World ME Day

Margaret Hodge Excerpts

Wednesday 1st May 2024 Westminster Hall

[Dame Margaret Hodge (Barking) (Lab)]

I am very pleased to serve under your chairship, Dame Siobhain. I want to raise the issue of the involvement of multiple Departments, and it relates to my constituent Sienna Wemyss, who is 16 years old. Sienna was diagnosed in 2022, but she still has not got an education, care and health plan. She got a place at our local Barking and Dagenham College, but when she arrived there, despite her mother having spoken to the teachers, she was sent home because she could not attend. She finds it difficult even to comb her hair, so she is at home and has lost out on her education.

Does the right hon. Member agree that it is really important that not only health but education plays its role? While I am on my feet, I should say that Sienna has to travel as there are no local health facilities to respond to her needs and to care for her. She has to travel into University College Hospital—miles from my constituents in Barking. Does the right hon. Member further agree that there should be local healthcare facilities to respond to the needs of people with this condition?

[Sir Sajid Javid]

I thank the right hon. Member for her intervention, and I agree with her on both points. She first emphasises the importance of the Government’s final plan being a proper cross-Government plan; I hope the Minister will speak to the cross-Government nature of the work that he is leading on their behalf. I also agree with her point about local health support. That must also be addressed and covered in the final plan that is published. I have heard very similar stories from constituents and others, and I completely agree with what she said. I thank her again for that intervention.

When I committed the Government to developing a cross-Government delivery plan, I stated in a written statement to this House:

“officials will work with stakeholders ahead of publishing the delivery plan later this year.”

Despite the commitment that the delivery plan would be published by the end of 2022, it was not until August 2023 that an interim plan was published. In the ministerial foreword to that interim delivery plan, the Minister’s immediate predecessor—my hon. Friend the Member for Faversham and Mid Kent (Helen Whately)—stated:

“The final delivery plan will be published later this year”.

That was the end of last year. We are now in May 2024, approaching exactly two years since I made the initial commitment.

I am also now hearing disturbing reports that, despite two years of waiting, the final delivery plan may not be published until the end of this year. Everyone knows that the Prime Minister has committed the country to a general election by the end of this year. We also know that when that general election is called, there will be no Government publication of any sort, which means there is absolutely no time to waste. I ask the Minister, when he responds, to give a specific commitment to the House that the final delivery plan will be published before the summer recess—or at the very latest, just after.

Recovering Access to Primary Care

Margaret Hodge Excerpts

Tuesday 9th May 2023 Commons Chamber

[Steve Barclay]

The short answer is this year, but the Chair of the Health and Social Care Committee is right to focus, as with all recovery plans, on deliverability. I hope he will take comfort from the fact that around half of GP practices already have cloud telephony, which is why we are so confident that it is the right approach. It is one that is already working. We are seeing from patients’ positive feedback that they hugely value online booking and call-back systems, but they also allow primary care to better triage calls to specialists and therefore to use the additional roles we have recruited in an optimum way. That will be rolled out this year, but it is already up and running and we can see that it is working.

[Dame Margaret Hodge (Barking) (Lab)]

I would like to take the Secretary of State out of the bubble of Westminster and the green Benches and into the reality of what is happening on the ground in my constituency. We have the second highest number of A&E attendances for minor injuries—people who should be going to their GP. We are the most under-doctored and second most under-nursed area in north-east London and, last year, just under 9% of patients could see their GP within 14 days of requesting an appointment. So for me, the recovery plan announced today is deeply underwhelming. I hope that the Secretary of State can answer these three questions. When will he, not plan, but deliver the 6,000 extra GPs promised? What work is he doing to move GPs from working part time to putting in more hours at the frontline with their patients? Where is the commitment to deliver face-to-face appointments for those who want them in my constituency? Only when I have answers to those questions will I feel confident that there really is a plan for GP services in Barking and Dagenham.

[Steve Barclay]

I know the right hon. Lady well, having served with her for four years on the Public Accounts Committee, so I hope that she will not mind me being slightly surprised about being told, as someone who lives in the Fens and not in London, that I am in the bubble. On her points, obviously, we have 37,000 more doctors than when the Government came to power. Directly, the changes to pensions lift about 9,000 GPs out of the tax changes. It is also about training more—4,000, compared with 2,600 in 2014—so being on track in terms of the number we are training. It is also about the additional roles that we are funding, the 25,000 and the manifesto commitment of 26,000. Also, the pharmacy announcement is all about freeing up GP capacity for face-to-face appointments for those who want come in. By enabling pharmacy capability for those who want to get oral contraception, have a blood pressure test or access services for the seven common conditions—including urinary tract infections and ear infections, for which prescriptions can then be given—we will free up GP time for face-to-face appointments. If we look at last year’s patients survey, we see that about two fifths of patients hugely valued continuity of care and face-to-face, which means about three fifths preferred to prioritise speed of access, rather than seeing the same GP or seeing someone face to face. So it is about tailoring the offer to what the patient wants, and patients do not always want the same thing. Some want speed and pharmacies can deliver that.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Margaret Hodge Excerpts

Wednesday 13th July 2016 Westminster Hall

[Dame Margaret Hodge (Barking) (Lab)]

I beg to move,

That this House has considered awareness and funding for treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis.

It is a delight to move a motion under your chairmanship for the first time, Mrs Gillan, and I am grateful to the Speaker for selecting this issue for debate. I am also grateful to the Minister and look forward to having a positive exchange with him.

I had never heard of Stevens-Johnson syndrome or toxic epidermal necrolysis—my pronunciation of some of these medical terms may leave a little to be desired—until my constituent Nadier Lawson, who had suffered from the condition, contacted me. She has set up an awareness group, SJS Awareness UK, which is based in my constituency. It was because of her and that group that I asked for the debate.

SJS—and its much more severe form, TEN—is a severe reaction that affects the skin. It is caused by a whole range of standard medicines that we all use regularly. The reaction is most commonly caused by drugs used to treat epilepsy; some antibiotics, such as penicillin and sulphonamides; over-the-counter drugs such as ibuprofen; and medications that are commonly used to treat HIV and gout. The adverse reaction triggered by those drugs is devastating. I have seen pictures of children and adults who have had such a reaction, and they are truly shocking. People start with a skin rash, which rapidly develops into excruciating blistering across their skin, which starts to peel off. The condition particularly attacks the mucus membranes in the body—in the mouth, eyes, nasal passages and guts—and is similar to having third-degree burns on the skin. The condition is classified according to how much of the body surface is blistered: if it is less than 10%, the condition is called Stevens-Johnson syndrome; if it is 11% to 30%, it is called overlap syndrome; and if it is over 30%, it is called toxic epidermal necrolysis.

The initial symptoms that people experience are non-specific. Someone can take a pill one day and feel nothing for up to a week or two but then start to feel unwell and develop a rash, which is often assumed to be chicken pox, and may experience flu-like symptoms. A key problem associated with the condition is that all too often, it takes far too long to identify. Obviously, the first thing to do is to stop taking the medication that is causing the condition. Failure to identify the condition early enough can lead to terrible lasting effects, including permanent damage to the eyes—resulting at its most extreme in blindness—and lungs, loss of nail beds, arthritis and chronic fatigue syndrome. At the very worst, people die. Around one in 10 people with SJS, the mildest form of the condition, and up to a quarter of those with TEN, the most severe form of the condition, die.

I have a whole lot of case studies, but I thought it worth reading out just one, which was given by a young man who came to an event that I held in the House to bring together people who had experienced the condition. He is called Stuart Doyle, and he wrote and said this:

“Nine years ago I had a TENS reaction. I burned from the inside out and lost around 95% of my skin, all through second and third degree burns with permanent scarring. My finger and toenails burned off and have never grown back. The enamel on my teeth burned away. Mouth, throat, lungs and stomach all burned. My eyes burned and ulcerated, then fused to my upper and lower eyelids. My tear film was destroyed, as was my tear production and I lost all saliva production too. I also had inner ear burning and am now partially deaf in one ear. My genitals burned.”

I will skip a bit and give just a summary of what he said and wrote. He continued:

“I spent six weeks in a ketamine-induced coma, which I was placed in just two days after I arrived at my first hospital. I arrived with what seemed to be meningitis, it was textbook and it was moving fast. Two days later my oxygen SATS had dropped to the point where brain damage had begun its process. They acted quickly; they had already started treating me, my son, and my partner for meningitis. It wasn’t until after the lumbar puncture results came back, that they realised it was not what they first thought it was.

The high doses of anti-biotics were stopped, by this point my throat and lungs had begun burning and blistering and a rash now covered more than half of my body. It was the lungs and throat burning that had begun to close up my airways and provoked the need for a ventilator to keep my brain intact. The ketamine-induced coma was to try and get my heart rate back down from the 180 beats per minute mark caused by the pain of the internal burning. If they’d not done that, I’d have certainly died from cardiac arrest there and then. I was to stay in the coma on full life support for six weeks; my total hospital stay was three months. I woke up in a different city.”

He goes on to describe how the condition has impacted his life, saying:

“I hoped I’d die, I wished every night for 3 years after my reaction that I’d not wake again. I had more surgeries than I can recall, my eyes were in a terrible state.”

This is the treatment that he requires today:

“My eyes require a tremendous amount of work. My day starts before 6am and ends around midnight. I have to change my lenses at least 20 times a day, put in more than 100 drops, both lubricants and steroids, and then there is the ever present pain. But, it’s totally worth the effort and I am so lucky, and grateful for all the work that my doctors put in to get me to here.”

He then says:

“The hardest thing about my new life, is the chronic pain”.

[Jim Shannon (Strangford) (DUP)]

I congratulate the right hon. Lady on raising awareness of this issue. As far as I am aware, this is the first time that this condition has been brought to the attention of Westminster Hall and the Minister. The background information about the condition indicates that it can be triggered by normal medicines such as paracetamol. Is it time for the Minister and the NHS to address the issue by raising awareness of the condition among GPs, consultants and everyone else? The condition affects only one or two people in every million, but it is an important issue.

[Dame Margaret Hodge]

I completely agree. We are raising awareness through the debate, and I hope that the Minister will take action so we can get early identification and therefore prevent people from suffering the condition’s worst impacts.

The condition is rare, and therein lies the problem. I would appreciate it if the Minister addressed the following issues. There is a lack of awareness among many medical professionals, who just do not come across the condition. Insufficient attention is paid to the condition and its symptoms in the education and training of all health professionals. Survivors whom I have talked to all talk about that. A young man, Laurence McCalla, went to my local hospital, Queen’s hospital. They gave him antibiotics; it took about 24 hours to identify the condition. At one point he had 20 doctors and consultants looking at him, because it was new to them and they wanted to learn from it as a case study. Another lad, from Worcester, said:

“There is one big thing that stands out the most from this though. It astonishes me that so many doctors I have seen do not know about it.”

Debbie Hazel was misdiagnosed three times, as doctors thought she had chicken pox. She says:

“One of the problems was the lack of knowledge doctors have about the condition.”

The mum of a 13-year-old son, who lives in Surrey, says:

“My son was so ill and I couldn’t hold him or kiss him. He was screaming because his skin was so raw. I felt helpless. Nobody could tell us what was happening because nobody knew.”

My first ask to the Minister, therefore, is for a commitment that the condition, and its symptoms and treatment, should be taught to medical students, nurses and pharmacists as part of their educational courses. SJS Awareness, the organisation in my constituency, has a fantastic poster about the symptoms and how to spot the condition. Those posters could, if the Minister were to help us, be distributed to all GPs. Early diagnosis, and therefore awareness, would not just alleviate suffering; it would save lives.

Guidance has also been prepared on the clinical pathway by the British Association of Dermatologists. What steps will the Minister take to ensure that that guidance is followed throughout the country so that identification and treatment of the condition is not a postcode lottery? SJS Awareness has asked me to ask the Minister whether we could have an SJS awareness week for the general public. We are talking about such regularly used medicines—Optrex, ibuprofen, penicillin. They are standard medications, which we do not even think about using. We need to raise our awareness about the potential side effects.

Finally, because the condition is rare, money for research on it is limited. However, there is a cost to the NHS from not understanding the condition or recognising it early and understanding how to treat it. I understand the cost of treating skin reactions is about £500 million a year and it simply makes economic sense, as well as being a question of people’s lives, of course, to use research to get better at understanding why some people have such a reaction to drugs. An interesting key finding on genetic testing is that, in China, there is a gene in the population that predisposes people to different types of skin reaction, putting them at a higher risk from the drug carbamazepine. I do not know whether the Minister has come across that. In China and Taiwan, doctors test for the gene before they administer the drug. If we did more work here, we could manage that.

We also want research on new and better ways of treating severe reactions. From what I gather, more treatment should happen in burns units; often that is not understood and people are put into the intensive care unit and given the wrong medication. Finally, it is very important that we should have research on better understanding the features of drugs that make them more liable to cause the reactions in question. Those are three hugely important areas of research. I hope that the Minister can give us some comfort on that point.

