Oral Answers to Questions

Justin Madders Excerpts

Tuesday 27th November 2018 Commons Chamber

[Stephen Hammond]

The hon. Gentleman is absolutely right. There can be no statement other than complete condemnation of attacks. We have changed the law, and it came into force earlier this month.

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

I welcome the Minister to his place. Although he is new, he will know that the A&E waiting target is not a recent initiative. It is a key part of the NHS constitution, but it has not been met for over three years. If he cannot make a commitment today on when the target will be met, will he accept that, at least for this winter under this Government, the NHS will once again be underfunded?

[Stephen Hammond]

As I said in my earlier answer, we recognise that this winter will be challenging. We recognise that the A&E performance standard is not currently being met, but, as the hon. Gentleman knows, we are investing an extra £20 billion in the NHS to ensure that the standards are met. The NHS will use that investment to treat 250,000 more patients and to improve A&E performance across the country.

Healthcare (International Arrangements) Bill (First sitting)

Justin Madders Excerpts

Committee Debate: 1st sitting: House of Commons
Tuesday 27th November 2018 Public Bill Committees

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

Q Mr Henderson, you said you consider that the system works well at the moment. I think it is pretty universally accepted that the cost recovery element does not work so well. Do you feel that more ought to be done in respect of that, and if so what would you like to see done?

Mr Henderson: I do not pretend to be an expert on the cost recovery system. I think our members would be very clear that they believe the primary effectiveness of the current arrangements is about providing effective healthcare for citizens across the EU. As clinicians, that is their primary responsibility.

On the recovery of costs, not just in this area but for other areas where recoverable costs were brought in more recently, there are always questions about the amount of effort and return in the whole system. I am not at all opposed to the idea of recovery of costs, but I am not sure we have yet found a hugely simple and easy way of recovering any costs really. I would happily support that, but it seems to us that this works as a system on its most important requirement, which is providing quick, clear and safe healthcare for people.

[Justin Madders]

Q You say that you have basically the same system for 32 or 33 different countries. If we end up in a situation in which we have to make arrangements with each individual country—potentially significantly different arrangements depending on what is negotiated—what effect do you think that will have on your members, in terms of what they can deliver?

Mr Henderson: It is not a hugely attractive prospect, is it, 32 different settings, for those presumably trying to agree the arrangements? In practical terms, the idea that if you are a GP or a hospital doctor trying to work out whether there are different arrangements for 32 different lots of patients sounds pretty much like a nightmare set-up. What clinicians on the ground want is a clear and simple system—ideally a single system—that will cover all the people they are seeing.

[Justin Madders]

Q May I ask Mr Jethwa some questions? Have you looked at all at the situation as it might affect the island of Ireland?

Raj Jethwa: We have done some work on that.

[Justin Madders]

Would you like to say what you are doing?

Raj Jethwa: Our concern about the situation there is primarily based on the fact that there are some very effective cross-border agreements which have facilitated healthcare over the last two or three decades, particularly through co-operation and working together as a programme. That is only one aspect of it. Given the population demands on the whole island of Ireland, both in the Republic of Ireland and Northern Ireland, there have been some fantastic examples of where clinicians have either co-located services in a particular trust or facility where there is not the demand from the local population to warrant it, or travelled across the border to work on different sites. Those two facets together have meant that there have been some great examples of cross-border co-operation. One of our concerns is that those arrangements remain in place in the future.

[Justin Madders]

Q Do you have any idea what the contingency plans might be if an appropriate deal is not put in place?

Raj Jethwa: That is something that we can write to the Committee about afterwards. We have been talking to our members about this situation. Our anticipation—our hope—is that an arrangement will remain in place whereby that work can continue.

[Justin Madders]

Q Have you looked at what the possible impact might be of a no-deal scenario on increased demand on services if, for example, pensioners currently living abroad came back?

Raj Jethwa: We are familiar with the research that the Nuffield Trust has done on this, as most people are. Our members are very cognisant of this. I know the Committee will be familiar with the figure of approximately 190,000 UK pensioners who may require access to healthcare facilities in the future if the S1 arrangements do not remain in place. We have concerns about that. In particular, if the arrangements do not remain in place in the future, those people may need to access healthcare facilities back in the United Kingdom. That would be a concern in terms of doctor and clinician numbers and beds, and the tight financial resources that the NHS has to work under at the moment.

[Julie Cooper (Burnley) (Lab)]

Q Good morning. Mr Henderson, you mentioned the protections around personal data in the Bill. Do you feel that the Bill gives enough protection? Are there enough controls in the Bill?

Mr Henderson: As Raj says, this is an enabling Bill, so it is slightly hard to say whether there is sufficient protection there or not. Clearly, it is a hugely important issue that needs to be fully addressed. Equally, we would say very strongly that, while individual patients’ data must be protected, the free flow of data and exchange of information are absolutely crucial. We should never forget that side of the equation: properly and safely sharing anonymised data for research purposes, clinical trials and so on is crucial. While it is absolutely essential that we ensure that personal data is protected, I would put more emphasis on that other side, which is ensuring that we continue to share and benefit from the exchange of anonymised data for purposes that benefit the health service and research.

--- Later in debate ---

[Matt Western (Warwick and Leamington) (Lab)]

Q Mr Henderson, I think you described the existing arrangements as pretty well universal. Could you explain a little more what the gaps are?

Mr Henderson: I am not actually sure I have all the detail. My understanding is that the European health insurance card and such arrangements work for all emergency situations, certainly, and most normal circumstances. I think, and Raj may know better than I, that there are some areas that are not covered particularly, but as I understand it, it is fairly universal. I am not an absolute expert in that, I am afraid.

Raj Jethwa: We can write to the Committee. My opinion is that it is pretty universal. There are probably niche areas that may not be covered. We can look into that and get back to the Committee if that would be helpful.

[Justin Madders]

Q I have one more question to both of you—I am not sure if either of you will know the answer. Some of the reciprocal arrangements we have at the moment are based on the actual cost expended and some are based on an average—Estonia, Denmark, Finland, Hungary, Malta and Norway. I am not clear why that is the case. Is there some sort of historical issue? If either of you can shed any light on that, that would be extremely helpful. One of you is shaking your head.

Raj Jethwa: I do not know that, but again we are happy to look into that and to come back to you if we find out that somebody back home does know the answer. I am not sure that I know.

Mr Henderson: It is probably lost in the mists of various previous agreements.

[Stephen Hammond]

Q Can I come back on the data point that you both commented on? Clause 4 deals directly with that and provides the usual protections in terms of data. I heard Mr Henderson’s point, and it is important that there needs to be a flow of data, although that needs to be secure. Are you happy that the protections in the Bill at the moment are the normal and adequate protections?

Raj Jethwa: One of the concerns we have is the reference to the authorised person and who could fit into that category. Without seeing more detail about what the arrangements will look like in the future, we do have some concerns and we are seeking that level of understanding. Without seeing that and knowing exactly what process will be used to, for example, recoup the money or make payments, it is hard to know exactly what those arrangements would look like and on what basis information would be shared. We do have concerns about the authorised person aspect of the Bill, and we need to ensure that we have greater understanding about exactly who would be an authorised person, beyond that list of specific bodies and individuals who are named in the Bill at the moment.

--- Later in debate ---

[Stephen Hammond]

So, the sooner the Bill gets Royal Assent, the happier you will be.

[Justin Madders]

Q On the cost point, I think some evidence was given to the House of Lords Committee that in a no deal you expected premiums to increase by between 5% and 10%. Does that sound like a familiar figure?

Alisa Dolgova: My colleague Hugh Savill gave evidence to the House of Lords, where he stated that there is likely to be an increase of between 10% and 20%. To be honest, we do not really know, because it very much depends on the particular insurer, who it insures and where that specific group of people travels to.

[Justin Madders]

Q In that context, what advice are you giving to people about insurance requirements post 29 March 2019?

Alisa Dolgova: The main message that insurers are giving to the customers is that it has always been important to have travel insurance because it covers things that EHIC does not, but it will be even more important to have it in case there is not a transitional period, because travellers would no longer have the benefit of EHIC. The message is that you need to have travel insurance in place, and that travel insurance will cover you, irrespective of whether you have EHIC.

[Justin Madders]

Q Has there been an increase in premiums because of that added uncertainty, do you know?

Alisa Dolgova: We have not currently seen an increase in premiums. Firms are currently pricing in the assumption that there will be a withdrawal agreement in place with a transitional period that will allow more time for the Government to enter into a reciprocal healthcare arrangement.

[Justin Madders]

Q In the event that there are not arrangements in place, have your members done any work on the number of people who might not be able to travel, because they effectively become uninsurable or the premiums are so high that they are prohibitive?

