Human Medicines (Amendment) Regulations

Jonathan Ashworth Excerpts

Monday 18th March 2019 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I beg to move,

That the Human Medicines (Amendment) Regulations 2019 (S.I., 2019, No. 62), dated 14 January 2019, a copy of which was laid before this House on 18 January, be revoked.

This motion concerns the serious shortage protocol. I thank the business managers for allowing time for this debate, but it really should not have come about as a result of the Official Opposition tabling a prayer against the regulations. The Government should have brought these proposals to the House for full debate and scrutiny, because the serious shortage protocol is perhaps one of the most far-reaching and contentious of the Government’s changes to medicines regulation in recent times.

The Government are using Henry VIII powers to enable Ministers to issue a serious shortage protocol for pharmacists to follow. The Department of Health and Social Care has stated that the protocol

“could be issued…in instances of serious national shortages and would enable community pharmacists and other dispensers to dispense in accordance with the protocol—rather than the prescription—without contacting a GP.”

These reforms represent a quite extraordinary power grab whereby Ministers can grant themselves the authority to instruct local pharmacists to ration drugs, overrule the GP’s prescription and dispense therapeutic generic equivalents or reduced dosages in the event of a medicines shortage.

[Norman Lamb (North Norfolk) (LD)]

Is the hon. Gentleman aware of the particular concern among people with epilepsy, who require absolute consistency of supply and for whom any change in medication can have dire consequences? The brilliant organisation SUDEP Action has raised very specific concerns about the risks to people with epilepsy.

[Jonathan Ashworth]

I thank the right hon. Gentleman. He is quite right to raise those concerns about patients with epilepsy, which I will touch on in the course of my remarks, echoing the point that he made with great eloquence.

These changes represent an extraordinary power grab. Ministers should have brought them to the House for proper scrutiny, and then, of course, they should have gone out for proper consultation with patients, patient groups and health stakeholder. That is why the Academy of Medical Royal Colleges stated that it is

“inexplicable and unacceptable that an issue of this importance is not the subject of wide consultation and that medical royal colleges as doctors’ professional bodies were not specifically engaged in the process.”

The British Medical Association said that it

“should have far more time to adequately consider the Government’s proposals for change.”

That is why we have brought this prayer motion and why I am pleased that we have the opportunity to debate these proposals today.

It is worth saying a word about the context in which we debate these proposals. Notwithstanding the confusion on the Government Benches about when we actually do exit the European Union—the Under-Secretary of State for Exiting the European Union, the hon. Member for Spelthorne (Kwasi Kwarteng) has given us no greater guidance today in his remarks at the Dispatch Box—it is worth recalling that, as The Lancet said only last month, Brexit, especially a no-deal Brexit, will affect the healthcare workforce, NHS financing, the availability of medicines and vaccines, the sharing of information and medical research.

Our effective joint working with our European partners has been vital for the NHS over recent years, in everything from infectious disease control to the licensing, sale and regulation of medicines. Developing new medicines depends on the international co-operation that is fundamental to accessing clinical trials. Patients in the UK are currently able to access EU-wide trials for new treatments, and the UK has the highest number of phase 1 clinical trials across the EU.

Thanks to the strength of our pharmaceutical base, every month, 45 million packs of medicine move from the UK to the EU, with 37 million packs going from the EU to the UK. We know that 99% of the insulin used in the United Kingdom is not manufactured in the UK. Current EU legislation allows for the legitimate trading of medicines quickly and swiftly cross-border, but the cost of no deal could see pharmaceutical products subject to 44 separate checks and controls at the borders, hugely delaying access to medicines.

[Daniel Zeichner (Cambridge) (Lab)]

My hon. Friend is making some very important points. I wonder whether he has seen the advice from the UK BioIndustry Association, which knows what is going in the life sciences sector and says:

“Despite the expertise and efforts of the MHRA…with 12 days …until Brexit, being prepared for a ‘no deal’ is an impossible task”.

[Jonathan Ashworth]

I thank my hon. Friend. As the Member of Parliament for Cambridge, he works very closely with the life sciences and pharmaceuticals industries and is a great champion for them. He is quite right to raise those concerns—although it is not clear if we are leaving in 12 days because, as I said, the Minister at the Dispatch Box earlier was pretty hopeless in giving the House any clarity on that matter. I suppose we will have to wait for further statements from the Government tomorrow, unless the Health Minister wants to clarify matters for us in a moment.

One of the issues that the organisation my hon. Friend mentioned is concerned about is the parallel trade in medicines, where pharmaceutical exporters seeking to profit from currency fluctuations could see medicines intended to meet UK patient requirements being quickly distributed out to the EU because of the advantage that a fall in sterling, perhaps, could accrue to them in those circumstances. This is why we have seen widespread concerns about medicine shortages in the event of no deal.

[Dr David Drew (Stroud) (Lab/Co-op)]

This is not something just for the future. I am already getting reports that certain medicines are in short supply, and patients are being advised to go back to their GPs to see if there are alternatives because somebody somewhere is already stockpiling and there is not the flow through. Does my hon. Friend accept that?

--- Later in debate ---

[Jonathan Ashworth]

My hon. Friend raises a very important point. There have indeed been reports of shortages in certain medicines. In recent weeks, we have heard of shortages of Naproxen, an arthritis medicine, with similar reports about EpiPens a few weeks ago. I have heard from some community pharmacists, directly themselves, that there is even an shortage of aspirin. I emphasise that these are anecdotal reports rather than information based on any national reporting that I have seen—this is what community pharmacists have told me when I have been in their pharmacies discussing this with them—but yes, there are shortages now as a result of the uncertainty in the pharmaceutical market.

Diabetes UK has warned that

“despite reaching out directly to the Department of Health and Social Care in December, we still have not seen the concrete detail needed to reassure us—or people with diabetes—that the UK Government’s plans are robust enough to guarantee no impact on insulin and medicine supplies in the event of a no-deal Brexit.”.

It was a similar story from the epilepsy bodies, who said:

“We do not have confidence in the current arrangements to ensure the continuity of life-saving medications for people with epilepsy.”

The Government have sought to reassure patients that their contingency plans are failsafe, but the report in The Lancet that I referenced earlier also said that

“stockpiling arrangements cannot cope for more than a few weeks.”

It also noted that some affected products, such as radioisotopes needed for treating some types of cancer, simply cannot be stockpiled. This chimes with the Royal College of Radiologists, which last month issued staggering concerns about the supply of medical isotopes, spelling out how the expected disruption would force clinicians to alter treatment plans and mean the prioritisation of some cancer patients over others. That is why the Government are proposing the serious shortages protocol contained in this statutory instrument and effectively using Henry VIII powers to enable Ministers to issue a protocol to pharmacies for them to follow.

As I said, this is an extraordinary power grab. It will effectively mean that a GP’s prescription can be changed by a pharmacist. No longer would a medicine be prescribed by a doctor who knows the medical history of the patient but instead by a pharmacist acting in accordance with a protocol drawn up by the Government. That is why these emergency measures have, quite rightly, raised alarm among various patient groups—because these changes could cause real problems for people with long- term conditions.

[Anne Marie Morris (Newton Abbot) (Con)]

Does the hon. Gentleman accept that it would be sensible if there was a sunset clause, because clearly giving that much power to a pharmacist as opposed to a physician who knows the patient is very dangerous if it is to be used for the long term or perpetually and not just to deal with the current crisis?

[Jonathan Ashworth]

The hon. Lady makes an entirely reasonable observation. I trust that the Minister took note of it and look forward to her reply to that point.

[Norman Lamb]

Does the hon. Gentleman agree that this puts individual pharmacists into quite an invidious position because they may well be having to make decisions that may impact adversely on a patient’s health and wellbeing when they are not necessarily skilled to make those judgments? My concern particularly relates to epilepsy but it applies to other areas as well.

[Jonathan Ashworth]

The right hon. Gentleman hits the nail on the head. That is exactly the point that has been put to me when I have visited community pharmacists and discussed this with them. Of course there are other pharmacists who have perhaps done more training and want to work at the top of their licence and believe that there is a role for more autonomy. However, there are real concerns about the way in which these changes are being rushed through without any resource put into education, explanation or wider training that may be needed. In those circumstances, it is appropriate that we raise our concerns, support our motion and oppose the Government’s proposal today. He is absolutely right—I have heard that concern expressed directly. Many community pharmacists do not necessarily want this responsibility, given the wider concerns and implications that he highlighted.

[Helen Goodman (Bishop Auckland) (Lab)]

The point made by the right hon. Member for North Norfolk (Norman Lamb) raises two issues. First, what is the point of doctors having all this training if anybody without it is suddenly able to dole out prescriptions? Secondly, are pharmacists insured, and is there an insurance scheme for them if they make mistakes? Doctors have a professional insurance system, and pharmacists presumably have a completely different one.

[Jonathan Ashworth]

My hon. Friend is right. That is exactly the point that community pharmacists put to me in Loughborough about three weeks ago when I visited them to discuss this. Echoing her point, the BMA has said that it does not support a “blanket approach” to allowing pharmacists to provide therapeutic equivalents where a prescribed drug is not available. The National AIDS Trust has said:

“The only person qualified to safely alter the medication prescribed to a person living with HIV is that person’s HIV consultant.”

SUDEP Action, alongside a broader coalition of epilepsy charities, is particularly worried about these proposals.

After facing pressure from those groups, the Government accepted that replacement drugs were unsuitable for epilepsy patients, but they have left it open to pharmacists to reduce the strength or dosage of epilepsy medication. I am not convinced that that will eliminate the big risks faced by these patients. As the right hon. Member for North Norfolk (Norman Lamb) said, many patients with epilepsy—especially the elderly—are on other medications, and any changes require careful management because of the interaction between different medicines. Up to 90% of people with epilepsy state that even a deterioration in their mood can have a negative effect on seizure control. Anti-epileptic medications have more significant interactions than any other group of drugs.

There are situations where the specific brand, type, form or strength of a treatment must be carefully tailored to the individual based on their responses, which is done by the prescriber and the patient over time. If that is changed by a professional who does not know the patient or their individual risks, some have warned that the consequences could be a loss of control of the condition, failed treatment and an unnecessary emergency, with very serious consequences indeed.

[Anne Marie Morris]

The hon. Gentleman is making a first-class point. This puts patients at risk, and it is not appropriate for the pharmacist to make that decision. People think that generics are the same thing as branded drugs, but they are not. For some, a particular brand is crucial. I commend him for what he is doing.

[Jonathan Ashworth]

I am flattered to receive such commendation from the Conservative Benches, and I commend the hon. Lady for her extremely well-made point, with which I agree entirely. I hope that the Minister will respond to the second good point that the hon. Lady has made.

The stakes are too high to get this wrong, yet there has been no impact assessment or risk assessment undertaken on serious shortage protocols for this statutory instrument. This is an unacceptable risk to anyone with a long-term condition and should be recognised by anyone making contingency plans. I was particularly horrified to read in the explanatory memorandum for this SI—it is quite shocking:

“The main benefits of the protocol would be the NHS cost savings associated with GP time.”