People who saw the title of today’s debate would not have had a clue what I was going to talk about, yet the condition could affect any one of us, because we all take the medications concerned—they are standard. I have a file full of tragic cases of people affected by Stevens-Johnson syndrome, yet many people would not have a clue what we are debating. I ask the Minister, therefore, to do some practical things: to help us to raise awareness; to improve the training and development of all medical professionals, so that they understand the syndrome; and to get money for research so that we can understand the causes and prevent recurrences of this terrible condition in our population.

[The Parliamentary Under-Secretary of State for Life Sciences (George Freeman)]

It is a pleasure to serve under your chairmanship, Mrs Gillan, not least because on other occasions you have been a doughty champion of campaigns on rare diseases. It is also a pleasure to respond to the debate. I congratulate the right hon. Member for Barking (Dame Margaret Hodge) on obtaining it and thank her for raising the issue. It is my great privilege as the Minister for rare diseases to be educated every time we have such a debate. A process of huge preparations is triggered in the Department, so already, just by raising the issue, the right hon. Lady has struck a blow and alerted the machine to the condition and its causes. However, I want to go further.

Perhaps, as this is the day when we say farewell to the Prime Minister, I may pay tribute to his personal leadership in the field of medical research, and to his unleashing of UK leadership, building on what happened under previous Administrations. The Labour Government did a lot of great work setting up the National Institute for Health Research, but because of the Prime Minister’s experience with genetic conditions in his family he has been an incredible champion of genomics and of rare disease science and research. As he leaves I want to state that that is one of his great legacies. It has been my privilege to be his first Minister for Life Sciences, with the purpose of driving forward that quiet revolution and UK leadership.

I also want to pay tribute to SJS Awareness. As with so many rare conditions, it is charities and patient groups, the patients and victims of diseases, who take the early steps in speaking up, raising money, rattling tins, having raffles and raising awareness, which in the end lead, as I see often, to huge progress and advances in research and treatment. I encourage them to continue and not to give up. I hope that what I will say will send a good signal.

The truth is that the debate on this condition shows up a wider issue throughout the biomedical research community. The more we know about disease and how patients respond to drugs, the more we realise how many conditions there are. We discover them literally each month through the UK genome project, at a faster and faster pace, and that is changing the way drug discovery works, and the way the system thinks of conditions. The old model of diagnosing on a standard understanding of X number of conditions with clear symptoms no longer holds. We must, as the right hon. Lady said, think about how we will help a new generation of clinicians to have at their fingertips the genomics, data and informatics to be able to recognise conditions and triage patients into the right treatment.

The Government take the issue of rare disease treatment incredibly seriously, and that is why we have worked with NHS England on launching the UK rare diseases strategy. There are now 51 recommendations. It is not just a brochure; it is a serious document with commitments and an action plan. Although the number of rare disease patients suffering from a particular condition may be small—the one that we are considering affects about 150 patients a year—collectively more than 3 million people in the UK suffer from rare diseases, so they are not rare; they are very common, and they are experienced by a huge number of people. It is only fair that the system should recognise that, and start to adjust and adapt towards the mainstreaming of provision for people with rare diseases.

Research is, of course, vital, which is why the £1 billion a year that we spend on the National Institute for Health Research, the £850 million for the Medical Research Council and the £1.4 billion spent by the Association of Medical Research Charities and its members is so important. That underpins UK leadership in this space, and it is even more important for rare conditions such as Stevens-Johnson syndrome. There are some encouraging research projects under way which I want to highlight, partly because I think they give hope to patients and charities.

The National Institute for Health Research clinical research network is supporting the MOLGEN trial. It is actively recruiting patients from across 80 NHS trusts who have experienced adverse drug reactions. That study has already recruited 1,740 participants and plans to continue recruiting patients until February 2019 with an eventual aim of accurately predicting those patients at risk of developing severe reactions, including Stevens-Johnson syndrome.

Further research that is likely to benefit those with the syndrome include the 10-year study of chronic eye inflammation, including SJS, which is being taken forward by the NIHR clinical research network in the west midlands. That has recruited 224 patients to date and will continue until 2021. The MRC Centre for Drug Safety Science at the University of Liverpool is doing powerful work in this field and has already been instrumental in identifying some of the genetic markers that indicate that a patient group are at an increased risk of developing the condition. The progress we are making in genetics generally, in terms of deep science, diagnosis and genetics for new cures, holds real hope. Being realistic, that is not hope for those patients who are in that excruciating agony that the right hon. Lady powerfully described in the words of one of her constituents.

While patients with SJS are more likely to be identified earlier and receive the best forms of clinical management, we want to prevent the condition in the first place by understanding the underlying genetic causes. That is why we are so committed to the 100,000 Genomes Project. For those who are not aware of it, it was led and inspired by the Prime Minister. I describe it as the NASA of UK biomedical research. It is our world-leading project to take 100,000 entire, fully sequenced genomes from NHS volunteers and combine them with phenotypic hospital data to form a global reference library for understanding the genetic predispositions for both disease and drug reactions. It is that combination of the living medical record of patients at scale with their genomic information at scale that allows us to understand those genetic mutations, which are often not associated with a particular condition so are not studied. When we have the whole genome at scale we can see, for example, the reason why 20% of patients respond to a certain drug in a certain way is that all of them have a genetic variation, which we had not realised, in a sequence that nobody had realised was associated with that disease.

Although we are only partially through sequencing the first genomes, we are already identifying extraordinary insights into rare diseases. I saw recently, when meeting the informatics team at Genomics England, a man who had presented with a rare blindness disease. It presents in teenage years with early onset blindness and can lead to mortality at around the age of 40. He has two young boys. He volunteered for the programme and the scientists quickly identified five possible variations that may have accounted for the condition, of which they were able to knock out four that had nothing to do with the eye. One was a pathway related to the eye and on that information alone they were able to recognise that that pathway is one that is implicated in the disease, for which there is already a treatment that is available at pence as a generic. With the patient’s consent they decided to try it and the drug arrested the condition.

That is an extraordinary breakthrough that was based on genomics simply allowing us to understand, initially quite randomly, how to prevent that condition, though we have not got a cure for it. We have identified in the haystack of the pharmacopeia of drugs one that has already worked. The genome programme is already identifying early treatments that are giving patients with rare diseases real hope. I am delighted to say that while the programme is a bit behind on the recruitment and sequencing of cancer genomes, for a whole series of operational reasons, it is steaming ahead on rare diseases. The UK is driving world leadership in that space. I was recently in Washington and met the White House precision medicine team, which is looking to us for a steer on how to use genomics to drive rare disease treatment and diagnosis.

[Dame Margaret Hodge]

To be specific about SJS, are there volunteers who have the condition, or relatives of volunteers who have it, in that sample? I do not know what is appropriate; I am not a great scientist, but that would seem to me to be a very useful way of progressing on this particular rare disease, though I recognise it is one of many. Does the Minister know?

[George Freeman]

The right hon. Lady read my mind. I do not have that information at my fingertips but I have already asked that question and I will happily ask Genomics England to ensure that she and I have that answer. I will touch on the point she made about awareness because I think there is an opportunity for us to use the genomic programme to trigger greater awareness among those who suffer from rare diseases, and possibly to drive up recruitment rates for the programme.

Let me touch on the NHS rare diseases advisory group, which recently noted that SJS is a devastating disease with a very high mortality rate, and endorsed the proposal for a highly specialised service for SJS and toxic epidermal necrolysis. The intention is for a nationally commissioned service to standardise treatment around the country in a small number of expert centres. Those proposals include a network of centres for both treatment and research and for using the diagnostic material to support that research. The establishment of a national service should make it possible to implement the national guidelines for patient care that were published by the British Association of Dermatologists just last month.

The Government absolutely recognise the long-term impact of SJS on survivors and their families. That is why we are putting not just research but patient support and a patient voice at the heart of the UK strategy for rare diseases. It is crucial that people who suffer from conditions like these are able to both feel that their suffering is not in vein and that they are being listened to and supporting research, and also that they are helping to drive new care pathways.

I will address the specific questions the right hon. Lady asked. She talked about lack of awareness and training. She is absolutely right that that is a major issue for our health system because the more we discover those rare diseases, the more we have a real challenge to keep our medical students up to date. In the old days we trained medics for the conditions that we understood but, because of the pace of discovery now, we have discovered new diseases that were not known when their textbooks were published before they have even finished a year at medical school. That is a challenge for the whole system and I will raise that important point with the relevant agencies who are in charge of training to ensure that they are address it.

[Dame Margaret Hodge]

I take that point but I draw to the Minister’s attention the fact that this disease was identified in 1922; it is not entirely new. Early identification means the drug that is causing the problem is withdrawn and the more appropriate treatment can be started. I hope the Minister can go a little bit further.

[George Freeman]

Many of these conditions have been known about for years, but it is only now that we are really beginning, through genomics and infomatics, to get a handle on how we might track, spot earlier and use big data to analyse cause and effect and develop new medicines that could intervene. Some of these conditions that have been thought of as never treatable are now becoming treatable because of the pace of biomedical progress. We need to inform our trainee clinicians not to think, “Well, I’m sorry. You’ve got a diagnosis; there is nothing we can do about it. People have suffered for 80 years.” There is a genomics programme, an accelerated access review for new medicines and an early access to medicines scheme, and we are beginning to accelerate getting new cures through into treatment. I will raise the issue of greater awareness of rare disease and what is available for them with the agencies responsible for training medical students.

The right hon. Lady raised the idea of an awareness week, which I think is an excellent idea. The truth is there are many rare diseases and I foresee a clamour for every rare disease to have a week, for which there would not be enough weeks in the year. It may be that one has a rare dermatological conditions awareness week, which would heighten awareness. There may be different ways to do that but her idea is first class. She also talked about money for research; she would not be doing her job if she did not. The Government spend a considerable amount of money on research. The NIHR has a policy of not identifying particular diseases and earmarking money to them but, following the debate, I will raise with the NIHR how much is being spent that would be relevant for sufferers of SJS. I know it is taking steps to amend its research criteria in the years ahead so that it is responding to the progress made in the genomics programme and others.

The right hon. Lady made an excellent point about gene testing. The reason I am so inspired by that quiet revolution is that we are now at a point at which we can start to gene test patients, profile them and get targeted medicines to them. That is already happening with cancer and some other diseases. For the new drugs we have launched in the NHS this year for Hep C, it turns out we can profile which patients will respond in six weeks, in eight weeks or in 12 weeks. That is driving a new model of reimbursement that sits at the heart of my accelerated access review.

Lastly, the right hon. Lady raised the important issue of side effects and the wider science of drug side effects, which the Government are investing in through a whole series of programmes in the Department of Health and NHS England. Understanding side effects can be a cue to the science of new cures. I hope she is reassured that we are taking that seriously and I will follow up—or will ensure my successor follows up, if I am no longer in post after today—the points she has sensibly raised.

Barking, Havering and Redbridge University Hospitals NHS Trust

Margaret Hodge Excerpts

Wednesday 15th July 2015 Westminster Hall

[Margaret Hodge (Barking) (Lab)]

I congratulate my hon. Friend the Member for Ilford South (Mike Gapes) and join him in commending and thanking the many staff who work under huge pressure in both King George hospital and Queen’s for the very good work they do, which I hear a lot about from my constituents.

I have been involved with BHRUT and its predecessors for over 20 years. I have seen six chief executives and 12 different chairs, men and women. Every new generation blames their predecessors for the problems that they inherit. I am perhaps a little more sceptical than my hon. Friend: I do not think that we have suddenly, magically got a new team that will solve many of the intransigent problems facing that trust. It has been co-operative and is trying hard, but we are now over a year into the new regime, and on many of the indicators I cannot see demonstrable improvements. The trust has been bankrupt for years; the deficit has not gone down for years and I cannot think that it will go down much in the coming period, given the pressures and the failures to deal with some of the intransigent problems.

Quality has been pretty poor for years. We finally got the CQC report that put the trust into special measures, but the most recent report shows that the necessary improvements that I wanted for my constituents and that would take the trust out of special measures have not been made. Although I share my hon. Friend’s hope, I am not confident that we will get there by the time the CQC comes back yet again.

Compared with all other trust areas throughout the country, ours is the eighth most deprived area in terms of health need. The NHS ought to be delivering equal access to high-quality care to people wherever they live, but it is not. I sincerely feel that that is the biggest battle for my constituents. Where I live, I get much better access to much better quality healthcare than my constituents in Barking and Dagenham who use both Queen’s hospital and King George hospital.