Alisa Dolgova: I have briefly alluded to the work that we have been doing with the Financial Conduct Authority. The FCA published a feedback statement in June this year, looking at travel for people with pre-existing conditions. The finding was that there are products available on the market but they may be difficult to locate at the moment, which is why we are doing additional work at the moment. So there are products available that will cover people.

[Justin Madders]

Q I appreciate that. There will almost always be a product; it is the size of the premium that can dictate whether that product is really available. Have you looked at the potential size of premiums in those situations? Are there particular pre-existing conditions that people might have that will have a negative impact on the size of the premium?

Alisa Dolgova: I do not have information with me about which types of conditions are more expensive than others, but it will be the types of conditions that are more likely to require treatment while you are travelling, and insurers do take factors into account such as, “What has been your recovery time?”

[Justin Madders]

Q My final question is about the overlap between EHIC costs and insurance costs. I had a recent example in my constituency of a constituent who came back from Spain with a medical bill for £15,000. It was not for repatriation costs; it was purely for medical treatment. Obviously, the question is, why is that not covered by the normal arrangements? How often does that situation arise, and can you give me some insight as to why that might be happening?

Alisa Dolgova: Yes, sure. EHIC covers you for public healthcare in the same way as a person from that country would be covered, and healthcare provision differs a lot, depending on which EU country you are in. Some countries, such as Italy, have healthcare systems that are much closer to the NHS than others, and if you travel there, EHIC will give you greater coverage. Some countries, such as Spain, have a mixed public/private system and some countries, such as Germany, have a greater tradition of private healthcare. Actually, that means the degree you are covered by EHIC varies depending on where you travel and that is why you need insurance.

[Justin Madders]

Q Okay. I think my constituent’s situation was an emergency and I do not think that any consideration was given to the type of hospital. I think that what you are saying is that reciprocal arrangements do not necessarily give you the same or equivalent coverage in other countries, because it depends on the system that operates there.

Alisa Dolgova: Yes. It will give you more coverage across all countries, but what that coverage is depends on what the situation is in that country.

[Alberto Costa (South Leicestershire) (Con)]

Q You said that private insurance policies cover the areas above the benefits of the EHIC. But is it not the case that those of us who take out private travel insurance policies precisely for the healthcare benefits may not make use of EHIC? And is it the case that, because of that, the premium costs for private travel insurance are less, given that those of us who take out private insurance might not use EHIC and might rely on the private healthcare side instead?

Alisa Dolgova: It depends on the specific terms of the travel insurance policy that you have. For example, some policies have a specific provision that you need to use EHIC first and then have resort to your insurance policy, and insurers may also provide incentives to use EHIC as well. For example, they might provide a waiver for access costs of EHIC; that has been used.

--- Later in debate ---

[Stephen Hammond]

Q Finally, without putting reciprocal arrangements in place, as this Bill intends to give the Government the powers to do, presumably it would make it more or less impossible for your sufferers to travel.

Fiona Loud: Yes, it is our conclusion that it would be very hard. It is worth mentioning that at the moment it is generally easier to obtain dialysis at a unit away from your home in Europe than it is in the UK, because we have a heavily pressed NHS. Trying to get capacity in other units is possible with a lot of planning, but if you want to travel for a funeral or for something at short notice, it becomes very difficult to go away for more than one or two days in between dialysis sessions. NHS staff will help and do their very best, but it is easier to go away for two weeks in Europe and take a break in that way than it is to get two weeks in a UK unit, unfortunately.

[Justin Madders]

Q It is alarming to hear about some of your members seeing the expiry date on their EHIC card and assuming that carries—

Fiona Loud: I have heard it as a comment.

[Justin Madders]

Q It is perfectly understandable: why would they not assume that? Are you aware of any publicly available guidance to warn people that that date may not be absolutely set in stone?

Fiona Loud: I have not come across any publicly available guidance on that at all. We have given advice and organisations that we work with give advice, but it is informal advice. It is not formal, because it comes from us as a charity, not from any public health or other such body.

[Justin Madders]

Q Obviously, we hope that we do not need to get into that situation. Do your members plan things quite far in advance because of the need to get the right treatment?

Fiona Loud: That is what many people would do, for the very reasons we have given. We have people who are sometimes thinking about two years in advance. If you have kidney failure, it may well be that your income is quite limited. If you are spending three days a week in hospital and you are not particularly well, you would be likely to plan a long way in advance, because it is so important. As a charity, we give grants to kidney patients to be able to go away and have that break, so we hear quite a lot about it from various patients. Some can be up to two years in advance; others will be at shorter notice.

[Julie Cooper]

Q Good morning and thank you for coming along to help us. I want to ask about a couple of things. The aim of the Bill is to provide the confidence that we have talked about, to mirror as far as possible the reciprocal arrangements that we already enjoy. However, it does give the Secretary of State the authority to enter into any number of differential agreements with individual EU states. Do you have concerns about that? If we were in this situation—I hope we are not—the Bill empowers the Secretary of State to do that. What would be your view be on the arrangement with Spain being one thing and that with Italy another, and so on?

Fiona Loud: Although we completely understand the need to be able to have the latitude to make bilateral arrangements for everyone’s benefit, from a patient point of view we would like to see a simple arrangement that is the same across all countries. People will not be sitting in these Committees or reading these Bills in great detail. They simply want to be able to go away. They know how a system works at the moment: they will perhaps turn to somebody in their own NHS unit, or they will turn to us or to other specialists, and ask, “How do I go ahead and book my holiday?” and they will assume that, because they have that card, that is how it will be. That would be our wish and our preference, but we understand that that is not always possible.

If I may make a separate comment about Northern Ireland, there are potential issues there that are nothing to do with holiday but are simply about residents who are used to going across the border day to day for their care and treatments. There are pre-existing arrangements and protocols there. For example, somebody might be on dialysis in Northern Ireland but, because the rest of their family live in Ireland—it is only 10 or 15 miles away—they might be planning to retire there in a year or two and assume that they can just carry on having their dialysis there.

The provision exists for people who live in Northern Ireland to be listed on the Irish organ donor register—you can only be on one—and vice versa. They will need to look at where they are registered. Does that change immediately? There are also other arrangements for organ sharing. If an organ is donated in one of those two jurisdictions and the weather is too bad to take it to the mainland, it can be taken across by road. That is not used very often, but those are just a couple of examples of some of the detail that might affect people. That is to do with healthcare but it is also separate. There may, therefore, need to be some other bilateral arrangement for Northern Ireland, which is separate from the more general one that we have just discussed.

Nursing: Higher Education Investment

Justin Madders Excerpts

Wednesday 21st November 2018 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Davies, and I congratulate my hon. Friend the Member for Wolverhampton South West (Eleanor Smith) on securing this important debate. The level of interest from Members shows how important this subject is. My hon. Friend spoke from great personal experience, and I thank her and everyone else who has worked in the NHS for their contribution over many years to make it an institution of which we are all rightly proud.

My hon. Friend comprehensively dismantled the Government’s arguments on the merits of removing the bursary. As she said, it is indisputable that the number of applications and the numbers of people starting courses have fallen, and that the age profile of students has changed. She was right to say that the decision to abolish the bursary was a political choice, and not one that the Labour party would have made. Along with other Members, she highlighted areas that have fewer nurses in community and district hospitals and in settings that treat those with learning disabilities or mental health problems. Given that the pipeline for delivering nurses is not working as it should, those shortages may worsen. My hon. Friend was right to say that higher education is the best way to train enough highly skilled nurses to meet the needs of patients.

[Marion Fellows]

I wonder how many Members are aware that the Select Committee on Education will shortly publish the results of its inquiry into nursing apprenticeships.

[Justin Madders]

I thank the hon. Lady for her public service announcement. Let me now refer to some other contributions.

The hon. Member for Henley (John Howell) made a fair point about how the price of housing exacerbates the shortage of nurses in some areas, and all Members will be aware that earlier this year more than 1,900 nursing vacancies were advertised in the Thames Valley area, although only five were filled.

My hon. Friend the Member for Lewisham East (Janet Daby) gave a thoughtful and persuasive speech that highlighted the fact that the number of applicants over 25 has fallen by 40%, and she mentioned the impact of that in specialist areas. She was right to say that the nature of the nursing degree limits the opportunities for students to earn income outside their course demands.

The hon. Member for Sleaford and North Hykeham (Dr Johnson) made a considered contribution about her criteria for what would make a successful training course, and I will reflect on that good piece of advice.

As always, it was a pleasure to hear from my hon. Friend the Member for Sheffield Central (Paul Blomfield), who has great experience in this area. He referred back to a debate in 2016, and was right to say that this policy has damaged mature students and social mobility. Many concerns that were raised back in 2016—including by Government Members—have been ignored, or indeed come to pass.