In the same breath, it casually goes on to say:

“There may be some risks to patients”.

That is in the Government’s own paperwork. It is astonishing. How can the Government seriously prioritise NHS cost savings over patients’ lives and allow an explanatory memorandum to go out with that sort of wording in it? I hope that the Minister can explain how that got in there and at least reassure us that it is not the Government’s position. If it is the Government’s position that there may be some risks to patients, that suggests that the Government should have come to the House sooner to explain why they are making this regulatory change and not left it to the official Opposition to table a prayer motion to get this debate.

I would like clarity from the Government on a few things. It is not entirely clear from the legislation exactly when these powers would be used. I would like to hear from the Minister whether these powers will be introduced in a no-deal Brexit scenario only or whether we can expect them to be more permanent. I am also concerned that there will only be a review of new powers one year after a serious shortage protocol is issued by Ministers. This speaks to the point made by the hon. Member for Newton Abbot (Anne Marie Morris). One year is too long to wait if this causes serious problems for patients and the wider sector.

Considering that the stakes are so high, it is be essential that the Government deliver extensive communication and training to GPs, pharmacists, other healthcare professionals and the public, to help them understand any new protocols and manage expectations and any dissatisfaction. I would be grateful if the Minister outlined the Government’s plans. I talk and listen to frontline NHS staff all the time, and I know that there is a well-founded fear about the implications of a no-deal Brexit for hundreds of thousands of people in need of life-saving medicines. I am interested to hear from the Minister what information about these protocols has been shared with the health sector and professionals involved.

When the Secretary of State gave evidence to the Health and Social Care Committee a few weeks ago, he informed it that he will prioritise medicines over food. That glib assertion from the Secretary of State hardly offered the reassurance that patients deserve. Brexit should not compromise patient safety in any way. It is up to the Minister to allay the widespread concerns, but if she is not able to do so, we will test the opinion of the House. I commend our motion.

Integrated Care Regulations

Jonathan Ashworth Excerpts

Monday 18th March 2019 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I beg to move,

That an humble Address be presented to Her Majesty, praying that the Amendments Relating to the Provision of Integrated Care Regulations 2019 (S.I. 2019, No. 248), dated 13 February 2019, a copy of which was laid before this House on 13 February, be annulled.

I am grateful that we have found time to debate this prayer motion in my name and the name of my right hon. Friend the Leader of the Opposition. For the Government to have attempted to make these changes without proper scrutiny is a huge discourtesy to the House. These changes are fundamental, with potentially far-reaching implications for the NHS, and they have aroused concern—[Interruption.]

[Madam Deputy Speaker (Dame Eleanor Laing)]

Order. It is not fair to the hon. Gentleman that people who have voted are now having conversations here. I would be grateful if people who wanted to talk about other things left the Chamber.

[Jonathan Ashworth]

The changes in the regulations have aroused considerable concern in the country, and proper parliamentary time should have been made available for a proper debate on them; they should not have been made through secondary legislation.

The Opposition oppose the regulations and will seek to test the House’s opinion on them. We oppose the changes not because we are against integration. We have long called for greater integration of services to offer seamless care to patients, because the demands on the NHS are of a different nature from those of 71 years ago, when a Labour Government created the NHS with a tripartite structure. In those days, life expectancy was so much shorter, and infectious disease was the overwhelming medical challenge. In 2019, we are worlds away from the days when 30,000 hospital beds were set aside for the treatment of tuberculosis, or when wards were filled with row after row of iron lungs to treat those suffering from polio. Today, we are all living longer, with a variety of complex conditions, from diabetes to cardiovascular disease and chronic obstructive pulmonary disease—conditions that increase the risk of a poorer quality of life and mean a greater risk of premature death. Indeed, around 14.2 million people in England—nearly a quarter of all adults—have two or more conditions. More than half of hospital admissions and out-patient visits, and three quarters of primary care prescriptions, are for people living with two or more conditions.

The issue is not just ageing and frailty; poverty takes its toll. People in the most deprived areas of England can expect to have two or more health conditions at 61 years—10 years earlier than people in the least deprived areas. Health inequalities are widening, while advances in life expectancy are stalling. An ageing population, the increase in long-term conditions, and the increasing number of people with multiple health conditions means that we need to integrate services. Sometimes in these debates, when we talk of long-term conditions, we suggest that we are talking about a homo- geneous group, but it is quite the opposite. We could be talking of a 61-year-old man with renal failure and high blood pressure, or a 101-year-old woman with profound deafness and blindness. The way that such conditions affect quality of life, and the extent to which they are amenable to medical intervention, is likely to vary.

If health services are not better co-ordinated and not integrated, there is a greater risk to patient care through the poor co-ordination of medical care and increased time spent managing illness. The need to manage multiple medications may lead to poorer medication adherence, adverse drug events, and the aggravation of one condition by the symptoms or treatment of another. It can also mean damaging self-management regimes in which there are competing priorities, and a bewildering landscape for patients, who are often of an advanced age, with cognitive impairment and limited health literacy, so we support integration.

I have seen integration working on the ground. Just last week, I was in Bolton, where I visited the Winifred Kettle centre to see the model of integrated multi-agency work bring together mental health professionals, pharmacy, physio, occupational therapy and social workers. In Bury, I heard about how the local council’s chief executive doubles up as the chief executive of the clinical commissioning group. In Luton and Dunstable I saw with my own eyes that the hospital trust has various social care workers in its discharge unit, helping to avoid the indignity of huge numbers of elderly patients being trapped in hospital, ready for discharge but delayed for days on end, as happens too often. In Wolverhampton, a fascinating example is being developed: the hospital trust is taking on and employing GPs directly. In Wolverhampton, they call it vertical integration, although some might wish to go as far as to suggest that it is the nationalisation of general practice, something that not even Nye Bevan was able to achieve.

A Labour Government would move away from a competitive landscape of autonomous providers to one of area-based care delivered through integration, collaboration, partnership and planning. We will restore a universal, publicly provided and administered national health service. Locally, we envisage something akin to health and care boards, with a duty to provide health not only for those on a CCG list but for all residents. Nationally, the Secretary of State’s duty to provide care will be reinstated. We are consulting on these matters with patients, staff and wider stakeholders.

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

Very quickly, does my hon. Friend not agree that the big problem with integration, if we support it, is the lack of funding, and the lack of proper training in the various disciplines? Only a couple of years ago, there was a cut in the funding for pharmaceuticals.

[Jonathan Ashworth]

My hon. Friend makes a very important point. Integration is not about saving money. For integration to work properly, it needs to be fully funded, and, of course, the NHS has been through the biggest financial squeeze in its history. We do not oppose integration. Indeed, that is why the previous Labour Government introduced a section 75 partnership arrangement, and why we were so vociferous in our opposition to the Andrew Lansley Health and Social Care Act 2012, which went completely counter to international evidence and exacerbated local fragmentation of health structures. It is a delicious irony that Ministers, all of whom were dragooned through the Lobby to support the Lansley Act, despite expert after expert warning them what a mistake it would be to press ahead with it, are now trying to propose regulatory changes, so that we can essentially work around that Act. The reason why we cannot support the regulations today is that the most damaging part of that Act is still on the statute book.

[Tracy Brabin (Batley and Spen) (Lab/Co-op)]

On the point about the Health and Social Care Act, a third of the contracts have been awarded to private providers, and millions were wasted when they collapsed. The explanatory memo for this statutory instrument says that it is expected that organisations holding an integrated care provider contract will be statutory providers, such as NHS foundation trusts, but that is not legally binding. To protect our NHS, do we not need to know definitively that providers will be public, not private?

[Jonathan Ashworth]

My hon. Friend is absolutely right. Of course, the Minister cannot give that reassurance because of the Lansley Act that Ministers voted for in 2011.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

I am only sorry that I cannot be with my hon. Friend on the Front Bench tonight. I have really enjoyed working with him; he is a fine shadow Secretary of State, and I know that he will make an excellent Secretary of State. Unfortunately, I cannot be with him, because when we on these Benches vote against the Whip, we have to deal with the consequences.

As my hon. Friend knows from many debates I have taken part in for the Opposition, despite repeated questions to various Ministers, there has been no absolutely no reassurance that the private sector will not continue to be involved in these matters.

[Jonathan Ashworth]

My hon. Friend makes his point typically eloquently and with force. May I say to him that we miss him on the Labour Front Bench? He was a real rock in the shadow Health and Social Care team. It is typical of him that when he decided last week that he could not support the Labour Front Bench position on a referendum, he took the honourable course of action and chose to leave the Front-Bench team. I think that he has the respect of many in the House for that position.

This is the nub of our opposition tonight. Contracts are still being put out to competitive tender, even when some commissioners claim that they do not wish to do this. Here lies the danger: nothing prevents, and some things might encourage, these integrated care partnership contracts being put out to tender and perhaps being won by a private sector provider. Ministers repeatedly tell us that ICPs, and before them accountable care organisations, are not about ushering in a further role for the private sector. If that is the case, and if patients and staff are to have confidence that the ICP contracts will not end up in private hands, the Government’s overarching competition legislation must be changed first. As that legislation has not been changed, and as we will still have commercial contracting for the delivery of medical services, there is a risk that a multi-billion pound contract covering hundreds of thousands of people and packaged up for 10 to 15 years could be handed over to a big provider. That is why the Health Committee, which is broadly supportive of these integrated care models, issued this warning in its report:

“The ACO model”—

it was using the terminology of the time—

“will entail a single organisation holding a 10–15 year contract for the health and care of a large population. Given the risks that would follow any collapse of a private organisation holding such a contract and the public’s preference for the principle of a public ownership model of the NHS, we recommend that ACOs, if introduced, should be NHS bodies and established in primary legislation.”

We agree.

The impetus for this contract comes from the example of Dudley, which I am sure the Minister will want to talk about. When the chief executive of Dudley CCG attended the Select Committee, even he conceded—although he said that it was unlikely—that because of the procurement rules, it would not have been possible to have kept out private providers applying for the contract. When asked whether the contract could go to a private provider, he said:

“In theory, it is technically possible for that to happen”.

Although Mr Nigel Edwards of the Nuffield Trust shared the Minister’s scepticism that the contract could go to a private provider, he did concede before the Select Committee that:

“To privatise in the sense of handing over all the assets and staff to a private contractor is a theoretical possibility.”

NHS England’s own analysis of the contract published at the end of last week concedes:

“However, it should be understood that current NHS law and EU and domestic procurement law prohibits CCGs or NHS England from taking steps, whether through evaluation criteria used in a procurement or otherwise, to disqualify certain categories of provider (e.g. independent sector providers) from bidding or being awarded commissioning contracts.”

This is our first objection, because Labour is not prepared to nod something through when there is a theoretical possibility hanging over us that, in the words of NHS England, an independent sector provider could not be disqualified from being awarded commissioning contracts.

[Liz Twist (Blaydon) (Lab)]

Does my hon. Friend agree that to cure these problems, we need not secondary legislation, but a thoroughgoing review of NHS legislation?