I should like some assurances from the Minister about the north-east London sector. Not only are we bankrupt in our neck of the woods, but Barts City—predictably, I have to say—is also in incredible deficit. One knows how these allocations of moneys go and how views are taken about the health service across the country. There is a real danger that salvaging the new Barts hospital, with its £1 billion PFI and the massive call of that on revenue funding there, will come at the expense of BHRUT and the hospital provision that we need locally. I seek assurances from the Minister that, in considering an undoubtedly difficult financial situation across the whole north-east London sector, he does not disadvantage our residents by putting everything into the much more powerful Barts and the Royal London Hospital NHS Trust.

I want to raise three other issues. First, I have been shocked in recent times by how much is spent on agency staff by BHRUT. For example, in 2013-14, it spent £27 million, and in June this year it spent £2.5 million. When Matthew Hopkins gave evidence at the Public Accounts Committee, when we were looking at the state of a number of vulnerable trusts, he talked about a 50% shortage of consultants in the A&E department and told us that he was spending £1,760 on one 16-hour shift of A&E consultants. After that session, I asked a consultant in A&E during one of my usual visits round the hospital whether he was an agency consultant or a full-time employee. He had been a full-time employee, but deliberately switched to being agency staff because as an agency member of staff he earned more and did less. His doing so put the trust in greater difficulties.

That sort of behaviour is simply an unacceptable waste of what we all understand is a very small amount of money that is not enough for local healthcare. According to the CQC’s most recent inspection, a third of the nurses on night duty on the first night of its inspection were agency nurses. I should like the Minister to talk a little bit about how he is going to tackle the use of agency staff, who provide poorer quality care, because they do not know the systems or the people and do not know their way around the hospital, and cost the hospital a lot of money.

Secondly, although I recognise that there have been improvements, particularly in maternity, where we were first alerted to quality really going wrong in Queen’s, on reading the report I was worried about radiology. There is still a huge bill—millions of pounds—to be paid to people now litigating against the hospital because of what happened to the mothers and children through poor maternity care there, but the original CQC report in 2010 highlighted that the radiology department was poor. There were delays in people having scans done and scans were not passed to the relevant consultant, so people with cancer were simply not being diagnosed in a proper, timely manner that would have allowed them to access the treatment they needed. The recent inspection still finds problems there: it is too short-staffed, with too many locums.

One of the incredible things I read was that on one day of the inspections, five radiologists were on leave. What sort of culture does a hospital have if it allows five radiologists to go on leave on the same day and so provides a poor service to patients? There is a large backlog of patients who have waited well over 18 weeks. During the inspection, the CT scanner kept breaking down and patients had to be transferred from Queen’s hospital to King George hospital. That is unacceptable. It is about more than money; it is about a culture in the management that was originally identified in 2010 and now, in 2015, the A&E is still appalling.

I will raise a couple of other issues that I think are relevant and which my hon. Friend alluded to. The first is GP services. If we cannot sort out primary care, demand on acute and hospital services will continue to exceed their ability to respond. Barking and Dagenham has the highest number of GPs aged over 60 in the country: a third of our GPs are over 60. We have been completely open—we will try any experiment on the ground. We have had salaried GPs, private practice GPs and GPs linked to universities in an attempt to provide some training. We will do anything to attract and get more and a better cadre of GPs in our patch, but we have failed. We are still the eighth in London in terms of concentration of single-person practices. I raise this issue all the time with the powers that be in the health service locally. One in five of our GP practices remains single-handed. We know that that does not provide an adequate service to local people, yet there is not any sort of energy or urgency in the actions of the local health service officials to sort that out. They ought to be able to do so and to apply much greater pressures on some of the GP services, so that we get better primary care.

People cannot get appointments. We have done a survey of our residents—it is not a proper survey; I do it when people attend my very regular coffee afternoons. However, those surveys show that 50% of our residents had to wait more than a week to get access to their GP. Some 30% went to A&E because they could not get access to the GP. Nearly half said that they had found it difficult to get an appointment. The typical story is, “I ring up at half-past 6 to see the GP the next morning. I am told to ring the next morning. When I ring the next morning, it is engaged and engaged, and in the end I give up and go to the A&E.” Unless there is a forceful, determined attempt to sort out the failures of our primary care system, we will not make progress in the acute sector.

One of the little things we did was run a campaign on the use of premium phone numbers. From constituents who came to see me, we uncovered in 2013 that 10 GP practices in the constituency had 084 numbers. One constituent had spent £10 trying to get an appointment, because ringing such numbers from a mobile costs 41p or 42p a minute. Another constituent spent £30 trying to get an appointment for her son because she had to hang on until she was dealt with. She got through to the system, but the call was not answered by anyone to secure an appointment. We have run a tough campaign on that, but two and a half to three years on, we still have one GP practice—Castleberry medical centre—that is refusing to put in a landline, and three others that have a landline but have kept their premium phone line, and my bet is that patients cannot get through on the landline and have to use the premium phone line. Access to GPs is important. I thought we had halted the use of premium phone numbers after another PAC inquiry, but it has not happened.

My final plea is on access to the hospital for the poorest people in my constituency. They live in the most south-western part of my constituency, in Thames ward. Getting to Queen’s hospital from there takes three buses. I did the journey during the election period, and it took me about two hours. If someone has to go for regular chemotherapy or kidney treatment—whatever it is—that four-hour journey every day means that the person does not go and so does not get that treatment and therefore dies younger. I have been pleading with the Mayor and the transport authorities to ease that just by diverting the No. 5 bus so that it goes straight to the hospital. That would save people one change—they would get two buses, not three—but I have completely failed so far. I have been fobbed off. I urge the Minister to join me and write to the relevant authorities to ensure that while at least keeping those hospitals there, trying to get them properly funded, sorting out the financial mess and improving the quality, we also allow people to get there easily, particularly those who need the hospital services the most and are most dependent on public transport.

--- Later in debate ---

[Ben Gummer]

I understand the hon. Gentleman’s points. I accept that uncertainty is created at the King George site and that the effect of that is potentially destabilising, especially when the hospital and the trust have had to endure the whole process of special measures. His solution, however, is a false one in two senses.

First, the decision was clinically led in the first place, so to go against it would be to go against a clinical decision after several reviews. The hon. Gentleman is therefore suggesting that we make a political intervention against a decision made by doctors about the best distribution of trauma centres and urgent and emergency care centres according to population. Decisions have been made on a similar basis throughout the country. I do not believe that he really feels that that would be an acceptable route to take. Secondly, even were we to do that, it would not remove uncertainty, because there would still need to be some sort of reconfiguration in future in order to get the best outcomes for patients. So the uncertainty would remain.

The hon. Gentleman’s point is valid to an extent. If the situation were to occur again—clearly none of us would have wished things to proceed as they have done —we need to make it clear that reconfigurations can happen only when we have the correct sustainability in receiver organisations. That should be something we think about as we go ahead. However, we are where we are now with his trust, and to proceed on the basis that he suggests would not give either the patient outcomes or the certainty that he desires, whether for staff or his constituents.

[Margaret Hodge]

The Minister referred to a decision that was initiated in about 2009. That is correct, but circumstances change. Our area is the most rapidly expanding in London. I do not know the figures for Redbridge, but those for Barking and Dagenham show, potentially, another 30,000 to 35,000 houses being built over the next 10 to 15 years. That is massive expansion. I put it to the Minister that not only is the number of houses increasing, but the nature of the households is changing. What used to be a house lived in by a couple with perhaps two kids now tends to be lived in by intergenerational families with many more people. What regard has he paid to those changes? Should he not pay regard to them and review his decision in the light of them?

[Ben Gummer]

It is not ultimately my decision. It is the decision of the Secretary of State, but only on the advice of the Independent Reconfiguration Panel. The IRP takes a view over a long horizon, so it takes population growth into account in the original decisions—

[Margaret Hodge]

It did not.

[Ben Gummer]

I will come back to the right hon. Lady with a final comment, but that is what I understand. In the end, such decisions are left to local commissioners, who are the experts in buying the right kind of health provision for their patient groups. If their decision changes, that should be reflected in the IRP’s final decision, but the commissioners remain certain that that is the correct way to go for east and north-east London, and while that remains the case, we as politicians should support that clinical decision.

I will respond to some of the other points made by hon. Members. The finances of the hospital were brought up several times. It is true that it has had a sustained poor financial performance, but it is unlike other hospitals which have become indebted or are lifting up. The hospital’s position is a sustained one involving a large number—£38 million, which includes a very large figure for agency workers. That figure is now declining as the new management gets a grip on recruitment, and I heard some good stories about the improvement in recruitment when I went there only a couple of weeks ago. There is also £60 million annual provision for PFI payments, which is a problem in many trusts around the country, but there is no point rehearsing those issues, which the right hon. Member for Barking looked at many times in her previous role.

The chief executive is clear about the deficit. He shares my view and that of the Secretary of State that financial performance and quality go hand in hand. No hospital in this country offers outstanding care but has poor financial performance. We cannot get efficient care anywhere if the books are not being looked after at the same time, because the two work together. The chief executive understands that getting the trust into a decent financial position is central to providing the kind of consistently high-quality care that he wants to see across the trust, and not only in the specific areas rightly highlighted by the hon. Members for Dagenham and Rainham (Jon Cruddas) and for Ilford North.

The hon. Member for Ilford South was right to talk about capacity. There was a serious lack of capacity because of the failure to discharge patients and to get people through the system, which caused problems at the front end, in A&E. Remarkable change has been achieved in the past six months through the new measures put in place by the new management, but it is true that there is a great deal more to do. I heard a different story from the one the hon. Gentleman recounted: actually, they thought that the last CQC judgment was completely realistic; the action points highlighted were in large part already being addressed and needed to be done. The new management recognised that special measures was a regime that had to be exited once a sustainable improvement over time had been shown. That was gratifying to hear, because when it is heard from the shop floor, the management and the CQC, that shows that the whole team understands the problems and how they need to be addressed.

Several Members mentioned the problems in primary care, and I am aware of the acute issues in east and north-east London. They are the reason why my right hon. Friend the Secretary of State launched the new deal for GPs a couple of weeks ago. NHS England is now mapping hotspots of GP shortage across the country. It will use that information to target resources to make sure we are putting the new GPs being recruited into the right places and using every possible incentive to make sure that under-doctored areas are brought up to parity. Members will know that this is a historical problem and it will take a great deal of heavy lifting from all of us to change it. It is not simply about sheer numbers of GPs; we must have new models of delivering care and new diversity, so that we can deliver primary care appropriately rather than in a way that is based on a model that does not fit.

The right hon. Member for Barking raised understandable concerns that the existing system for the Barts trust was set up to finance one PFI deal. She is not alone in those concerns. I am taking a deep interest in the progress of the special measures regime at Barts. The financial performance and accounting procedures at that hospital and trust when it went into special measures were frankly shocking. They have now been changed, and we will be reviewing the situation on a weekly basis. I hope that if she discusses the matter with the CQC and the trust, she will understand better that it is not that the trust is subsidising one PFI but that there are systemic financial problems across the trust. I take her point completely, however. As we address the financial problems in east London we must reassure everyone that mergers have not happened simply to prop up one organisation at the expense of another.

Finally, I welcome the constructive approach and fair questions of the hon. Member for Denton and Reddish (Andrew Gwynne). I hope I have answered the majority of his questions, but I question the idea that Government policy has made the situation worse. The reason we are debating here is that the CQC gave an inadequate rating to the Barking hospital trust and put it into special measures. The ratings and the special measures regime were a creation of the previous Government. They have provided transparency and clarity that we did not have before and allowed us to have an honest discussion about what is wrong and what is right. I can now stand up and say where the problems are and accept responsibility for what needs to change. None of that was possible when we could not say that anything was wrong and had to pretend there were no problems, because there was a culture of denial rather than one of transparency and openness.

We are not at the acme. We have a great deal of distance still to make up, but we are in a much better place than we were back in 2013, when the trust was put in special measures, or in 2010, when the review was completed. We now have clarity about what we need to do and the process for doing it. I believe that we will soon have a much better health economy in north-east London than the one that Members have had to endure so far.

Accident and Emergency Departments

Margaret Hodge Excerpts

Thursday 7th February 2013 Commons Chamber

[Mr Virendra Sharma (Ealing, Southall) (Lab)]

I beg to move,

That this House has considered the matter of the closure of accident and emergency departments.

On behalf of all my Back-Bench colleagues who wanted time to be allocated for this important debate, may I put on record my thanks to you, Mr Deputy Speaker, and to the Backbench Business Committee for today’s scheduled parliamentary time? The closure of accident and emergency departments is a national issue and one that has profound impacts on the current and future provision of health care across the country. Concerns about the A and E closures and accompanying hospital reconfigurations have been voiced by members of all political parties including Back Benchers and Front Benchers on both sides of the House, so it is crucial that we have this debate.