The hon. Member for Chelmsford (Vicky Ford) gave us the benefit of the thoughts of nurses in her constituency. It is always a good idea to hear directly from those on the frontline, and she came up with some interesting practical suggestions about what could be done to make the lives of nurses easier. Along with other Members, she mentioned the impact of this policy on the number of mature students applying, and the impact that that has on particular specialisms.

My hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh) set out why, due to a combination of factors, now is not the time to experiment with a flawed and unproven model. She mentioned the challenge of retention, and related some graphic and moving stories from her constituents. She was right to say that if we do not fix this issue now, we will pay the consequences for decades to come.

Finally, my hon. Friend the Member for Lincoln (Karen Lee) spoke of her own frontline experience, and mentioned the expense and risk of over-reliance on agency staff. No doubt the challenges that we face and have discussed today will be exacerbated, which will place even more reliance on temporary and agency staff.

We have had a broad and wide-ranging debate. This is the Minister’s first outing in his role, and I welcome him to his place and congratulate him on his appointment. I was trying to work out whether he is the fourth or fifth Minister I have shadowed since I was appointed to my role just over three years ago, which shows that it is not just the NHS that has problems with retention.

The NHS faces a significant workforce challenge, and nowhere is that more pronounced than in nursing. England is missing about 42,000 nurses and, according to conservative estimates, without significant intervention that figure may rise to more than 48,000 by 2023. The situation is serious—other Members have described it as a “crisis”, which is absolutely right, but this crisis could have been avoided.

As Members have said, we are facing a perfect storm, with recent trends showing that more nurses are leaving the profession than joining it, the ongoing uncertainty over Brexit, the fact that one in three nurses is due to retire within the decade, and the catastrophic decision to scrap bursaries for nurses, midwives and allied health professionals. According to the Royal College of Nursing,

“without enough nurses, care is fundamentally unsafe, frontline staff are compromised and people seeking access to health and care services are not able to receive the care that they need.”

The RCN also reports that services are sometimes so short-staffed that nursing students are inappropriately used to plug gaps in the workforce and have to look after patients before they are qualified to do so. That is an extremely worrying development.

This is a crisis of the Government’s own making. Before I come on to the current policy context of higher education funding, I will say a little about the circumstances leading to the decision to undertake the reforms back in 2015. As my hon. Friend the Member for Wolverhampton South West said, workforce planning has not traditionally been a great strength of the NHS.

One of the first decisions of the coalition Government back in 2010 was to cut the number of nurse training places at university. In 2010-11, 20,092 places were funded, but that fell sharply to 17,741 in 2011-12 and dropped again to 17,546 in 2012-13. At that stage, David Green, vice-chancellor of the University of Worcester and a former chair of the west midlands group of universities said:

“We are heading straight for a national disaster in two to three years’ time.”

The RCN also warned that the cuts would cause

“serious issues in undersupply for years to come.”

Those warnings were not heeded by the Secretary of State at the time, and a completely predictable and preventable crisis in the nursing workforce was created. Had the coalition Government only maintained the levels set by the last Labour Government, 8,000 additional nurses would have been trained in the last Parliament alone.

In the midst of this completely manufactured crisis, the abolition of undergraduate nurse bursaries was announced. I ask the Minister to consider whether that response to the crisis was the correct move. In just two lines in the 2015 autumn statement, with no consultation and no evidence base, the Government committed themselves to a huge gamble with the future of the NHS workforce and with patient safety. The then Minister described the proposal as

“potentially one of the most exciting things that we will do in the NHS in the next five years to increase opportunity and quality, and the presence of nursing staff on wards.”—[Official Report, 4 May 2016; Vol. 609, c. 196.]

We were told at the time that our many concerns were misguided, and that the changes would lead to an additional 10,000 training places being provided. However, as we have heard, the opposite has happened. As of September 2018, almost 1,800 fewer people are due to start nursing university courses in England. The number of mature students has plummeted by some 15%, which as we have heard has had a particular impact on specialist areas. There has been a 12.9% reduction in the number of mental health nurses since 2010.

As my hon. Friend the Member for Stroud (Dr Drew) said, there has been a shocking 40% reduction in learning disability nurses. Learning disability nursing celebrates its 100th anniversary in 2019. It will be an astonishing failure of the Government’s if they allow it to disappear altogether. That reduction comes at a time when the needs of people with learning disabilities have never been more paramount, with premature mortality resulting from complex health conditions and people being detained in assessment and treatment units for far longer than necessary.

We warned at the time that this policy would have precisely the effect that is has. After meeting representatives from the profession and looking at the evidence, the Government carried on. On the other hand, they did not formally consult the Royal Colleges before announcing their plans. I know that there has been some dialogue since then, and I will be grateful if the Minister will set out his recent discussions with the sector about the impact of the bursary cut and what steps the Government are taking to deal specifically with the crisis in learning disability and mental health nursing, which have been particularly hard-hit by the changes.

As various Members have said, the new Secretary of State recognised the crisis by saying

“simply put: we need more”

nurses, and that:

“That is something we will specifically address in the long-term plan for the NHS”.

That plan is due to be published any time now, and we will examine it very closely. However, if the Secretary of State is serious about tackling the workforce crisis and increasing the nursing workforce, he needs to make a key element of the strategy the reintroduction of NHS bursaries. It remains our policy to do so, and there has not been a single jot of evidence since they were removed to dissuade us from our initial view that their abolition was short-sighted, damaging and, ultimately, self-defeating. In a written answer on 19 April this year, the former Minister indicated that the Department would publish an update on the effect of the plans later this year. Will the Minister advise us of where that is up to?

Although I have referred to a lot of large numbers to highlight the overall impact of the policy, it is important to hear, as we have from some Members, about the impact on individuals. I do not know if the Minister had the opportunity to attend the RCN drop-in earlier today. If he did not, I convey to him how well the students I spoke to conveyed how difficult it is to work what they and I consider to be unsafe hours to make ends meet; how the inclusion of the student loan in income for benefits calculations leaves families worse off; and how the students notice that, each time they return to the lecture theatre, there are fewer and fewer of them. What assessment has the Department made of the attrition rate of university courses since the abolition of the bursary?

In conclusion, the uncertainty created by Brexit means that the reliance on recruitment from the EU that we have seen in recent years is no longer an option to shore up nursing numbers. Our NHS staff cannot keep giving more at the same time as we give them less. The Government need to fund our future and invest in nursing higher education. They simply cannot afford not to.

Healthcare (International Arrangements) Bill

Justin Madders Excerpts

Wednesday 14th November 2018 Commons Chamber

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

Of course, the Opposition welcome any efforts to safeguard healthcare for the estimated 190,000 UK expats living in the EU and the 50 million or so nationals who travel abroad to EEA countries each year. We have concerns about some clauses, which we will address in Committee. It is 874 days since the UK voted to leave the EU, although for many of us it seems a whole lot longer. It is also a year since the European Union (Withdrawal) Act 2018 was introduced, so it is a matter of some concern that this Bill is only now being introduced.

As the Minister rightly said, the Bill gives the Secretary of State wide-ranging powers, including the power to amend primary legislation through a Henry VIII-style clause, but it places no obligation on the Secretary of State to report back to Parliament, even in the event that a reciprocal deal cannot be reached. That, combined with the scope for extensive use of statutory instruments under the negative procedure, represents to us an unacceptable lack of parliamentary oversight of an issue that will impact on the daily lives of millions of people. The Secretary of State ought to have learned from previous attempts that this Parliament does not react kindly when asked to sign a blank cheque. We will, therefore, seek to ensure that any new powers granted are proportionate and that all regulations are subject to the affirmative procedure.

We recognise the need for this Bill, because without a reciprocal agreement, UK citizens living in the EU, and vice versa, could find themselves having to pay for and make complicated arrangements to access healthcare in the country in which they live or that they visit. The biggest impact will be felt by the 190,000 state pensioners living abroad, and by those with long-term health conditions who could be prevented from travelling for business and leisure by prohibitively high insurance costs. There does appear to be some doubt about the figure of 190,000. The DWP website Stat-Xplore, which provides details of UK pensioners across EU and EEA countries, shows the figure for the EU27 as 468,793 in May 2018. I would be grateful if the Minister offered some clarification on that discrepancy.

We support the Government’s aim of retaining the current model of reciprocal healthcare. We are, however, extremely concerned that, with just over four months to go until we leave, there is still a great deal of uncertainty about whether all the hoops can be jumped through. Although the arrangements may continue as part of a withdrawal agreement if it gets through Cabinet, Parliament and the rest of the EU, there is just as much chance that we will need a whole new set of arrangements, which could radically alter the situation.