[Jonathan Ashworth]

My hon. Friend is right; we need to sweep away the Lansley legislation and put the NHS on a sustainable public footing. NHS England attempts to reassure those who are concerned about this contract by putting in place some further conditions. It talks about transparency and insisting on a “minimum level of assets”. Note the qualifier “minimum”—not all assets. It also talks of a

“restriction on carrying out any business other than that required by the ICP Contract”.

Again, note the words used—not a prohibition on other business activities, just a restriction. This is in the circumstance when the contract is awarded to a non-statutory provider.

NHS commissioners are obliged by law to advertise many larger NHS contracts, giving firms such as Virgin Care the chance to bid. Since the Lansley Act came in, £10 billion of contracts have gone to private providers, and there is a further £128 million of NHS tenders in the pipeline. It is all very well for the Secretary of State to go to the Health and Social Care Committee as he did a few weeks ago and say:

“There is no privatisation of the NHS on my watch, and the integrated care contracts will go to public sector bodies to deliver the NHS in public hands.”

The Secretary of State is not in a position to make that promise to the Committee, because of the legislation that is in place.

[Dr Sarah Wollaston (Totnes) (Ind)]

As my Committee has already been quoted, I think that it might assist the House if I were also to quote from the conclusions that we came to on this issue. The Committee said:

“We recognise the concern expressed by those who worry that ACOs could be taken over by private companies managing a very large budget, but we heard a clear message that this is unlikely to happen in practice. Rather than leading to increasing privatisation and charges for healthcare, we heard that using an ACO contract to form large integrated care organisations would be more likely to lead to less competition and a diminution of the internal market and private sector involvement.”

[Jonathan Ashworth]

The hon. Lady makes an interesting point. She is correct in as much as there is not currently a long queue of companies lining up to take control of whole health systems, but that could change if some new form of Transatlantic Trade and Investment Partnership is brought in by a post-Brexit deal. A number of these companies are becoming increasingly litigious in the courts, which is why Virgin Care took the NHS in Surrey to court. However, even if a private provider is not gifted a whole contract, which is the point that the hon. Lady is making, there is nothing to prevent it from buddying up with NHS bodies in joint ventures as a way of exercising influence over the way in which local health systems are configured. There is already evidence of private sector involvement in the establishment of the integrated care system, with Centene UK—an offshoot of an American health insurer—working with Capita in the Nottingham ICS.

[Karin Smyth (Bristol South) (Lab)]

Earlier in his remarks, my hon. Friend talked about confidence for people locally in what is happening in the NHS. Further to the point made by the hon. Member for Totnes (Dr Wollaston), only in February NHS England itself issued its case for primary legislative changes in which it says, with regard to these proposals, that it wants to

“start a broad process of engagement with the NHS, its partner organisations and those with an interest in how our health service operates.”

That will hopefully involve patients and the public. In Bristol, we embarked on a 10-year contract for community services on the day after the NHS plan was invoked without consultation with local people, an assessment of basic health needs or alignment with the rest of the situation. The problem is that we have yet another change that people locally do not have confidence in. It really is time for the Government to come forward with a cohesive change for the future.

[Jonathan Ashworth]

That is absolutely right. Notwithstanding the sincere views of the Select Committee, there is a lack of confidence out in the country about the way in which these commercial contracting arrangements work. We are seeing that in Bristol, as my hon. Friend so eloquently outlined. Despite the blasé attitude of the Secretary of State in the Select Committee, this is the same Secretary of State who has sat back and done nothing while a PET-CT cancer scanning contract in Oxford is privatised, leading to a fragmented service putting patient safety at risk.

[Anneliese Dodds (Oxford East) (Lab/Co-op)]

I know my hon. Friend has been working very hard on this issue. I have had droves of patients and staff contacting me with their concern about what is happening. They are astonished that this privatisation is continuing given the comments made by the Secretary of State. There seems to be no willingness at all for any challenge to NHS England’s decision, which is going above the heads of those who deliver the care and which, as my hon. Friend says, would threaten its quality and safety.

[Jonathan Ashworth]

We keep being told by Ministers, by those who are favour of integrated care and by various interested stakeholders that Labour Members are scaremongering and that we have nothing to worry about—that it is all going to be fine and all going to be in the public sector—yet at the same time we are seeing controversial privatisation after privatisation all across the country, of which the one in Oxford is just the latest example. This has happened since the Secretary of State went to the Select Committee and said that there would be no privatisation on his watch.

In south-east London, private companies are in a three-way fight for the biggest-ever NHS pathology contract—a £2.2 billion contract for 10 years. If the Secretary of State was sincere in his commitment to no privatisation on his watch, he would bring forward legislation to ensure that ICPs are statutory public bodies that are publicly accountable. He would first take the advice of the NHS itself, as embodied in the long-term plan and the subsequent proposals for legislative change, and rid our NHS of the morass of competition law and economic regulation that was brought in by the Health and Social Care Act 2012. Everyone agrees that this particular aberration has had its time.

While the NHS proposals do not yet go as far as Labour Members would want and would not resolve all the problems of the internal market and private sector involvement that our NHS struggles with, they would remove the default assumption for competitive tendering that would currently make many ICSs feel obliged to put contracts for ICPs out to tender for fear of falling foul of the competition rules. Overall, they provide a far preferable base from which to pursue integrated care than the maze of contradictions and obstacles that Andrew Lansley’s Act forced on them. Rather than this regulated change, why is the Minister not bringing forward the legislation that NHS England has called for?

I have two other quick points for the Minister. The new secondary legislation seeks to substantially change the regulations underpinning the existing contractual arrangements for the provision of NHS GP services. We should remember that general practice is already hard to recruit for and we are already losing GP numbers, yet the proposal to incorporate GP practices into ICPs appears to cut across the idea of GPs beginning to work in wider networks covering 30,000 to 50,000 patients, retaining their GP contracts but sharing common resources. That was highlighted as a direction of travel to be celebrated by the Prime Minister when launching the long-term plan.

GP practices can already network and collaborate without this new contract. The contract will offer a sweetener to GPs of new money if a GP practice signs up to the new contract, but the proposals have been opposed by the BMA. Dr Richard Vautrey has said:

“We have repeatedly expressed our serious concerns about ICP contracts which leads to practices giving up part or all of their General Medical Services contract as a result. Practices should not feel pressured into entering an ICP contract as to do so could leave their patients worse off.”

Perhaps the Minister can explain why he is correct and Dr Vautrey is wrong.

I want to make a quick point about the pooling of budgets with respect to universal free-at-the-point-of-use NHS and means-tested social care. If the boundaries between health and social care are dissolved, will the Minister mandate ICPs and clearly specify that which is considered healthcare and that which is considered social care? I raise that because we are already seeing CCGs across the country cutting back on their responsibilities to provide continuing healthcare for some of the most vulnerable people. Can he guarantee that some services currently provided free on the NHS—whether rehabilitation care or nursing care provided by district nurses, such as wound care or continence care—will not suddenly be designated as social care, so that charging creeps into the system?

[Kevin Hollinrake (Thirsk and Malton) (Con)]

The hon. Gentleman talked about the funding of social care. One of the recommendations made by the Health and Social Care Committee, in concert with the Housing, Communities and Local Government Committee, as a solution to adult social care funding, was a system of social insurance. Would he support that on a cross-party basis?

[Jonathan Ashworth]

The hon. Gentleman is a passionate campaigner for his social insurance proposal, and I have heard him make that point many times. I say to him gently that when the Government bring forward their Green Paper—I emphasise the word “when”—we will engage fully in the debate, and I am sure he will make that point then, whether the debate happens this year, next year or the year after; we will wait and see.

There is a problem with the dissolving of boundaries between health and social care and what that could mean, with charges creeping into the system for some services that were previously considered NHS services but are now designated as social care services. Is the Minister prepared to mandate ICPs, so that we have clear guidelines about that? Finally, where is the patient voice in any of this? Where are the guarantees that decisions will be made not only in public but with the public involved in the decisions that affect them locally?

We on the Opposition Benches support integration; we have long called for it. We support greater collaboration. We support the planning of health and social care delivery in local areas. We support restoring local area-based health bodies delivering care, rather than the fragmented mess we have today. We have, of course, had such bodies before—we used to have district health authorities and strategic health authorities, and some have suggested rather mischievously that we seem to be going back to what we used to have in the past.

Until the default assumptions of tendering and wasteful procurement exercises are removed from primary legislation, such secondary legislation will always create further dangers of private operators gaining control of NHS services. Until that is done, Ministers will have no one to blame but themselves if the spectre of privatisation continues to haunt their ICP plans. We oppose NHS privatisation. We oppose NHS cuts. We oppose anything that undermines the fabric of a public national health service. We oppose these regulations. We seek to annul them, and I commend our motion to the House.

--- Later in debate ---

[Jonathan Ashworth]

Will the Minister confirm that, because of the competition and procurement rules and the regime brought in by the Andrew Lansley Act, he cannot rule out the possibility of an independent provider winning a contract? He might say it is unlikely, but he cannot rule out the possibility, so why does he not introduce a measure—a simple one-clause Bill, perhaps—to give the assurances that many campaigners want?

[Stephen Hammond]

The hon. Gentleman is right: it is highly unlikely. More than that, it is stated and restated in the long-term plan that NHS England has the clear expectation that the ICP contracts will be held by public statutory providers. He knows that, and others who have discussed this point have made it clear.

--- Later in debate ---

[Lyn Brown (West Ham) (Lab)]

Should my Whip, who is not listening at the moment, wish me to sit down, he needs to indicate that to me and I will do exactly what I am told. The changes that we are discussing today are technical, but important. The creeping fragmentation and privatisation of our NHS, where more and more services are contracted out to unaccountable profit-making companies, has occurred precisely because of such obscure, technical changes.

My constituents need integrated care services across different organisations, as well as more preventive health and public health action. That is urgent, it should be a priority, and there should be legislation and full debate to make it happen. Currently, just 54% of my constituents—barely more than half—receive the breast cancer screenings they need. We have lower rates of physical activity than the national and London averages, as well as higher rates of smoking, and 44% of local children leave primary school obese. If the legislation we are talking about were just about joining up care for patients, creating genuine efficiency by avoiding duplication of services, or enabling patients to receive effective care closer to home in the community, rather than in hospital, I would absolutely welcome it.

[Jonathan Ashworth]

My hon. Friend is making an excellent speech, and I hope she continues to make an excellent speech. On the point about what is happening in east London, there is a very good integrated programme there for dealing with diabetes. The point is this: there are very good examples of integration taking place across the country without the need for this contract, which could usher in greater privatisation.

[Lyn Brown]

My hon. Friend is absolutely right. I believe, and I know he believes, that these changes are important and should not be done by statutory instrument. The goal of healthcare integration can and should be pursued with the full scrutiny provided by primary legislation.

Locally, these plans have raised huge concerns. Currently, Newham is in a sustainability and transformation partnership with seven other boroughs—Havering, Redbridge, Barking and Dagenham, Waltham Forest, Tower Hamlets, Hackney and the City of London. Those are really very different places, not only politically but in terms of age, ethnicity and levels of deprivation. Any integration plan that covers that wide an area will be incredibly difficult to get right.

