink alcohol responsibly and in a socially acceptable way, causing harm neither to themselves nor to others. The people who would be most penalised by minimum pricing are those who are already on tight budgets, such as pensioners, people on fixed incomes or those in low-paid jobs. I simply cannot understand how hon. Members, in a time of economic austerity, are prepared to force some of their poorest constituents to pay more for alcohol, when they know full well that the overwhelming majority of those constituents drink alcohol responsibly and in moderation. If hon. Members want to tackle binge drinking and alcoholism, they should focus their efforts on binge drinkers and alcoholics, not on everyone in the country, which would be unjustifiable.

The Institute for Fiscal Studies produced a report on minimum pricing that found that poorer households, compared with richer households, on average pay less for a unit of off-sale alcohol. For example, households with an income of less than £10,000 a year pay 39.8p per unit, while those on a household income of more than £70,000 pay 49.3p per unit on average. As a result, a minimum price of 40p or 45p per unit would have a larger impact on poorer households and virtually no impact on richer ones.

--- Later in debate ---

[Stephen Gilbert (St Austell and Newquay) (LD)]

It is a pleasure to follow the hon. Member for Brighton, Pavilion (Caroline Lucas). Like other hon. Members, I congratulate my hon. Friend the Member for Totnes (Dr Wollaston) on securing a debate that she has revisited time and again since coming to the House.

As a relatively new MP, I was reflecting on the fact that my hon. Friend the Member for Shipley (Philip Davies) is a bit like a bellwether. When he is the first to rush to defend the Government’s policy, one knows that the policy is wrong. This morning, many hon. Members have asked where the evidence is that leads us to consider the need to introduce minimum pricing. In 2008, the university of Sheffield conducted a Government-funded study, which found that setting a minimum price of 50p a unit for alcohol could result in 3,000 fewer deaths a year. In 2009, the chief medical officer in England supported that view. In 2010, the Select Committee on Health and the National Institute for Health and Clinical Excellence also backed a minimum price. Also in 2010, that policy found its way into the coalition agreement, which states:

“We will ban the sale of alcohol below cost price. We will review alcohol taxation and pricing to ensure it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries.”

That is exactly the point that other hon. Members have made. The opposition to minimum pricing is setting up a straw man in saying that it would penalise moderate drinkers. In fact, as other hon. Members have said, the study by Alcohol Concern suggests that with a 50p minimum price, moderate drinkers would be only £12 worse off a year, whereas the cost to the harmful drinkers—those who cost our economy through lost productivity, revenue lost to the health service, and tragic deaths such as that identified by my hon. Friend the Member for Southport (John Pugh)—would be £163 a year.

[John Pugh]

I hate to stand up for the hon. Member for Shipley (Philip Davies), but the relationship between price and consumption is a lot more subtle than hon. Members have indicated. Recently, at least until a couple of years ago, the price of alcohol was going down, and levels of consumption have also reduced throughout the country.

[Stephen Gilbert]

My hon. Friend makes a valid point, but the issue concerns consumption among problem drinkers and those vulnerable people about whom we in the House must be especially concerned. In many cases, people suffering from addiction are not able to articulate the best course of action for themselves.

NHS (Private Sector)

John Pugh Excerpts

Monday 16th January 2012 Commons Chamber

[John Pugh (Southport) (LD)]

Far be it from me to presume to criticise the wise counsel of other Members, but it is absolute nonsense to think that the NHS has always been a monolithic system of public provision. It is absolute nonsense to think that private health providers always think only of profit instead of providing a good service or that services delivered by a public body are necessarily less costly or always better than those delivered by a private provider. It is nonsense to think that choice and competition are never needed, that diversity is bad or that reform or improvement—I prefer that word—is not needed. Sensible, pragmatic, evidence-led arguments can be made for mixed provision, for improvement, for choice and competition, for the involvement of the private sector and for diversity. That is not the problem.

