Oral Answers to Questions

Justin Madders Excerpts

Tuesday 21st March 2017 Commons Chamber

[Mr Hunt]

I entirely agree with my hon. Friend on that. Despite the current debates, the pharmacy sector has a very bright future, and we have set up a £40 million integration fund precisely to help pharmacists to play more of a role in the NHS and, in particular, to reduce pressure on A&Es.

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

This year, the winter crisis in A&E has been the worst ever. Things have got so bad that, rather than waiting in A&E, record numbers of people are just giving up—I am sure there are many who wish the Secretary of State would do likewise. In January, nearly 1,000 people were stuck on trolleys waiting more than 12 hours to be admitted to A&E. Will the Secretary of State accept that that is far more than just a small number of isolated incidents? After five years in the job, he has to accept responsibility for the crisis he has created.

[Mr Hunt]

I accept responsibility for everything that happens in the NHS, including the fact that, compared with 2010, we are seeing 2,500 more patients within four hours every single day. We are also seeing a big increase in demand, which is why there were particular measures in the Budget to make sure that we return to the 95% target, including £2 billion for social care, which is £2 billion more than the Labour party promised for social care at the election.

Health Service Medical Supplies (Costs) Bill

Justin Madders Excerpts

Ping Pong: House of Commons
Wednesday 15th March 2017 Commons Chamber

I believe that those Government amendments, built on engagement with Members of both Houses and with industry, will help to improve the Bill further.

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

I support the Lords amendments. I believe that they will improve the Bill significantly, and that they draw on many of the points that Opposition Members made during its earlier stages.

When I was asked to lead the debate for the Opposition—it was the first time that I had done so on a Government Bill—I was assured by my colleagues that this Bill was relatively short, but by comparison with the legislation that we passed on Monday, it strikes me as something of an epic. I only hope that we have more success today than we did on Monday with the amendments that were passed in the other place. As with that other Bill, however, the length of this Bill should not in any way detract from its importance. The exploitation of loopholes by a small number of unscrupulous companies left the Government with no option but to act, and we agree with the thrust of the Bill. We welcome the Lords amendments, both those that the Government are supporting today and the amendment relating to a duty to have regard to the life sciences sector and access to new medical treatments.

Let me first deal with the matters on which there is agreement. Lords amendments 1 and 2 relate to special medicinal products. They will do much to improve the reimbursement for specials, given that the current arrangements are in many cases failing to secure value for money for the taxpayer. As the Minister will know, there is a significant price variation between hospital and community care, with the result that many patients are currently denied access to some specials. The amendments could lead to significant savings throughout the NHS by introducing a more cost-effective whole- market procurement system, as well as having the potential to improve access to treatments. I am pleased that there now appears to be cross-party consensus that action is needed. However, I would welcome confirmation from the Minister that any savings made as a result of the amendment will be used to improve access to specials and other new treatments, rather than simply being returned to general budgets.

We also support Lords amendments 4 to 7, which relate to medical supplies. They add a much needed duty to consult before introducing secondary legislation to control the prices of medical supplies. That goes some way to addressing widespread concerns throughout the sector about the failure to engage before measures relating to medical supplies were introduced in the Bill. Lords amendment 7 would subject the first order to control the prices of medical supplies to the affirmative procedure. That means that if the Government wanted to introduce a new pricing scheme, they would have to convince Parliament that there was a case for doing so.

When we last debated these issues, concerns were expressed that the Government were asking us to give them powers in respect of medical supplies, but were not in a position to tell us how they might be used. The amendment does much to allay those concerns by giving a further opportunity for challenge should Ministers wish to exercise those powers. We are pleased that the Government have given some ground in that regard.

We also welcome Lords amendments 8 to 10, which introduce a trigger mechanism for information-gathering powers. These amendments make it clear that the Government would be required to issue an information notice before they could collect certain types of information. Amendment 9 sets out in detail what information would need to be provided, as well as the related form, manner and timings. Importantly, it would also introduce a right of appeal for those served with an information notice. This again goes some way towards resolving the concerns that we set out in this place about the potentially onerous effect of the new information-gathering powers.

Lords amendments 11 to 14 relate to the provision of information to Welsh Ministers and stem from the recommendations of the Delegated Powers and Regulatory Reform Committee in the other place. We welcome these measures, which I understand also have the support of the Welsh Assembly. We also support the remaining amendments, which are consequential.

That leaves us with amendment 3, which would introduce a duty on the Government when implementing the legislation to have regard to the life sciences sector and access to new medicines and treatments. This measure received cross-party support in the other place and I am disappointed that the Government intend to oppose it today.

We strongly support the core of the Bill, which seeks to close loopholes and to secure better value for money for the NHS from its negotiations with the pharmaceutical sector. However, if amendment 3 does not form part of the final legislation, the Bill will be looked upon as a missed opportunity.

The likely departure of the European Medicines Agency raises extremely worrying questions about the future of the life sciences and the pharmaceutical industry in this country. It is reported that up to 20 other countries are now queuing up to host it after it leaves these shores. That shows just what an attractive proposition it is for those looking to say to the sector, “This is a place to invest in.”

We have the strategic disaster of the EMA going against a backdrop of the sector’s investment in R and D already falling in recent years. Between 2003 and 2011 there was significant growth in spending in this area, eventually reaching a peak of £5 billion. However, by 2014 that had fallen to £4 billion, a reduction of 20% in just three years. We are extremely concerned that the potential loss of the EMA could see this figure fall back even further.

Over the last six years, we have ended up with the worst of all worlds: falling investment in R and D by the pharmaceutical industry and appalling rationing of treatments, leaving patients unable to access a range of medicines and treatments unless they have the means to pay for them privately. Members on both sides are beginning to find it ever more frustrating that when increasingly crude and arbitrary rationing is raised, the response from the Minister is often to agree with the concern, but simply to say that it is a matter for the individual clinical commissioning group in question. How many more times will Ministers sit and listen to huge concerns from every area of the country about treatment being denied to people in desperate situations before they finally accept that the unprecedented levels of rationing are not the consequence of a series of decisions that are unconnected and remote from Government, but a direct result of the systematic underfunding of the health service for the past seven years?

[Daniel Zeichner (Cambridge) (Lab)]

Does my hon. Friend agree that some of the debates in Westminster Hall and the concerns expressed by Members across the House have been prompted by the fact that the resources for new treatments have not become available in the way that was expected because, as the Secretary of State admitted, although the large amount of rebate from the pharmaceutical sector goes to the NHS, it is not being used specifically for new treatments?

[Justin Madders]

My hon. Friend is right to express that concern. We do not really know where this rebate has ended up, but all Members know from their personal experiences and our debates that across the board rationing is reaching unprecedented levels, particularly for new and innovative treatments. This is not just a manifestation of the financial straitjacket the health service currently operates in, nor is it just a disaster for individual patients, nor is it just an abrogation of the Minister’s responsibility to uphold the fundamental principles of the NHS; it is also a direct threat to the future prosperity of our life sciences industry. In answer to the Minister’s question about whether we are on the side of patients, I say we absolutely are. Proposed new clause 3(b) makes it very clear that we are on the side of patients, and in particular their ability to access new and innovative treatments.

It is impossible to look at the health of the pharmaceutical sector in this country without considering the central issue of access to treatments. The UK is home to about 4,800 life sciences companies and it continues to have the largest pipeline of new discoveries anywhere in Europe. We are all rightly proud of that. However, the fruits of this innovation are increasingly being enjoyed by patients in other parts of the world before NHS patients can benefit. For every 100 European patients who can access new medicines in the first year they are available, just 15 UK patients have the same access. How can anyone look at that and not say that something is going badly wrong?

As I set out in previous debates on the Bill, a recent report by Breast Cancer Now and Prostate Cancer UK showed that NHS cancer patients are missing out on innovative treatments that are available in any other comparable country to the UK. That should surely shame us all, and it looks as though the situation will get worse. A number of cancer charities estimate that the proposals by NICE to introduce a budget impact threshold could affect one in five new treatments. With one of the options available being a longer period for a phased introduction, the worry is that more patients will be denied access to those critical treatments. I thought that this Bill was meant to be the mechanism by which the cost of drugs would be controlled. Can the Minister explain the flaws in the proposed new pharmaceutical price regulation scheme that make this extra method of cost control necessary?

A debate in this place a few weeks ago drew attention to a number of breast cancer drugs, including Kadcyla, Palbociclib and Perjeta, that might no longer be funded due to changes to the cancer drugs fund. Those are but three examples. Media analysis by the King’s Fund found that there were 225 stories relating to rationing of services in 2016, compared with 144 in 2015 and 86 in 2011. There is clearly a trend developing and we need to reverse it.

We do not have much time today, so I shall draw my remarks to a close by reminding the House that this debate touches on many important issues that are all interlinked—three of them in particular. The first involves securing better value for the NHS; the second involves ensuring full and rapid access to treatments for NHS patients; and the third involves the need to support and promote our life sciences sector. The Government will not achieve any of those aims unless they adopt the right approach to all three. The Bill aims to put in place a system that will deal with the first of those aims, which we support. The amendment that we support today seeks to send a clear message to patients and to industry that the Government consider the other two elements equally important. That is why we are so disappointed that they are not prepared to listen to the overwhelming view expressed in the other place and support that amendment. I urge the Minister to reconsider.