Weighty decisions are being made about A and E closures across the country by NHS bureaucrats, under the guise of localism and clinically led decision making, without the democratic accountability that is vital for decisions of such importance. In order to bring these decisions to the Secretary of State for Health, local council scrutiny panels have to refer such decisions to the independent reconfiguration panel, which then reports its findings to the Secretary of State. Why are primary care trusts in their dying days making such critical decisions and not clinical commissioning groups? It is vital to have democratic accountability for these decisions and, although it is not sufficient, this debate will shine some much-needed light on these huge decisions that will have profound impacts on all our constituents. I am pleased that the Government have belatedly announced a national review of A and E services, but I am horrified that the review is planning to report by March this year. This is being done in an obscene rush, and it cannot be the considered review that we need.

There are proposed and actual A and E closures in my constituency and in those of other hon. Members. It is clear that this is an NHS-wide change that will affect every constituency in the land. The NHS needs to change and be fit for purpose in the 21st century, and I am not saying that there must be no change. Clearly, we have to provide health care in changed ways, but I am concerned about the pace of change, the impacts on the poorest and the financial drivers of the changes. The financial drivers are clear. The Nicholson challenge means that the NHS is seeking to cut spending by £20 billion by 2014-15.

[Margaret Hodge (Barking) (Lab)]

Does my hon. Friend agree that the care of patients must be at the heart of any changes in the NHS, and not finance? In my part of London, there is a proposal to close the A and E at King George hospital, but it would be madness to do so at a time when Queen’s hospital in Romford has far too many A and E patients and when a Care Quality Commission report has just condemned the quality of care for people who visit that A and E unit.

[Mr Sharma]

I thank my right hon. Friend for putting that case so strongly. I do not think anyone—inside or outside the House—would fail to agree with that suggestion.

In North West London NHS, the proposal translates into a £1 billion cut to budgets over the same time scale. The medical director of North West London NHS said that it would

“literally run out of money”

unless the closures proceeded. The scale of change driven by this financial pressure is unacceptable. It is targeting the poorest and most vulnerable, and it is unfair on the hospitals that have been financially solvent. That last point was graphically illustrated last week at Lewisham hospital, whose A and E was unjustly proposed for closure because of a neighbouring trust’s financial insolvency. That brought tens of thousands of incensed protesters on to the streets.

Sadly, this is happening in Ealing, too, whose hospital is faced with losing its A and E department, yet it is financially viable and has been for many years. It is being sacrificed on account of financial problems in other neighbouring hospital trusts. This threat of closure in Ealing exists even after the Prime Minister assured me, in a response to my question, that there was no such threat.

--- Later in debate ---

[David Morris]

I shall come to that in my speech.

A concerted Labour campaign has been mounted by local party members who actually work in the NHS to make people believe that the A and E department is likely to close. The campaign involves press briefings, an online petition, a Facebook group, and even people walking around the centre of Morecambe with clipboards inviting people to join it. I want the e-petition to be removed from Directgov, and I have written to the Cabinet Secretary asking him to intervene. We cannot allow a dishonest campaign to be fought on Directgov e-petition platforms. If the A and E department is not under threat, it must be concluded that people are being frightened for the purpose of political advantage, which, in my view, is morally wrong.

Perhaps it is time to admit the truth: the trust is getting better under the present Government. A new and better management was introduced by the former Secretary of State. Only a few weeks ago, the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) opened a new minor injuries unit in my constituency. A new health centre in Heysham, costing £20 million, was opened last year, and four new wards have just opened at Lancaster hospital. I pay tribute to my hon. Friend—for he is my hon. Friend outside the Chamber—the Member for Barrow and Furness (John Woodcock) for ensuring that maternity services in Barrow remained secure.

All that was paid for by a 2.8% increase in funding for the NHS under the present Government. This debate is part of a national campaign to scare people into believing that the NHS will be deconstructed.

[Margaret Hodge]

Will the hon. Gentleman give way?

[David Morris]

I will later.

This, I believe, started with a disingenuous story in Corby, which was used to great effect. It has now become the scare story in Lewisham and now, surprise, surprise, the scare story in Lancaster and Morecambe. Those A and Es are not under threat. They are not closing down. The public will see through this Labour campaign to start a fire and then claim to put it out, saving us all.

[John Woodcock (Barrow and Furness) (Lab/Co-op)]

It is a pleasure to follow the hon. Member for Morecambe and Lunesdale (David Morris), who made what I must say was a quite extraordinary speech. I realise that I may be in danger of being a little ungracious, given that he was kind enough to thank me. I shall say a little about the University Hospitals of Morecambe Bay NHS Trust, which our constituencies share. However, I must first say to him—on behalf, I think, of several Members who are present—that to suggest that the impending closure of Lewisham A and E department is a scare story from the local Labour party does an incredible disservice to the many thousands of families who are deeply alarmed and worried about what is happening in the area.

[Margaret Hodge]

I congratulate my hon. Friend on managing to save his A and E department, but does he not agree that money should go to where patients are? In my area, north-east London, 132,000 patients currently attend the Queen’s hospital A and E department, and 100,000 attend King George’s hospital A and E. Closing an A and E department that serves more than 100,000 patients is unfair to patients and madness in terms of funding distribution.

[John Woodcock]

My right hon. Friend is right to speak of the crazy situation in which heavily used accident and emergency provision across the country is under threat. I intend to say a little more about the particular challenges faced by geographically isolated regions such as mine, but first let me say how grateful I am to the Backbench Business Committee for securing the debate, and congratulate my hon. Friend the Member for Ealing, Southall (Mr Sharma) on a very powerful opening speech.

I want to speak briefly about the accident and emergency department at Furness General hospital in my constituency, and, in doing so, stress the importance of ensuring that A and E provision remains accessible to the high-tech, highly skilled industries in which this nation must continue to lead the world. Barrow’s A and E department is not yet under immediate threat of closure, but there is grave concern about the impending review of services throughout the Morecambe Bay area, which has been driven at least partly by the trust’s need to make significant cuts in its operating budget in the years ahead.

A trust covering 300,000 people would often be served by just one A and E department, but in the Morecambe Bay area there are two. That is due to the particularly challenging geography of the area, and, in particular, the time that it takes to travel the 50 miles from my constituency to Lancaster with only a single road connecting Barrow to the M6.

The hon. Member for Morecambe and Lunesdale directed all his fire at the local Labour party, and in doing so highlighted—probably quite helpfully for the party—the excellent work that it is doing with its campaign on the streets. I was probably more disappointed than surprised that he made no mention of his hon. Friend the Member for Westmorland and Lonsdale (Tim Farron), who is campaigning hard to take A and E provision away from Lancaster and transfer it to Westmorland General hospital.

Let me make it crystal clear why no one should get the idea that Barrow’s A and E department could move. Not only would every single resident in the geographically isolated Furness peninsula suffer unacceptably long journey times if it were closed; its removal would be a significant blow to industry in the area, and would ultimately threaten our potential to become a national cradle for advanced manufacturing. The manufacturing companies on which our local economy depends—including shipbuilding, nuclear engineering and pharmaceutical companies—have enviable safety records, but they nevertheless carry a small but inherent risk of industrial injury. As responsible business men, local employers seek to mitigate and manage that risk, but part of their management includes access to a full accident and emergency service in the locality.

BAE employs 5,500 people in Barrow, representing the largest of the many sites in the nation’s critically important nuclear submarine supply chain. This is what the company’s submarine arm told me for today’s debate:

“BAE Systems Maritime Submarines is possibly one of the highest risk manufacturing sites in the UK with a broad spectrum of safety hazards. Although these hazards are effectively managed and the site has a strong safety record, the absence of locally provided A and E services would have serious implications for the business. The treatment administered within the first hour following incidents is critical. A number of minor incidents, particularly associated with foreign object ingress to eyes, are referred to Furness General Hospital per week. Therefore additional ambulances would be required to transfer injured personnel, significantly increasing the ambulance demand within the area. Decontamination of people would currently be provided by FGH Accident and Emergency following a major incident at the Barrow site. This may include the cleansing of chemicals or radioactive substances.”

If, God forbid, something like that were to happen, time would be of the essence. Here in Furness, as in several areas of the country, A and E closure could put at risk the lives of employees who perform a service to their country and would ultimately endanger key parts of the nation’s prized industrial base. It is vital that Ministers wake up to the full spectrum of risks posed by the approach they seem intent on imposing on our national health service.

King George Hospital

Margaret Hodge Excerpts

Tuesday 8th November 2011 Westminster Hall

[Mike Gapes (Ilford South) (Lab/Co-op)]

I want to raise the issue of the Care Quality Commission report on the Barking, Havering and Redbridge University Hospitals NHS Trust in north-east London, the related independent reconfiguration panel report and the recent decision by the Secretary of State for Health to endorse the recommendations in the panel’s report and, as a result, significantly to downgrade services at King George hospital in Ilford. It is not the first time that the problems in north-east London health services and hospital provision have been debated in Westminster Hall or the House. Indeed, I introduced debates in 2006, 2009 and 2010, and my right hon. Friend the Member for Barking (Margaret Hodge) introduced a debate in June about maternity services.

Members of Parliament throughout north-east London have been very concerned, and there has been cross-party consensus, in very unusual circumstances, involving eight Members of Parliament: myself, my right hon. Friend the Member for Barking, my hon. Friends the Members for Leyton and Wanstead (John Cryer) and for Dagenham and Rainham (Jon Cruddas), the hon. Members for Ilford North (Mr Scott), for Hornchurch and Upminster (Angela Watkinson), and for Romford (Andrew Rosindell), and the Secretary of State for Work and Pensions. We have had massive support in the community. Decisions have been made by local authority health overview and scrutiny committees and there is wide public concern, with huge petitions and public meetings, about proposals that were initiated in 2006 to downgrade services at King George hospital, the smaller of the two hospitals in the trust.

That trust, in the words of the first paragraph of the Care Quality Commission’s summary,

“had a history of poor performance under the previous regulatory framework. It has long-standing and escalating debts (in 2005/06 this was just under £16m; by 2009/10 it was close to £117m). There have been numerous changes at executive level.”

Queen’s hospital, Romford is the newer of the two hospitals, having opened towards the end of 2006. It cost a huge amount of money and is run under a private finance initiative arrangement, which has led to certain difficulties. There was high-profile publicity, particularly about deaths in maternity services, and the CQC began a series of investigations, as a result of which it decided to carry out a full investigation of the trust as a whole, encompassing both hospitals and all services. That investigation went on throughout this summer, and its report was published at 10 am on 27 October.

At the same time, there have been proposals from the NHS London region bureaucracy, driven by the people within it, who have a vision of reducing the number of hospitals in north-east London from six to five, transferring services to large hospitals and reducing facilities in the Redbridge and Barking and Dagenham areas. We have ended up with a series of proposals that, when they were initially put forward, were deemed by Professor George Alberti to be clinically unsound. Later, they were revamped, tweaked and remodelled, and they became known as the health for north-east London proposals.

Those proposals envisaged principally getting rid of the accident and emergency department at King George hospital, Ilford. There has been an accident and emergency department in the district general hospital there since 1931, when the population was 85,000. Now it is 264,000 in the London borough of Redbridge, and the hospital also serves Barking and Dagenham, with a population approaching 200,000. The proposals also included getting rid of King George hospital’s maternity services, which serve young mothers in an area with a growing, diverse, predominantly ethnic minority population. Many of those young mothers have come recently to the United Kingdom, or at least have recently moved to Ilford. At the same time, it is proposed to increase the number of births taking place at Queen’s hospital in Romford—the one about which there were particular concerns—to make it what some people have called a baby factory. Those words were used in the reports by the CQC and the independent reconfiguration panel.

In March 2010, following concern and a campaign against the proposals, the then Secretary of State for Health referred the matter to the independent reconfiguration panel. The IRP then decided not to carry out an investigation, but to allow the consultation process to continue. That process led to final proposals, which were published towards the end of 2010, and then went through the so-called consultation and decision-making process, based on the primary care trusts. The joint committee of primary care trusts rubber-stamped the proposals despite overwhelming public opposition: aside from the tens of thousands of people who signed petitions against the proposals, within the committee’s own limited, and rigged, consultation procedure the public were opposed by a two-to-one majority—and an eight or nine-to-one majority in areas that were directly affected—to what was put forward.

We were told, however, that there was clinical support. There was no ballot of GPs, or system to ascertain what ordinary GPs thought.

[Margaret Hodge (Barking) (Lab)]

My hon. Friend says that there was no ballot of GPs, but does he accept that I undertook a survey of GPs in Barking and Dagenham, and there was unanimous support for retaining the two A and E departments, at both King George hospital and Queen’s?

[Mike Gapes]

Yes, I should have said that there was no official ballot of GPs, because, of course, the view of the NHS bureaucracy was that the clinical leadership and the practices should make the decision; therefore, there was a strange kind of managed democracy and consultation.

--- Later in debate ---

[Margaret Hodge]

Perhaps the Minister will be able to help us in his reply, but my understanding is that the business plan put forward by NHS Outer North East London at the end of the summer suggested that, for the finances to stack up, the proposals will have to be implemented by April 2012. If that has been superseded, that is welcome news, but the local information is that the NHS ONEL business plan suggests the closure of the A and E and maternity services by April 2012.