The Government’s impact assessment seems seriously to underestimate the consequences of a no-deal scenario, and I would welcome clarification from the Minister on that when he sums up. There are a number of reasons why I say that. As one would expect, the impact assessment sets out that the cost of establishing a future reciprocal healthcare arrangement on the same basis as the current one would be around £630 million per year, which is about the same as the cost of the current arrangements. However, the impact assessment goes on to say that, in the event of a no-deal scenario, the costs are expected to be similar or less, depending on the number of schemes that are established. Assuming that we still need and want to have an agreement with every country with which we do now, that would seem to imply that fewer people might need treatment. I doubt that even the biggest advocates of a no-deal Brexit would claim that leaving the EU without a deal will somehow miraculously lead to an upturn in people’s health.

Some clarity from the Minister would be appreciated, because the impact assessment appears completely to underestimate the complexity and cost of implementing what might end up being a diverse array of agreements. When they gave evidence to the House of Lords European Union Committee, the British Medical Association and the Royal College of Paediatrics and Child Health were clear that should no EU-wide reciprocal agreement be achieved, the significant costs of establishing bilateral reciprocal arrangements with EU and EEA countries would fall on the NHS. The BMA said:

“Managing access to health services by non-EU citizens is bureaucratically more burdensome than managing access for EU nationals currently”

which,

“in the event that the current reciprocal arrangements with the EU were to be discontinued, could have considerable resource and administrative implications for hospitals in both the UK and the EU.”

I therefore ask the Minister why those associated potential administrative costs have not been included in the impact assessment.

Expenditure on UK state pensioners and their dependants accounts for approximately 75% of the total amount that we spend on reciprocal healthcare and supports UK state pensioners and their dependants living in Europe. In 2016-17, that equated to an estimated £468 million. The Department for Health and Social Care has accepted that the system is extremely cost-effective for the UK, not least because treatment overseas is often cheaper than it is in the UK. For example, Spain’s latest average pensioner cost is €4,173, compared with £4,396 in the UK. If we were unable to reach a full agreement, there would be two likely outcomes. In some cases, UK expats would face having to fund private medical insurance. However, in many cases, particularly for those with chronic conditions or complex healthcare needs, such insurance could be prohibitively expensive, if it could be found at all. In those cases, the planning and funding provision for those individuals would fall on the NHS.

Analysis by the Nuffield Trust has found that, if British pensioners lost their healthcare cover in EU states and had to return to the UK to access care, the additional annual cost to the NHS could amount to as much as £1 billion. The trust also predicts significant additional resource implications. It said in a report from 2017:

“Looking at relative hospital demand by age group, we might expect 190,000 people to require 900 more hospital beds and 1,600 nurses, as well as doctors, other health professionals, and support staff such as porters. This number of additional beds would be equivalent to two new hospitals the size of St Mary’s Hospital in London.”

The implications for and potential demand on resources if arrangements are not made are huge. Of course, if the higher figure for pensioners in the EU is correct, those demands could more than double.

The European health insurance card benefits everyone who travels from the UK to EEA countries, but it is particularly beneficial for those with long-term conditions. The Academy of Medical Royal Colleges has set out that the EHIC enables such individuals to do so

“without the need for expensive travel and health insurance.”

One example of that is the 29,000 patients in the UK who receive kidney dialysis, typically three days per week. For those 29,000 patients, who can currently access dialysis across Europe—from Rotterdam to Rome—taking away the EHIC would take away their freedom. Travelling for work, for leisure or to visit family would be prohibitively expensive for them if we were not able to reach a comprehensive reciprocal healthcare agreement. Even if the Government were able to negotiate bilateral agreements, it would be of little comfort to a kidney dialysis patient who wished to attend a family wedding in Italy if they could access treatment only in France, Spain or Ireland.

The BMA and others have set out that patients with disabilities would be among the most affected if there were no reciprocal healthcare agreement. According to the BMA, without the EHIC, people with disabilities could find that travel or health insurance was

“especially expensive and potentially difficult to arrange”.

The Law Society of Scotland has reported that more than a quarter of disabled adults already felt that they were charged more for travel insurance, or simply denied it, because of their conditions. It is a matter of concern that the impact assessment does not explore the consequences of not reaching a deal for disabled people and those with long-term conditions. I therefore call upon the Minister to ensure that such an analysis is undertaken as an early priority.

Another question mark that hangs over the entire process is how dispute resolution will work, in either a deal or a no-deal scenario. Throughout the entire Brexit process, one of the red lines in the negotiations has been the role played by the European Court of Justice. However, I have yet to hear any suggestion about how, if we manage to reach a full reciprocal healthcare agreement with the EU27, disputes could be resolved without some reference, ultimately, back to the ECJ. The same would apply to bilateral agreements. If, for example, we reach an agreement with Spain and there is a disagreement about a payment made or the administration of the scheme—that could happen from time to time—who will determine which side is in the right?

When he gave evidence to the Health Committee, Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, considered this dilemma and said that

“as the two simplest ways”

of resolving dispute resolution

“have been ruled out by the Prime Minister, I do not see how you can do it.”

What kind of dispute resolution procedure does the Minister envisage either in a full agreement scenario, or in the case of bilateral agreements with individual states? Can he confirm whether the Government’s position is still that the ECJ will have no jurisdiction over such issues?

Clause 4 provides a legal basis for processing data to facilitate any agreements after the UK leaves the EU. Although facilitating data processing is a necessary element of any reciprocal agreement to support the making of payments for healthcare outside the UK, I note that appropriate safeguards are referred to in the Bill, and I ask for clarification about what those safeguards are and how they would work in practice. We have concerns that the Bill appears to allow the Secretary of State to hand personal data to private providers and to allow private providers to process that data. We will look to explore that further in Committee if the Minister, in winding up, is not able to satisfy us on the need for those powers, the extent to which they will be used, and what safeguards will be applied.

Another issue we will face, particularly if we are not able to agree a full reciprocal agreement, is cost recovery. Members have already referred to the challenges on that. The BMA set out clearly to the House of Lords Committee that:

“Managing access to health services by non-EU citizens is bureaucratically more burdensome than managing access for EU nationals currently”,

and that

“in the event that the current reciprocal arrangements with the EU were to be discontinued…could have considerable resource and administrative implications for hospitals in both the UK and the EU.”

As I set out before, it is deeply concerning that this potential challenge does not appear to have been considered in the impact assessment. Even under the current arrangements, cost recovery is something that we do not appear to have handled satisfactorily and the fault lies with the Government.

In 2012-13, the NHS charged only about 65% of what it could have done to visitors from outside the EEA and Switzerland, and only 16% of what it could have done to visitors from within that area. I accept that things have improved since then, and that the Department set itself a recovery target of £500 million overall and £200 million for EEA and Switzerland patients, which it hoped to achieve by 2017-18, but it still appears to be well behind on those targets. I would therefore be grateful if the Minister could advise us on the latest projections for that. He mentioned a figure of £66 million earlier, but it was not clear which particular period that related to.

The Law Society of Scotland was clear on the importance of this issue when it gave evidence to the Lords Committee. It said:

“as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for funding cross-national use of health services are put in place.”

Even the Health Minister in the other place admitted that there was a “job to be done” on cost recovery. Irrespective of Brexit, it is deeply concerning that millions of pounds that should be spent on UK patients by the NHS is going to waste because of a failure to get a grip on cost recovery.

Giving evidence to the Public Accounts Committee, NHS Improvement said that it was going to monitor charging and cost recovery, and intervene where trusts have not met their statutory obligations. Will the Minister advise us on whether it has done so? If there is an additional administrative burden on the NHS in setting up new systems of cost recovery, will the Minister give a commitment that NHS providers will be adequately compensated?

It is a concern that the Bill gives the Secretary of State wide powers with little recourse to Parliament. Where are the checks and balances if the NHS ends up having to police 27-plus different sets of arrangements? What if the deals reached end up costing far more? What if our cost recovery continues to lag well behind what it should be? There needs to be greater parliamentary oversight of all these issues.

The importance of getting a good deal on reciprocal healthcare is more significant in the countries where it is accessed most, none more so than in the case of the island of Ireland. For anyone who has visited some of the more rural areas along the border between Northern Ireland and the Republic of Ireland, as I did during the summer, it is clear the extent to which crossing the border is a part of day-to-day life for those communities. The border area has a dispersed population of around 2 million people. Currently, this combined population offers the economies of scale necessary to provide health services, which would be completely unsustainable were a hard border to be put in place. Cooperation and Working Together, a partnership of health services from both sides of the border, has set out clearly that there are many examples where patients’ lives have been saved because of free and open access for emergency services across the border. If we do not get the right agreement in place, there is a real danger that we could see a situation where one ambulance drives up to one side of the border and another from the other side meets it to transfer a patient. These are the very practical implications of the Bill we are discussing today.