[Dr Murrison]

I shall speak briefly to Lords amendment 3, but first I chastise the hon. Member for Ellesmere Port and Neston (Justin Madders), if I may, for his remarks about money. He is right to say that this is all about money, but I seem to remember that less than two years ago, he stood for election on a manifesto that would have had the effect of opposing the money that is currently going into the national health service, so we should not take any lessons from the Labour party on financing the NHS.

The Government are absolutely right to oppose this amendment. It looks a bit like a probing amendment, to be honest, and I am a bit surprised that it has got this far. It would subject this very good Bill to a whole shedload of judicial review. It would be a lawyers’ beanfeast. It bewilders me that people in this House who argue that the NHS needs more money, which it most certainly does, should support such a proposal when all the money would be going into the pockets of lawyers.

NHS England must fund any new drug found to be cost-effective by NICE within 90 days of that approval. This afternoon, the NICE board will approve this new measure, which will establish a budget impact threshold of £20 million. The hon. Member for Ellesmere Port and Neston is right to say that about one in five drugs will probably be within scope of the measure, and that is a cause for concern. Patients in the UK do not enjoy the full range of advanced medicines that are reckoned to be more or less routinely available in countries with which we can reasonably be compared—or if they do, they usually find that they are subject to unwarranted delays before they are treated. That is of course critical in the case of conditions such as cancer, and could well mean the difference between life and death; it will certainly mean a whole load of difference in quality of life. It is vital that we do nothing that would extend that process.

In response to my earlier intervention, the Minister gave me sufficient reassurance that the delay that the measure would introduce would be small, and that this would be an opportunity for NHS England to negotiate a lower price for these very expensive medicines. Indeed, that is the intention. Given that, I am more than happy to support the Government on this. However, any delay at all will send a signal to those in the life sciences sector; it is important that we make it clear that this will not introduce unwarranted delays in the introduction of new medicines, because frankly that would put them off. A lot of worthy work has been done recently, which has involved spending a lot of money, to support a vital part of our economy, and it would be a great pity if anything in the Bill reduced our life sciences sector’s ability to prosper in the years ahead.

Draft Nursing and Midwifery (Amendment) Order 2017

Justin Madders Excerpts

Wednesday 22nd February 2017 General Committees

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

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

Few professions, if any, carry the respect, trust and affection of the nation like nursing and midwifery. We hugely value the role that all nurses and midwives play in caring for people who are sometimes in the most vulnerable conditions. In the current climate of an underfunded health and social care sector that is struggling to keep up with demand, we know that they are working harder than ever to hold our health service together.

As we have heard from the Minister, the proposed changes in the order affect two main areas: regulation and fitness to practise legislation. While we do not oppose the order in its totality, we have some concerns about the proposed changes to midwifery regulation that are reflected across the sector. I hope that when the Minister responds he will be able to allay any fears we may have about potential negative impacts.

It is fair to say that the current fitness to practise legislation is outdated and costly. As we know, about three quarters of the Nursing and Midwifery Council’s budget is spent on fitness to practise work, despite less than 1% of nurses and midwives being referred to it. That is against a backdrop of significantly increased registration fees in recent years, at a time when public sector pay has failed to keep up with the cost of living. That very significant call on the NMC’s resources is made because it is required to hold hearings in almost all cases and to hear the evidence even if there is no disagreement about the facts. Those hearings often take a number of days and are costly and time-consuming to organise.

We all know from speaking to constituents the immense strain those investigations bring, not only for the professionals who are being investigated but for the families, who often feel that the time the proceedings take only exacerbates an already very difficult situation. Even when the allegations are admitted, the case must go to a full adjudication. As we have heard, there are also elements of duplication in investigations.

We agree that the draft order will allow case examiners to streamline the system and have authority to issue warnings or agree undertakings with nurses or midwives. I understand—and hope—that that will avoid the need for hearings to take place in all cases where the facts are not in dispute and the circumstances are less serious, which of course would enable a resolution to be reached much more quickly. That would enable those under investigation to focus on the future more quickly than they can now. As the Minister said, the proposed changes will also bring the Nursing and Midwifery Council into line with other professional regulators, including the General Medical Council, which already has these powers.

Although we support the changes enabling swifter resolution in less serious cases, I am sure the Minister will be unsurprised by our request for an assurance that the right balance is struck between efficient and proportionate regulation, maintaining public confidence and protection at all times. With such changes to any system, it is vital to get that balance right. I would welcome hearing what the Minister has to say on that. There are also proposals to reduce the number of interim hearings, which will reduce costs, associated bureaucracy and the length of time that matters take to be concluded, as well as some of the undoubted stress individuals feel.

The Minister referred to the other significant changes specifically related to midwives, and acknowledged that there has been significant unease, about, if not outright opposition to, some of the changes that the Government are proposing. Although we often speak of nurses and midwives as one, it is important to remember that nursing and midwifery are, of course, two distinct professions with very different qualifications and roles. Given that in England the Nursing and Midwifery Council regulates many more nurses than midwives, it is easy to understand why midwives may be anxious that their voice will be lost if these change are pursued. Currently, their voice is amplified by the NMC’s midwifery committee, which advises the council on policy issues affecting midwifery practice, education, statutory supervision and ethical issues. As the Minister acknowledged, there has been concern in the profession about the proposal to abolish the legal requirement to have a committee—indeed, 91% of the midwives responding to the consultation were strongly opposed to the change. The Royal College of Midwives has warned that there can be effective midwifery regulation only if the body that sets the standards for the regulations has a good understanding of the context in which midwives work.

Although the consultation response has not led to any change in the legislation that is being proposed, I note that the concerns have been recognised by the NMC, which intends to reconstitute the midwifery panel, which will have a remit to provide strategic input into policy or regulatory proposals affecting midwifery. I also understand that the NMC has stated in clear terms that it remains obligated in law to consult midwives on matters that affect their profession and that legal requirement will not be affected by the draft order, as the Minister also acknowledged. The NMC has also indicated that it will be holding twice-yearly listening events where all midwifery views from across the UK can be aired. I understand the NMC is committed to creating midwifery-specific expert groups when it reviews matters such as pre-registration education standards.

This is not the statutory footing that the RCM would have wanted, but I understand that it has responded positively to the proposals. However, that is no reason for us not to keep a watching brief on the issue. Although the Minister has expressed his support for continuing to give midwives an opportunity to speak on these issues, I ask him to set out specifically the steps he will be taking to monitor and safeguard the distinct voice of the midwifery profession in the sector.

The order will also formally separate regulation and supervision, which, as we know, was a recommendation of Dr Bill Kirkup’s report into the Morecambe Bay NHS Foundation Trust. The report found that the hospital displayed

“a potential muddling of the supervisory and regulatory roles of Supervisors of Midwives”,

which was a significant factor in the poor response to the failings that occurred. We owe it to the families affected by Morecambe Bay to ensure that the recommendations are implemented. Therefore, we welcome the transfer of supervision to the organisations that employ midwives. That will provide much needed clarity about who needs to take action when things go wrong.

It is also vital to ensure that concerns about a potential loss of support and development are addressed. I therefore ask the Minister whether the Government will consider making available earmarked funding, either centrally or through NHS bodies, for the training and education of those midwives who will be undertaking roles in the new system of supervision. Also, what steps do the Government intend to take to monitor the roll-out of the new system? When he responds, will the Minister indicate whether he would be prepared to give an undertaking to report to Parliament on the effectiveness of the new arrangements following the first year of their operation?

It is clear where responsibility for supervision will rest following the implementation of the changes, but it is less clear whether the NMC will continue to be required to produce standards and guidance for midwives. Can the Minister confirm that that will be the case and that all changes, standards and guidance will continue to be subject to extensive consultation with the profession?

Removal of statutory supervision removes the requirement for local supervising authority midwifery officers, which are currently very senior positions at a national level in Wales, Scotland and Northern Ireland and at a regional level in England. The Royal College of Midwives has expressed concern that removing those positions will leave a significant gap in midwifery leadership within the profession, particularly in England, as the devolved Administrations already have well-established senior midwifery positions. I therefore ask the Minister to consider the proposal to appoint a chief midwifery officer at the national level and directors of midwifery within NHS England regional teams.

In conclusion, we do not oppose the measures. However, it is vital to ensure that public protection will not be weakened and that the distinct voice of the midwifery profession can be heard loud and clear. I would welcome any assurances that the Minister can give on that and answers to the specific points that I have raised today.

Community Alarm Services: Social Housing

Justin Madders Excerpts

Tuesday 21st February 2017 Westminster Hall

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

I beg to move,

That this House has considered social housing community alarm services.

It is a pleasure to serve under your chairmanship, Mr Hollobone. I am pleased to have secured a debate on this important issue. I sincerely hope, despite the extremely difficult and tragic circumstances that I will outline, that we will be able to reach a positive outcome and improve the safety of the many people across the country who rely on community alarm services.