[Mike Gapes]

There is obviously some uncertainty, because I was not told that when I spoke to NHS ONEL. Perhaps it is having a rethink in light of the report.

--- Later in debate ---

[Margaret Hodge (Barking) (Lab)]

I congratulate my hon. Friend the Member for Ilford South (Mike Gapes) on securing this debate and on giving us the opportunity to comment on something that impacts on all constituents of all hon. Members participating today.

I am really disappointed, because I feel that the Minister and his Secretary of State have reneged on promises that he gave to my constituents before the election. First, he said that he would never close the A and E, and we all know that the closure of such a department means the closure of a hospital over time, because most patients who go through a hospital come in that way. Secondly, he said that there would be more money in real terms for the NHS. Sadly, that is not true either, and it is impacting dreadfully—[Interruption.] The Minister can reply if he wishes. A 0.1% increase in cash terms is not real-terms growth, especially when inflation is running at about 5%. Thirdly, he promised no more top-down reorganisation. In north-east London, we are suffering from his reneging on those three promises. He must listen to that, because it has a terrible impact on the quality of the health service offered to my constituents. I have said to him privately, and will say to him publicly, that that will grow health inequalities in London.

I do not want to repeat what others have said about the Care Quality Commission. What I will say is that a lot of emphasis has been placed on confidence in the new management at Queen’s. I am on my fifth chief executive there, and every time a new one arrives, I think, “Perhaps this one will be a little better.” The new chief executive has been in place for six months, and so far I am not sure about that confidence. If one looks at the maternity services, why in September did we suddenly see elective caesareans being transferred from Queen’s to the London hospital? None of us knew why; none of us could understand it; none of us was told the reason, but it was because the CQC went back into the maternity unit because it was so bad and threatened to close the entire unit. The only way for the hospital to maintain the unit was for it to accept that caesareans should be transferred. The teams were not talking to each other; people were not taking responsibility, and no one was putting the patient at the heart of care, but the required cultural change has not occurred. Yes, new midwives are being recruited, but not at the right grade and not to manage the unit. The Minister is putting too much on Averil Dongworth, because she will not be able to turn around those cultural issues. The record so far shows that she does not share information freely, particularly with Members of Parliament, and that she has not done much.

The most recent case that I have had at the unit is an anonymous one—the woman does not want to reveal her name, although the case will be investigated. This mother was left for hours without being checked on, and it was her mother—the grandmother—who had to look after her. She was almost lifeless and delirious, and she was discharged without anyone checking her scar from the cuts she was given or changing her dressing. She was asked to give water samples, but they were left in the bathroom and were still there when she left, which is just not on. Queen’s provides facilities for 7,000 births, and if the proposals go ahead that will increase to 9,000, making it the biggest single maternity unit in the country. Given the quality of care, the problems faced and the population growth, it is sheer madness to go ahead with a proposition that closes a hospital in this area of London.

Perhaps the Minister will give us some words of comfort about the finances. The trust’s finances have been in a mess for ever, since well before the Labour Government came into office. I assure the Minister that when I became a Member of Parliament in 1994 there was already a deficit in the trust. David Varney, a well-respected and talented man with a lot of experience, was chairman of the trust although for a very short time, and I breathed an enormous sigh of relief that at last we had someone there who could sort the trust out. He went to NHS London and said, “Write off the debt, give me a blank sheet of paper and I’ll provide you with a decent health service within budget.” NHS London refused, so David Varney walked away. That was a tragedy for the people of that part of London, and such tragedies will continue to be repeated. The problems will not be sorted out until somebody grasps them properly and says, “Right, we will do something about the finances,” enabling the trust to run a decent service within budget rather than always chasing a deficit.

One thing about the CQC report that has not been raised is that it is about not only maternity but accident and emergency. One of the most shocking things, for me, involves radiology. The results of scans are just sitting around. Some scans show a possibility of cancer, but individuals are seen so late that the cancer has grown. People’s lives are being threatened and death warrants are being written simply because the hospital has no systems to transfer knowledge from a scan to a consultant who can quickly pick up on the symptoms and deal with the patient.

That is awful, as is the fact that people sit in theatre all the time. The fact that A and E is bound to be bad again this winter is awful. The fact that proper records are not kept of who has had cannulas inserted for treatment is awful. The culture throughout the hospital is awful, and it seems to me that it will take a heck of a lot more than Averil Dongworth, whose only record is the closure of Chase Farm hospital, to turn that around.

I am conscious of time. I campaigned for years to reopen a birthing unit at Barking hospital, for all sorts of reasons, including pressure on Queen’s, population growth and the fact that I wanted babies to be born in Barking again. I was grateful when it was finally built. Those hospital beds have been ready for occupation since March this year, but they are still not occupied. When I last asked NHS London what was happening, I was told that the unit would be open by March next year. That is a 12-month wait. If the hospital is kept empty, £1 million in costs for security, electricity, heating and so on will go down the drain each year. Now the deadline has changed from next March to next spring.

That is absolute madness. There is pressure on Queen’s. Queen’s is failing to deliver, so people are being sent to London, while a brand-new facility that could provide for many more births than my hon. Friend the Member for Ilford South has suggested stands empty. Will the Minister give us an assurance that the unit will be open not next spring but by Christmas, so that people in my constituency can have hope?

The decision whether to close the A and E at King George hospital was predicated on the idea that fewer people should go to A and E; I agree. If and when the Minister can demonstrate to me and other Members of Parliament that fewer people are actually going to A and E, maybe we can have a serious conversation about whether that part of north-east London has too many hospital places. The reality is that we have a mobile and transient population, many of whom have not registered with a GP and who, if they want to access health care, go first to A and E.

Another reality is that GP and community services also have issues. Before taking a decision, is the Minister willing to do a comprehensive inspection of GP services in my area to ensure that they can fulfil the demands on them, as the decision to close assumes they can? If GP services prove to be up to scratch, again, I am willing to enter into conversation with him about whether there are too many hospital places. However, at present, he is letting down the people in my borough.

Time and again people say to me, “I rang the GP at 6.30 in the evening. He said to ring back the following morning. I rang at 8 o’clock in the morning, and I couldn’t get through. By that time, I felt that the only way to be seen was to go to A and E.” [Interruption.] The Minister looks at me in amazement. That is the reality on the ground.

[Mr Simon Burns]

I am fascinated to hear the right hon. Lady say that. Does she know who the authors were of the GP contract that ended evening and weekend work for GPs? It certainly was not my Government.

[Margaret Hodge]

Making a political point does not get at what is happening in practice. It is not about the contract; it is about the practice, attitude and culture in the whole NHS economy in our part of north-east London. That is the problem that the Minister must tackle. Making a cheap political point does not help make any advances in the quality of health care in my quarter of London, for which he is responsible.

Finally—I have said this to the Minister privately, and I will say it publicly—there is inequality in health care across London. The teaching hospitals in the heart of London take away necessary resources from outer London, whether north-east or south-east. If Queen’s becomes the only hospital in our part of London, it will have to meet the health needs of 500,000 people, according to the CQC. The catchment area in inner London has a population of about 200,000. It is completely different.

I have spent my whole adult life bringing up my children in north London. The catchment area where I live has four hospitals that I can reach within 10 minutes and that provide excellent health care for me and my family. In north-east London, where I work, if King George hospital closes, it will take those who live on the Thames View estate an hour and a half on three buses to get to Queen’s hospital. People with weekly hospital appointments will not go. With the greatest respect to the Minister, that means that they will die earlier. His Government have said that they want to tackle health inequalities. Our Government tried to tackle them, but did not make much progress. Those health inequalities will grow.

Why does the Minister not take a bold move and consider the configuration of teaching hospitals in inner London? For example, the Royal Free hospital is not a good hospital. The physical building is terrible, and it sits on an extremely valuable site that would do a lot to sort out the financial situation faced by the NHS, but some talented and good people with the right culture and attitude work there. Those people ought to be working in areas of health need, such as our bit of north-east London. They should be operating out of the brand-new Queen’s hospital on the Romford site. If he did something radical and sensible like that, it would improve health outcomes for people in my constituency. It would also help him tackle some of the financial problems that he faces, and it would make sense in terms of tackling health inequalities across the capital.

--- Later in debate ---

[Andrew Gwynne]

I appreciate that, but we heard today that there is a great deal of concern across local authorities and the communities, and I would like to know what weight was given to their views.

[Margaret Hodge]

Does my hon. Friend agree that it appears that money has been the key factor in forming the decisions, and not the care of people? The views of bureaucrats have taken precedence over the views and experiences of local communities.

--- Later in debate ---

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

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

I congratulate the hon. Member for Ilford South (Mike Gapes) on securing the debate because, from personal experience in a previous debate and from meetings, I know that he and other right hon. and hon. Members have a tremendous interest in, and concern about, securing the highest-quality health care for their constituents. I share their desire for excellent health services in hospitals and in the community, whether in Barking, Dagenham, Ilford or elsewhere in London and the country. That is why it is so important that the issues raised by the Care Quality Commission’s investigation into Barking, Havering and Redbridge University Hospitals NHS Trust are acted on immediately and that safe services are realised and sustained.

Before I go on, I extend my sympathies to anyone who has experienced poor care at the trust. We can all be united in our concern and, in certain cases, even horror at what the CQC report showed. It is unacceptable in this day and age for services to deteriorate to that level, with such low-quality patient care. The improvement of the quality of care in that area and throughout the NHS is crucial—it is imperative and a priority. I can assure right hon. and hon. Members that the Secretary of State, my ministerial colleagues and I take such issues every bit as seriously as they do.

Although the CQC report identified some risk of poor care throughout the trust, it is the maternity service that requires immediate action and where the biggest risk of poor care was identified. The local NHS has taken immediate action at the trust to ensure that services are safe. NHS London and the Outer North East London PCT cluster have been working in collaboration with the trust to manage capacity and demand, to support its clinical leadership and to address the gaps in capability.

[Margaret Hodge]

Will the Minister therefore ensure that the unit at Barking hospital is open before Christmas?

[Mr Burns]

Since the right hon. Lady has specifically mentioned it, I will discuss that now, instead of later as I had intended. There is a plan to move the midwifery-led unit services into Barking hospital; that is a continuing, high priority for the hospital, and currently I believe that capacity is about 50%. [Interruption] She ought to have waited until she had heard the end of my answer. If she wants to intervene again, I point out that I have only been left seven minutes and there is a lot to deal with. However, it is not for me in Whitehall to micro-manage decisions; services and the speed at which services are provided must be a local decision by the local health economy. The only assurance that I can give—it is an assurance—is that the MLU is a priority for the hospital. I am advised that the whole service is expected to be provided at Barking hospital by April 2012, which I think is the date given to the right hon. Lady.

NHS London continues to monitor closely the actions taken in the local NHS, including twice-weekly discussions with all key stakeholders, as well as regular meetings with the PCT cluster, the trust and NHS London’s performance and chief nurse’s teams. Some concrete actions, which I hope reassure right hon. and hon. Members, have already been taken. To ensure safety, NHS London, PCTs and the trust decided to cap the number of deliveries to 20 a day at Queen’s and seven a day at King George from the beginning of October. In collaboration with the South West Essex commissioning cluster, a number of women with Essex postcodes due to give birth at Queen’s or King George will give, and have given, birth in hospitals in Essex instead. Additional, part-time professionals are being brought in—including the well-respected head of midwifery from the Royal Free hospital—to support the maternity unit until substantive leadership can be appointed.

Five supervisors of midwives from surrounding trusts have agreed to support the team at Queen’s. A senior obstetrician has been recruited and will begin working with the trust shortly. Given CQC concerns about the number of vacancies and the skill mix in the maternity work force, NHS London’s chief nurse has set up a midwifery leadership scheme to attract 12 experienced midwives to the trust. For an initial period of eight weeks, Caesarean sections have been transferred from the trust to Homerton university hospital in Hackney. All such actions are having an immediate impact on the ground and protect patients.

In February of this year, the trust gained a new chief executive, Ms Dongworth. The CQC and NHS London have confidence in her and have given her their full support. The CQC reported:

“Almost without exception, staff were positive about the impact the new Chief Executive is having at the Trust. They have embraced the Chief Executive’s inclusive style and believe, for the first time in many years, that there is a real opportunity for positive change.”

It is my belief that such positive leadership can help the trust to move forward from the report and to continue to make the improvements that are so badly needed. A recruitment drive has already brought in an additional 72 midwives, enabling the trust to have one of the best midwife-to-birth ratios anywhere in London, and one of the highest levels of senior doctor cover. There is now regular, independent monitoring of performance every week. The trust has made it absolutely clear that continuing to improve is its top priority. All local NHS partners are committed to making that happen. The Secretary of State will also actively monitor developments.