I understand that the current thinking is more about dividing that eight-borough STP into three new integrated care systems, or ICSs. Newham will be lumped together with Waltham Forest and Tower Hamlets. I am very worried that pushing these areas together, with one extremely overstretched budget, will result in money being taken away from my constituents in Newham, whose needs are extremely high. If the Government were talking about enabling greater integration at local authority level, where democratically elected councillors could be properly involved, the issue would not be that much of a concern.

To be frank, I have absolutely no confidence that there would even be a proper consultation about integrating Newham into a three-borough ICS. I know that that is what local leaders expect only because I asked them about it before the debate. I am told that not one health body locally actually wanted to sign up to the STP—not one local body. But that did not matter to those who are really in control, so it was just put in place anyway as the East London Health & Care Partnership. This supposed partnership was given an incredibly complicated governance structure. Again, no one actually wanted it. That was not because health bodies do not want to collaborate; it was because this Government’s failed reforms do not have the confidence of clinicians.

There are many basic questions that need to be answered and that have not been. I have five for tonight. One, how do the Government plan to prevent fragmentation, given that there are so many different ways that these arrangements could be made? Two, how will existing borough-level partnerships slot into these new structures? Three, how are dedicated NHS staff, elected local representatives or even—horror!—patients themselves going to have control over how these structures are implemented, which areas are joined together and which services are included? Who will have that control?

Four, once one of these integrated bodies has been set up, what actual accountability will there be? As we know, public health and social care services are currently in the hands of councils. Even beyond that, many health and wellbeing objectives are the statutory responsibility of local councils too. Therein lies accountability to local people, but it is totally unclear to me how councillors will be able to hold the new ICPs to account in turn. If those new bodies are going to be responsible for making decisions, they should have to be transparent and accountable. I am not at all opposed to the integration of services, but we must create more accountability, and not risk losing the little that is currently there.

My fifth and final question is this. How will the Government guarantee to my constituents that this change will not become another back-door privatisation? How can they reassure me that the enormous, inefficient, profiteering “health maintenance organisation” monsters that exist in the United States will not be given a foothold here in exchange for, say, a trade deal post Brexit? This is what I find most offensive about the statutory instrument. Ministers have been offered the chance, time and again, to say that private companies will not be able to act as integrated care providers, and will not be able to bid for the huge contracts that will be created. But I have heard no good reason why the Government will not make those commitments.

Oral Answers to Questions

Jonathan Ashworth Excerpts

Tuesday 19th February 2019 Commons Chamber

[Matt Hancock]

Well, it is getting scrutiny and debate now. The change that is being proposed is about making sure we can get people the drugs they need. Of course the responsibility is on the pharmacist to ensure that it is the appropriate drug and, if necessary, that the GP is involved. However, it is absolutely right that we make changes to ensure that we have an unhindered supply of medicines whenever there are shortages—whether that is to do with Brexit or not.

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

The Secretary of the State spoke with his characteristic self-confidence about the supply of insulin, but at the end of last week Diabetes UK said that

“despite reaching out directly to the Department of Health…we still have not seen the concrete detail needed to reassure us…we cannot say with confidence that people will be able to get the insulin and other medical supplies they need in the event of a no-deal Brexit.”

Why is Diabetes UK wrong and the Secretary of State right?

[Matt Hancock]

Diabetes UK is not a supplier of insulin. Of course, it plays an important role in representing those who have diabetes. We have given Diabetes UK reassurances, including, for instance, that the stockpiles we have for insulin are more than twice as long as we proposed and as required. That is an important assurance.

[Jonathan Ashworth]

I hope the Secretary of State will contact Diabetes UK to give it those reassurances directly.

On the various no-deal medicines statutory instruments that the House will debate today and on other occasions, the Government’s own impact assessments say that, in a no-deal scenario, the NHS will pay more for drugs, UK firms will face more red tape, and NHS patients will go to the back of the queue when it comes to international innovation. Given that the consequences of no deal would be so devastating for the NHS, will the Secretary of State—as, apparently, the Justice Secretary will—resign from the Government if it means blocking no deal?

[Matt Hancock]

If the hon. Gentleman really cared about stopping no deal, he would vote for the deal. There is something else that is worth saying about this shadow Secretary of State. He is a reasonable man—he is a sensible man—and I like him. My politics are probably closer to his than his are to those of the leader of his party, so why does he not have the gumption to join his friends over there on the Back Benches in the Independent Group, instead of backing a hard-left proto-communist as leader of the Labour party?

NHS 10-Year Plan

Jonathan Ashworth Excerpts

Tuesday 19th February 2019 Commons Chamber

[Louise Haigh (Sheffield, Heeley) (Lab)]

The long-term plan acknowledges that life expectancy continues to improve for the most affluent 10% but has either stalled or fallen for the most deprived 10%. In Sheffield, life expectancy for the most deprived women has fallen by four years over the nine years that this Government have been in power. Does the Minister have any analysis of why life expectancy has fallen for the most deprived women on his watch?

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

Very good question.

[Stephen Hammond]

I am sure that there will be a number of excellent questions and interventions, but it was a good question. The plan sets out that all local health systems will be expected to outline this year how they will reduce health inequalities by 2023-24, and the intention is that that process will consider exactly the health inequalities that the hon. Member for Sheffield, Heeley (Louise Haigh) mentions.

Additional money for the primary sector will ensure that funding for primary medical and community health services, such as GPs, nurses and physiotherapists, increases by £4.5 billion in real terms in the next five years. That will mean up to 20,000 extra health professionals working in GP practices, with more trained social prescribing link workers within primary care networks. By 2021, all patients will be offered a digital-first option when accessing primary care. The plan also considers the future of the health system, and the new proposals for integration are the deepest and most sophisticated ever proposed by the NHS.

--- Later in debate ---

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I thank the Minister for his brevity. I am sure the House will appreciate the way in which he both took a number of interventions and made his remarks speedily. I will endeavour to copy him. [Hon. Members: “Hear, hear.”]

I start where the Minister almost concluded, by thanking NHS staff for the work they do day in, day out. He is a relatively new Minister to the post—so new that you gave him a different surname, Madam Deputy Speaker, but we will gloss over that. He inherits his portfolio after a time in which the NHS has suffered the most severe financial squeeze in its 70-year history. At one point under the Conservatives’ spending plans for national health services the money was set to fall on a head-for-head basis, although they have now revised the spending plans. Because of that financial squeeze over many years, he inherits a portfolio where 4.3 million people are on waiting lists and 2,237 people are waiting more than 12 months for treatment, more than 2.9 million people waited more than four hours in an accident and emergency department, and nearly 27,000 people wait two months for cancer treatment. The 18-week referral to treatment target has not been met since February 2016, the cancer target has not been met since December 2015, the diagnostic target has not been met since November 2013, and the A&E target has not been met since July 2015. Those targets are all enshrined in the NHS constitution and in statute, and they were routinely delivered under the last Labour Government. Under this Government, they have, in effect, been abandoned.

[Gloria De Piero (Ashfield) (Lab)]

People in my constituency have to wait longer than most people in the country for a GP appointment: 23% waited more than two weeks; and 15% waited more than three weeks. Does my hon. Friend agree that one of the many brilliant things the last Labour Government did was introduce the 48-hour target to see a GP?

[Jonathan Ashworth]

The last Labour Government put record investment into the NHS, which was voted against every step of the way by the Conservatives. That Labour Government delivered some of the best waiting times on record and some of the highest satisfaction ratings, and they increased access to GPs in constituencies such as Ashfield.

The A&E standard is important not only for patients waiting in an overcrowded A&E but because it tells us much about flow through a hospital. Last week we had the worst A&E performance data since records began, with just 76.1% of those attending type 1 A&E seen, discharged or admitted to a ward in four hours. Behind the statistics are stories of patients left waiting in pain and distress and of the elderly languishing on trolleys. In fact, we have had 618,000 trolley waits in the past year. Patients have been waiting without dignity, at risk of cross-infection. There is no road map at all in the long-term plan to restoring access standards. Of course, the A&E standard is being revised in the long-term plan, even though the Royal College of Emergency Medicine has said:

“In our expert opinion scrapping the four-hour target will have a near catastrophic impact on patient safety in many Emergency Departments that are already struggling to deliver safe patient care in a wider system that is failing badly.”

I hope that when the review reports we can have a full debate in the House.

[Dr Poulter]

The hon. Gentleman is right to highlight the Blair Government’s injection of cash into the NHS and the meaningful difference that that made to many patients’ lives. On the waiting-time targets, if we are serious about parity for mental health and physical health, we should reflect on the fact that historically there have not been access targets for mental health of anywhere near the same standards that there are for physical health. Will the hon. Gentleman join me in urging a rethink of that and a much greater push for access targets for mental health services as a way to raise standards and improve the time within which patients get care?

[Jonathan Ashworth]

The hon. Gentleman makes an important point. There are elements of the long-term plan that we welcome, including the access targets for mental health. We also welcome the commitment to save 400,000 lives, although there is no detail in the plan about how those lives are going to be saved. We welcome the rolling out of early cancer diagnostic and testing centres—after all, it is a policy that I announced in the 2017 general election campaign. We welcome the roll-out of alcohol care teams in hospitals—a policy that I announced at the Labour party conference last year. We welcome the commitments on perinatal mental health—again, a policy that we announced previously. We welcome the commitment for preferential funding allocated to mental health services—another policy that the Labour Opposition previously announced—but we will need to study the details carefully, as the hon. Member for Oxford West and Abingdon (Layla Moran) said.

The points about mental health from the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) were well made, because currently three in four children with a diagnosable mental health condition do not get access to the support they need. Child and adolescent mental health services are turning away more than a quarter of the children referred to them for treatment by parents, GPs, teachers and others. That is quite disgraceful, so I hope the extra investment in mental health services reaches the frontline quickly, and I hope that in summing up the debate the Minister will give us more details about when we can expect to see progress on that front.

[Darren Jones (Bristol North West) (Lab)]

Does my hon. Friend agree that for hospitals such as Southmead Hospital in my constituency, which is one of the largest hospitals in Europe, frontline delivery requires a workforce that is able to meet the demand? Does he therefore agree with the comments from the King’s Fund, which says that the Government not only failed the test on the workforce but did not even turn up for the exam?

[Jonathan Ashworth]

My hon. Friend makes a good point, and I will come on to discuss the workforce in a few moments. First, let me pick up the point made by my hon. Friend the Member for Sheffield, Heeley (Louise Haigh).

There is recognition in the plan that widening health inequalities are becoming a more important issue, which we need to confront. There is much in the document about widening health inequalities. After years of austerity, with poverty rates increasing and child poverty at 4.1 million, we now see life expectancy in this country stalling for the first time in a hundred years, and actually going backward in the poorest parts of the country. Child mortality rates for children born into the most deprived of circumstances have increased. The truth is that poorer people get sick quicker and die earlier. For me, as a socialist and a Labour politician, that is shameful. We should be creating conditions in which people live longer, healthier, happier lives, which is why we need to end austerity across the board. The focus on health inequalities is therefore welcome, and that includes the stark recognition that inequalities are costing the NHS £4.8 billion a year in admissions—a remarkable figure.