At 18.35 on 5 November 2015, Ronald Volante, father of my constituent Rita Cuthell, triggered the community alarm service in his property. It was operated by the social housing provider, Magenta Living. He was in a considerable amount of distress and could only manage to cry out the word “help” to the individual receiving the call. Two hours later, an ambulance finally arrived at Mr Volante’s house and the paramedics who attended found that he had sadly died. He was found next to a note addressed to his daughters, which said, “I love you.” It is difficult to appreciate fully the suffering that Mr Volante experienced during those hours, or the pain and anguish that those closest to him have suffered since as the full extent of the circumstances of his death have become known.

What has become clear is that a number of opportunities that could have saved Mr Volante’s life were missed. Nothing that we can say in this debate today can change that fact. What we can do is seek assurances that nobody else will have to go through such an appalling experience ever again. Mr Volante was a resident at the Maritime Park social housing complex, which is owned by the Regenda Group housing association. During daytime hours, a warden was present at the facility. Out of hours, residents relied solely on a community alarm service provided by the Magenta Living housing association. Mr Volante was 74 years old and suffered from coronary artery disease and thrombosis. He had previously suffered a myocardial infarction that required heart surgery.

After Mr Volante triggered the alarm, his call was answered by an operator within six seconds. The operator’s notes state that they could not ascertain what Mr Volante was requesting, other than help. After attempting without success to call both of Mr Volante’s daughters, the operator called for an ambulance at 18.38. I have seen a transcript of the conversation with the North West Ambulance Service, which lasted for just over six minutes. During the call, the operator speculated as to whether Mr Volante might be having some kind of speech problem, as all they could hear was the call for help. The operator was unable to provide a great deal of detail about Mr Volante’s condition, as they were communicating with him remotely from a call centre and had no visual contact. At no point during the conversation did the operator inform the North West Ambulance Service of Mr Volante’s heart condition, despite that information being available. Although the ambulance service knew that the caller was not actually with Mr Volante and was calling from a lifeline service, it made no further enquiries about his medical history.

Following the call to the emergency services, the operator confirmed to Mr Volante that they had called an ambulance. At that stage, they received no response from Mr Volante. Despite that, they closed down the community alarm service at that time, 18.46. The call to Mr Volante lasted a total of 10 minutes and 41 seconds. No further efforts were made to contact Mr Volante’s family at that stage.

[Frank Field (Birkenhead) (Lab)]

I thank my hon. Friend for securing this debate, which affects his constituent, and my constituent, who unfortunately died in this incident. Is one of the many lessons that we might draw from this that the service works all right if a person is not in the process of dying? However, once someone is in the process of dying, there seem to be some real faults. One is about how an operator follows up when they do not hear any more from someone after they call for help. That is one area that should be attended to.

[Justin Madders]

My right hon. Friend is absolutely right. I will come on to the issue he raises later in my contribution.

Almost an hour and a half later, at 20.07, the North West Ambulance Service, having still not arrived, contacted the community alarm service to advise that it had been receiving a large number of emergency calls—it was bonfire night—and asked whether the ambulance for Mr Volante was still required. The operator advised that they were not sure, as they had had no further contact with Mr Volante. Ambulance control advised that it would attend as soon as it could and asked the operator to provide an update to Mr Volante. A second operator made a call to update Mr Volante at 20.11, but no response was received. At this stage, a second operator telephoned Mr Volante’s daughter, Mrs Cuthell. She expressed concern that nobody had attended the flat in an hour and a half. At 20.30, just under two hours after the initial call to the alarm service by Mr Volante, an ambulance finally arrived at his address. At 20.37, the alarm service received a call from the ambulance service, which confirmed that Mr Volante had sadly been found deceased.

As I said when I began my remarks, a number of opportunities were missed throughout the two hours—opportunities that could have led to Mr Volante’s life being saved. The inquest was opened on 28 January 2016. The coroner, Mr Rebello, determined that Mr Volante died of natural causes, because there was no certainty that an earlier intervention would have saved his life. However, Mr Rebello also issued a report under regulation 28—also known as a report to prevent future deaths—because he believes, as do I, that action should be taken to prevent future deaths in similar circumstances.

I am therefore now requesting the assistance of the Minister and his colleagues to ensure that action is taken, not only by Magenta Living but by every provider of community alarm services. I also believe there are messages for ambulance service providers across the country, and I hope that the Minister will be able to take them on board. The first serious issue was the fact that a 999 call on behalf of a 74-year-old gentleman with a serious heart condition was categorised as a green 2 call. While there is a national standard that an ambulance will be provided in response to the most urgent telephone calls—also known as red 1 and red 2 calls—within eight minutes, there are no national standards for a response to a less urgent green 2 call. In those cases, the North West Ambulance Service sends an ambulance as soon as is practical, which sadly on a busy night like 5 November can be hours rather than minutes.

In her evidence to the coroner, Irene Weldon, the acting manager for the emergency operations centre covering Cheshire and Merseyside, confirmed that it was very likely that the call would have been treated with a higher level of priority—red 1 or red 2—if the call handler had been made aware of Mr Volante’s history of heart disease and thrombosis. When I put that to Magenta Living and asked why Mr Volante’s medical conditions were not disclosed to the ambulance service during the call, I was provided with the following response:

“Proactively providing medical history to the ambulance service at the point of contact by call handlers does not form part of the procedure accredited by the TSA.”

TSA is the Telecare Services Association. It is the industry body for community alarm services. It sets national standards for providers to adhere to and provides a framework that sets out how its members should respond to calls. Clearly it is not acceptable that the framework does not require vital medical information to be provided to ambulance services when a 999 call is made by an alarm service operator. The coroner called for action to be taken in that respect in his report to prevent future deaths, and I echo that call for action.

The second issue is that while Mr Volante was able to vocalise his request for help when he contacted the community alarm service, by the time the operator made contact to confirm that an ambulance had been called just a few minutes later, he was no longer responsive. That important change in circumstances was not reported to the ambulance service. Again, that could have led to the call being given higher priority. When I asked Magenta Living about that, it said:

“Historically, a change of circumstances would not result in a call handler updating the emergency services. This practice was adopted due to the fact that keeping the line open could potentially impact upon the monitoring of the centre’s ability to respond to further activations from residents at the same scheme.”

It is completely unacceptable that community alarm providers do not routinely inform the emergency services of a deterioration in the condition of a caller. If the ambulance service had been informed of the possibility that Mr Volante was no longer breathing, it is very likely that the priority of the call would have been upgraded. That was another concern raised by the coroner.

As I said previously, we cannot possibly say with certainty whether earlier intervention in this case would have saved Mr Volante’s life, but we know that in all urgent cases of this nature, every minute matters, so I can say with absolute certainty that if the medical condition of callers, or any deterioration in their circumstances, is not being reported to ambulance services as a matter of course, the lives of the 1.7 million people who use community alarm services are being put at risk. When he sums up, will the Minister indicate whether he agrees with me that the national framework set out by the TSA should be urgently updated to ensure that those issues are addressed? I also ask him to join with me in asking all social housing community alarm service providers to ensure that their local processes reflect the recommendations set out by the coroner in Mr Volante’s case.

Since her father’s death, Mrs Cuthell has been tireless in pursuing those issues, so that she can feel that justice has been done for her father. I know that her biggest wish is that nobody will ever have to go through such a terrible experience again. It is to her absolute credit that throughout the trauma of her father’s death and the incredibly difficult experience of the inquest she has maintained a great focus on making sure that lessons are learned and improvements are made. She has shown calm dignity and incredible determination to bring about change, and I am pleased to say that that is beginning to bear fruit. We have held numerous meetings with the TSA and the North West Ambulance Service. There has been progress, albeit at a much slower pace than we would have liked.

The TSA has arranged meetings with the Association of Ambulance Chief Executives and is working with it and its members to develop protocols for its quality standards framework, which it hopes will be fully implemented by June. That will mean that when a call of this nature is made in future to the service providers, the call handler will provide reassurance to the caller until the responder is actually present. It also plans to have clear procedures in place to communicate with the responders and, crucially, plans to escalate the matter where it becomes clear that a responder is not available. A national emergency algorithm is also being developed that will enable all necessary information to be passed to the ambulance services when a call is made, to enable the ambulance service to prioritise such calls more accurately.

The right approach is being taken by the TSA to ensure that the tragic situation is not repeated, but the TSA does not represent every provider in the sector. Membership of that organisation is voluntary, and that is where we need assistance from the Minister. We would like to see all telecare services adopting the same approach and adhering to the same standards that the TSA is developing. Is the Minister prepared to look at making that a requirement across the board?

I want to touch on some concerns about ambulance services. I understand that the primary issue in this case was the fact that the call had been awarded a lower priority because important facts were not reported to the ambulance service. It is nevertheless unacceptable that it took almost two hours for that service to respond.