I now pick up on a point made by my hon. Friend the Member for Ilford North (Mr Scott) which, to be fair, I think was a special plea about his urgent care centre. The urgent care centre at King George’s will see the majority of patients who already attend. I must advise my hon. Friend that few blue-light cases are actually taken to that unit. He might have been hoping that I would do something to upgrade the centre to an accident and emergency unit, but I am afraid that that is not within my remit. However, under the modernisation of the NHS, nothing prevents the clinical commissioning group, when commissioning care for its patients, from looking at the situation if it is so minded. If it wants to commission enhanced care in an urgent care or A and E centre, it has the powers to do so if it wishes. I cannot prejudge what a local CCG might or might not want to commission in the future, but the opportunity is available.

Owing to the shortage of time in the debate, I have not been able to answer all the points made by the hon. Member for Ilford South, or by the right hon. Member for Barking (Margaret Hodge) and the hon. Member for Dagenham and Rainham (Jon Cruddas). I commit to writing to them with the answers to their specific points, made during this interesting and in many ways traumatic debate. I appreciate, as they do as constituency MPs, that it is totally unacceptable to have poor-quality health care for our constituents and for patients within the NHS.

Health and Social Care (Re-committed) Bill

Margaret Hodge Excerpts

Wednesday 7th September 2011 Commons Chamber

[Nadine Dorries]

The hon. Gentleman is a man of great conviction and, I think, a lay preacher, and we all respect and honour his views. However, the amendment is not about the unborn child; it is about the woman accessing counselling.

[Margaret Hodge (Barking) (Lab)]

Will the hon. Lady give way?

[Nadine Dorries]

No, I want to continue for a bit longer.

The diagnosis of pregnancy happens very quickly. One can buy a pregnancy testing kit for £1. It is possible that the reason some women suffer distress following an abortion is that they can be tested before they have even missed their first period. For some women, that is fantastic and they go straight for an abortion when they find out. For others, however, it all happens so quickly that they can be aborted by the time they are seven or eight weeks pregnant, and then afterwards, when the pressure has gone and the coercion has disappeared, they realise—

Maternity Services

Margaret Hodge Excerpts

Wednesday 22nd June 2011 Commons Chamber

[Margaret Hodge (Barking) (Lab)]

I am most grateful to you, Mr Speaker, for enabling us to debate the maternity services on which people in my constituency and neighbouring constituencies depend. On behalf of those people, I hope that the Minister will feel able to respond positively to the proposals that I wish to make, which I know are supported by neighbouring MPs.

Let me preface my remarks by saying that I know there are many dedicated and committed individuals working in the NHS in Barking, Dagenham, Havering and Redbridge who give their all to the maternity services in the borough. I fully acknowledge and warmly thank them for what they do. However, my overriding responsibility and duty is to all the women in the area who want to be certain that when they have their babies, there will be a bed for them, and enough experienced and appropriately qualified midwives looking after them, and that the care they receive during their pregnancy and birth will be of a consistently high quality, giving mothers the support they need and ensuring that we can all be confident that the pregnancy and birth will be safe for both mother and baby.

That is not a lot to ask and expect, but shockingly, it is not delivered and guaranteed at present to all mothers dependent on our hospital trust. Barking, Havering and Redbridge University Hospitals NHS Trust has one of the highest birth rates in the country, with just under 10,000 babies born in trust facilities last year. In my constituency, the birth rate went up by more than a third between 2002 and 2010. Across all the communities served by the trust, the number of births has been growing year on year by 500 additional births, and everybody believes that this trend will persist for the foreseeable future. However, a report from the Care Quality Commission this March expressed major concerns about the quality of care at one of the trust hospitals—Queen’s hospital in Romford—which is a huge indictment of the service and a dreadful worry for families who are having their babies.

The CQC found that maternity services at Queen’s were failing to meet essential standards of care, and that the trust was not taking all proper steps to ensure the safety of women in the maternity unit. Inspectors stated that services were so understaffed that mothers and babies were at risk. They found that too many staff did not have the right skills and that the appropriate equipment was sometimes missing. Inspectors reported mothers in labour being left alone for long periods without the pain relief that they needed. They also found significant delays in patients going to theatre and said that babies were being born in what they termed “inappropriate locations”. Inspectors expressed concerns about respecting and involving mothers in their own care, and found that the trust did not give bereaved mothers proper facilities in a separate room, away from other new mothers who had had their babies safely.

Sadly, the CQC confirmed what all of us already knew—we knew it from the fact that more women die while under the care of the trust than elsewhere. Four women have died in BHRT maternity units in the past 12 months, with five dying in the past 18 months. Maternal deaths there are five times greater than the national average. The trust has paid out £15 million in compensation in the past five years on claims against the obstetric services. That is one of the biggest compensation bills across the whole of the NHS. Those statistics are heart-rending. What should be moments of joy for mothers and their families become experiences filled with fear and pain—and, at their worst, loss and grief. As local MPs, we are told of far too many cases of people having to put up with terrible care, particularly at Queen’s hospital.

One of my constituents gave birth at Queen’s in July last year. She was kept waiting for hours in reception when she was already in labour, with other patients waiting in the same area. She was told that staff were too busy to give her an epidural. The same staff then failed to give her an episiotomy, and she suffered second degree tears and had to have 20 stitches in her vagina. Yet she had to wait for three hours to be stitched because, the hospital told us,

“not all midwives have had the required training to perform this procedure.”

Another constituent went to Queen’s when she was two weeks overdue. She had been having contractions for over a week and was losing weight. But, instead of inducing her there and then, the hospital sent her away. Shortly afterwards, she gave birth to a stillborn baby. A third constituent was supposed to have a home birth. The midwives arrived late, and without enough pain relief or oxygen. After an hour, she was in such agony that she had to go to Queen’s where she had to have an emergency caesarean. The trust later accepted that she had not been properly examined while she was in labour at home.

There have also been some high-profile cases recently of women who have tragically lost their lives at Queen’s because the care that they received was so lacking. Sareena Ali and her unborn baby died after staff failed to identify that she had a ruptured womb which triggered a heart attack and a major organ failure. She had not been checked for two hours, despite her husband begging staff to check whether anything was wrong because she was in consistent agony. She had an emergency caesarean —on the antenatal ward in front of other women in labour—but the baby was stillborn. Staff tried to resuscitate Sareena with a disconnected mask; it was her sister-in-law who spotted this. Sareena died five days later—a death that could have been avoided.

Earlier this month, Violet Stephens went to Queen’s at 31 weeks pregnant with dreadful gastric pain and high blood pressure. After four days in hospital, she was eventually diagnosed with a life-threatening complication called HELLP syndrome. She had an emergency caesarean and, although the baby was delivered healthily, she died. Violet had had similar symptoms during her previous pregnancies, but the system failed her and her case is currently under investigation. In August last year, Saira Choudhri was sent home from Queen’s even though she was having contractions every two minutes. She was found blood-soaked and in agony by two nurses in the car park. Thankfully, her baby survived.

This litany of tragic instances of unacceptably poor care has to stop, and the Minister and her Secretary of State must take responsibility for improving our maternity services. In part, the problem lies with shortages of staff, and shortages of properly qualified and experienced staff. The new chief executive is recruiting midwives from abroad and I welcome that, but we have been here before, and the trust has to find ways of retaining as well as recruiting good midwives over the longer term.

Mothers talk about the lack of respect for them as patients and the failure to involve them in decisions about their care. Most women see a different community midwife at every appointment. All of that suggests a deeply worrying cultural problem among the midwifery staff who work for the trust. When Sareena Ali died, there was a full complement of staff on duty and there was no unexpected pressure on them. They blatantly failed to do their job and to take proper care of her. There appears to be a poor working culture, with midwives not co-operating effectively together as a team and with individuals not accepting their proper personal responsibility. All too often, they seem literally not to care.

Furthermore, the trust’s complaints procedure is not working. Individuals complain, but the trust’s response is all too often incomprehensible and it seems never to learn the lessons from past mistakes. Saira Choudhri, the woman who was almost forced to give birth in a car park, complained to the trust about the attitude of staff and the care that she received. Her complaint was brushed off with a technical response that completely failed to address the real issue, and nothing seems to have changed. If the trust had an open, rigorous and patient-focused complaints protocol and acted on those complaints in order to improve care, some of those tragedies might have been avoided. If it had listened and learned from what patients were telling it, other women might not have had to go through similar ordeals and Sareena Ali might now be at home with her husband and baby. There is going to be a full inquest into the death of Sareena Ali, which I trust will help to ensure that nothing like this ever happens again.

All the local MPs believe that the health authority’s determination to close the maternity service at King George hospital is complete madness. Birth rates in the area are rising and the quality of care at Queen’s is simply unacceptable. What on earth do the bureaucrats think they are up to? The Government’s health reforms are supposed to put the patients’ interests at the heart of what is done, but that is not the case in Barking and Dagenham. Decisions appear to be driven by money, not patients, and by consultants’ convenience, not women’s interests. Queen’s hospital simply cannot cope and things will only get worse if the King George goes.

Local GPs in my area are also strongly opposed to the proposal, and across north-east London, tens of thousands of my and my colleagues’ constituents have signed a petition against it. This is not a bit of MP nimbyism. It is a common-sense conclusion, with the support of a cross-party group of MPs, based on a proper understanding of what local people should be entitled to from our national health service.

I know the decision on the King George hospital has been referred to the independent review panel, but I would urge the Minister to ask the Secretary of State to exercise his power to halt the proposed closure. The Department, NHS London and the trust need to sort out the quality and the finances, not shut the door for patients by killing off the hospital.

Worse still, we campaigned for years—ever since I became the MP more than 16 years ago—to get new health services, including maternity services, built on the old Barking hospital site, which was closed in the 1980s. My constituents want high-quality maternity services close to home, with babies born in Barking again.

We finally won that battle and now we have a brand-new, state-of-the-art maternity unit on the site literally standing empty while Queen’s hospital continues to fail. I have been told today that no babies will be born in Barking hospital until March 2012. That is an outrageous scandal. It was supposed to open last year and the building has been ready for months. I ask the Minister to confirm in her reply that she will investigate the reasons why this unit has not opened and instruct her officials to get it open and working as soon as possible.

Lastly, but most crucially, I ask the Minister to establish a full, independent and impartial inquiry into maternity services at Queen’s. We have had enough, and we want somebody with extensive experience in their profession to be appointed by the Secretary of State to establish what is wrong and to prescribe action to put it right. I sincerely say to the Minister that I have now concluded that nothing less will do.

Perhaps the Minister will listen to the words of some women who have been through the experience of having a baby at Queen’s. One woman said:

“All of my friends that have had their babies at Queen’s have all received such poor treatment that it’s really made them think twice whether to have any more children.”

Another said:

“I struggle to see how closing a maternity unit that is better performing in favour of one that is in effect under notice to improve can be the right decision for local people.”

A third woman said:

“If I have another baby I flat refuse to go to Queens.”

I ask the Minister to listen to those women, to act to support their best interests and to protect mothers and babies in our corner of north-east London by delivering a safe, patient-focused service in which we can all have confidence.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I congratulate the right hon. Member for Barking (Margaret Hodge) on securing the debate, and thank her for bringing this important issue to wider attention. Her message came across loud and clear. She has campaigned vigorously in support of her local health services for many years, both on the Government and Opposition Benches, and Members are to be congratulated on their vigilance in doing exactly what they were elected to do.

It is never good enough for patients anywhere to experience poor-quality health care, and it is clear that the problems at Queen’s maternity unit must be fixed now, so that the people of north-east London can regain trust in their maternity units. Regaining such trust is never an easy business. When mothers go to a maternity unit to give birth, they implicitly trust that they will receive the best-quality care. That is a vital part of maternity services, and it means that mothers can feel comfortable and safe with midwives, wards and hospitals. The shocking deaths at Queen’s maternity unit have put that relationship and that trust at risk, and I know that local concern is running extremely high. I offer my heartfelt sympathy to the families involved. To lose someone at what was expected to be a time of celebration is especially traumatic, and no words that I can say today will console those families. However, I believe that the message has been conveyed by the right hon. Member for Barking, the hon. Member for Ilford South (Mike Gapes) and my hon. Friend the Member for Ilford North (Mr Scott).

I understand that two investigations of maternal deaths are taking place at the unit; I hope Members will understand that I cannot comment on them at this stage. I know that the Care Quality Commission found that maternity services at the trust were failing to meet essential standards of quality and safety, but, although that was partly due to unsuitable staffing levels, they are not the only issue.

Unfortunately we cannot turn the clock back, but what we can do is ensure that decisive action is taken immediately to improve the position and ensure that the Queen’s maternity unit performs as it should have all along. In response to the CQC’s report, the trust has drawn up an urgent action plan and is taking steps to improve its maternity services. I understand that it has recruited an extra 60 midwives, and that a further 60 are shortlisted for interview. I also understand that it has revised the training programme for all midwives, created a new triage system enabling all women in labour to be seen by an experienced midwife within 15 minutes of arriving at the unit—the right hon. Lady particularly mentioned waiting times—and introduced a telephone triage system so that women can get advice even before they leave home. That is a start, although it is a start from a very low base. Although all those facilities should have been in place already, it is good that they are there now.