Reciprocal healthcare arrangements on the island date back to before the UK and the Republic of Ireland joined the EU, but they are now underpinned by EU law. We welcome the commitment by both Governments to ensure that the current arrangements will continue after Brexit, but the UK Government have yet to explain clearly exactly how they will approach these issues in practice. The border issue has clearly been a sticking point in the overall negotiations, so we will have to monitor very closely what the final deal says on that.

I want to say a few words about devolution. The Scottish and Welsh Governments have clearly and robustly articulated their support for a continuation of reciprocal healthcare agreements. I would be grateful if the Minister could set out the extent to which he has engaged with the devolved Administrations as part of that process. The House of Lords Committee was clear in its recommendations that there should be active participation of the devolved Administrations in setting the UK’s position on future arrangements, but I am not aware that anything has taken place to date. The Bill gives wide-ranging powers to the Secretary of State, but places no obligation on him to consult or engage with the devolved Administrations before making regulations. What assurances can the Minister give us that that will take place, particularly well ahead of any new arrangements being put in place?

In conclusion, this is a very short Bill, but one that will have far-reaching implications. The Secretary of State is asking for powers, which will have a direct influence on the day-to-day lives of hundreds of thousands of people without providing us with clarity on how he will use them. The Bill has been two years in the making and yet the impact assessment provided is totally insufficient, if not inaccurate, and there seems to have been little appreciation of the complexity of the task at hand or the implications if things go wrong. All of that is amidst the deal or no deal circus we have at the moment. The Government are asking for the powers to make agreements with other countries, but they cannot get an agreement around the Cabinet table. We will see, possibly by the end of the debate, whether that turns out to be correct.

We are in no doubt that the continuation of reciprocal healthcare is absolutely essential. We will not oppose the progress of the Bill today, but we will press for the safeguards needed to ensure that proper regulations and oversight are put in place, and that the interests of patients are protected.

Oral Answers to Questions

Justin Madders Excerpts

Tuesday 23rd October 2018 Commons Chamber

[Stephen Barclay]

My hon. Friend is right to draw attention to the valuable role played by pharmacies. This is part of a wider education campaign within the NHS and increased access to clinicians, such as through 111, is another component of that. We want to ensure that rather than people’s first port of call being a GP, they access the NHS and pharmacies at the appropriate time.

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

At the end of the last financial year, trusts owed the Department a staggering £11 billion. NHS providers say that this is locking some trusts into

“a vicious circle of inevitable failure”,

and the King’s Fund says that there is no prospect of them ever repaying. Trusts with the biggest debts are forced to pay the highest levels of interest. How can the Minister expect trusts to be efficient when they are paying an interest rate of 6% on debts to his Department?

Draft Medicines and Healthcare Products Regulatory Agency Trading Fund (Amendment) (EU Exit) Order 2018

Justin Madders Excerpts

Thursday 11th October 2018 General Committees

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

It is a pleasure to serve under your chairmanship, Mr Bailey. As the Minister said, there is little in the draft order that is controversial; the changes it makes are of a technical nature and are necessary as we approach Brexit.

Of course, there is much wider controversy about Brexit as a whole, and—in the context of this debate—particularly about its impact on the British pharmaceutical industry. I do not believe that anyone voted to make the national health service worse off; indeed, the bus advertisements would have led people to think that they were voting for the contrary. However, the decision to leave the European Medicines Agency could have far-reaching consequences, which is why the head of the Association of the British Pharmaceutical Industry recently stated that we are seeing a British success story being broken up. Until the decision was taken, the EMA headquarters in London had approximately 900 high-quality jobs. The MHRA also played a leading role in the EMA authorisations process.

In 2016, the UK was the rapporteur on 22 applications for new medicines and co-rapporteur on a further 19. That represented 36% of the total number of applications. This year, with a much different environment envisaged, the MHRA bid for 36 contracts, but was awarded only two. Of course, there will be no more contracts in the future.

Will the Minister explain what impact the loss of contracts will have on the MHRA? Will there be any shortfall, and can the Minister confirm that any shortfall will not be made up from existing NHS budgets? As we know, the life sciences sector in our country has a turnover of more than £60 billion a year, generates exports worth £30 billion and has a trade surplus of over £3 billion per annum. It employs 220,000 people, and 25% of the world’s top prescription medicines were discovered and developed in the United Kingdom.

The north-west, where my constituency is based, is one of the leading regions of the country for pharmaceuticals, employing about 18% of the total national workforce. Projects such as the proposed Cheshire science corridor are a really important factor in that. Can the Minister indicate what he thinks the likely impact of the decision to leave the EMA will be on the sector as a whole, and what steps he is taking to minimise that? There are also potential effects on patients’ access to new medicines and treatments.

The Office of Health Economics has warned that the average likely submission for marketing authorisation in the UK could take up to three months, that up to 15% of applications could be submitted more than a year after an European economic area submission, and that some products may not be tested or marketed in the UK at all. The OHE also found that 45% of applications were not submitted to Australia, Canada or Switzerland following submission to the EMA. Can the Minister give us assurances on the risks to the general availability of prescriptions and medicines for patients?

We do not oppose these regulations, but there are much wider and more profound questions about the Government’s attitude towards medicine regulation in this country. I hope the Minister can reassure us that the Department is stepping up to that particular challenge.

--- Later in debate ---

[Steve Brine]

I am not giving the hon. Lady that guarantee. I am saying that it is a live consultation and it would not be appropriate for me to pre-empt it. I do not share the hon. Lady’s half-full view of our ambition for the future, which the Prime Minister set out in terms of our relationship with the EMA. The EU does not have a relationship with the UK as a third country at the moment. That is why we have set out an ambitious proposal for our new relationship with the EU and its agencies, including the EMA. I am hopeful, as are the Prime Minister and the Government whom I speak on behalf of, that we will secure a good deal. We still think that that is the most likely outcome. That includes a new relationship with the EMA. We should remember that the expertise that we have in this country, and the work we do with the EMA, will not suddenly change because it is based in Amsterdam. It will still need that expertise and that relationship. I am ambitious about the future, which is why I say what I say.

The matter before the Committee today is technical, to make changes to enable the agency to function after exit day.

[Justin Madders]

The Minister is speaking with great confidence, without any basis in fact, in saying that the MHRA will not need any state handouts in the future. Will he commit to report back to Parliament, if it turns out that it is not, in future, self-financing?

[Steve Brine]

Of course, if there is any change to any arm’s length agency that the Department works with, we will come back to Parliament for that discussion. That is partly what the consultation is about at the moment. So if the hon. Gentleman wants a blank cheque to say that we would come back to the House to have discussions around any future changes, the answer is self-evidently yes.

Question put and agreed to.

Baby Loss Awareness Week

Justin Madders Excerpts

Tuesday 9th October 2018 Commons Chamber

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

I am humbled once again to respond to such an important debate on behalf of the Opposition. I would like to begin by congratulating the hon. Member for Eddisbury (Antoinette Sandbach) on securing today’s debate and on her continuing work in drawing from her personal experience to campaign on behalf of thousands of others who have been affected by this important subject. I also pay tribute to my hon. Friend the Member for Washington and Sunderland West (Mrs Hodgson), who could not be with us tonight. As we have heard, her contribution to the all-party parliamentary group is greatly valued, as is the work of all the members of that group who have spoken tonight. There are something in the order of 630 registered APPGs, but few if any can claim to have so much success in bringing attention to a vital subject and securing a tangible change in policy.

As several Members have said, today’s debate has once again shown Parliament at its best, and I would like to reflect on some of the contributions that we have heard. The hon. Member for Eddisbury spoke in positive terms about the success of the national pathway and gave interesting statistics on parents’ feedback. Some 98% felt that they had been treated with respect, which is really important and, critically, 90% felt that they had been provided with information that was easy to understand. She gave the example of a parent who had to go and speak to the doctor on about five occasions to get an explanation that they were comfortable with, which brought home how important it is in this difficult area for parents to be empowered to ask questions and understand what has happened. It was also interesting to hear that medical professionals gave positive feedback as well.

The hon. Member for Eddisbury expressed concern about ongoing investigations in the Shrewsbury area at the Countess of Chester Hospital, and I am sure that when they conclude we will both have questions to ask. It is worth saying that one of the things of which I have been aware, particularly in relation to the Countess of Chester issue, is the impact on the local community. Many parents, whether they are directly affected or not, have children who were born at the hospital, and were understandably concerned when the news came out. We need to take that on board for future learning.