Although much of the recent media focus has been on when people get to hospital, ambulance services have suffered the most worrying deterioration in recent years. There is a national standard that says that red 1 and red 2 calls should be attended within eight minutes; the reality is that that target is not met in about a third of cases, and has not been met for some time. The most recent figures show that just 68.5% of red 1 cases—where a patient has suffered a cardiac arrest or stopped breathing—are responded to in eight minutes. In other life-threatening emergencies in the red 2 category, just 62% of calls received a response within eight minutes. Lives are being lost and patients are being put at risk because funding to the NHS has not kept up with demand. I know that the Minister cannot tell us what the Chancellor has planned for his Budget next month, but I call on the Government to deliver the rescue package that our NHS so desperately needs.

Whatever happens with funding, the other steps I have outlined today do not come with a price tag and can be implemented across the board. We know that will not bring back Mr Volante, but it would allow us to look his family in the eye and say that lessons have been learned and the mistakes that led to his death will not happen again.

Oral Answers to Questions

Justin Madders Excerpts

Tuesday 7th February 2017 Commons Chamber

[Mr Dunne]

My right hon. Friend is a regular attender at Health questions, and I am pleased to be able to confirm to him, once again, that the success regime for mid-Essex is looking at the configuration of the three existing A&Es, none of which will close, and each of which might develop its own specialty.

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

Analysis of the STPs by the Health Service Journal this week found that a substantial number of A&E departments throughout the country could be closed or downgraded over the next four years. The Royal College of Emergency Medicine has described that approach as “alarming”. Over the past month, we have all seen images of A&E departments overflowing and stretched to the limit, so surely now is not the time to get rid of them. Will the Minister pledge today that the numbers of both A&E beds and A&E departments will not be allowed to reduce below their current level?

[Mr Dunne]

The hon. Gentleman is right to point out that the STPs are looking at providing more integrated care across localities. A number of indicative proposals have to be worked through. At the moment, NHS England is reviewing each of the STPs, and the results will be presented to the Department for its consideration in the coming weeks and months. On bed closures, I gently remind him that, in the past six years of the previous Labour Government, more than 25,000 beds were closed across the NHS. In the six years since 2010, fewer than 14,000 were closed by this Government and the coalition.

Public Administration and Constitutional Affairs Committee

Justin Madders Excerpts

Thursday 2nd February 2017 Commons Chamber

[Mr Jenkin]

I certainly agree that the vast majority of our constituents who experience the care of hospitals or GP practices are extremely grateful for the quality of care that they receive. However, we cannot underestimate how corrosive the blame culture has been throughout our health system. Crises such as those at Mid Staffordshire and at the Morecambe Bay maternity unit arise from the defensive culture that exists in the NHS. If we are to change that into a much more open and collaborative system of learning from mistakes, we need HSIB to set the tone throughout the entire organisation. It is not just about dealing with a few complaints, but about setting a whole new standard for a whole new profession in the NHS about how complaints and clinical incidents are investigated. I am most grateful to have the opportunity to present this report.

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

Labour welcomes this constructive report and thank all of those involved in producing it. It highlights some worrying statistics, including the fact that the most recent NHS staff survey found that 43% of staff thought that their organisations treat staff involved in near misses, errors and incidents fairly. Clearly, from the Chairman’s candid contribution today, there is a long way to go before we eradicate the culture of defensiveness that he has described. To give HSIB the strongest start, it was the clear view of the Committee, HSIB, the Expert Advisory Group, HSIB’s chief investigator and even the Minister himself that legislation is needed, but, as of today, no legislation has been forthcoming. Given that, does the Chair of the Committee agree that it might be better to delay implementation to allow time for legislation?

[Mr Jenkin]

I am most grateful to the hon. Gentleman for his question and for his support. I am also extremely grateful to my Committee for its work on this report.

I hesitate to lose the progress that we have made. We have approved the appointment of the chief investigator of HSIB, who spent 25 years as chief investigator of the Air Accidents Investigation Branch of the Department for Transport. He brings with him that wealth of experience and perspective about how this organisation should work. The answer is, as the hon. Gentleman suggests, for the Government to bring forward the legislation as quickly as possible. I know that efforts are being made in that direction, but perhaps the Minister will have something to tell us.

Agenda for Change: NHS Pay Restraint

Justin Madders Excerpts

Monday 30th January 2017 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Evans. I congratulate my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) on the eloquent and knowledgeable way that she introduced this debate on behalf of not only the Petitions Committee but the more than 100,000 people around the country who signed this petition.

When she introduced the debate, my hon. Friend said that it is not enough for us simply to state our support for NHS staff—it has to be shown. The excellent attendance that we have had today, despite the important international business taking place in the main Chamber, has shown the huge support for our NHS staff and it is high time that the Government matched that support with action. In an intervention, the hon. Member for Kettering (Mr Hollobone) put the proposition that it is incredibly hard for the Government to justify ignoring the recommendations of an independent pay review body when we as Members of Parliament have our own pay agreed and implemented by an independent body. Can the Minister not see how repeatedly ignoring independent pay reviews strikes at the very heart of the bond of trust that exists in an employment relationship? Can he not see how it makes us look like we are uncaring and wrong? It is self-defeating and the approach needs to change.

My hon. Friend rightly highlighted the particular problems in ambulance trusts and the issues with the recruitment and retention of paramedics. She described the expenditure on agency staff as “nonsensical”. Certainly, no business would consider this a sustainable model. The personal testimonies that she gave from her constituents were compelling. None of us could fail to appreciate how difficult the situation is for some of our nurses. One said that she grieves for her profession, and that highlights just how dire the current situation is.

We also heard from the hon. Member for Foyle (Mark Durkan) about his perspective in Northern Ireland. He told us how the use of terminology appears to lead to people in different jobs being paid lower rates of pay for effectively the same job. That is certainly not how Agenda for Change should work in practice, and the pay freeze only exacerbates the sense of injustice that individuals feel. He summed up the situation perfectly when he said that the long-term pay freeze is in fact a pay cut. He said their sense of vocation “is being exploited”. He was right about that, but is it not incredibly sad that a Member of this place can say that without fear of contradiction? Just how low have we sunk?

We also heard from my right hon. Friend the Member for Leigh (Andy Burnham), who has great experience in the health service. He rightly said that nursing is “more than a job” and it is clear that he appreciates that, but he is right that when nurses feel that those above them do not appreciate what they are doing, it becomes a false economy and drives people into the arms of staffing agencies.

[Andy Burnham]

My hon. Friend has just mentioned people feeling a sense of fairness, particularly in the pay of those above them. Does he share my concern that in this current climate, while nurses’ pay is being cut, we are seeing large pay increases self-awarded to members of clinical commissioning groups and senior management? Does that not completely demoralise the whole local profession?

[Justin Madders]

I agree entirely. We all know—it is well documented—the financial pressures that the health service is under. It defies belief or explanation that those in senior positions can still fly in the face of that. I can only sympathise profusely with how nurses must feel when they see those headlines.

[Lilian Greenwood (Nottingham South) (Lab)]

Important as nurses are as the backbone of our health service, many other NHS staff are affected by the Agenda for Change pay freeze. Does my hon. Friend share my particular concern for the many staff who work in support services? Given the financial pressure that trusts are under, they have been forced to privatise parts of the service, and support services staff have moved off Agenda for Change terms and conditions altogether, which is what has happened at my local trust. The private sector tries to recruit new members of staff for less than Agenda for Change, because it is implementing the funding cuts that it faces.

[Justin Madders]

My hon. Friend has encapsulated the challenge we always face when a service is privatised. Most often the only way in which the savings promised by the private company can be delivered is by changes to staff terms and conditions. I also agree that the pay freeze affects not only nurses, but the whole of the Agenda for Change workforce. Today we are focusing in particular on some of the effects on nurses, because there are clear reasons why that position is unsustainable.

To return to some of the contributions we have heard today, my right hon. Friend the Member for Leigh described clearly the impact on a ward of having agency staff, and how that creates uncertainty and is not the most efficient way of working. There is also the manifest unfairness of having someone on the same ward, who is only there for that particular shift, earning significantly more than permanent members of staff. How demoralising must that be for those involved? He was right to say in conclusion that we cannot afford to lose the good will of the nursing profession further.

In common with many hon. Members who have spoken today, I pay tribute to everyone who works in the NHS and the health and social care sector, not only to doctors and nurses, but to other allied health professionals such as porters, healthcare assistants, cleaners, receptionists, care workers, paramedics and countless others. It is important to remember that behind every story about the crisis that our NHS has faced this winter are patients waiting too long for treatment, and hard-working public servants doing everything that they can to prevent a very difficult situation from getting worse.

The NHS is the biggest employer in the country—and one of the biggest in the world—and it depends on the tireless efforts of its staff to keep going and meet the challenges of rising demand and insufficient funding. Let us be clear: we cannot indefinitely keep asking them to do more for less. I would argue, as other hon. Members have, that only the good will of NHS workers has stopped the current crisis from turning into a catastrophe. I recently heard the staff who work in our NHS described as “shock absorbers”. That seemed to be a pretty good description of how they are taking and absorbing the relentless pressure and stress of being on the frontline of an underfunded health service. They can take that for only so long before something snaps, which is why it is so important that we fully explore these issues today.