The problem is that pragmatism and evidence count for very little because for the past eight years health policy in this country has been in the grip of an unspoken ideology. Put very simply it goes like this: the Government have no real business in providing health services but should buy them from health providers in a market. Some will be private providers that will make a profit, some will be voluntary bodies or social enterprises and others will be the fragmented, dissected pieces of the old NHS—foundation hospitals, trusts and the like. All can be branded as NHS providers if we want and all can have the NHS logo. The differences between them all will become increasingly blurred and of no consequence. Some people believe it should not matter which of these bodies delivers health services so long as the taxpayer and not the patient pays and the Government keep out of the provider business. That idea is rather like what exists already in other countries, except that generally in those places it is insurance, not tax, that funds the system.

And it is not privatisation. Ministers can truthfully say, “We are not privatising the NHS.” It is marketisation. What is happening is that the Government are buying health in a market, either national or local—an external market. They are gradually giving up on providing health services and in my view clearly mean to do so. It is a beautifully clear, coherent ideology that is rarely explicitly set out, defended, discussed within parties or put to the electorate. Indeed, to do so might be electoral suicide.

Stage by stage over the past eight years that ideology has been progressed. If one assumes it and holds it in mind one can understand why hospitals have to become foundation hospitals independent of the state—that was a Blair idea—and why it was necessary to create a bigger private sector by offering it preferential terms, which was another Blair idea. One understands why services formerly run by primary care trusts, such as community nurses and the like, are being forced to become social enterprises and why it is suggested that NHS hospitals might do up to 49% private work and that private hospitals can do as much NHS work as they like. One also understands why the Health and Social Care Bill abolishes the Government power to start a new hospital, why there is such unseemly haste to extend “any willing provider” and why the Secretary of State, even at the cost of peace in the Lords, does not want the word “provide” back in the list of his powers. If anyone is unpersuaded regarding any of that, let them turn it the other way around and point to one—just one—recent policy initiative that clearly shows that that market solution is not the endgame and the ultimate goal.

I do not believe that ideology is in itself bad, and this ideology has the virtues of being clear, consistent and radical, but in my view it is basically wrong because a health market cannot ensure that health services integrate well—the Future Forum spotted that—or that scarce NHS funds are spent in the most efficient way, as previous Treasury reports have shown in abundance. It cannot ensure that people get the services to which they are entitled and it cannot ensure that health inequalities are properly addressed. It clearly cannot easily make the strategic planning decisions needed to sustain services, encourage training and organise research, which is precisely why these issues have been so problematic in the Bill and why we are going to find slimming down the financially challenged hospital sector so painful and so uncontrollable in its consequences.

I am not here to argue against this market ideology, because, frankly, few have the honesty to argue for it openly. It is not the official Labour policy or the official Liberal policy. I do not believe it is even the official Conservative policy. It was smuggled past all of us, including the general public, shrouded in vague pragmatic talk about choice, diversity, reform and independence, but we should have no doubt: it is ideology. How else can we possibly explain the headlong pursuit at pace of a set of reforms that complicate and make riskier the huge £20 billion efficiency programme? How else do we explain the overloading of bodies such as the Care Quality Commission and Monitor, whose inadequacies, if not apparent now, will soon become painfully apparent after the Mid Staffs inquiry reports?

[Andrew George]

Does my hon. Friend agree that it would be worth revisiting the issue of whether the NHS should be pre-eminent as first provider or in some other role before we finally make what may be a catastrophic error?

[John Pugh]

My fundamental point is that this is not evidence-led pragmatism. If we join up the policy dots, we see pure, simple, unalloyed faith in the market system to deliver health in this country. Time after time, in issue after issue, ideology trumps pragmatism and prudence.

The Labour motion is a potpourri of varied sentiments, some of which are true and some of which are confused, and some, given the history, that it is surprising the Opposition have the gall to table at all. However, we should be genuinely grateful to them because they have given us an opportunity—a platform—to name the beast, to define real choice and to cut to the quick.