We heard from the hon. Member for Ceredigion (Ben Lake), who gave specific examples of how we should improve outcomes, and raised the importance of training and awareness of foetal movements, and improvements in ultrasound scanning. The hon. Member for Banbury (Victoria Prentis) gave a wide-ranging speech. She always speaks with great personal knowledge and authority on this matter. She said that media coverage of this issue was pretty impressive and very sensitive, and that there was much more of it. She spoke positively, as did every Member who contributed, about the impact of the pathway. However, she pointed out that only 46% of maternity units provide mandatory bereavement training, some of which lasts only an hour or less. She was right to talk about the impact on staff of some of the issues with which they have to deal. She was right to highlight the fact that of course we need more midwives and that the focus should not just be on recruitment but on retention, and the serious challenges not just in midwifery but across the NHS workforce.

My hon. Friend the Member for Coatbridge, Chryston and Bellshill (Hugh Gaffney) spoke from personal experience, and I thank him for doing so. He again raised access to mental health support and the lack of bereavement facilities in all units. He discussed the Bumblebee charity in his constituency, which was another example of how individuals turned their own experiences into a force for good. He ended with a tribute to his mother, who had to deal with stillborn babies in, presumably, the early years of the NHS, when things were treated very differently. We ought to pay credit to the service that she gave to the health service in a very different era for dealing with these issues.

It was a pleasure, as always, to hear from the hon. Member for Colchester (Will Quince), who gave a wide-ranging and compelling speech. He spoke about why it was important that we talk about these issues. No matter how short someone’s life, it is incredibly important to the parents. He will know of my own constituent, Nicole Bowles—the badge that I am wearing gives a signal that someone has suffered child bereavement and it is all right to talk about it. That is a really important message that we cannot repeat enough: it is okay to talk about these things, because it helps to raise awareness and discuss matters.

The hon. Gentleman was crystal clear that we need bereavement suites in every unit up and down the country, and he was right about having more midwifery training. He made a very fair point, which I presume comes from his own personal experience, about continuing support for parents when they are dealing with subsequent pregnancies. One can only imagine the anxiety that they face throughout the whole pregnancy in that situation, and I am sure the Minister will reflect on that. The hon. Gentleman also made one of the strongest arguments I have heard in support of international aid and what a difference it can make to tackling baby loss around the world.

The hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) eloquently reminded us that this issue affects grandparents and the wider family, as well as the parents. The hon. Member for Sleaford and North Hykeham (Dr Johnson) spoke from her professional background and experience when she said that the first question the parents always ask is, “Why?” and the second question is, “What can be done to prevent this happening again?” We have heard countless stories of parents taking that second question and using it as a force for good. She raised, as she did in the last debate, the impact on families of having to go to specialist units a long way from their homes, and I hope the Minister will reflect on that. She was also right to highlight the recent increase in sudden infant death syndrome, which is of great concern and is certainly perplexing.

The hon. Member for Strangford (Jim Shannon) spoke with great sincerity about his own family’s experiences. He drew a contrast between how his mother’s generation dealt with such issues and how we are beginning to talk about them much more openly today. He was right to say that we are all probably connected in some way to someone who has suffered such a loss.

As we have heard, today’s debate coincides with the 16th year of Baby Loss Awareness Week, which is an important opportunity for us all to unite with bereaved parents and their families and friends to commemorate the lives of babies who died during, before or shortly after birth. I echo the comments made in praise of the more than 60 charities that now collaborate on this week. When I first spoke on this subject two years ago, around 40 charities were involved. That increase in numbers shows what an impact this week has had on raising awareness and bringing people together, which is what we want to see. Each of those organisations should be extremely proud of what they do and of the way they work together to drive through change on a national basis. It seems to be a characteristic of this issue that personal tragedy moves people to go to huge lengths to help others in the same position. In doing so, they display extraordinary levels of courage and resilience, and I pay tribute to them all.

As well as using today’s debate to raise awareness, this is an opportunity to take stock of progress and once again highlight the fact that although excellent care is available in the country, it is not available to everyone everywhere. It has been said many times before and during the debate that one of the key challenges for the Government is to tackle regional disparities. In England alone, there is still a 25% variation in stillbirths. Although there has been a reduction in the stillbirth rate and the perinatal mortality rate, it is quite a slight one, and sadly the neonatal mortality rate in England and Wales has increased two years in a row.

While we can rightly say that we are beginning to improve the approach to those dealing with the consequences of baby loss, it seems that we still have a long way to go in understanding and really tackling the causes of it. The example we have heard a number of times today is that 15 babies every single day are stillborn or do not live past the first month, and it is believed from studies that up to 80% of those deaths could be avoided. As the hon. Member for Colchester said, too many deaths remain unexplained, and as many Members have said, we are still a long way behind where we should be in terms of prevention. According to The Lancet, the annual rate of stillbirth reduction in the UK has been slower than in the vast majority of comparable high-income countries.

One measure that may hopefully make inroads into improving outcomes is the maternity safety training fund, but as a one-off limited fund, it was by definition restricted. I raised the concern last year that time might not be found for the training to reach all those who would benefit from it, so it was disappointing to hear from Baby Lifeline that workforce pressures meant that many staff could not access the training available under the scheme. It gave clear examples of where the training given has improved outcomes, but this must not be the end of the story. The fund needs to be repeated on an annual basis and, crucially, staff need to be given the time and space to take advantage of what is on offer.

In many areas of the NHS, workforce challenges are the biggest barrier to improving outcomes. The “Bliss baby report 2015: hanging in the balance” stated that 64% of neonatal units did not have enough nurses to meet safe staffing levels and 70% of units looked after more babies than is considered safe. That was three years ago, and on many indicators the staffing situation is more acute now than it was then. We know that we have a shortfall in nurses of more than 40,000. We have more nurses and midwives leaving the register than joining it, and registrations by people from the European economic area are dropping dramatically. We know that the demographics of the existing workforce are not in our favour, which is why the retention issues raised are so important. I would be grateful if the Minister updated us in his concluding comments on whether any progress has been made to improve the figures that Bliss set out in 2015.

It is also worth considering staffing challenges in the context of the worthy aim of introducing a continuity of carer model, when even the modest target of 20% of women being covered by March 2019 looks challenging. Can the Minister say whether we are on track to meet that and when he anticipates there being full coverage? There is ample evidence to show that continuity of care can make a big difference to outcomes as well as the patient experience.

Finally, I want to say a few words about the national bereavement care pathway, as it has been rightly trumpeted this evening. It is clearly making a big difference on the ground, but it needs to be rolled out comprehensively as soon as possible. The Prime Minister indicated some time ago that it would be rolled out nationally by about this time. Again, I wonder whether the Minister can update us on that ambition.

In conclusion, the debates that we have had over the last few years, and again tonight, underline the importance of the work undertaken by hon. Members and the many charities in the sector. It means that the silence that we talk about is now beginning to end. It is not possible to overstate how courageous those who have spoken out about their personal experiences are or how influential those interventions have proven to be. Having now spoken out, we must continue to talk about what we need to do to improve outcomes. This year my council will be joining the wave of light, and I am hopeful that other public buildings in my constituency will join in—I am doing what I can to encourage them. Such symbolism can only increase public awareness of this subject, and if actions like that reach just one grieving parent who may have felt that they were alone, but who now feels that they have someone to turn to, then it will have been worth it.

Integrated Care

Justin Madders Excerpts

Thursday 6th September 2018 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I congratulate the hon. Member for Totnes (Dr Wollaston) on her knowledgeable and measured introduction to this extremely important debate. I also thank the Health and Social Care Committee for an extremely useful and detailed piece of work on a rapidly changing area. In her speech, the Chair of the Committee set out from a patient’s perspective why it is so important for us to have a more co-ordinated approach than we do. “Having to tell the same story over and over again” was a phrase mentioned by not only the Chair but a number of other Members, and we all recognise the frustrations that we and our constituents have when that occurs. She was right to say that it is important that we look at the subject primarily from the point of view of patients. Their experience has to be at the very front and centre of all our plans for the future.

The hon. Lady articulated clearly how the financial pressures in the existing legislative framework, which we have all talked about many times, can inhibit transformation. She was right to say that an earmarked fund for transformation has to be protected, and it should not just be a capital pot. She set out clearly the need for a degree of flexibility.

As always, it was a pleasure to hear my hon. Friend the Member for Stockton South (Dr Williams). He made a pertinent point about the challenge for integrated care partnerships: to be considered successful, they should make a difference for those with the greatest health needs. He is right that we need to do much better as a nation on health inequalities, but how we approach prevention and health generally in this country does not necessarily lend itself to that. It would be most welcome if we can tackle that as part of integrated care.

My hon. Friend also expressed the genuine concern about the risk that changes could affect performance quality and safety, which are the pillars of an excellent health system. He made a strong point about governance and how existing decision-making processes are probably the wrong way round. The report acknowledges that they are certainly cumbersome and do not lend themselves to streamlined decision making. He highlighted well the dilemma faced by CCGs when tackling that agenda. This place needs to take a lead on that. He concluded by saying that integrated care has the potential to transform the lives of millions of patients—that really underscores why it is so important for us to get the integration right.