The incredible determination, professionalism and compassion that we see from staff comes against the backdrop of six years of pay restraint. Salary increases for NHS staff have either been frozen or capped at a level far below the rate of inflation. According to Unison, between 2010 and 2016 that represented a cut of more than £4.3 billion from NHS staff salaries, or a loss of between 12% and 19% in actual value since 2010. The Royal College of Nursing believes that since 2011 there has been a real-terms drop in earnings of 14% for its members. With Treasury forecasts indicating that the cost of living will go up by more than 3% every year between 2018 and 2020, it is not difficult to see how the current policy on pay restraint is unsustainable.

The policy is already beginning to have a huge personal impact on some of those affected. Registration fees have gone up by more than a third in two years, and we know well that wages have not kept pace with the cost of living. As we have heard, particularly from my hon. Friend the Member for Newcastle upon Tyne North, staff surveys from the RCN and Unison found that nearly two thirds of staff feel worse off financially than they did a year ago. Forty-nine per cent. had asked for financial support from a family or friend, 13% had used a debt advice service and 11% had used a payday loan company. About a third of nurses are struggling to pay their gas and electricity bills, 53% are working extra hours just to pay their everyday bills and 11% had pawned possessions. The Cavell Nurses’ Trust also found that 20% of nurses had skipped a meal in the last year due to money worries. Those are not abstract figures; they represent real people.

There was a lobby of Parliament today, and I am sure that some hon. Members in the Chamber went to hear at first hand from nurses how they are struggling. I met a nurse from the west midlands who works three days a week because of her caring responsibilities. She told me that she is living below the poverty line. Are we not ashamed that someone caring for our most vulnerable has to live like that? Are we really comfortable with a situation in which the people we are asking to care for our loved ones are having to pawn their possessions in order to make ends meet? In one of the richest countries in the world, can any of us accept the sight of nurses going to food banks?

Nowhere is the problem more acute than in our capital city. The Nursing Times reported that 40% of nurses who currently live in London say that the cost of housing means they will be forced to leave the capital in the next five years. Of course that challenge is not unique to the health service, but vacancy rates in the London area are among the highest in the country, with at least 10,000 nursing vacancies. How long will it be before we reach a tipping point from which there will be no recovery?

The impact is not just on nurses in their daily lives outside work, but on their working environment. NHS staff surveys paint a picture that cannot be ignored. The 2015 survey for England found that 48% of those surveyed stated that a lack of staff was impinging on their ability to do their job, and only 43% felt able to manage all the conflicting demands on their time. The warning signs are there for us all to see.

Analysis of NHS England data by the Health Service Journal found that 96% of NHS hospital trusts in England had fewer nurses covering day shifts in October than they had planned, and 85% did not have the desired numbers working at night. In 2013, the regulator Monitor, now part of NHS Improvement, warned about the potential impact of continuing pay restraint, stating in a report:

“Capping wages for longer to keep costs down would be self-defeating for the sector in the long term as it would make recruiting and retaining good quality professionals increasingly difficult.”

We had that very clear warning four years ago, but we have not heeded it.

The evidence that we have heard today and on previous occasions has proved that that prophecy was correct. The Public Accounts Committee reported that the number of nurses leaving their jobs increased from 6.8% in 2010-11 to 9.2% in 2014-15. Simon Stevens gave evidence to that Committee in 2014, stating that pay restraint would not be an “indefinitely repeatable strategy”, yet that is exactly what the Government propose to do.

Pay restraint, along with a cut to the number of nurse training places in 2010, led to a situation in which the amount of money that the NHS spent on agency staff soared by £800 million in a single year to £3.3 billion in 2014-15. Although considerable steps have been taken to bear down on the figure since then, the situation only developed because of poor and short-term decisions made by the Government, and it remains the case that we still spend far too much public money on agency staff because the NHS has been unable to recruit and retain enough of its own. If we had maintained the levels set by the last Labour Government, we would have had 8,000 more nurses trained during the last Parliament.

Recent figures have revealed that the agency staff cap has been breached almost 2.7 million times in its first nine months of operation. That is a clear example of the impact of the recruitment and retention crisis on all areas of the NHS and how the current workforce balance is completely out of kilter. The use of agency staff is meant to be a temporary measure in times of particular demand and stress for the workforce, not a permanent feature. The fact that these incidences have run into the millions in less than a year should be a huge concern to the Government and a clear warning that the stability and continuity that we all want to see in our workforce is a long way from being achieved. The Government urgently need to address the situation in which hospitals seem unable to provide safe levels of care without relying permanently on agency staff.

The dependency on agency staff has made the case for a pay increase as strong as it has ever been. That is the view not only of the Royal College of Nursing, but of those that look at the impact of skills shortages on the wider economy. In March 2016 the Migration Advisory Committee found that many nurses are moving to agency work or leaving the profession altogether. The fact that the Government have had to put nurses on the skills shortages list should have been the point at which they realised that their pay restraint policy had reached the end of the road. Instead, they have ploughed on regardless, treating the symptoms rather than the cause.

In that regard, the disastrous policy of having tuition fees for student nurses will almost certainly make the position worse, not better. The Royal College of Nursing warned at the time that the policy could act as a disincentive for students from some backgrounds—particularly mature students and those on lower incomes—and early indications are that applications to study are down by at least 20%. If that turns out to be an accurate reflection of the position, the pressure on existing staff can only increase.

[Dr Huq]

At the weekend, on the doorstep, I met my constituent Dr Linda Burke, who is pro vice-chancellor for health and education at Greenwich University. She is really worried, because her university’s figures look like they are down by between 20% and 30%—UCAS will have final figures for late applications. She says that that is serious because it will directly reduce the number of nurses for the NHS. We should be thinking about our future workforce. Does my hon. Friend have anything to say about that?

[Justin Madders]

I am glad to hear that my hon. Friend is out on the doorstep on a Saturday morning, but sorry that the news she was given is so concerning. It is not, however, a surprise. This is something that just about everyone interested in the matter warned the Government of and, as she says, we will find out in the next month or so what the final figures are. If they are of the order that we are hearing about, the Government will have the opportunity seriously to reconsider the policy. Today, when I attended the lobby, I heard some student nurses saying that they are finding it difficult to get staff mentors, because senior staff are exhausted. They do not blame those staff for that; they understand the intolerable pressure, because they too see it for themselves.

The change to student fees will add an extra penalty on those training from this year onwards, due to the Government’s decision to freeze the student loan repayment threshold at £21,000. That means that all future nurses will face a real-terms pay cut. According to Unison, based on current salaries, the average nurse, midwife or allied health professional will lose more than £900 per year to meeting their debt repayments. In practical terms, for a nurse on band 5, that means a salary cut approaching 5%. It is abundantly clear that that will make staff retention harder, not easier; there is a clear link between pay and retention levels.

Nobody is suggesting for a minute that anyone who goes into nursing is motivated by money, but when someone who has just finished yet another draining shift, going above and beyond the call of duty time and again, finds that they do not have enough cash in the bank to feed themselves and their family, and when each year their wages buy them less and less, they could be forgiven for thinking, “Is it all worth it?” It is morally wrong for the Government to put our nurses in that position, and it makes no sense economically either.

[Lilian Greenwood]

That is precisely the point that one of my constituents, a nurse, made when she wrote to me. She said that she graduated last year and is earning only £21,900, one of the lowest starting salaries among her graduate friends. She says that only months into her dream profession, she feels

“worn down by the strains put on the NHS. I face continued pressures every day. Most 12-hour shifts I don’t get my unpaid break, and I leave late.”

That is on top of knowing that she is not being properly rewarded for the work that she does. Is that not precisely why our nurses are feeling so demoralised?

[Justin Madders]

Yes. It is sad to hear that someone who has only just started out in the profession is being ground down so much already and is feeling so unappreciated. It is a story and a message that we hear repeatedly from our constituents who work in the health service. The Government need to listen carefully to it.

The RCN’s submission to the pay review body not long ago said:

“Having faced a long period of pay restraint, it is inevitable that a large number of staff are now undertaking agency work as a way of restoring the real value of their earnings. Further restraint will only lead to even more damaging impact to the recruitment, retention and motivation of the most valuable asset the NHS has.”

Those comments were echoed by the House of Commons Health Committee in July 2016, which said that

“a long term pay squeeze has unintended consequences for recruitment and retention, which may drive higher costs.”

The independent Nuffield Trust made a similar statement after the 2015 summer Budget. It said that

“curbing public sector pay may make it even harder for the Government to realise some of its totemic pledges, such as seven-day working and reducing reliance on temporary staff.”

All those comments have come before the implications are clear for recruitment and retention of the thousands of staff who come from the EU. If they left tomorrow, it would make the current staffing gaps seem like a golden age.

I conclude with a couple more quotes. The first states that

“as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff.”

That quote is from a document that I am sure is known to us all, the NHS “Five Year Forward View”. Median weekly earnings for full-time employees in the private sector rose by 3.4% in 2016. I referred earlier to the anticipated increases in the cost of living over the next three years, which are bound to put more upward pressure on private sector wages.