Chris Mullin, in his excellent “Diaries”, describes a discussion with a fellow Member of this place, a Yorkshire MP, “a mild-mannered fellow”—I do not know who that would include—who in 2005, prophetically, said of the Labour party:

“We’re opening the door…Whatever safeguards we put in place, whatever assurances we give will be absolutely worthless once the Tories are in power…I think we will lose the next election. The Tories will come to some sort of understanding with the Lib Dems—”

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order.

Breast Implants

John Pugh Excerpts

Wednesday 11th January 2012 Commons Chamber

[Mr Lansley]

I am sorry that the hon. Lady framed her question in that way, because I thought I had made it clear that the NHS would always be there to support women. We will seek to recover the cost to the NHS if the original provider was a private provider: that approach has been adopted for years, and I am sure that it would have been adopted by my predecessors. No woman should have to feel that she will not be looked after, but I am making a different point—namely that, in the first instance, women should be looked after by the original providers, who have a continuing duty of care. They also have legal obligations—as well as the moral obligations to which I have referred—but it is not for me to advise on those.

[John Pugh (Southport) (LD)]

If the Government are paying for something that is needed, it is logical to assume that some private firms must be dodging their responsibilities. If those firms are not indemnified against the risks of surgery or willing to accept responsibility for its consequences, why on earth do we allow them to practise? Does the remedy not lie in our hands?

[Mr Lansley]

I entirely understand my hon. Friend’s point. The position we have inherited is that I have no powers in relation to the provision of private health care by private companies. As I said to the right hon. Member for Leigh (Andy Burnham), the Health and Social Care Bill provides for the establishment of Monitor as a health sector regulator that will license such providers. I am not making any judgment at this point on whether it would be appropriate for conditions to be attached to such licences in relation to the continuity of service to patients, but it is one option that we can consider.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 10th January 2012 Commons Chamber

[Mr Burns]

It is nice that the hon. Gentleman got the mantra in at the end—I have been expecting it all through this Question Time. He is wrong; what is important and what this modernisation has at its heart is the need for GPs to commission care for patients, because GPs are best equipped to know the needs of their patients. That is the way forward. Also, we are cutting bureaucracy and administration by 45% so that we can reinvest that money in front-line services. We want to spend money on health care and on improving outcomes, not on managers and bureaucracy.

[John Pugh (Southport) (LD)]

May I congratulate the Secretary of State and the Prime Minister on the productive ward initiative? The NHS document “Top Tips for spreading The Productive Ward” says:

“Set a realistic time scale. Take your time and do not rush. Take small steps and complete them before moving on to the next.”

Is this advice generally applicable to NHS reform?

[Mr Burns]

As the hon. Gentleman recognised at the beginning of his question, this is important and excellent advice for nurses and other health care professionals to give care, consideration and attention to all patients so that they can be looked after in an appropriate and caring way. That is the way forward to making the health service more responsive to the needs of patients and to the improvement of health outcomes.

Life Sciences

John Pugh Excerpts

Monday 5th December 2011 Commons Chamber

[Mr Lansley]

I am grateful for that question. What we are setting out is hosted by the Medicines and Healthcare products Regulatory Agency, which will be able to link datasets for which it is responsible, which do, in some cases, have a UK basis rather than an England-alone basis.

[John Pugh (Southport) (LD)]

I welcome the statement. The Secretary of State mentions telehealth, which is currently making greater progress in Scotland than in England. Has this anything to do with less structural reform or more strategic leadership?

[Mr Lansley]

My hon. Friend might like to know that while initial and very positive steps were taken in Scotland —for example, in Lanarkshire—we have now undertaken, through the whole system demonstrator pilots, the world’s largest randomised control trial of telehealth technology, and that gives us a strength from which we can develop telehealth systems that is unparalleled anywhere in the world. In so far as there is a capacity to provide telehealth systems and provide for their use across health care systems, I suspect that we shall shortly see England overtake Scotland in that respect. It is a form of competition that I am perfectly happy to be engaged in—and if the Scots can do better than us, then good luck to them. However, we are showing, through these pilots, how we are ready to go at developing something of great benefit to patients.