[Matt Rodda (Reading East) (Lab)]

I concur on the benefits of our Labour health policy and how the Government should do much more to fund healthcare in this country. Does my hon. Friend agree that there is a particular problem of retaining public sector workers in many high-cost areas? In areas such as Reading and Oxford—my hon. Friend the Member for Oxford East (Anneliese Dodds) is sitting in front of me—there is severe pressure on the NHS because of the relatively low pay of many skilled staff.

[Jonathan Ashworth]

Absolutely. I will come on to the workforce in a second.

Overall, there are welcome commitments in the long-term plan. We have counted up to 60 commitments to improve, expand or establish new services, but sadly there is no detail on how they will be delivered. There are commitments to expanding access to general practice, but where is the plan to recruit the workforce we need in the national health service?

When the previous Secretary of State came to the House last June, he said that there would be a full workforce plan—not an interim plan shared by Dido Harding, but a full workforce plan to coincide with this long-term plan.

[Hon. Members]

Where is it?

--- Later in debate ---

[Jonathan Ashworth]

It has been delayed. There are no details about training budgets, because the Department has to wait for the spending review. We have 100,000 vacancies across the national health service, with think-tanks warning that we will have 250,000 vacancies unless we do something. We cannot wait for this workforce plan; we need action now.

Also missing from the long-term plan is any serious investment in public health services—this is picking up on another point that the hon. Member for Central Suffolk and North Ipswich made. Public health services are being cut again this financial year under this Government. When we take into account the cuts to public health services, the cuts to infrastructure, and the cuts to training, there is actually a £1 billion cut to health spending this year. The cuts to public health are equivalent to 1,600 fewer health visitors, 1,700 fewer school nurses, and 3,000 fewer drug workers. They mean that our constituents become sicker and demands on the wider NHS become greater. Drug and alcohol services will be cut by £34 million this year, even though the unmet need for treatment for alcohol problems has risen to 600,000 and admissions to hospital where alcohol is a primary factor have increased by 30%.

Also cut are smoking cessation services and obesity services. Cuts to health visitors and early years initiatives correlate with a fall in vaccination rates. Admissions to hospital for whooping cough are up by 59%. There have been deep cuts to sexual health services at a time when infections such as syphilis and gonorrhoea are increasing. These cuts to sexual health services are having an impact on women’s reproductive health, with experts expressing concerns that the use of long-acting reversible contraception is decreasing. Abortion rates among the over-30s are increasing and 8 million women live in areas where funding for contraception has decreased.

Let me read the House a quick extract from the Health Committee involving my friend—I will still call her my friend—the hon. Member for Liverpool, Wavertree (Luciana Berger). I am desperately sad that she felt that she had to leave the Labour party. I hope that the Labour party will get on top of this antisemitism issue. At the Health Committee, she asked about the health consequences of delays in accessing sexual health services. In responding, Dr Olwen Williams from the British Association for Sexual Health and HIV said:

“We are seeing neonatal syphilis for the first time in decades and neonatal deaths due to syphilis in the UK…We are seeing an increase in women presenting with infectious syphilis in pregnancy, and that has dire outcomes.”

These public health cuts were endorsed, not reversed, in the long-term plan.

[Paul Scully (Sutton and Cheam) (Con)]

rose—

[Jonathan Ashworth]

I will give way for the final time.

[Paul Scully]

I am grateful to the hon. Gentleman for giving way. He talked about a few different topics, but I think that I heard him say that there was an overall cut in the health service—I think he did so when he was welcoming some of the Government’s measures. In the 2017 manifesto, Labour committed to a 2.2% increase, whereas this Government committed to a 3.4% increase, so I hope that he welcomes that increase as well.

--- Later in debate ---

[Jonathan Ashworth]

We committed more in our 2017 manifesto than the Tory party did in the manifesto on which the hon. Gentleman fought the election. The Tory party revised its spending plans because of pressure from the Labour Opposition. [Interruption.] Madam Deputy Speaker wants me to hurry up.

The final point that I want to make is this: the most intriguing part of the long-term plan is the remark that the Health and Social Care Act has created a complete mess, hindering integration; and it proposes scrapping the so-called section 75 provisions. We do not want to say, “We told you so,” but we did tell them so, and Tory MPs should apologise for voting to pass the Lansley Act. If they are going to support NHS England’s call to get rid of the section 75 arrangements, which put through a proposed privatisation, why do they not block the £128 million-worth of contracts that are currently out to tender? If they do not, it will be clear that the Tory party is still committed to privatisation in the national health service.

The truth is, the Tories have spent nearly nine years running down the NHS, refusing to give it the spending that it needs. They are privatising it still; there will be a £1 billion cut to the NHS this year. It is Labour who will rebuild the national health service.

Oral Answers to Questions

Jonathan Ashworth Excerpts

Tuesday 15th January 2019 Commons Chamber

[Matt Hancock]

No, absolutely, we have ensured that there will be aircraft available, and air freight, to make sure that we can get those isotopes that have a short shelf life and cannot be stockpiled, and that there is unhindered supply. I make the following point to the hon. Lady and her colleagues, with an open mind and in a spirit of collaboration: if she is worried about no deal, which she seems to be, she and her party should support the Government tonight.

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

The Secretary of State boasts of being the world’s biggest buyer of fridges to stockpile medicines, but if sterling drops because of the Government’s mishandling of Brexit, the parallel trade in medicines could mean that stockpiles rapidly deplete as medicines are quickly exported back into the EU. Will he impose restrictions and suspend the necessary export licences that he is responsible for? Otherwise, he risks his fridges standing empty.

[Matt Hancock]

Of course, we have the legislative tools and powers the hon. Gentleman describes at our disposal; we know that. Nevertheless, stockpiling is going according to plan—it is going well—and the pharmaceutical industry has responded very well, with great responsibility. But I say, rather like a broken record—[Hon. Members: “You are.”] Yes, and it is important that I say it again and again and again. There is one route open to the House to avoid no deal, which Opposition Members purport to be worried about. They cannot complain about no deal unless they are prepared to do something about no deal, and to do something about no deal, they need to vote with the Government tonight.

[Jonathan Ashworth]

If the Secretary of State has those powers, he should use them now. This is going to be the biggest disruption to patient safety we have ever seen. He is also proposing emergency legislation that means patients might not get access to the medicines their GPs prescribe. Can he tell us whether an insulin patient will be able to get their prescription within a day of presenting at a pharmacy? He is the Secretary of State for Health; why will he not do the responsible thing and rule out no deal, which will do so much damage to the NHS and patients?

[Matt Hancock]

Because of the votes of most of us in the House, including the hon. Gentleman, no deal of course is the law of the land unless the House passes something else. He is a reasonable man. He is a mentor of the old Blairite moderate wing of his party. He is absolutely a centrist. I do not believe that, privately, he believes in the hard-left guff that comes from other Opposition Front Benchers. He is a very sensible man and I like him an awful lot, so after this session and before 7 o’clock tonight, why does he not take a look in the mirror and ask himself, “In the national interest, is it best to vote for the deal and avoid no deal, or is it best to play politics?”

NHS Long-term Plan

Jonathan Ashworth Excerpts

Monday 7th January 2019 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I welcome the advance copy of the Secretary of State’s statement, but may I quickly say at the outset that Churchill’s Tory party voted against Labour’s NHS 22 times?

We welcome many of the ambitions outlined today by NHS England. We welcome the greater use of genomics in developing care pathways. We welcome the commitment to early cancer diagnosis; after all, it was a Labour policy announced at the general election. We welcome the commitment to new CT and MRI scanners; it is a Labour policy. We welcome the greater focus on child and maternal health, including the expansion of perinatal mental health services; again, it is a Labour policy. We welcome the roll-out of alcohol teams in hospitals, because, yes, it is another Labour policy.

The Secretary of State did not mention this, but we will study carefully the details of any new proposed legislation, because we welcome the recognition that the Health and Social Care Act 2012 has created a wasteful, fragmented mess, hindering the delivery of quality healthcare. Healthcare should never be left to market forces, which is why scrapping the competition regime and scrapping the Act’s section 75 procurement regulations, as proposed today by NHS England, are long-standing Labour policies. The Government should be apologising for the Health and Social Care Act. But why stop halfway? Why not commit to fully ending the purchaser-provider split? Why not commit to democratic accountability when planning care? Why not commit to consigning the whole Lansley Act to the dustbin of history?

What about the other holes in today’s announcement? Waiting lists are at 4.3 million, with 540,000 waiting beyond 18 weeks for treatment. A&Es are in crisis, with 618,000 trolley waits and 2.5 million waiting beyond four hours in A&E. So why is there no credible road map today to restoring the statutory standards of care that patients are entitled to, as outlined in the NHS constitution? They were routinely delivered under a Labour Government. Is it not a damning indictment of nearly nine years of desperate underfunding, cuts and failure to recruit the staff we need that those constitutional standards will not be met as part of this 10-year plan?

The Secretary of State boasts of the new budget for the NHS. Will he confirm that once inflation is taken into account, once the pay rise is factored in and once the standard NHS England assumption about activity is applied, there is actually a £1 billion shortfall in the NHS England revenue budget for this coming financial year? When he answers, will he tell the House—I will be listening carefully to what he says—whether he has seen or is aware of any internal analysis from the Department, NHS England or NHS Improvement that confirms that £1 billion shortfall figure?

Can the Secretary of State also confirm that despite his rhetoric about prevention, the public health budget is set to be cut again in the next financial year as part of a wider £1 billion of cuts to broader health spending, and that when those cuts are taken into account, spending will rise not by 3.4%, as he says, but by 2.7%? That will mean deeper cuts again to smoking cessation services, deeper cuts again to drug and alcohol addiction services and deeper cuts again to sexual health services when infections such as gonorrhoea and syphilis are on the rise. By the way, why is HIV/AIDS not even mentioned in the long-term plan? What was the Secretary of State’s answer when asked about public health cuts in his weekend interviews? Targeted Facebook advertising. Given that life expectancy is going backwards, health inequalities are widening and infant mortality is increasing, the public health cuts should have been reversed today, not endorsed.

The NHS long-term plan admits that

“the extra costs to the NHS of socioeconomic inequality have been calculated as £4.8 billion a year in greater hospitalisations alone.”

Does that not confirm that, for all the rhetoric on prevention, the reality is that the Government’s austerity and cuts are making people sicker and increasing the burden on the NHS? Nowhere have we seen greater austerity than in the deep cuts to social care, but where are the Government’s proposals today? They still do not have any.

With respect to social care, surely the Secretary of State agrees that:

“It is not possible to have a plan for one sector without having a plan for the other.”—[Official Report, 18 June 2018; Vol. 643, c. 53.]