The second quote is from a document entitled “The Conservative Party Manifesto 2015”, which I do not generally quote. Page 38 says:

“We will implement the NHS’s own plan to improve health care even further—the Five Year Forward View.”

As the Conservative party manifesto includes a clear commitment to delivering “Five Year Forward View”, and as it is clear that pay restraint needs to end to improve recruitment and retention rates, I must ask exactly what is preventing that from happening. I would be grateful if the Minister, when he responds, could tell us whether he considers the current policy of pay restraint to be consistent with the successful delivery of “Five Year Forward View”.

Labour agree with what has been said, be it by the cross-party Health Committee, the King’s Fund, the Nuffield Trust or the Health Foundation, about the need to end pay restraint. We agree with their crystal-clear message, and that of many hon. Members who have spoken in this debate, that further pay restraint for NHS staff would be self-defeating and unsustainable. We therefore endorse the wording of the petition.

I conclude with another quote from the Migration Advisory Committee, which said:

“The restraint on nurses’ pay instituted by the government was presented to us, and in the evidence to the pay review bodies, as an immutable fact. It is not. It is a choice”.

That is the nub of it: this is a political choice that does not need to continue. The Government have persisted with a damaging policy in pursuit of an objective that they have now abandoned, yet despite all the evidence that that policy is self-defeating and will cost more in the long run, the pay cap remains in place. It is a choice that they have made. It is the wrong choice, and it is time that they accept that they have got it wrong and change course before it is too late.

--- Later in debate ---

[Mr Dunne]

I will make some progress.

We recognise that the NHS faces a number of very challenging pressures: not just the ageing population, but the expectations of the public, who rightly demand quality personalised care at home or in hospital every day, not just from Monday to Friday. Those pressures will not be resolved just through pay, but by engaging with staff as they adapt and respond to new ways of working, including by introducing change that comes with scientific development and by supporting them through appropriate training and development.

We know that inflation is increasing. We continue to rely on the independent pay review bodies, which for decades have applied their expertise and objectivity in making recommendations to Government, and we have huge respect for their important work. The hon. Member for Newcastle upon Tyne North and the hon. Member for Torfaen (Nick Thomas-Symonds) referred to the NHS Pay Review Body’s 2014-15 recommendations. Last year the Government accepted its recommendations for 2016-17. We have provided our evidence to the current round—as have others, including trade unions—and we expect its recommendations in the coming weeks.

[Justin Madders]

Will the Minister give way?

[Mr Dunne]

I will first answer, if I may, some of the comments made about the NHS Pay Review Body’s recommendations and how they sit alongside other elements of the NHS.

The allegation was made that there have been significant pay rises across NHS boardrooms, which are demoralising for those who have suffered pay restraint. However, I say to the hon. Members who raised that point that in 2016 the median rise across all board positions in NHS trusts was 0%. There are individual examples, when very senior managers are introduced to trusts that are going through a management change or are in difficulty, where higher pay rates may have to be introduced than for the previous incumbent, but generally speaking the opposite is happening: in many cases, those coming into new positions are coming in on slightly lower salaries.

--- Later in debate ---

[Justin Madders]

The Minister talks about respecting the independent NHS Pay Review Body’s recommendations. Without having seen them, can he say whether the Government are likely to respect those recommendations?

[Mr Dunne]

The hon. Gentleman will not be surprised to hear that I cannot give him any reassurances on that. We will have to see what the recommendations are and then take a view. However, we are not very far away from that point now.

The hon. Member for Foyle (Mark Durkan) referred to the national living wage. I got the impression from him that some NHS staff members in Northern Ireland are earning only the national living wage; I can reassure him that no NHS staff in England are earning only at that level.

--- Later in debate ---

[Mr Dunne]

No, I am afraid I am going to make some progress.

Hon. Members need to recognise that there is clearly a balance between pay and jobs in the NHS and across many public services. I note that the Opposition spokesman was full of recommendations about what not to do but had none, as far as I could calculate, about what should be done in relation to the delicate balance between pay and jobs. If pay were increased beyond the proposal from the NHS Pay Review Body, or beyond what the Government intend to pay, clearly there could be an impact on the number of jobs that can be afforded in the NHS within the financial envelope that we have.

[Justin Madders]

We are very clear that we believe that the recommendations of the independent NHS Pay Review Body should be accepted. Much of what I said was about how we should recognise that, given the pressures on nurses’ pay, that will not necessarily cost the Exchequer anything in the long run.

[Mr Dunne]

I am not sure that that provides much clarification, but I thank the hon. Gentleman for having a go.

Employers in the NHS know that they need to deliver greater efficiencies and improved productivity to help protect frontline jobs. Making the workforce more expensive, through higher pay rises, will not help.

It is therefore disappointing that trade unions have alleged that staff have suffered a pay cut of about 14% in real terms—an allegation that has been repeated by a number of hon. Members in the debate. The truth is that the Government have ensured that no NHS employee —indeed, no employee—should be paid below the national living wage. As I have said, no NHS employee employed under the Agenda for Change pay system is paid below that.

The truth is that average earnings of NHS staff as a whole remained well above the national average salary for 2015, which was £27,500, and have increased by more than annual pay awards. For most NHS staff groups, half of employees employed in 2010 and still in employment in 2015 benefited from double-figure increases in earnings, equating to between 2.2% and 2.9% annually, depending on staff group. The average annual consumer prices index figure over the same period was 2.4%.

NHS Fertility Services

Justin Madders Excerpts

Thursday 19th January 2017 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mrs Gillan. I congratulate my hon. Friend the Member for Birmingham, Selly Oak (Steve McCabe), the right hon. Member for Wantage (Mr Vaizey)—they both made excellent contributions—and the right hon. Member for Carshalton and Wallington (Tom Brake) on securing this extremely important debate. My hon. Friend has been a keen campaigner on this issue, and his expertise and passion were clear when he described the urgent need for change. This is a huge issue that affects many couples up and down the country.

My hon. Friend described the rationing that CCGs are undertaking as crude and based on pseudo-moralistic prejudice. He rightly said that, in other areas of the health service, we would not base decisions on allowing access to treatment on such prejudices. He highlighted well the human aspects of this issue with personal accounts that I do not think any of us could have failed to be moved by, and he rightly highlighted the additional burden on the NHS of having to deal with complications from births resulting from treatments received abroad, where regulatory regimes may be less strict. I do not know whether the Minister is able to examine the cost of that for the health service, but that may be one way to build a financial argument for not rationing treatment. The moral argument has already been put extremely well.

The right hon. Member for Wantage also spoke in a measured and knowledgeable manner. He summed up the issue when he said that signals are being sent that the fertility service is a second-class service. He rightly pointed out that the cost of treatment has come down and its effectiveness has increased. In those circumstances, one would expect availability to improve, but that is clearly not the case. He spoke about the personal experiences of his constituents, one of whom said that infertility is not a choice. That is the perfect riposte to those who argue that IVF treatment is a lifestyle decision.

My hon. Friend the Member for Coventry North East (Colleen Fletcher) spoke about her own friends’ experience. She conveyed clearly how their hope evaporated as time went on, and how after five years that hope was finally dashed on the cruel and inhumane ground that they had suffered a miscarriage in the last three years. We know from other debates how hard it is for a couple to lose a child in that way, so it is surely unconscionable that we allow that to be a factor in denying people access to fertility treatment.

Since being appointed to the Front Bench, I have been involved in several debates about issues that traditionally have not received the attention that they deserve, perhaps because they have been seen as too difficult to discuss or seemed taboo. As my hon. Friend the Member for Birmingham, Selly Oak said, this issue was not debated at all in the previous Parliament, so we clearly do not talk about it enough, despite the fact, as Members have said, that it is the second most common reason for women to visit their GPs. As we have heard, one in seven, or one in six couples are affected by infertility. Whichever of those figures we want to stick with, that means that millions of people face a serious and lasting impact on their lives. Sadly, that results in stress, anxiety, depression and relationship breakdown. In some cases, infertility is the result of another serious condition, the impact of which couples are already having to deal with. I therefore welcome the opportunity to give a voice to people who often struggle silently with this disease and increasingly face the additional frustration of an unfair and unjustifiable postcode lottery.

Before I talk about the rationing and decommissioning of infertility treatment, I, too, want to talk about the human impact to put into context what we are talking about. Like other Members who have spoken, I have been contacted about this issue by a constituent. Her name is Zoey Evans, and she was denied IVF treatment by NHS West Cheshire clinical commissioning group, despite the fact that her infertility was caused by gynaecological treatment, part of which was undertaken without her express consent. The reason the CCG gave for her ineligibility is one that we have heard given by other CCGs—that her partner had a child from a previous relationship. The exceptional circumstances of her case and the cause of her infertility do not appear to have been adequately considered. I know from talking to Zoey how devastating the decision to refuse her the opportunity to become a mother has been for her, and the fact that she finds herself in that position only because of previous treatment on the NHS has made it even more difficult to deal with. Every avenue has been explored. I do not mind saying that I know that Zoey would make a great mum, and it is hugely frustrating to know that, if she had lived in a different area, she might have been given that chance.