Social Care Funding

John Pugh Excerpts

Thursday 10th November 2011 Westminster Hall

[Tony Baldry]

I agree entirely with my hon. Friend, but I think that we have all slightly lost track of the number of Green Papers, discussion documents and other things that we have had in relation to social care. What will be really important next spring is that we get a White Paper that has a summary that everyone can understand and that makes it very clear what will be the basic system for funding residential social care for the future. I think that that would be greeted in the House by a quick rendering of the “Hallelujah Chorus”.

Following my hon. Friend’s point, if the White Paper can set out the direction of travel for the rest, that would be good news. What we have seen all too often in the past is a discussion paper that concludes that the issue is so huge and so difficult that we have almost lost the will to live. Spring 2012 has to produce a White Paper with a clear commitment to the funding of long-term residential care, and then direction of travel for the rest is important.

Finally, I agree with the need to enhance the status of care workers. In my experience, the model adopted by many residential care homes has often been to recruit people from the Philippines or eastern Europe. The deal was that they came over, got trained, were often paid the minimum wage and, having been trained, worked in the national health service. Because the Government, perfectly understandably and quite rightly, are capping immigration from outside the European Union, it is no longer possible for nursing homes and residential care homes to recruit from the Philippines or outside the European Union, so we have to enhance the status of care workers, both in the NHS and in residential care homes.

On my patch, I have suggested to the chief executive of the Oxford University Hospitals NHS Trust—I am glad that he has responded positively—and others that we should consider setting up in Oxfordshire one of the new Government’s work academies, specifically for care workers. We need to ensure that far more people see care and working in the care sector as a valued profession that makes a real contribution to society. It needs a career path, with a national vocational qualification, training and proper involvement from further education colleges. The issue is of as much interest to the national health service as it is to residential care homes, because if those care homes have sufficient care workers it will be easier for discharges into them to take place. Moreover, we often need to ensure that the NHS has sufficiently well-motivated and well-qualified nursing care assistants. I hope that we will begin to see centres of excellence around the country that will train people as care workers, to ensure that we do not find ourselves in difficulties because nursing homes and residential care homes have to close because they cannot recruit qualified staff.

[John Pugh (Southport) (LD)]

Would not the consequence of that be that care homes would have to pay better wages than they do at present? The hon. Gentleman has mentioned people from the Philippines. I had some in my constituency who were allowed to stay provided that they were paid for their qualifications, but the care homes refused to do so in some cases.

[Tony Baldry]

The management of any sensible care home will want to ensure that it invests in its staff. It has a duty and responsibility to do so. It has to play its part in ensuring that it, like any employer, helps with the required skills, qualifications and training of those people. This is an important issue and one that we have to get right if we are to have proper levels of care in the community, of residential nursing home care, and of care in the NHS.

--- Later in debate ---

[Margot James]

I thank the hon. Gentleman for his intervention. It is true that a £100,000 threshold would provide protection, and I hope very much that we can afford that element of Dilnot’s proposals. That threshold would provide a huge amount of help and protection for just the sort of cases that he and the hon. Member for Lewisham East mentioned.

Turning to the cap that Dilnot recommends, I believe that it should be rethought. He said that it should be between £25,000 and £50,000, beyond which no one should have to pay. Although my suggestion would introduce some complexity—I accept that that is a disadvantage—we must consider a scale on the cap that is linked to people’s assets. A one-size-fits-all approach, whether it is £50,000 or £25,000, does not reflect the huge variation in house prices throughout the country. The average house price in Dudley borough in my constituency is £145,000, but the average house price in Greater London is £420,000, so for families in my constituency, and perhaps in that of the hon. Member for Luton North, the cap on care represents a third of their assets, whereas for families in London in a house with an average value it represents little more than 10% of that value. That is unfair, and I hope that the Minister and his team will look at ways in which the problem can be overcome.