The hon. Member for Strangford (Jim Shannon) made a typically thoughtful contribution. I agree with him about the need to bring people along with us when we set out our vision for the health service. The report touches on how that has not been as successful as we might like in recent years. His comments on the use of acronyms were particularly perceptive—they may initially save time, but they actually increase complexity. Although I agree with the sentiment that we should keep things simple, anyone who looks at the Health and Social Care Act will realise that at the moment we probably cannot achieve that readily.

The hon. Member for South West Bedfordshire (Andrew Selous) made an important contribution. No one will disagree with what he said about putting patients at the centre of all this and the quote he gave about the kind of care they want. I was very interested to hear about his visit to the Larwood centre in Worksop; that sounds like the kind of model that we need to showcase what a good new procedure looks like.

It is clear from reading the report that I am not alone in being critical of the way some of the proposals in the past few years have been communicated. I do not underestimate the damage that has done to public confidence in the aims of the policy.. Releasing the new draft ICP contract in the middle of the summer with no publicity has not increased transparency about the Government’s agenda. It was interesting that the report described how public understanding of the proposed changes has been seriously compromised by the “acronym spaghetti,” which a number of Members mentioned. At another point in the report there was a reference to the acronym soup of

“changing titles and terminology, poorly understood even by those working within the system.”

That highlights well the difficulty we all get into sometimes when acronyms can take over—that will resonate with anyone who is a member of a political party. The use of food terminology in the report shows that perhaps the author was a little hungry when they wrote it.

To reinforce the point, since the report was published we have ICPs on the horizon—yet another acronym. Although I appreciate that the change was made to avoid conflation with the American model of ACOs, it is clear that we do not need new acronyms, but a clear explanation from the Government along with a timeframe for what they are seeking to achieve and, importantly, the criteria they will use to determine whether those objectives have been achieved. The chief executive of the Nuffield Trust, Nigel Edwards, described this as

“perhaps the biggest weakness, not just with the STP process but arguably with the ‘Five Year Forward View’.”

It is clear from both the evidence sessions and the report itself that confidence in the Health and Social Care Act 2012 is at an all-time low and that the current direction of travel is really an admission that the Act has not worked. As we know, the last top-down reorganisation put in place a siloed, market-based approach that created statutory barriers to integration. Now, there is a lot of tiptoeing around the current legislation but we need an admission that that legislation has had its day. We need new proposals that are properly scrutinised.

The initial STP process was imposed from the top and was based around 44 geographical areas that were determined very quickly without recourse to the public. The Government acknowledged in their response to the report that perhaps that was done rather too quickly. Although some of the areas that emerged after that initial consideration had well-established networks of co-operation, in others there was a vast and unwieldy network of commissioners and providers with completely different approaches put together at very short notice. They were told to produce plans in private, again very quickly, which were focused not on integration but on organisations balancing their budgets. The only beneficiaries of this process seem to be the private consultants who were drafted in to complete those hastily arranged plans. As Professor Chris Ham pointed out,

“most STPs got to the finishing line of October 2016, submitted their plans and breathed a huge sigh of relief. No further work has been done on those STPs.”

Will the Minister set out what his plans are for those areas, as the local bodies appear to be working in a vacuum? They want to work together, but at the moment they have a legal duty to compete.

The report makes it clear that being asked to solve workforce and funding pressures caused by national decisions exacerbates tensions and undermines the prospect of each area achieving its aims for its patients. The report also makes it clear, as my hon. Friend the Member for Stockton South said, that where support has been provided towards integration, it has been directed at those who are furthest ahead. Those at the bottom of the curve, sometimes through no fault of their own, have lost potential funding that they need to work together to improve services. The chief executive of the NHS Confederation, Niall Dickson, told the inquiry,

“There is a sense in which some organisations find themselves in a really difficult position. Just taking their STF money away…is like somebody digging a hole. Instead of…helping them to get out of the hole, they jump in with a larger spade and dig even faster.”

That is a colourful and alarming analogy.

Where local areas are able to proceed to the next stages of integration, there is understandable concern among patients and staff about precisely what that will mean. The integrated care provider contract has the potential to radically alter the entire health and social care landscape, but is continuing without any parliamentary scrutiny. Despite assurances that it is unlikely that a private company will win the contract to be an ICP, it remains the case that it will be possible, as a number of Members have said. As we heard, not long ago the NHS was forced to pay out millions of pounds to Virgin because it lost out on a contract. I am concerned that we will face similar challenges if this process continues without legislation.

It is not scaremongering to say that the Government are introducing a contract whereby a private company could be responsible for the provision of health and social care services for up to 10 years—it is a fact and a possibility under the legislation. The Chair of the Select Committee was right to say it would be extremely helpful to have a clear statement from Government to rule that out. It is within the gift of Ministers to say there will be no private involvement in those bodies in future. Will the Minister make such a commitment today?

It is clear in the report that staff are concerned about the lack of engagement in a process that in some areas has excluded them completely. They are also concerned about their jobs being transferred to non-NHS organisations; hopefully the Minister will deal with that today. Almost half all NHS providers were in deficit last year and we are entering uncharted territory in budget setting, so what steps will be taken in the event that an ICP reaches a significant deficit position that it is unlikely to be able to resolve alone? Given the recent news that loan repayments to the Department of Health are now a bigger financial burden to providers than private finance initiatives, will the Minster confirm that deficits caused by structural funding issues will not be resolved through further loans being issued?

It is also clear from the draft contract that the ICP rather than the CCG will be responsible for managing demand. That raises questions about accountability and transparency. What safeguards are in place to prevent further rationing of services and who will be accountable in the event that patients want to challenge such a decision? These are important questions that I hope the Minister will respond to. Will he also commit to set out in full the direction of travel, the Government’s objectives, the criteria that will be used to determine when those objectives have been achieved, and a timeline for primary legislation, which just about everyone across the sector believes is needed?

[Dame Cheryl Gillan (in the Chair)]

Before I call the Minister I remind him, although I am sure he knows, that we like to leave two minutes for the Member leading the debate to make her closing remarks. I call the Minister.

NHS Whistleblowers

Justin Madders Excerpts

Wednesday 18th July 2018 Westminster Hall

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

It is, as always, a pleasure to serve under your chairmanship, Mr Davies.

I congratulate the hon. Member for Central Ayrshire (Dr Whitford) on securing the debate and on her powerful and knowledgeable contribution. As always, she drew on her many years of experience in the national health service. She listed a series of scandals in the NHS and raised themes common to them all. They lasted too long, and too often those who blew the whistle paid a high personal price for their actions. She raised the real risk of clinicians finding themselves with potential conflicts of interest, which requires further thought, and rightly highlighted the fact that the current legislation does not create an obligation to investigate the original complaint—it is primarily concerned with protection after the event.

In his analysis, the hon. Member for Stirling (Stephen Kerr) suggested that PIDA was intended to be a deterrent but that, given the way it has operated, it is not that at all because whistleblowers are still being punished. Both he and the hon. Lady pointed out the woeful success rates in employment tribunals, which should give us all pause for thought about whether the legislation is fit for purpose. The hon. Member for Stirling talked about how litigation can sometimes be a war of attrition and employers can be very defensive at times, and how at the bottom of all this is an individual—sometimes a highly skilled individual—whose talent has been wasted and lost because they have blown the whistle.

My hon. Friend the Member for Hartlepool (Mike Hill) spoke with great passion and no little knowledge of some of the experiences of those who have blown the whistle. He was right that some employers have not embraced the spirit of the legislation; in fact, they contrive policies to run contrary to what we are trying to achieve here. Having met many of the staff in the NHS, I know they care deeply about the work they do and they want to do the best by their patients. That is why it is so important that we provide an environment where they are able to raise their concerns about things they may be worried are going wrong, without fear of repercussion or unfavourable treatment. They must also be confident, once they have raised those concerns, that action will be taken.

However, despite some notable advances in the protections available in recent years, it remains the case that even the best run organisations, with the most comprehensive policies in place, can still feel very daunting for individuals who want or need to blow the whistle. I know from my many years working as an employment lawyer—although not one who lined his pockets in this particular area—that it is extremely difficult for an employee to raise those issues. As we have heard already, the consequences of doing that can be hugely damaging. They can face anything from being shunned by their colleagues to summary dismissal on spurious charges, and the impacts of the kinds of things they deal with can last much longer than the period of employment to which we are referring.

In that respect, it was deeply concerning to read in the Francis report about staff who were on the brink of suicide because of the treatment they had received after speaking out. One of the few criticisms on the record of the NHS is the fact that many promising careers have lain in tatters as a result of ineffective protections under this legislation, while other people have spent years languishing in the legal system, with the taxpayer racking up tens of thousands in legal fees in the process.