I have met Averil Dongworth, the new chief executive of the trust. She has assured me that everyone at the hospital—particularly the midwives and the support staff in the unit—is determined to improve standards and rebuild confidence. That may sound hollow to the Members who are present, who have probably heard it before, but Averil Dongworth struck me as an impressive woman with a steely determination to turn things around. She has also promised to keep in touch with and meet the local Members of Parliament regularly. I think it important for them to feel that, on behalf of their constituents, they are monitoring the position regularly and frequently. I have asked Averil Dongworth to keep me up to date. The position is very simple: nothing but the best will do for anyone who is seen in the NHS.

I also understand that NHS London, the local strategic health authority, is taking action to improve clinical leadership. It is important for that leadership to be in place, because its absence is often the reason why things go wrong, particularly midwifery in this instance. I understand that the authority has asked a senior obstetrician and an experienced midwife to spend time working in the team.

The right hon. Lady mentioned the health for north-east London review, which includes proposals to change the way in which Barking, Havering and Redbridge University Hospitals NHS Trust delivers maternity care. As Members have mentioned, under those proposals King George hospital would continue to provide antenatal and postnatal care, but would no longer provide maternity services during delivery. Maternity services would be consolidated at Queen’s with a new midwife-led unit that could deliver more than 2,500 babies a year. I understand that the unit is empty. The situation is extremely disappointing, but the proposals have been referred to my right hon. Friend the Secretary of State for Health, and the independent reconfiguration panel will advise him within the month, no later than 22 July. I know that Members look forward to hearing the decision, but obviously I cannot prejudge it.

The financial payouts in litigation that the right hon. Lady mentioned really pale into insignificance when compared with the human cost. There is not just the human cost when things go tragically and irreversibly wrong, but the poor experience that women have had, which is a very bad start to their new family life. Nothing can compensate for any of those things. She mentioned Sareena Ali and the unresponsive nature of the trust in relation to complaints. That has to change and I sincerely hope that Averil Dongworth will turn that around so that local people can start what will be a very long and slow journey to building that trust.

The right hon. Lady also mentioned that the problem is not just about recruiting staff but keeping them. That is the real challenge. When local people have lost faith in a local NHS organisation, the recruitment of staff becomes increasingly difficult. Keeping up morale is very important, which is why I think it is an important step in that journey for the chief executive to keep in touch with local MPs.

The right hon. Lady rightly said that this should be about the care of women and their babies and families, and not about other people’s convenience. My hon. Friend the Member for Ilford North reiterated many of the same points and I am always impressed when there is cross-party support on issues such as this. This place does not always have a good reputation but at times like this our reputation should soar because that cross-party working is extremely important to get things done. The hon. Member for Ilford South also spoke about the cross-party support and referred to the culture and institutional problems, the issues that are so very difficult to dig into and turn around. I sincerely hope that we can start to do that.

The Government are doing all we can to stamp out instances of sub-standard care. As I have said, nothing but the best will do for anyone. New standards of care are being developed for antenatal services and the management and care of women in labour, as well as for delivery and post-natal care. We are also keeping up the record number of midwives entering training—nearly 2,500 this year and 2,500 next year. I want to see the potential of the whole maternity team being realised. There are new technologies out there and new techniques improve care and deliver value for money while improving the experiences of women, their babies and the wider family. We will continue to work with the Royal College of Midwives to make sure that we have an appropriately resourced but also skilled maternity work force with the leadership they need. Of course, that will be of scant consolation to many of the families involved, but sadly I cannot turn the clock back.

[Margaret Hodge]

I am grateful for the Minister’s remarks, but in the last couple of minutes available, may I ask her to comment on two other specific issues? First, I think that we need an independent inquiry. I recognise all that has been done, but will she respond to that point? Secondly, will she respond to my point about the Barking hospital site where we have a brand-new, state-of-the-art maternity unit that is being kept closed?

[Anne Milton]

I thank the right hon. Lady for making those points, but I honestly do not know that an inquiry is the right way forward. The tragedy of this is that we know what some of the problems are and there has been a failure to turn them around. Certainly, an empty building and a midwife-led unit that could deal with 2,500 deliveries a year for women of low risk would be an important development, but I do not want to prejudge the Secretary of State’s decision on that. I hope that the right hon. Lady, her constituents and the families involved will at least take some heart from the fact that steps are going to be taken to prevent any of this from ever happening again. I will make sure that those efforts remain at the top of the trust’s agenda. I can assure her, my hon. Friend the Member for Ilford North and the hon. Member for Ilford South that I will take a personal interest in this and make sure that we monitor progress towards giving local people what they deserve—the very best from their local NHS.

Question put and agreed to.

Life Expectancy (Inequalities)

Margaret Hodge Excerpts

Thursday 3rd March 2011 Westminster Hall

[Margaret Hodge (Barking) (Lab)]

I welcome the opportunity, despite the sparsity of Members in the Chamber today, to debate one of the many reports that we have published since July, when we were established as the new Public Accounts Committee for this Parliament. I take the opportunity to thank the members of my Committee who, although many have not stayed for the debate this Thursday afternoon, do a fantastic job in coming to grips with all the issues on our hugely busy and diverse agenda and in holding the Executive to account over a vast range of areas. I thank the staff of the House, particularly our Committee Clerk and his staff, for working incredibly hard to keep up with the volume of work, and the National Audit Office, which always provides us with excellent material as a basis for our investigations into this vast range of Government business.

Health inequality is the most awful and terrible thing. People who live in poorer wards can expect to die seven years earlier than people who live in the most affluent wards in this country. Furthermore, they spend, on average, 17 years of their lives with a disability. That is unacceptable in a free, democratic, fair and compassionate society. Let me give some reality to those statistics. Some 3,000 more individuals die than otherwise might have done as a result of the dreadful inequalities between the richest and poorest areas. My own personal passion for tackling inequality comes, in part, from the knowledge that I have of how it impacts on my own constituency. The estimates say that, if someone lived most of their life in Barking and Dagenham, they are likely to die eight years earlier than a person who lived most of their life in Kensington and Chelsea.

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

Is my right hon. Friend aware that there are twice as many doctors in Wandsworth as there are in Barking and Dagenham, and that for every stop further that a person lives on the Jubilee line between Westminster and Canning Town, their life expectancy goes down by at least a year?

[Margaret Hodge]

My hon. Friend makes a hugely important point, and I want to spend quite a lot of my contribution talking about the distribution of general practitioners, and the relationship between that and health inequalities.

As a Committee, we believe that addressing health inequality should be at the heart of every Government. All MPs from all political parties share the desire and commitment to work towards eradicating those inequalities. It is because it is a shared ambition that our report makes particularly depressing reading. The previous Government came into power publicly committed to reducing health inequalities, so there was a strong political commitment to achieve progress in the area. During the 13 years of that Government, there was a huge injection of money into the health service, which resulted in welcome improvements for everybody, including increases in life expectancy among the whole population. We now have life expectancy for men of 78 years and for women of 82 years. In our session on pensions yesterday, we received evidence from the King’s Fund that showed a massive improvement in life expectancy over the past decade or so, whereas in the last century there was hardly any improvement.

Given the general positive trend, it is horribly depressing to see that, while the health of the nation as a whole has improved, the gap between the richest and poorest, as measured by life expectancy, has widened. If we compare the life expectancy of men in the spearhead authorities—the most deprived authorities, in which a quarter of the population live, that were selected by the previous Government—the absolute gap and the relative gap increased between 1998 and 2007-09. In absolute terms, the increase was 8.6% and in relative terms it was 4.6%. If we look at the same statistics for women, the absolute gap increased by 9.3% for women and the relative gap by 6.5%.

What is so worrying about those statistics is that the gap between the richest and poorest women is growing at a faster rate than the same gap between the richest and poorest men. As yet, we do not have any good answers for why that is—unless the Minister can help us—except that women are smoking more today than they were a generation ago and are, therefore, more prone to diseases such as lung cancer that then kill them. I urge the Government to do some better evidence collecting so that we can understand what is happening and see whether we can take appropriate action to improve the figures.

Given our real determination to tackle health inequalities, why have we failed so far, and what should this Government do to improve performance and therefore close those unacceptable inequalities? We all understand that this is a hugely difficult area, and it is not just an issue for the health service; inequalities arise from socio-economic factors. If we consider the evidence, most of the inequalities—between 80% and 85%—come from socio-economic factors, such as income, education and housing, and probably between 15% and 20% arise from poor access to good-quality health services. It is important, therefore, that the health service does what it can. If it performed better, we would reduce that gap, but on its own it cannot tackle the problems of life expectancy that arise from whether someone is rich or poor or where they tend to live.

If we accept the importance of those wide socio-economic factors, it is vital that we have a comprehensive and coherent approach across Government. Integrating health inequalities into the wider agenda of tackling poverty inequality becomes hugely important. Without wanting to be politically partisan, I have to strike a warning note about the proposed cuts in public expenditure, which look as though they will hit the poorest hardest. If that is the case, I have not yet seen anything that provides me with the comfort that the direction of travel will reduce inequalities. In fact, quite the contrary, inequalities could be intensified. Will the Minister address that issue in her response to the debate?

I urge the Government to keep a focus on health inequalities as part of their agenda of tackling poverty and general inequality, and to judge all the actions that they take by how they will impact on health inequalities. That focus is hugely important.

[Mr Richard Bacon (South Norfolk) (Con)]

I agree with the right hon. Lady that the Government need to maintain focus. I noted that our Committee’s report says that the Department of Health itself acknowledged that it was slow to put in place key mechanisms to deliver its target and that it had used such mechanisms in other areas such as treatment of cancer, diabetes and stroke, where national clinical directors have proved quite successful. Does she think that there is scope for doing more in that regard in relation to health inequalities?

[Margaret Hodge]

Absolutely. I am grateful to the hon. Gentleman, who took through our recent inquiry into cancer. That inquiry demonstrated that, if there is that focus, outcomes will improve, although we can always do better. Having set the context in my opening remarks, I was going to make that point: access to and the responsiveness of the health service are hugely important. We need to do a lot of work to improve those things.

Tackling health inequality must be a real priority for everybody involved, which is the first lesson that we learned from our inquiry. It is not just about the politicians, for whom it has always been a priority. It must be a priority for the Department of Health, the new NHS commissioning board, GPs and all health service providers, local authorities, pharmacists and all others who have an interest in ensuring that we are healthy and live longer.

There is a criticism to be made of the previous Government. They were good at writing policy papers, but less good at following through those policies with specific actions. There were plenty of papers. We had the commitment in 1997, when the Government came in. We had the Acheson report in 1998. We had a target in the comprehensive spending review in 2000, which was pretty general but was about reducing inequalities. We had a refined target in 2002, which was more specific but perhaps a little less ambitious, and was aimed at reducing inequalities by 10% in the 20% of health authorities where there was the lowest life expectancy. We had a plan of action in 2003. That is an interesting point to pause at, because that plan of action had 82 so- called commitments. I do not think that our Committee looked at the plan in detail. I certainly have not done so. By December 2006, the then Government claimed to have met 75 of those 82 commitments, but we know from the statistics that the outcomes grew worse in terms of inequality. So there is something to be learned from the focus of that plan of action.

In the 2004 comprehensive spending review, the then Government revised and revisited the target. Again, we focused on it. We made it slightly less ambitious but more specific by focusing on 70 spearhead areas of the country. However, there is a danger with that approach, because more than half of the people who have an unequal life expectancy outcome at present do not live in those 70 spearhead areas. Inevitably, therefore, by concentrating action on those areas, we were leaving out far too many people.

Finally, in 2006—nine years after the previous Government came into office—reducing inequalities became one of the top NHS priorities. I think that it was at that point that we started to get things right. One of the lessons to learn from that is that, if we are not specific and focused, and tackling health inequality is not a high priority, we will not deliver, despite having the best intentions. In 2007, we got the primary care trusts to report on the progress that they had made on health inequalities.

Therefore, the view of the Committee is that reducing health inequality must be an explicit priority throughout the system and that it must be measured. I hope that the Minister will agree with that comment and I look forward to hearing her response to learn how she will ensure that the agenda on reducing health inequality is taken forward by this Government.

[Ms Abbott]

I have listened with great care to my right hon. Friend, who has had the opportunity to study these matters in detail. Does she agree that one of the problems in tackling health inequalities is that it does turn on good public health, which has never had the glamour or the immediacy of acute care in hospitals?