I am afraid we will to have to ask more of people who have seen the value of their home spiral over the last 25 years. I trust that with better use of resources, and thanks to Dilnot and the Government’s commitment to seek a cross-party solution to the vexed problem, we will no longer have to ask people to sell their home to fund their care. However, if we cap the amount that people must spend on care, we may have to ask them to remortgage part of the value of their home to contribute to the overall cost that Dilnot recommends. I cannot see a magic pot of £1.5 billion in the Government’s credit balance, so we must be realistic in what we ask them to do. Asking people to remortgage part of the value of their home to contribute to their care is not as bad as the current system, which requires so many to have to sell their home and to invest so much of the proceeds, if not all, in residential care costs.

In conclusion, the reaction to Dilnot has not been as favourable among health and social care managers as it has been among those of us, including organisations outside Parliament, who campaign on behalf of older people. They fear that they will have to find money from their cash-strapped adult and social care budgets. As the other main activity outside residential care is home care—I have described a situation that is far from satisfactory, as have other hon. Members—they fear that there will be less money to fund home care if they have to implement the Dilnot report to fund the higher cost of residential care. I share that concern.

What else can be done? I have said that I do not expect the Government magically to conjure up £1.5 billion in the serious and perhaps worsening economic situation. We must find a better way of managing our resources, and that money must probably come from one of the only protected areas of Government spending—the NHS. Hon. Members have mentioned that the Government have diverted £1 billion from the NHS to social care, and that has been well received, but I do not believe that it goes far enough. NHS spending has risen hugely in the past 10 years, and 27% for the six-year period does not cover the half of it. It does not cover the private finance initiative costs, which have been astronomical.

Too many older people in hospital would be better managed in the community. We have heard about bed-blocking, and that occurs in Dudley borough. People are waiting for residential care places, but the funding is not coming through to meet the need. That funding should be reconfigured more substantially in favour of community care. Many experts who know more about the NHS than I do—the King’s Fund, some hospital consultants and so on—recognise that we have too many hospitals. I am not saying that there is an easy answer, and no one wants hospitals on their patch to be closed, least of all me, but there may be a way of utilising that space and resource more effectively. I urge the Minister to discuss that with the Secretary of State to see what can be done. That would be a more fitting tribute to the Dilnot inquiry than trying to implement every detail in his report.

[John Pugh]

rose—

[George Hollingbery (Meon Valley) (Con)]

rose—

--- Later in debate ---

[John Pugh (Southport) (LD)]

I congratulate the hon. Member for Truro and Falmouth (Sarah Newton) on securing this debate and on introducing it so lucidly. I do not know whether any hon. Members, apart from me, attended an event in the House earlier this week called, “Preparing for Old Age”, and organised by Age Concern and the Prudential. As I went in, I picked up various brochures with rather grim titles such as “What to do when somebody dies”, “Paying for care costs”, “Insuring against ill health” and “Coping with dementia”. I looked in vain for something called, “How to have fun in your 90s”, but there seemed to be nothing about that.

We are fortunate to have a Minister to respond to the debate who has a distinguished record in this area, both when in opposition and as a Minister. My reputation in this area has been somewhat more ignominious. I was in Richmond house for the first time when, as leader of the Liberal Democrat group on Sefton council, I was summoned with other party leaders for a dressing down by the then Minister, Lord Boateng, subsequent to a law case that had gone against Sefton, which was not an uncharacteristic event.

We were taken to court by, I believe, Help the Aged, because we took the view that we could resource care needs only according to the resources that the Government had allowed us. We lost the case, and went to Richmond house to explain our side of the story. We were called into a room and waited patiently until the Minister breezed in, gave us a dressing down, told us how tough the Labour party would be with councils henceforward, and sent us on our way. The interesting point is that the press release hit the streets even before we had left the room, so clearly it had been written considerably prior to the event.

Later, when I became leader of the council, I rationed the number of care homes, which were rather more expensive in the public sector than in the private sector, and found that my Labour opponent—he is now the distinguished deputy leader of Liverpool city council—had gone to the press and engineered a photograph showing a 100-year old resident with a placard saying, “Please do not close my home, Councillor Pugh”. Unfortunately, we did close it, because it had been endowed to the local authority and was unsuited for its purpose. It was costing us twice as much to run, as indeed were some private sector homes then.