Those are not my words, but the words of the Foreign Secretary when he stood at the Dispatch Box last June as the Secretary of State for Health and Social Care. I agree with him; it is a shame that the current Secretary of State does not.

By the way, the Foreign Secretary also promised that:

“Alongside the 10-year plan, we will also publish a long-term workforce plan”.—[Official Report, 18 June 2018; Vol. 643, c. 52.]

Where is it? The Secretary of State has not done it. We all want to know where the staff are coming from to deliver the ambitions that have been outlined today. We are short of 100,000 staff. We are short of 40,000 nurses. The Secretary of State talks of doing more for mental health services; we are down 5,000 nurses in mental health. He talks of doing more for primary and community care; GP numbers are down by 1,000 and district nursing numbers are down by 50%. Now, the Home Secretary wants to impose a £30,000 salary cap on those coming from abroad to work in our NHS, ruling out nurses, care assistants and paramedics. The Secretary of State should do his job and tell the Home Secretary to put the future sustainability of the NHS first, instead of his Tory leadership ambitions, and ditch that salary cap for the NHS.

There are certainly many welcome ambitions from NHS England today, but the reality is that those ambitions will be hindered by a Government who have no plan to recruit the staff we need, who have no plan for social care and who are pushing forward with deep cuts to public health services. Patients have been let down as the Government have run down the NHS for nearly nine years. We do not need 10 more years of the Tories. The NHS needs a Labour Government.

[Matt Hancock]

Well, I think we discovered from that that Labour has absolutely nothing to say about the future health of the nation. The hon. Gentleman did not even deign to thank the people who work in the NHS for their incredible work. Did we hear any acknowledgement of the million more people who are seen by the NHS, of the record levels of activity going on in the NHS and of the fact that we have more nurses and doctors in the NHS than we had in 2010? He had nothing to say. He talked about the workforce. Chapter 4 of the document is all about the workforce plan. He gives me the impression that, like his leader on Brexit, he has not even read the document he is talking about.

The hon. Gentleman asked about targets and legislation. On legislation, when clinicians make proposals on what legislation needs to change to improve the NHS, we listen. We do not then come forward with further ideological ideas. We listen. So we will listen to what they have said. The clinicians have come forward with legislative proposals and we will listen and study them closely.

On the money that the hon. Gentleman talked about, it was a bit like a broken record. He asked about a £1 billion shortfall in the NHS budget. I will tell him what we are doing with NHS budgets: we are putting them up by £20.5 billion. There is an error in the analysis by the Nuffield Trust, because it does not take into account an improvement in the efficiency of the NHS. Is it true that every year we can improve the way the NHS delivers value for taxpayers’ money? Absolutely. We can and we must, because we on the Government Benches care about the NHS and about getting the right amount of money into the NHS, but we also care about making sure that that money is spent wisely. The hon. Gentleman would do well to heed the views of the NHS itself, which says that yes, the NHS is probably the most efficient health service in the world, but there is always more to do.

The hon. Gentleman argued about various budgets. The budgets in the NHS are going up because we care about the future of the NHS. The Labour party called for an increase of 2.2% a year; we are delivering an increase of 3.4% a year. Labour has nothing to say on health, as it has nothing to say on any other area of domestic business. We will make sure that we are the party of the NHS for the long term.

Oral Answers to Questions

Jonathan Ashworth Excerpts

Tuesday 27th November 2018 Commons Chamber

[Matt Hancock]

Yes. General practice will be at the heart of the long-term plan. GPs are the bedrock of the NHS. We will put an extra £3.5 billion, at least, into primary and community services to help keep people healthy and prevent them from going to hospital.

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

The Secretary of State got into a muddle last week with his GP figures, so may I suggest that he download an exciting new app to his phone? It is called a calculator. He has said that there will be more for community and primary care by 2024. Can he guarantee that there will be the extra GPs and district nurses to provide the services that he is promising?

[Matt Hancock]

Yes, I can; given that we have the money coming into the NHS, we are doing everything possible to ensure that we have the people to do the work. I am delighted to say that we have a record number of GPs in training right now.

[Jonathan Ashworth]

But GP numbers have gone down by 700 in the last year, have they not? There are 107,000 vacancies across the NHS, acute trusts are closing accident and emergency departments overnight, the closure of chemotherapy departments is being considered, and Health Education England’s training budget is the lowest that it has been for five years, with more cuts to come next year. Does the Secretary of State agree that if the long-term plan that he will publish next week is to be credible, he must reverse those training cuts and deliver the staff that our NHS needs?

[Matt Hancock]

That was a bit of a surprise, because the hon. Gentleman is normally such a reasonable fellow. I thought that he would welcome the record number of GPs in training, and the record number of nurses in the NHS. Because we love the NHS, of course we want to do more, and we will.

Gosport Independent Panel

Jonathan Ashworth Excerpts

Wednesday 21st November 2018 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I thank the Secretary of State for an advance copy of his statement. I welcome the statement and the tone of his remarks, and I thank him for repeating the unambiguous and clear apology that the previous Secretary of State, the right hon. Member for South West Surrey (Mr Hunt), offered at the Dispatch Box before the summer—it is good to see the previous Secretary of State sitting on the Treasury Bench today.

We welcome the Secretary of State’s apology today. The whole House was shocked when the previous Secretary of State reported the findings of the Gosport inquiry to the House. This Secretary of State is right to remind us that everyone who lost a life was a son or daughter, a mother or father, a sister or brother. As he said, our thoughts are with the families of the 456 patients whose lives were shortened because of what happened at Gosport, and the families of the 200 others who may have suffered—whose lives may have been shortened; because of missing medical records, we will never know for sure. That lingering doubt—never knowing whether they were victims of what happened at Gosport—must be a particularly intolerable burden for those families affected.

Like the Secretary of State, I pay tribute to the victims’ families, who, as he says, have in the face of grief shown immense courage, fortitude and commitment to demand the truth. I think the whole House will pay tribute to them today. I also reiterate our gratitude to the former Bishop of Liverpool, James Jones, for his extraordinary dedication, persistence, compassion and leadership in uncovering this injustice. Finally, I applaud those hon. Members who played a central role in establishing this inquiry, not just the previous Secretary of State, but the right hon. Member for North Norfolk (Norman Lamb) and the Minister for Care, the hon. Member for Gosport (Caroline Dinenage), who in recent years has played an important role in her capacity as a constituency MP.

The Secretary of State is correct to say that lessons must be learned and applied across the whole system. We all understand that in the delivery of healthcare and the practice of medicine, sadly, tragically, things can and do sometimes go wrong, but we also understand, as Bishop Jones said in his report, that

“the handing over of a loved one to a hospital, to doctors and nurses is an act of trust”,

but that that trust was

“betrayed.”

I still believe that that betrayal was unforgivable. Patient safety must always be the priority, so when there are systemic failures, it is our duty to act, learn lessons and change policies.

I wish to respond to the Secretary of State’s announcements today. We welcome his commitment to legislation placing more transparency duties on trusts, and we will engage constructively with that legislation. Is it his intention to bring forward amendments to the Health Service Safety Investigations Bill, and if so when, or should we expect a new bill altogether? We look forward to his proposals on strengthening protection for whistleblowers, but he will know that the NHS has just spent £700,000 contesting the case of whistleblower Dr Chris Day, a junior doctor who raised safety concerns. He will also be aware of the British Medical Association survey showing that not even half of doctors feel they would have the confidence to raise concerns about safety. Moreover, he will be aware of how Dr Bawa-Garba’s case played out, with her personal reflections effectively used in evidence against her. Can he offer more details on how he will change the climate in the NHS so that clinicians feel they can speak out without being penalised?

I welcome the thrust of the Secretary of State’s remarks on medical examiners, and I agree they are a crucial reform, but can he offer us some more details? Is it still the Government’s intention that they will be employed directly by acute trusts? He will be aware that this has provoked questions about their independence. We would urge him to go further and base them in local authorities and extend their remit to primary care, nursing homes and mental health and community health trusts. If legislation is needed, we would work constructively with him.

We welcome the review into improving safety when prescribing and dispensing medicine. Clearly, one of the first questions that comes to mind when reading the Gosport report is: how were these prescriptions monitored? The Government’s own research indicates that more than 230 million medication errors take place a year, and it has been estimated that these errors and mix-ups could contribute to as many as 22,000 deaths a year, so this review is clearly urgent. Can the Secretary of State tell us whether it will be an independent review, who will lead it and when we can expect it to report?



Finally, patient safety is compromised when staff are overworked and overburdened with pressures. He will know that we have over 100,000 staff vacancies across the NHS. Some trusts are proposing closing A&E departments overnight because they do not have the staff, and some are even proposing closing chemotherapy wards because they believe that the lack of staffing means services are unsafe. How does the Secretary of State plan to recruit the staff our NHS desperately needs to provide the level of safe care patients deserve?

In conclusion, I offer to work constructively with the Secretary of State to improve patient safety across the NHS, and we support his statement today.

[Matt Hancock]

I appreciate the tone of the hon. Gentleman, who rightly focuses on the need to ensure that this never happens again, and I join him in thanking Bishop James Jones for his work on this and other inquiries. It was quite brilliant empathetic work. I also thank the right hon. Member for North Norfolk (Norman Lamb), for whom I have an awful lot of respect.

The core of the questions the hon. Gentleman raised, about the need to ensure that whistleblowers are listened to and that people are heard in the NHS, comes down to culture change. A whole series of policies underpins that culture change, and I will come to them, but ultimately it comes down to this: errors happen in medicine—it is a high-risk business—but what matters is behaviour, that everything is done to minimise errors and, when they are made, to learn from them, rather than try to cover them up. The culture change needs to be driven across the NHS. It has changed and improved in many areas, but there is still much more to do.

The hon. Gentleman asked whether amendments would be tabled to the Health Service Safety Investigations Bill or in separate legislation on whistleblowers. We are looking at both options. Partly it comes down to the technicalities of scope and the exact distinction and definition of the amendments, but I look forward to working with him on that legislation.

The hon. Gentleman asked why gagging clauses are still in use. I may well ask the very same question. They were deemed unacceptable by my predecessor—I join in the tributes to him—who did so much on this agenda. Gagging clauses have been unacceptable in the NHS since 2013. Trusts, which are independent, can legally use them, but I find them unacceptable, and I will do what it takes to stamp them out.

The hon. Gentleman said that too many people in the NHS feel unable to speak up. To ensure a route for this, we now have, in every single NHS trust, an individual separate from line management to whom staff can go to raise concerns. This is part of the culture change, but it is not the whole. Line management itself in every hospital should welcome challenge and concerns, because that is the way to improve practice. Challenges and concerns that are raised with managers should be deemed an opportunity to improve the service offered to patients, rather than a problem to be managed.

The hon. Gentleman also mentioned medication errors. Of course, this was not a case of medication error—it would have been far less bad had it been; it was a case of active mis-medication that led to deaths. Medication errors are an important issue, however, and we are bringing in e-prescribing across the board to allow much more accurate measurement, audit and analysis of medication.