Zoey’s situation, like many of the other personal tales we have heard today, demonstrates the point that has been raised already that infertility, as defined by the World Health Organisation, is a disease with an identified treatment—a treatment that is recommended by the National Institute for Health and Care Excellence. We are in a situation where, in some parts of the country, the NHS is allowed to ignore an individual’s healthcare needs as well as the NICE guidelines and effectively add another barrier to treatment by introducing further arbitrary criteria.

In the run-up to this debate, I was contacted by another individual, Richard, who also contacted my hon. Friend the Member for Birmingham, Selly Oak. As we have heard, Richard lives in Dunstable, and as such, he and his partner were entitled to only one cycle of NHS-funded treatment, which sadly was unsuccessful. He emailed me and described what it is like to deal with infertility. My hon. Friend read one quote, but I picked out another, about the human impact, that I thought was equally powerful. Richard said:

“It is very hard to explain to someone who has not experienced infertility the mental health struggle that you go through. If I had to describe our feelings with one statement, I would liken them to the emotion and turmoil that one goes through when a relative dies, the difference being with infertility, the feelings experienced do not slowly ease over time—they intensify.”

He told me of his anger about the fact that, if he lived just one mile from his current address, he would fall into the Luton CCG area, where he would have been entitled to three cycles of treatment rather than the one he received, which might have helped him to become a parent. That illustrates the perverse and cruel nature of the postcode lottery for treatment, which I will now address.

As we know, the NICE clinical guidance on infertility issued in 2004 is extremely clear. It says that

“all eligible couples should have access to three full cycles of IVF where the woman is aged below 40.”

Further guidance was issued in 2013, which recommended that women aged between 40 and 42 should have access to one full cycle. NICE, which was founded in 1999 to end the postcode lottery in prescribing, made those recommendations after deeming such interventions to be a reasonable cost and a clinically effective use of NHS resources. Incredibly, as we have heard, the charity Fertility Fairness found that, of the 209 clinical commissioning groups in England, just four follow the NICE guidance in full, despite CCGs having a legal duty to have regard to NICE guidelines when commissioning treatments. Again, the words of the right hon. Member for Wantage about a second-class service ring true.

When the previous public health Minister, the hon. Member for Battersea (Jane Ellison), was challenged on that in a written question, the response we got was:

“NHS England expects that all those involved in commissioning infertility treatment services to be fully aware of the importance of having regard to the National Institute for Health and Care Excellence fertility guidelines.”

The reality is, as we have heard, that there are enough caveats in that statement to render it meaningless. In another response, she went further and said:

“Blanket restrictions on procedures that do not take account of the individual healthcare needs of patients are unacceptable.”

We all agree with that. However, she stopped short of saying what the Government planned to do about the fact that 98% of CCGs are failing to apply the NICE recommendations in full. We know that at least 45% of them do not offer a full cycle and that more than 80% do not meet the recommendations on the number of cycles. If those restrictions are unacceptable—I think there is general agreement on that—we need to know what Ministers will do to change the situation. What is the point of having NICE recommendations if CCGs, facing huge financial pressures, can disregard them without any penalty?

As my hon. Friend the Member for Birmingham, Selly Oak said, access to treatment is being reduced, and about 10% of CCGs, including my own, West Cheshire, are consulting on that. What can we ask from the Government to stop the further slide away from recommending treatments? Does the Minister accept that something needs to be done? The impression given is that the guidelines can be routinely ignored. Does she accept that the impression can be given of an abrogation of responsibility? Does she accept that that raises real issues about accountability and legitimacy? It is called local decision making, but I do not think people on the receiving end feel that decisions are being made locally in their interests at all.

If the Government do not take a more robust stance when NICE guidance is being ignored by CCGs, they are not only accepting but entrenching the notion of a postcode lottery. We therefore need to look again at whether to strengthen NICE’s role in cases where there is clearly stated treatment that is affordable and effective but we see CCGs failing to implement that advice. I hope that the Minister will reflect on what has been said by me and other Members about how we can move that issue forward.

As we know, infertility treatments are far from the only example of NICE-recommended treatments not being commissioned. Postcode lotteries exist for a whole range of medical interventions such as hernia repair, hip and knee replacements, cataracts and varicose vein surgeries. Further rationings of treatments are being proposed by CCGs across the country as they struggle to cope with finances that simply are not keeping up with demand.

I have mentioned my CCG several times already. I do not wish to be over-critical of it because it is in a difficult position: its core funding allocation for the year is £9 million less than the funding formula says it should be. That gap is projected to close slowly in the next five years, but there will still be millions of pounds of shortfall every year over that period. At a time of increased demand, inevitably, it is being forced into this position, as are many other CCGs. Clearly, financial pressures are driving those decisions not just in my CCG but across the country. That does not chime with the claims we have heard that the health service has been given everything it has asked for.

As my hon. Friend the Member for Birmingham, Selly Oak and the right hon. Member for Wantage said, the postcode lottery is exacerbated by the huge variance in the amounts that CCGs pay for a single cycle of IVF, from as low as just over £2,000 to possibly three times as much in other parts of the country. In response to a written question on 21 April 2016, the previous public health Minister said that

“the Department and NHS England are considering options for addressing variation in the prices that CCGs are currently paying for in vitro fertilisation treatment.”

A report by an expert group on commissioning NHS infertility provision identified that

“a lack of knowledge and expertise in commissioning fertility services was a barrier to compliance with NICE guidelines”.

How close are we to a national benchmark on price? What support can be put in place to assist CCGs when they are commissioning fertility services?

I bring my remarks to a close by reminding us of the founding principles of the national health service: good healthcare, available to all and free at the point of use. Those founding principles came some 30 years before the first IVF birth, but, whatever the advances in medical science, they should apply to any treatments where a medical case is made for their use, not just to people living in certain parts of the country.

--- Later in debate ---

[Justin Madders]

The Minister has correctly identified that some CCGs are not providing any treatment at all. Does she think that blanket policy should be dealt with?

[Nicola Blackwood]

I am about to go on to work that we are doing to assist CCGs with better commissioning, including giving them advice on pricing, which the shadow Minister mentioned. Perhaps he will allow me to do that; I think it will be enlightening for him.

Work is under way to assist CCGs in better commissioning fertility services for their local community. It is right that we do that. My right hon. Friend the Member for Wantage was correct—the cost of IVF is falling, but not all CCGs are benefiting from that. We know that the prices that fertility clinics charge CCGs for an IVF cycle vary, and that some CCGs are not contracting in the most effective way.

The Fertility Fairness survey reported that the price being charged by service providers for an IVF cycle varied across the country, from around £2,000 at the bottom end to more than £6,000 at the top, although it is not clear what all of those treatment cycles involve. The Department of Health, NHS England and professional and stakeholder groups are working together to develop benchmark pricing for fertility services to ensure that CCGs get the best value for their money. That is obviously the first step to be taken before NHS England’s longer term work towards developing a national tariff, which my right hon. Friend called for.

In addition to that initiative, the national fertility regulator—the Human Fertilisation and Embryology Authority—is developing commissioning guidance that aims to improve the quality of commissioning, for example by encouraging greater use of single embryo transfers where appropriate for a patient. That does not reduce the chance of a woman having a baby but significantly reduces the incidence of multiple births, with their attendant risks and complications for mothers and their babies. NHS England has agreed to disseminate and promote that guidance to all CCGs in England.

Those approaches are intended to raise the level of knowledge and expertise within CCGs to ensure that they are able to commission services appropriately in what is a specialist area, exactly as my hon. Friend the Member for South West Bedfordshire (Andrew Selous)—who is no longer in his seat—called for. It would also be helpful for CCGs to pool their resources and expertise and collaborate more with each other to get a better deal for their patients. That has happened in the north of England, where members of two commissioning collaboratives are able to offer three IVF cycles to qualifying couples.

As I hope has been clear, it is the Government’s view that infertility is a serious medical condition. Those suffering from infertility who meet the criteria in the NICE fertility guidelines for NHS-funded treatment should be able to seek that treatment. We do not agree that clinical infertility should not be part of a comprehensive national health service. Reflecting on the strength of feeling expressed today, I will be writing to NHS England to ask that it communicates clearly to CCGs the expectation that NICE fertility guidelines should be followed by all.

The Department of Health, NHS England and professional and stakeholder groups will redouble efforts to develop the benchmark pricing for fertility services, which, as I have said, is a precursor to NHS England introducing a national tariff. NICE will continue with its review of fertility guidelines this year. I hope that series of actions demonstrates just how seriously the Government take this situation, and leaves all those watching the debate confident of our commitment to finding practical solutions to this serious problem.

Pennine Acute Hospitals NHS Trust

Justin Madders Excerpts

Tuesday 17th January 2017 Westminster Hall

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

It is a pleasure to serve under your chairmanship, Mr Streeter. I congratulate my hon. Friend the Member for Blackley and Broughton (Graham Stringer) on securing this extremely important debate and on the knowledgeable way in which he introduced the subject. He set out the history of the concerns, which stretch back as far as the establishment of the trust. He made a powerful case about the need to give the people we represent in north Manchester the excellent health service they deserve.