Only the other day, Sefton council had a judgment against it when the freezing of care home fees was ruled to be unlawful. It is a balanced council with three parties in the cabinet. The managing director of the solicitors who took the case against Sefton council said,

“There is every reason to believe other councils are doing exactly the same as Sefton.”

Sefton responded by saying that the court was merely critical of some elements of the process. Sefton is a borough with the 13th highest proportion of people aged 65. The bulk of its controllable budget—it has many contracted-out services—is taken up by social services. Sefton unexpectedly had £30 million up-front costs to find by way of savings. It is completely unthinkable that that could be done without eliminating other departments and without affecting social services in some way. Funding social care is a difficult problem. That is what I have learnt.

[Kelvin Hopkins]

We hear constantly about the difficulty of funding. The amounts we are talking about are very small in the overall scheme of things. The £1.7 billion for Dilnot would be less than half a penny on the standard rate of tax—that is the equivalent. Free long-term care for all would be 2p on the standard rate, which is what my right hon. Friend the Member for Kirkcaldy and Cowdenbeath (Mr Brown) cut the standard rate by before the election. We are not talking about massive amounts. I have spoken to many groups, and if I ask, “What do you prefer—the fear that you could have your house taken away to pay for granny’s care or paying 2p on the standard rate?” time and again they will all say, “2p on the standard rate”.

[John Pugh]

We all accept that, whatever it may amount to in the round, it is hard for local authorities to meet their care costs within current budget constraints. It is hard for NHS hospitals that suffer because of people who should not be staying there, who they recognise ought to be in care, but it is sometimes cheaper to keep them in the hospital rather than anywhere else, which is not in the hospital’s interest. It is hard for families who have the job of fulfilling caring responsibilities, which can conflict with employment, and it is difficult if they live at some distance from their elderly relatives, as they tend to these days. It is particularly hard for the individuals in need of care and who have increasing costs set against diminishing resources. It will not get any easier for the reasons hon. Members have already rehearsed: an extension of what we might term our declining years; the demographic bulge that we have all spoken about; many carers are taking up their responsibilities at an age at which they are not in, let us say, the first flush of youth; and in terms of social policy we are discovering that neither community nor personalised care are cheap options.

Nevertheless, society has made some significant achievements. Since the great Liberal Government of the early 20th century, the state has underwritten the fundamental problems that used to afflict old age—poverty and infirmity—by providing a safety net. When that reform was introduced, there was the presupposition that families would continue to accept responsibility for elderly members—they usually did—and that people would also look out for themselves to some extent. The old age pension was a mechanism to ensure that they could do that, and people had the opportunity to take still more precautions via provident societies and so on.

However, we have moved on and today we have two central problems. I do not think I have heard other problems apart from these. The fundamental problem that has been cropping up in this debate is that, assuming the system meets basic needs, which I guess it does at the moment, there is the capacity of those needs to become so severe that they can wipe out people’s inheritance, and many people regard that as not in the order of things and not how things should be. There is the other problem, which has not been touched on to the same extent, but I get it in my constituency: a sense of injustice about what might be called the free-rider problem. People have told me that they have saved for their old age, and as a result they feel that they have been penalised, because people who have made no effort to save, or who have blown the money prior to reaching an age when they might need it, get the benefits that the savers are to some extent denied. Those two problems seem to linger around the system.

[George Hollingbery]

Perhaps the problem is even deeper. People in my constituency surgery do not just say that they think others have had a free ride; they say that they are actively advising younger people and their families not to save for old age, because it is no longer worth doing so. Plainly, the system is stacked so far to the advantage of those who do not save that people should not save at all.

[John Pugh]

The hon. Gentleman has usefully illustrated my point. We can argue that the state does not have a duty to preserve a family’s inheritance, notwithstanding the valiant defence of inherited wealth from the hon. Member for Luton North (Kelvin Hopkins). In normal circumstances, that is an unusual stance for him to take.

[Kelvin Hopkins]

I was defending the small amounts of inherited wealth for relatively poor people, not the vast amounts inherited by very wealthy people. I would substantially reduce the threshold for inheritance tax, but my party would not agree.