Finally, the hon. Gentleman said that pressures often come from staff shortages. Again, that was emphatically not the concern here, and we absolutely must not muddle up the behaviour here with the issue of staff shortages. Nevertheless, I acknowledge the need for more staff in the NHS. Indeed, we are putting £20 billion into it over the next five years to make sure we have the people we need to deliver the NHS that everyone wants.

Prevention of Ill Health: Government Vision

Jonathan Ashworth Excerpts

Monday 5th November 2018 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

I thank the Secretary of State for advance sight of his statement. We welcome his remarks on the use of medicinal cannabis and on the appalling, barbaric abuses of those with learning disabilities and autism, by which we have all been shocked. I understand his point about the review and about asking NHS England to carry out some work, but is it not time that these institutions were closed down and proper support provided in the community instead?

Of course we welcome the emphasis and focus on prevention, but these promises are not worth a candle if they are not backed up with real, substantive action. They come on the back of £700 million-worth of cuts to public health services, with more cuts to public health services pencilled in for next year, including £17 million-worth of cuts to sexual health services, £34 million-worth of cuts to drug and alcohol services, £3 million-worth of cuts to smoking cessation services and £1 million-worth of cuts to obesity services.

The Secretary of State did not mention childhood obesity in his remarks.

[Matt Hancock]

indicated dissent.

[Jonathan Ashworth]

I apologise if I missed it. Could the Secretary of State tell us when he plans to outlaw or ban the advertising of junk food on family television and when the consultation will end?

Immunisation rates for children have fallen for the fourth year in a row, so a big part of prevention should surely be a focus on investment in children’s and early years health services, yet Government cuts to those budgets and, indeed, the privatisation of many of those services in our communities have seen health visitor numbers fall by more than 2,000, school nurse numbers go down by 700 and 11% of babies miss out on mandated health checks. What is the Secretary of State’s plan to reverse those cuts to health visitors and school nurses?

All in all, alongside wider Department of Health and Social Care budgets, there will be £1 billion-worth of cuts to health services next year, with public health budgets taking considerable strain. Those £1 billion-worth of cuts should have been abandoned today, and it is a missed opportunity that the Secretary of State has not abandoned them. When he was asked about this in the Budget debate, he said it was a matter for the spending review. Well, today the Association of Directors of Public Health has said that the spending review should allocate an extra £3.2 billion for the public health grant next year. Does he accept that figure?

Of course prevention is about more than just public health; it is also about primary care. But GP numbers are down by 1,000 since 2015, and since 2010 district nurses have been cut by more than 3,000, so can the Secretary of State tell us what his plan is to increase the primary care workforce to support his wider ambitions on prevention? We know he wants a higher proportion of NHS spending to go to general practice, so does he agree with GPs that general practice should again receive around 11% of the overall NHS budget? If not, why not?

Of course, prevention is also about mental health services, but 30% of patients referred to IAPT—improving access to psychological therapies—services never receive treatment. What is his plan to ensure that everyone who needs IAPT services next year gets them?

Finally, on the wider social determinants of ill health, the shameful reality is that people in poorer areas die earlier and get sick quicker. Life expectancy has begun to stall, and has actually gone backwards in some of the poorest parts of the country. Rates of premature mortality are twice as high in the most deprived areas of England compared with the most affluent, and mortality rates for the very sickest of babies are increasing. As laudable as many of the aims that the Secretary of State has announced today are, this document does not even mention poverty or deprivation. It does not even recognise that some of the deepest cuts to public health grants have been in the areas of highest need and highest deprivation.

Yes, we welcome a focus on prevention—we have long called for such a focus—but a genuine commitment to prevention would go hand in hand with a genuine commitment to ending austerity. That must start with reversing the public health cuts and blocking the £1 billion of further cuts to health services to come next year. On that test, the Secretary of State has failed today.

[Matt Hancock]

Great, well I take that as a broadly positive response from the hon. Gentleman, and I will address the points he makes. He asked about money, and we are putting £20.5 billion extra into the NHS—this is the largest and longest financial commitment any Government have made to any public service ever. Of course, as well as the NHS budget, local authorities have budgets for public health; as he said, that will be addressed in the spending review. The increase in funding must ensure that we do more on prevention, which means more going into community services and into primary care, as well as making sure we get the appropriate level of spending into public health.

The hon. Gentleman asked about the consultation on advertising as part of the obesity plan. As he knows, that will be published before Christmas. He also asked about rates of immunisation. I want to see immunisation used right across the country. There is a campaign all of us can take part in to persuade people and ensure that immunisation takes place. We do not have compulsory immunisation in this country. I believe that is right, on civil liberties grounds, but by goodness it means it is incumbent on all of us to persuade everybody of the health benefits of immunisation.

The hon. Gentleman asked about GP numbers. We want 5,000 more GPs, and I am glad to report that we have got record numbers of GPs in training, thanks to action by this Government. Finally, he asked about the economic causes of ill health. The No. 1 economic cause of ill health is not having a job, and there are record numbers of jobs in this country. If he says that inequality has an impact on ill health, he should probably welcome the fall in inequality that we have seen under this Government.

Budget Resolutions

Jonathan Ashworth Excerpts

Tuesday 30th October 2018 Commons Chamber

[Matt Hancock]

I pay tribute again to my right hon. Friend, who has worked tirelessly in support of that project. The Defence and National Rehabilitation Centre in Loughborough will link world-class military medical facilities with our NHS. That means lessons learned in the medical field from treating our brave troops who come back from the frontline can be brought into the NHS—for instance, surgical techniques that were learned in battle can be adapted to help civilians here. I pay tribute to her and others for the work they have done.

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

Here is a representation from a Jonathan from Leicester. Further to the question from the Chair of the Select Committee on Health and Social Care, the hon. Member for Totnes (Dr Wollaston), can the Secretary of State confirm that, in next year’s spending review, the cuts to capital budgets and the £700 million-worth of cuts to public health budgets will be reversed, and that there will be real-terms increases in funding for capital, training and public health? Can he guarantee that?

[Matt Hancock]

The spending review is next year. What I can guarantee is a £20.5 billion increase in NHS spending. That is the biggest increase in any spending commitment for any public service in the history of this country. [Interruption.] It is a pity that the Leader of the Opposition is not interested and does not want to hear about it. If he stayed, he could also hear about the reforms we are going to make. He should hear this more than anyone. We are acutely aware on the Conservative Benches that this is not Government money or NHS money but the hard-earned money of taxpayers, and we need to ensure that it is spent wisely. When he sprays his commitments around, Opposition Front Benchers would do well to remember that this is money from taxpayers.

--- Later in debate ---

[Dr Sarah Wollaston (Totnes) (Con)]

May I start by apologising for being absent for much of this debate because I was chairing the Health and Social Care Committee? I also declare a personal interest, as three members of my immediate family are employed as NHS doctors.

We need to take a whole-system approach to health— to think of it not just as the NHS, but as a system including social care, public health, the prevention arm and training budgets. I return to a point that I made in an intervention: I wholly welcome the uplift in the NHS budget, but the increase in the NHS England budget that will take place between 2018-19 and 2019-20 is £7.2 billion, whereas the uplift in the wider health budget in the Red Book is only £6.3 billion. It concerns me that this might indicate that some of the uplift in the NHS England budget will come by way of being taken out of other aspects of the health budget, particularly the Public Health England budget, as we have seen in previous years. I hope that the Minister will touch on that in his response.

[Jonathan Ashworth]

I think that the hon. Lady may have left the debate to attend her Committee when I re-emphasised her point directly to the Secretary of State, who told us that we would have to wait for the spending review. Would she share my disappointment if the Government tried to pull the same trick that they pulled three years ago, and actually misled us or gave us bogus figures for NHS spending that did not include public health expenditure, capital and training?

[Dr Wollaston]

We need absolute transparency around health spending, and to take not only a whole-system approach but a long-term view.

Public health is the prevention arm of the system, and taking money out of public health has a serious impact on future spending and our ability to tackle health inequalities. It would be very troubling indeed if much of this uplift came directly from a public health cut. We need to be specific about that, and it is not sufficient to wait for the spending review to clarify that point; I hope that the Minister will be able to tell us further about what it means. People need to plan for the future, so if £900 million is going to be taken out of public health grants, we need to know that now.

When we ask the public which parts of the system they prioritise, public health tends to be at the bottom of the list. It is up to the Government to look at the evidence, and they must be clear that the evidence shows that we must focus unrelentingly on the prevention arm of healthcare. That is the right thing to do, and it is where we have the greatest chance of tackling the burning injustices of health inequality, so it is an important point to address.

The other aspect I want to touch on is social care. The Health and Social Care Committee has just had a sitting with the Care Quality Commission on its excellent “State of Care” report. The report comments on “fragility,” and the report of a couple of years ago talked about “a tipping point.” The CQC told us that that tipping point has been passed for many people in social care. The interaction between social care and the health service is so close that, if we do not focus on social care, we are simply tipping more costs on to the health service.

Of course it is welcome that there will be an in-year increase for adult social care of £240 million this year and £650 million next year, but it is widely recognised that, because of the extraordinary increase in demand and pressure—driven not just by the welcome fact that we are living longer but by the great increase in the number of people with multiple long-term conditions living to an older age and by younger, working-age adults living with multiple complex needs—social care needs more than £1 billion a year just to stand still, so we need to go further.

I recognise that much of this will come alongside next year’s social care Green Paper, which we are all looking forward to, but the system is under considerable challenge. I hope the Minister will recognise in his closing remarks that we are not there yet on social care. He needs to say what we are going to do in the long term to address our social care needs. As I have said before, we will require an approach that involves the Labour Front Benchers, too. We need to see political consensus, otherwise the politically difficult decisions on funding will not get through the House.

If there are to be cuts to public health, the Government will have an even greater responsibility to provide other levers in their public health policy to reduce demand in the system. The Chancellor specifically referred to wanting to reduce the tragedy of lives lost to suicide. Unfortunately, at the same time, the delay in the reduction of the maximum stake for fixed odds betting terminals means that we have passed up on an important opportunity to address the misery of gambling addiction. That is a hugely wasted opportunity. Likewise, there is a missed opportunity to look at what has happened in Scotland on minimum unit pricing to make sure we are addressing some of the key drivers of public health problems. The Government cannot duck that if we are to see cuts to the public health grant.

Finally, there is the impact of Brexit. The Chancellor has said that there will be £4.2 billion for preparations for a no-deal Brexit. I am afraid that the costs will be far higher. The Health and Social Care Committee recently heard from the pharmaceutical industry that it is having to plough hundreds of millions of pounds into preparing for no deal. That is phenomenal and inexcusable waste; it is money down the drain. I hope the Government will rethink their policy, because no version of Brexit will provide more money for the NHS. There is a Brexit penalty, not a Brexit dividend, and I hope both Front-Bench teams will come together and agree that, ultimately, we need the informed consent of the British people for whatever version of Brexit we come up with, with the option to remain and properly use the money instead for tackling austerity and improving the lives and the health of our nation.