Of course, while protecting whistleblowers is vital across all professions, it should be pointed out that NHS staff also have a professional duty to raise concerns. The NHS England and NHS Improvement policy states:

“If in doubt, please raise it. Don’t wait for proof… It doesn’t matter if you turn out to be mistaken as long as you are genuinely troubled.”

We cannot say that enough; I just wish it was easier to see that delivered in practice.

The Minister recently brought forward regulations to provide some additional protections for the present and future employment prospects of whistleblowers, which we welcomed. I raised a number of concerns during that debate and the Minister was good enough to write to me afterwards setting out some of the responses. However, one issue that I do not think we have got to the bottom of was protections for other workers who support whistleblowers. There is a worrying gap in the existing legislation. It is easy to envisage circumstances, particularly in the health service, where two or more employees might have an issue of concern that they jointly notice, but only one of them, in law, can make that protected disclosure.

When I raised that point to the Minister, her response made clear that the only remedy available to such associated parties would be to register a grievance under their employer’s grievance policy. That is a very worrying omission from existing legislation and I ask the Minister to consider whether she will look at that again, as well as at the many points that have been raised about the deficiencies of the existing legislation.

Another lacuna in the existing law was exposed much more prominently by Dr Chris Day. On 10 January 2014, Dr Day made a protected disclosure about critically low staffing ratios during a night shift on an intensive care unit at the Queen Elizabeth hospital in Woolwich. Unfortunately, the trust and Health Education England decided not to act on his concerns and terminated his contract, based on what Dr Day believes were false allegations, thereby stalling his progress to consultant.

Sadly—like many whistleblowers, as we have heard today—rather than having his rights protected by his employer, Dr Day was instead forced to defend them via legal redress at an employment tribunal. This is because Health Education England contended that

“even if the facts alleged by Dr Day were true, HEE could not be liable in law for any acts causing him detriment.”

That was significant because, while not acting directly as the employer, HEE recruits doctors in training, supplies them to various trusts and appraises them. The result was a wholly unnecessary and extremely lengthy legal battle, whereby Health Education England, which is a body of the Minister’s Department, effectively sought to move around 54,000 doctors out of whistleblowing protection. Despite the clear principles at stake, the Government consistently refused to become involved in the case to prevent the costly and embarrassing outcome that we have now arrived at.

In September 2017, in a written parliamentary question, I asked about the cost to the NHS of defending the legal action brought by Dr Day. I was told that the total legal fees incurred by Health Education England stood at over £100,000, while Lewisham and Greenwich NHS Trust had incurred costs of £30,000. In May this year, Health Education England was ordered to pay Dr Day’s solicitors’ legal costs of £55,000 after it backed down and accepted that it should be considered an employer after all.

After four years and more than £200,000 of taxpayers’ money spent, Health Education England has accepted its responsibility and made a statement that I consider frankly astonishing:

“Having never wished to do anything other than facilitate whistleblowing for doctors in training, HEE is happy to be considered as a second employer for these purposes if it removes a potential barrier for junior doctors raising concerns.”

I ask the Minister to explain why this situation was allowed to go on for so long, when the case was refuted not on the basis of the facts, but on a technicality that flies in the face of everything we have tried to achieve today.

[Dr Whitford]

As in the case of Dr Day, the issue of poor staffing levels or rota gaps is a common incidence for people blowing the whistle because they feel it is unsafe. Scotland has just passed a safe staffing law, and I wonder whether, as with Datix and other systems, we need staffing level reporting to be seen not as whistleblowing but as something that should be done routinely. Whistleblowing would then start to become a smaller and smaller part of what staff might feel they had to do.

[Justin Madders]

That is an important point; we should see reporting issues such as staffing levels as something that would not be such a big deal. As is happening in Scotland, the safe levels should be ingrained not only into law, but into the culture of the workplace.

In conclusion, I repeat the same point that I made when the recent statutory instrument was discussed: that we now have a two-tier whistleblowing system, which provides some NHS employees with a greater level of protection than others working in the health and social care sector—social care workers, construction workers or anyone else who does not happen to work within those particular areas. Social care in particular is an issue. Public Concern at Work found that more than half of whistleblowers also reported some kind of victimisation, with 23% saying they had been dismissed after raising concerns. I ask the Minister, who is of course also responsible for social care, whether she considers that a satisfactory state of affairs.

Whistleblowers should be not just protected, but celebrated for the role that they play in defending the safety of others. Nobody making such a disclosure should do so in fear, wherever they work, nor should they face the risk of having their livelihood taken away. We owe it them to ensure that those protections are as effective as they can be.

Health and Social Care (National Data Guardian) Bill

Justin Madders Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Friday 6th July 2018 Commons Chamber

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

I congratulate the hon. Member for Wellingborough (Mr Bone) on his success in making progress on this Bill in pretty quick time—as he candidly said, quicker than some other private Members’ Bills, which may well be down to the Government’s view on the merits of particular Bills. As the hon. Gentleman said, there are other Bills that we would like to see make progress, but that is not to detract from the merits of this one.

As I said when we last debated the Bill, the Opposition welcome the decision to put the National Data Guardian for Health and Social Care on a statutory footing. As we know, the use of data has the potential to improve every aspect of the NHS, from transforming the way in which we diagnose illnesses such as cancer to improving the patient experience by ensuring that every clinician at every stage has the complete picture. We know from experience that the use of data in the NHS can be controversial at times, and patients sometimes raise concerns. Those concerns are not unfounded.

Official figures show that more than 100,000 patients were caught up in NHS data blunders in 2016-17. The number of serious data incidents has doubled in a year and they are now occurring at a frequency of one every three weeks. It emerged last year that NHS Shared Business Services had failed to deliver just under 709,000 letters from hospitals to GP surgeries, with the correspondence being left in an unknown warehouse. Such examples show the importance of an effective, modern data protection system with robust safeguards, which is central to securing public trust and confidence in the NHS.

[Scott Mann (North Cornwall) (Con)]

The hon. Gentleman might or might not be aware, but in Cornwall we have a higher proportion of cases of glaucoma than any other place in the country, and we know no reason why. Does he agree that sharing information on that could help us to understand why some of these complex conditions occur? Does he also agree that when the Data Guardian is in place, they might be able to look at and break down the data to work out why some of these conditions exist?

[Justin Madders]

The hon. Gentleman is absolutely right that there are many variations in conditions and, indeed, outcomes throughout the whole country. The importance of data in establishing patterns cannot be understated.

[Chris Philp]

The British Heart Foundation recently said of the research environment that “too much” of its researchers’ time

“is taken up with unnecessary red tape and bureaucracy. The weight of this form-filling is slowing down vital discoveries”.

Does the hon. Gentleman share my hope that putting this role on a statutory footing will help to address such concerns?

[Justin Madders]

Whenever we speak to anyone in the NHS, particularly GPs, they express concern about form filling, but it is important that due processes are followed and that there is a clear audit line. I am sure that the hon. Gentleman can have a word with the Minister about what practical steps can be taken to deal with some of the British Heart Foundation’s concerns.

We support the establishment of a statute-backed Data Guardian because it is one way to improve confidence in the way data is used. As I said in Committee, we are concerned that the Bill does not include an absolute obligation for data controllers to act on advice—only to have regard to it—and there appears to be no requirement for organisations to state proactively how they have dealt with such advice. Responses to question 5 of the Government’s consultation were overwhelmingly supportive of such a provision. In that question, the Government proposed that

“organisations holding health and care data which could be used to identify individuals should be required to publish all materials demonstrating how they have responded to advice from the National Data Guardian.”

In their response to the consultation, the Government said:

“Responses were supportive of the proposal that the national data guardian should be given formal advice giving powers.”

That would certainly provide reassurances that the National Data Guardian will have real authority and act as an independent voice for patients. Without statutory backing, it is foreseeable that the National Data Guardian’s authority and independence could be undermined. Without a requirement for organisations that receive advice to provide evidence of their response, it could be difficult to be sure that the National Data Guardian is effective in doing the important job required by the Bill.

I am sure that Members will recognise that the requirement for a body to have regard to advice does not always mean that the body acts on that advice. We know that how clinical commissioning groups interpret the guidance of the National Institute for Health and Care Excellence leads to some variations in the way in which treatments are dispensed and that advice does seem to be ignored with impunity by CCGs.

I know that the hon. Member for Wellingborough does not see the need for additional powers to be handed to the guardian and does not want to see effectively a regulator, which is the road that my proposals may be taking us down, but it is important that, when the Minister responds, she gives us some indication as to what yardstick she proposes will be used to ensure that the concerns that I have set out will be effectively judged by the guardian.

In conclusion, although I have set out some concerns, we are not intending to oppose the Bill as it is currently drafted today.