[John Pugh]

We might dispute the borderline between the wealthy people who do not deserve it and the not so wealthy who do, but we have a system in this country, unlike in Germany, where the family has no legal obligation, and we ought to be alert to that. We have already heard in the debate about how some families, in seeking to preserve their inheritance, actually support their elderly relatives, which sometimes is a laudable and desirable outcome. On the free-rider problem, we can argue that, in allowing a reasonable level of retained capital prior to benefits, there is a reward for people if they show a degree of providence. Those who have more than that and therefore do not benefit to the same extent might regard themselves as not simply provident but fortunate.

I am not certain that Dilnot fully addresses the problem. It is too dramatic to say that people have the choice of dying or destitution, or dying before destitution or whatever. Realistically, the option that most people fear is the reduction of their resources to the level that they become solely dependent on the generosity of the state. It seems to me that that is what Dilnot seeks to avoid or prevent. It attempts to deal with the problem that Members have spoken about, which is the total wipeout of a life’s accumulated family resources. The issue is whether Dilnot’s proposals to cap people’s costs have produced a scheme that is both affordable and socially just. It can be argued whether, if someone is vastly wealthy, the cap ought to apply to the same extent.

Whether Dilnot is affordable is not a question that is easy to answer. Does it depend on front-end costs being picked up by adequate and affordable insurance schemes? It depends on the insurers being willing to offer such products. I have spoken to insurers who would prefer to offer annuities or suchlike arrangements, and who question whether they will be in the market to provide the products that Dilnot requires. The other issue is what counts as front-end costs, because we exempt things such as hotel costs. It may be some appreciable time before people get to Dilnot’s benchmark of £35,000, or, if they take out insurance, premiums may be higher than we currently imagine. Asking whether Dilnot is affordable is like asking how long a piece of string is. As the hon. Member for Stourbridge (Margot James) illuminated in her speech, it depends on where we set the lines.

Certainly, what is more affordable to Government is likely to be less attractive to individuals and their families, or might be more problematic for insurers. However, the one thing that we all accept, if we ever redesign Dilnot, is that there is a genuine need for cross-party consensus to work out what blend of insurance risk Government and individuals can support.

That is another point we must consider, and perhaps we have not quite got there yet. I understand the cynicism about what the Treasury may or may not be prepared to do, but before it works out what it can afford, we need a degree of consensus concerning what the state’s role should be on this issue. We need to know not only about the state’s detailed implementation of the policy, but what the purpose of the state is in this business. We must look at how we intervene, and at how we wish to intervene.

--- Later in debate ---

[Liz Kendall]

I could not agree more. The deal must not be done behind closed doors. There has to be a discussion between political parties, but most importantly, there has to be a discussion with the public—not just the current users of the system and their carers, but people who are not in the care system and younger people, who are working now and who will have to understand the issue. We have to have a full and proper debate.

[John Pugh]

During the previous general election, we all had a number of hustings meetings. Whenever the topic cropped up, a theme that came across forcibly from all members of the public was that they wanted the parties to discuss the issue together and that they were rather saddened by what happened immediately before the election.

[Liz Kendall]

I was not a Member of Parliament then, but from my own experience in hustings, I think that people feel let down when such an important issue becomes a political football. The hon. Member for North Norfolk (Norman Lamb), who was the health spokesperson for the Liberal Democrat party at the time, did not engage in that kind of behaviour. I do not want to go over old ground.

We need to discuss the matter, but it will be difficult. We all know what politics is like, and how parties use things to get at the other side. The issue will not be easy—it is about public spending and implications for individuals. What will they and taxpayers have to pay? We would be kidding ourselves if we thought that the issue would be an easy one.

I agree with all hon. Members who have said that the issue is one of the biggest challenges that we face, even if that is a cliché. We all think about it for our constituents and in our own families. I think about it, as many other hon. Members do, for myself, as I hope to live to a ripe old age. It will be a difficult challenge, but I hope that today’s debate shows that we are at least prepared to engage with the difficult issues to take the debate forward.