My hon. Friend made the key point, which we should all reflect on, that life expectancy in that part of the world is much lower than in other parts of the country. We all want to see that improve. He said, and I agree, that there is a delicate balance between getting to the bottom of what has gone wrong and creating a credible plan for the trust’s future. I agree that the vast majority of clinicians at Pennine acute are highly committed and professional. He told us that he led a debate on the subject a decade ago. I have read extracts of the Hansard report of that debate, and many of the points that he raised then have been raised again today. We should all reflect on that. It is a completely unacceptable situation.

The hon. Member for Bury North (Mr Nuttall) said that the problems at Pennine acute are not all down to money, and that some of them date back to a time when the NHS was receiving record levels of investment, but I think that some of the staffing shortfalls are finance-driven—the Care Quality Commission report refers to the financial pressures. I agree that leadership is very much an issue, and that a period of stability is required.

My hon. Friend the Member for Heywood and Middleton (Liz McInnes) also spoke about having a period of stability, with great knowledge and experience from her long history of working in the NHS. She said with great eloquence that there seems to be a constant rollercoaster of change. She also pointed out that the trust is undergoing two initiatives, which seem to be pulling it and the staff in slightly different directions. She highlighted very well the anxiety that the staff feel about their future, and said that we need a period of stability. She also highlighted the maternity services’ funding issues, and said that they are dealing with about three times as many births as they receive funding for. If correct, that is an unsustainable situation.

My hon. Friend the Member for Oldham West and Royton (Jim McMahon) also has significant connections with the trust. He described it as a family, but he was right to say that that should not mean that we cannot ask difficult questions about what has gone on. He conveyed how demoralising it is for the staff who work there. He said that leadership is a key issue, as did the hon. Member for Rochdale (Simon Danczuk), who also said it is about capacity and resources. I think we all agree that leadership was lacking in the past, but most Members who spoke were positive about the new leadership.

I, too, pay tribute to everyone working at Pennine Acute Hospitals NHS Trust. As Members said, it is not an easy time for them. It is not an easy time for anyone working in the NHS, let alone for those who work in a trust that has been the subject of such negative coverage. We should be mindful of the fact that the crisis currently engulfing the whole of the NHS would be so much worse if it were not for the good will of the staff who go above and beyond the call of duty every day. As my hon. Friend the Member for Oldham West and Royton said, we should be extremely grateful for the contribution they make. I recognise how difficult it must be to work in a trust such as Pennine acute. As he said, it has sadly been in the headlines all too often for the wrong reasons. It is worth pointing out that the most recent CQC report into the trust rated the leadership inadequate, but rated the care good. Although we are deeply concerned about the reports about the trust, we recognise that the vast majority of staff are extremely dedicated and caring.

No one can read the CQC report or the other reviews that have been published without feeling deeply uncomfortable about what has gone on at Pennine acute. The report should be a wake-up call for the wider health service. It talks about low morale, severe staff shortages and, worryingly, a feeling among staff that until recently the culture focused on financial matters and operational delivery, rather than quality. We hear such concerns across the whole of the health service. I am not for a minute suggesting that the most concerning incidents at Pennine acute will be repeated, but we should recognise that the pressures that we hear about in Pennine acute can be found in many other trusts up and down the country. The history of this matter should act as a warning to us that such problems cannot be ignored and will not be resolved without effective interventions and leadership.

The CQC report made it clear that the issues it outlined are not new. To paraphrase it, they appear to be part of the culture at Pennine acute. As my hon. Friend the Member for Blackley and Broughton said, there is a strong resemblance between the CQC report and a 2005 report by Sir George Alberti, which was very critical of the trust. The only real difference between those reports is that the severity of the criticism has grown. During that decade, there was inaction, patients and staff were let down, and there was a lack of leadership. Although there are concerns about a number of services, the most serious issues appear to be with maternity services, where the CQC said it found

“a poor culture with deeply entrenched attitudes where some staff accepted sub optimal care as the norm…and specific needs were not appropriately considered or met.”

As we have said several times already, this is about leadership. Although it is not right to point a finger at individuals on this occasion, it seems that there have been repeated failures over many years and at many levels, and a failure to drive the changes needed to improve outcomes for patients. I was particularly concerned by the statement that not all reportable incidents were reported on the system because

“there was often no managerial response or feedback.”

The CQC report also says:

“Incidents and risks were not escalated in a timely way or at times not escalated at all; consequently they did not gain robust executive scrutiny or the required response from managers and the senior team.”

Although the report says that only some departments failed to respond correctly, it is deeply troubling that it happened at all. We can see why some of those incidents happened: there was a culture in which reports were not acted upon.

There were other warnings. Between 2010 and 2015, the trust paid the highest number of compensation claims of any trust within the NHS Litigation Authority. As my hon. Friend the Member for Blackley and Broughton said, in one year the compensation totalled £58 million. Compensation levels in maternity claims obviously tend to be extremely high, but no one could claim that those figures did not require further investigation and more action. However, only after the CQC inspection of February 2016 was decisive action taken.

In July last year the Manchester Evening News learned from a whistleblower that an internal review had been carried out into maternity services at North Manchester general and Royal Oldham hospitals. Unfortunately, the newspaper’s requests for a copy of the review were repeatedly sidestepped, until eventually, in August, the trust stated that the review did not exist. It was handed over only after further requests to the trust and the intervention of the Information Commissioner. What does denial of the report’s existence say about the trust’s defensiveness, secrecy and unwillingness to learn from mistakes?

As we have heard from Members today, the report painted a deeply concerning picture of a chronically understaffed service unable to provide patients with the level of care that they deserve. We have heard of incidents such as a mother dying of a catastrophic haemorrhage after her symptoms were attributed to mental illness; a baby who died because staff failed to identify the mother’s rare blood type; and a patient who was left with a colostomy because her condition was missed three times.

My hon. Friend the Member for Blackley and Broughton read out the most distressing of those reports, which was the case of a premature baby. It is incredibly difficult for us to comprehend just how distressing that must have been. I agree with him that that incident was inhuman. We cannot undo that terrible event, but we can do our best to prevent it from being repeated and to ask the pertinent question of why the warning signs, which occurred over a number of years, did not bring about more effective change. Only after the CQC got involved did change begin.

It is also deeply concerning that only the diligence of a single journalist at the Manchester Evening News pushed the issue of the internal review into maternity services. When the Minister responds, will he agree that steps should be taken to unearth the full extent of what happened at the trust, so that we may learn the right lessons for the future?

Members who have spoken in the debate have recognised that the leadership of Sir David Dalton since April has been received positively. The CQC has recognised the improvements made since his appointment. As the hon. Member for Bury North said, even an individual of Sir David’s ability, however, cannot be expected to lead two trusts, as large as they are, as well as carrying out his other responsibilities. I will welcome any comments the Minister might have about the long-term leadership at the trust.

The CCG has, I understand, been able to invest an extra £9 million, but the Government have not allocated any additional funds to the trust, as would usually be the case with a turnaround effort of that nature. The Secretary of State acknowledged that improving Pennine acute would be “incredibly difficult”, but suggested that it was possible after citing the example of the Frimley Health Foundation Trust. According to the Health Service Journal, however, Frimley Health will receive £90 million in revenue support, as well as £130 million of capital funding. Is the Minister therefore satisfied that the trust has the resources not only to maintain services in an incredibly challenging climate, but to drive through the improvements that are clearly needed?

Over the years, many opportunities to turn the trust around have been missed. I hope that the Minister will be able to satisfy us that this is a turning point and that we will not be back here in 10 years’ time with another set of patients and staff who have been let down badly.

Oral Answers to Questions

Justin Madders Excerpts

Tuesday 20th December 2016 Commons Chamber

[Mr Hunt]

I absolutely agree with the hon. Gentleman, which is why it is extremely frustrating that the current signals from the EU are that it is unwilling to bring forward negotiations about the status of EU nationals here, and indeed that of British nationals in the EU. No one from either side of the Brexit debate has ever said that there will be no immigration post-Brexit; they have simply said that we will control that immigration ourselves through this House and through decisions made by the British people at general elections.

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

On behalf of the official Opposition, may I echo the words of the Secretary of State in relation to the tragic events in Berlin and send our condolences to the people there?

The Institute for Employment Studies has today warned that Brexit could make nursing shortages even worse. That follows The Times reporting that

“applications for nursing, midwifery and allied health courses were down by about 20%”

and that in some institutions applications had halved. The decision to scrap nurse bursaries is having the consequences that every expert predicted it would. With the uncertainty of Brexit looming over our workforce, now is not the time to be taking a massive gamble with our nurses so, in the light of the evidence, will the Secretary of State now agree to scrap that disastrous policy?

[Mr Hunt]

I simply say to the hon. Gentleman that the purpose of that policy was to allow us to train more nurses; in fact, we will be training 40,000 more nurses during this Parliament. We have more than 11,000 more nurses in our NHS wards, and at Countess of Chester hospital—the hon. Gentleman’s own hospital—there are 172 more nurses than in 2010.