--- Later in debate ---

[Jonathan Ashworth (Leicester South) (Lab/Co-op)]

With your indulgence, Mr Speaker, may I preface my remarks by briefly mentioning the awful tragedy that took place at Leicester City football club in my Leicester constituency this weekend? My city—the city I represent—is grieving. We have lost a much loved friend who enjoyed the respect, affection and admiration of not just Leicester City football fans but everyone across our city. Our condolences go out to the loved ones of all who lost their lives in that terrible helicopter crash, and again I pay my tribute to our extraordinary emergency services—the police, the fire and rescue services, the NHS and all other staff—for their quick response, their dedication and their professionalism.

This was supposed to be the Budget that ended austerity, but instead, as my right hon. Friend the shadow Chancellor outlined, we have more of the same. Cuts to public services will continue. Poverty will increase. The very poorest households in society will lose out. Austerity has not ended; we know austerity has not ended because that is the headline in George Osborne’s Evening Standard this evening.

Members have spoken in this debate with great passion, and I am sure the House will forgive me if I cannot mention each and every one of them, but some did catch my attention. My hon. Friend the Member for Huddersfield (Mr Sheerman) began the debate with a tour de force and reminded the House that PFI was a Tory policy begun by—[Interruption.] Conservative Members are chuntering. Perhaps they should have a word with the International Trade Secretary who from this Dispatch Box used to urge us to pursue PFI because it was

“exclusively to fund private capital projects”—[Official Report, 8 January 2003; Vol. 397, c. 181.]

Perhaps they should have a word with the Chancellor of the Duchy of Lancaster who used to give a “warm welcome” to PFI. Perhaps they should have a word with the former Brexit Secretary; I know he is on the Back Benches now, but he used to say in this House:

“The PFI has many virtues—after all, it was a Conservative policy in the first instance.”—[Official Report, 10 March 1999; Vol. 327, c. 429.]

Perhaps they should have a word with the Business Secretary, who said:

“PFI was initiated by the previous Conservative Government.”—[Official Report, 12 February 2013; Vol. 558, c. 787.]

Perhaps they should also have a word with the Scottish Secretary, who said that PFI was a “successful basis for funding”, or with the Welsh Secretary, who said:

“I am a fan of PFI in general.”—[Official Report, 4 November 2010; Vol. 517, c. 1124.]

We will take no lessons on PFI from the Tories.

We have heard other welcome contributions to the debate today. My hon. Friend the Member for Easington (Grahame Morris), who is no longer in his place, spoke eloquently about the need for investment in radiotherapy and cancer treatments. It was a very constructive speech and I saw the Health Minister on the Front Bench nodding at the time; he has obviously had to leave the debate now. The hon. Member for Redditch (Rachel Maclean)—I do not know whether she is still here—mentioned the importance of more investment in and recognition of the menopause. I entirely agree with her on that.

My hon. Friend the Member for Sheffield Central (Paul Blomfield) talked about the terrible and devastating consequences of gambling addiction. As someone who has spoken out about how addiction has taken a devastating toll on my own family, I completely endorse what my hon. Friend said today. The Government really need to push ahead with changes to fixed-odds betting terminals. My hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) and others talked about health inequalities and how the advances in life expectancy were beginning to stall for the first time in 100 years, and were indeed going backwards in some of the poorest parts of our country. This should shame us as a society, and I endorse the calls for an inquiry. If we had a Labour Government, we would have a specific target for narrowing health inequalities.

The hon. Member for Glasgow Central (Alison Thewliss) spoke eloquently about the effects of the Budget on children. I commend all her work as chair of the all-party parliamentary group on infant feeding. It is shameful in our society that, as we saw on Channel 4’s “Dispatches” last night, one in 100 families are now turning to baby banks in our constituencies for access to baby clothing, food and toys. That is absolutely disgraceful. The hon. Member for Mid Dorset and North Poole (Michael Tomlinson) complained about chuntering from our side as he spoke about the importance of marriage. I agree that marriage is an immensely important institution, but I say to him that children should take priority in social policy and that the Government should be investing in children regardless of the marital status of their parents.

I hope that Members will forgive me if I do not mention everyone, but I did enjoy the passionate speech from my hon. Friend the Member for Kingston upon Hull West and Hessle (Emma Hardy) on the value of public services. At one point, she said, “This is my truth.” I do not know whether she was referring to the Manic Street Preachers or to Aneurin Bevan, who also said:

“This is my truth, tell me yours.”

My hon. Friend’s speech was a superb successor contribution to some of the speeches that Bevan would have made from the Dispatch Box when he created the NHS and the Conservatives voted against its creation.

The Health Secretary does not seem to be in this place to hear the wind-ups, but I am sure that he is on his way. I am told that he is a fan of horse-racing, but I am afraid that his speech fell at the first hurdle day. You see, Mr Speaker, it is not just the Chancellor who can do rubbish jokes in the Chamber. The Health Secretary forgot to tell us what eight years of austerity had delivered for the national health service and what eight years of the deepest and longest financial squeeze in the NHS’s history had delivered. We now have 4.3 million people on the waiting list and 2.8 million people waiting for more than four hours in A&E, of whom more than 600,000 are designated as trolley waits. Over 25,000 people are waiting beyond two months for cancer treatment, which is twice the number in 2010.

Winters are now so bad in the NHS than they were branded a “humanitarian crisis” by the Red Cross. Last winter, 186,000 patients were trapped in the back of cold ambulances and not even able to be admitted to an overcrowded hospital. Hip replacements, knee replacements, cataract treatments and rounds of IVF are being rationed and restricted. There were 84,000 cancelled operations in the past year, including nearly 19,000 cancellations of children’s operations for broken bones, for the removal of rotten teeth, for eye surgery and even for cancer.

Nowhere is the disgraceful neglect of children in our health service more prevalent than in mental health services. Three in four children with a diagnosable mental health condition do not get access to the support they need. The numbers of young people attending A&E with a recorded diagnosis of a psychiatric condition have trebled in the past eight years. A fifth of children and young people referred for an eating disorder wait more than four weeks for treatment, while more than 1,000 children are sent far from home—sometimes more than 100 miles away—for in-patient care. That is what happens after eight years of cuts, closures, service privatisation and failure to invest in staffing. That is what austerity has done, and it will continue.

One really must examine the small print of the spending readjustments for the NHS. The Health Secretary talked about £20 billion extra for the NHS over five years, but there is no new money for the winter ahead, which hospital bosses are already warning will be even tougher than last year’s. According to Ministers, the NHS budget is set to grow by 3.6% next year. If the shadow Chancellor were Chancellor, it would grow by 5% next year.

Let us look at what is not included in the health budget, which the hon. Member for Totnes (Dr Wollaston), who chairs the Health Committee, and others alluded to. First, even though the Health Secretary tells us staffing is his priority, we have 107,000 vacancies across the NHS. We are short of 40,000 nurses and midwives and of 10,000 doctors. The number of GPs is down by 1,000, the number of district nurses by 43% and the number of mental health nurses by more than 5,000. And what has happened to training budgets? They were excluded from that 3.6% allocation and, as my hon. Friend the Member for Lincoln (Karen Lee) pointed out, the Chancellor failed to reinstate the nursing bursary. There is no plan in the Budget to increase NHS staffing.

Secondly, the Health Secretary promised us a “technological revolution”. Our NHS faces a £6 billion repair backlog, relies on 12,000 fax machines and uses at least 1,700 pieces of outdated and often faulty equipment, yet capital budgets are excluded from the 3.6% allocation. In fact, according to the Red Book, capital will be cut by £500 million. The Chancellor boasted that he was ending PFI—I do not why he thought that would embarrass the shadow Chancellor or the Leader of the Opposition; he has obviously not followed the history of the Labour party in recent years—but the Government’s response to the Naylor report on infrastructure needs for primary care signalled that £3 billion would be raised from private finance investment. If PFI is abolished, where will that £3 billion for primary care transformation come from? Or is the reality that the Chancellor has not abolished private financing of public capital projects, but has simply abolished an acronym?

Thirdly, despite the Health Secretary’s hollow commitment to prevention, public health services are still being cut. We have seen £700 million of cuts so far, with another £96 million to come. For example, substance misuse services in our constituencies will be cut by £34 million next year at a time when we have some of the highest drug deaths and alcohol-related hospital admissions on record. Sexually transmitted infections are on the increase, yet sexual health services are set to be cut by £17.6 million next year. We are falling behind internationally on children’s health outcomes, from obesity to immunisations and support for new mums with breastfeeding, and the numbers of health visitors and school nurses are falling, yet early years health services will be cut next year because of cuts to the public health grant. Those cuts should have been reversed in the Budget, not endorsed.

Taken together, there will be £1 billion of cuts to public health, training and capital, which means this health settlement represents an increase next year not of 3.6% but of 2.7%. That is not enough to deliver the level of service that patients expect.

Let us look at what the £20 billion will fund. We have been told there is £2 billion extra for mental health, but growing mental health spending in line with the increase in overall health spending costs an extra £2 billion. That is more spin and smoke and mirrors. The Institute for Public Policy Research says we need £4 billion extra. NHS England advises us that NHS activity increases by 3.1% a year. Demand is rising, the burden of chronic disease is rising and the number of patients with multiple chronic conditions using the NHS is increasing. Those demographic changes and the rising burden of disease will take up £16 billion of that £20 billion. The pay increase, which the Government have been forced into because of campaigning of staff, the trade unions and the Labour party, will take up another £3.5 billion. That is £19.5 billion of the £20 billion already taken up—and still no plan to reduce waiting lists, tackle the A&E crisis, invest in general practice, or deal with the £4.3 billion of underlying deficits of hospitals and loans owed by NHS trusts.

The Chancellor’s answer in the Red Book is to say that we should have 1% efficiencies a year in the NHS. What does that mean? It means more cuts and greater rationing of treatments. In the Red Book, the Chancellor also says that we can create savings through prevention—even though he is cutting prevention budgets—and integration of care. How can we integrate care with the health sector when billions of pounds have been cut from social care? Some £7 billion has been cut from social care, so 400,000 people now go without care support and over 50,000 over-65s with dementia are admitted to hospital because of a lack of social care.

The Chancellor said yesterday that he is giving more to social care, but he is cutting local authority budgets by £1.3 billion with one hand and is offering councils £650 million to be shared between adult and children’s social care with the other. He is literally asking councils to choose between supporting vulnerable children with social care and supporting vulnerable adults with social care. That is not a serious choice; it is callous, cruel, nasty politics. We need a comprehensive settlement for social care, not the ongoing short-term drips from this Government.

We need a plan for the NHS. Yesterday was an opportunity to turn around our greatest institution, but it is not enough to deal with waiting lists or the crisis in recruiting the staff we need. There is no plan to bring waiting lists down and end rationing of treatment, no plan to recruit the doctors and nurses needed for the future, no plan to reverse the cuts to children’s health services and end privatisation, no plan to rebuild social care and improve care for those living with dementia, no plan to expand community health services and general practice, and no plan to transform services for the future. The record will show, yet again, that you simply cannot trust the Tories with the NHS.