[Margaret Hodge]

I agree and I will develop that point a little later. However, the previous Government almost doubled the expenditure on public health, from an incredibly low base: it was 1.9% and it increased to 3.6% of NHS spending. I hope that the present Government will do even better in that regard. However, spending on public health is still a minute part of NHS resources, especially when it is an area that would prevent a lot of the health inequalities from emerging. Having conducted a study on cancer, both my hon. Friend the Member for Blaenau Gwent (Nick Smith) and the hon. Member for South Norfolk (Mr Bacon) would agree that the earlier that one can diagnose a condition the better the outcome. That was a key finding of the report that our Committee published this week on cancer.

I move to the issue of resources and I will talk about it in three contexts. First, I will talk about the resources—the actual money—that are distributed between geographical areas. Secondly, I will talk about the distribution of general practitioners. Thirdly, I will talk about the expenditure on prevention.

On resources, our study made it clear that at present there is an inequitable distribution of resources. The report showed that, in 2010-11, 68%—more than two out of three—of the spearhead PCTs were still not receiving the money that they should have been receiving on a needs-based allocation formula. That meant that more than £400 million of NHS money was diverted from those neediest areas to other parts of the country.

From the response of the Government in the Treasury minute, I know that they will continue to try to redistribute resources, but I would be grateful if the Minister gave us some indication of a time frame within which she would hope that there would be a much fairer distribution of resources to reflect need and therefore at least to give our neediest areas the capability and capacity to tackle health inequality.

I also note from the response of the Government in the Treasury minute that responsibility for the distribution of resources will go to the NHS commissioning board. What comfort can the Minister give my Committee about the instructions that the Department will give to the commissioning board regarding the action that it needs to take to ensure that there is genuine equity in the distribution of funding? Again, I know from my own borough that there is a real need for political commitment and drive to achieve that redistribution of resources. Obviously, there is a limited cake, we are in difficult financial circumstances and we are trying to see how we can cut that cake differently.

I and some of my colleagues in our local PCT area had to work extremely hard with Ministers in the previous Government to achieve a fair distribution of resources for Barking and Dagenham. That was the one area where we did okay. Obviously, that work was very local and it is not a pattern that we observed when we carried out the study across Government. So that is the first issue—a proper distribution of resources to poorer areas.

On the issue raised by my hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott), we must spend money on prevention. The issue of public health investment is crucial, because we know that other key causes of health inequality are what are known as “the risk factors”: obesity, smoking, drinking, diet and lack of exercise.

In that regard, the previous Government did well. They increased the spending on public health, doubling it from an extremely low base to a pretty low level of 3.6% of NHS spending in 2006-07. I think that the members of my Committee would say that we need further progress in that sector to ensure that we prevent people from developing the illnesses that limit their life expectancy.

Under the present Government’s reforms, we will have the new health and well-being boards, and they will receive resources. However, there are huge pressures on local authority budgets. Local authorities are probably having to absorb more cuts than any other part of the public sector. I have particular concerns about what mechanisms will be in place to ensure that local authorities spend the money they have, and prioritise expenditure on public health facilities and policies.

The commissioning board will have the responsibility to ensure proper expenditure on prevention, but the evidence given to the Committee showed that the problem with expenditure being devolved to GPs, who one would think were best placed in the health economy to think about investing in prevention rather than cure, is that their record in pursuing such investment is poor. GPs who have already been commissioning, and who control their budgets, do not have a good record of ensuring that they properly spend on prevention.

Finally on this point, the national health service has to find between £15 billion and £20 billion of expenditure savings, and while I accept that that money will be redirected within health, it is easiest to cut that which is most difficult to measure, which is investment in the prevention of poor health outcomes. In a climate in which the health service is trying to identify the very challenging savings that the Government have asked it to find—I accept that the savings were initiated by the previous Government—I fear that investment in preventive health measures will fall to the bottom of the agenda. How will the Minister and the Government ensure that money is properly spent on prevention?

[Ms Abbott]

Is my right hon. Friend aware that even now local authorities and primary care trusts are cutting public health expenditure, for example on community midwives and smoking cessation? Such expenditure is non-statutory, and it is going. Although one appreciates the intentions of Ministers in giving local authorities ring-fenced moneys, the danger is that those authorities will, under force majeure, use the money to backfill expenditure on environmental health and social care, and I have even heard of authorities believing they can spend their public health money on leisure services.

[Margaret Hodge]

I have a rather depressing example from my own area. We have had an effective smoking cessation service, but the regional health body looked at the expenditure both there and in Waltham Forest, which is spending far less, and instead of considering the impact and effectiveness of that expenditure, asked, “If Waltham Forest can do it for less, why can’t Barking and Dagenham?” That very effective intervention is now being cut because the comparison made by the regional health body was on the basis of inputs rather than outcomes, and that is a depressing trend that we will see mirrored elsewhere in the country.

Thirdly on resources, we need to ensure that there are the right GPs in the right areas. All the statistics that were provided to the Committee on that make for extremely depressing reading. The least deprived areas of the country have on average 64 GPs per 100,000 people, and the most deprived have 57. In Barking and Dagenham we have only 40 GPs per 100,000 people. I hope those statistics are right—I got them only the other day—because it is shocking if they are. The previous Government tried to tackle that issue locally, and the Committee was given evidence about what they did nationally. For example, in 2007 we had the £250 million programme to establish 112 new practices and 150 GP-led health centres in areas with the fewest primary care clinicians. I assume that that programme is coming to an end and that most of those facilities have now opened, but perhaps the Minister can confirm that.

In my borough, we have had a paucity of GPs, and a concentration of single-person practices and very poor environments and, try as we might, we still have this very challenging problem. Over the past 10 to 12 years I have been engaged in encouraging innovation, including having salaried GPs, and linking our GPs to universities as an incentive, and we were the first borough to try to encourage private providers to come in. One of them was successful, but the health authority has, I think, closed the other one’s contract. We have new health centres and practices, but the problem is that GPs are essentially independent providers and can choose to work wherever they wish. That is a hugely important point, and not just in tackling health inequalities, because if the Government cannot make the situation better, there will be much greater pressure on accident and emergency units and hospitals, and resources will be driven into the acute sector at the expense of community services.

[Nick Smith (Blaenau Gwent) (Lab)]

When we discussed the role of GPs in public health, I was disappointed to discover that they were not incentivised by GP contracts to treat public health issues seriously and put resources into them. If they had been, that would have made a difference.

[Margaret Hodge]

I agree entirely with my hon. Friend. I understand that the Government have said in their Treasury minute that they intend to try to renegotiate the GP contract, and to increase the focus of the quality and outcomes framework on prevention, with 15% of the outcomes centred on it. I am really interested in hearing what the Minister has to say about that. We have to provide incentives in the system, but we also need to ensure that GPs do not cherry-pick. There must be incentives to ensure that GPs focus on the hardest-to-reach groups—on those people who do not automatically go to their doctor when they feel ill.

Finally, what will the Government do to support the health service to do what works? One of the most depressing findings in our report was in this area. We know that most health inequalities arise because of issues that are outside the control of the NHS, but 15% to 20% of them come about because of the quality of the health service that people experience, and their access to it. We also know that two thirds of the difference in life expectancy is due to people dying from respiratory and circulatory illnesses, and from cancer. I have no doubt that the hon. Member for South Norfolk will want to draw attention to the report on cancer that we published this week, which talks a lot about the fact that if we got better at early identification of cancer, particularly in poorer areas, we would be more successful in reducing health inequalities. We also know, from the Marmot review, that if we do not get better at reducing people’s propensity to develop such illnesses, the additional associated treatment cost to the NHS, and therefore the cost of dealing with health inequalities, will be £5.5 billion. There is a fantastic financial incentive as well as an ethical incentive to spread practice that we know works in a much better, more structured and more defined way.

Our inquiry found three cost-effective interventions. They are so simple that we were all slightly gobsmacked that they are not more widely used. The first is giving anti-hypertensive drugs to lower blood pressure, the second is giving statins to lower cholesterol levels and the third is dealing properly with smoking cessation. There is probably a class bias involved. I cannot think of middle-class people who are not aware of those preventive interventions for respiratory and circulatory illnesses and who do not take them almost before they need them. However, poorer communities lack the same understanding and self-advocacy, which would support a reduction in health inequalities. Our inquiry also found that it would cost a mere £24 million—I say “mere,” but it is relatively small in NHS expenditure terms—to ensure that those three interventions were properly implemented in the spearhead areas. At present, those spearhead authorities spend £3.9 billion each year on treating people who develop the illnesses that arise through lack of preventive action.

We also found that our record on reducing health inequalities varied across the country. London, for a change, did relatively well, whereas Yorkshire and Humberside did particularly badly. However, the Department of Health had not developed any proper understanding of why such differences existed, and therefore had not decided how to use the data to lever action.

Probably the most shocking graph in our report involved smoking cessation. There is a lot of evidence that one-to-one sessions do not particularly help people to stop smoking, whereas putting them into groups where they are influenced and encouraged by their peers tends to have a better impact, yet PCTs were putting nearly all their money into one-to-one sessions and very little into group sessions. That seemed an absurd waste of investment and a failure of those empowered to take decisions to do the right thing with their money, which could have had much more impact.

What are the good and bad things that we know so far about how the country will perform on health inequality under the reforms? The Government have said that reducing health inequality remains a key priority, and I welcome that, as we all should. I welcome the fact that the NHS commissioning board will have a duty to reduce inequality, but that in itself is not enough; we must understand how the board will focus on it. I welcome the fact that central Government will make information about good practice available, but I worry that the implementation of that good practice will not be directed more from the centre, if not mandatory. What does the Minister have to say about that?

I worry that there will be no central benchmarking of cost-effectiveness in reducing health inequalities. I welcome the commitment to move towards fairer funding between areas, but I worry about the rate of change. Will the Minister comment on that? I welcome the fact that the Government are seeking to renegotiate the GP contract and are minded to give greater weight to local health needs in that regard. I welcome the fact that they wish to change the quality and outcomes framework, and that health premiums will be available to local authorities that reduce inequalities.

However, there are risks, to which my hon. Friends have alluded, in relation to the public health proposals and local authorities’ capacity properly to meet their requirements for reducing inequalities. I worry that the health premium will reward disadvantaged areas only if they make progress, and will disadvantage such areas further in the distribution of resources if they fail to do so. That would mean that people living in poor areas, who are likely not to live as long as people elsewhere, will be disadvantaged by a failure of the institutions that we have established.

How do the Government intend to ensure that local bodies work cost-effectively to reduce inequalities and provide value for money in their work? What powers, if any, will the Department, the NHS commissioning board or local health and well-being boards have to direct local GPs and providers who are not reducing health inequalities or are doing so in a way that gives bad value for money? What measures, if any, will be taken to ensure that the £20 billion in savings will not lead to short-sighted cuts to prevention budgets?

If the Minister can answer some of those questions, hopefully the good report that we as a Committee have put together can support the shared national endeavour to tackle this hugely difficult problem, which is so important in the life of our society.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to be here this afternoon serving under your chairmanship, Miss Clark, for what I think is the second time.

I will endeavour to answer all the issues that have been raised in the debate. I welcome the report from the Public Accounts Committee. There is no doubt that health inequalities belong to another age and certainly have no place in modern society. Anything that brings this issue to the fore is entirely welcome. As the right hon. Member for Barking (Margaret Hodge) said, health inequalities are terrible, and it is shocking that they exist to such a great extent. I shall deal later in my remarks with the questions that have been raised. If Members wish to intervene, I will be happy to take interventions, but if they hang on, I will get to all their questions in time.

The hon. Member for Hackney North and Stoke Newington (Ms Abbott) was absolutely right to say that lessons should be learned. The problem with government generally, at every level and irrespective of political party, is that people tend to turn up bright-eyed and bushy-tailed but do not take any notice of what has gone before. In fact, the Government and politicians should have the humility to recognise that if things were not achieved earlier, it was not necessarily because of the incompetence of the previous incumbents but because sometimes it is difficult to do something, and this is one area where that applies. As was said earlier, this is not a partisan issue. It is something that we need to act on across the board. The important thing is truly to understand what we are talking about when we talk about public health.

I do not think that, strictly speaking, I have to register an interest, but I should mention that my husband is a public health physician, although not working as a director of public health. It is extraordinary that we have had this discussion this afternoon without yet mentioning the public health profession or directors of public health—members of the public health profession will be somewhat disappointed, because they are pivotal to many of the changes that we want to introduce.

My Government want to improve the health of the poorest most quickly. If we are to achieve better health outcomes, particularly compared with other countries, that must be more than a pipe-dream. My hon. Friend the Member for South Norfolk (Mr Bacon), who is, indeed, my favourite member of the Public Accounts Committee— [Interruption.] This is a love-in. He mentioned that it is extremely easy to assert things, but we do not want assertions but real action. That must be a fundamental part of our strategy in health care and in other areas such as housing, education and social care. We believe that the more devolved health system that we are developing will enable a sharper focus on disadvantaged areas across the country.

The Government want to provide far more opportunities for local people and organisations, including statutory organisations, to plan and run health initiatives specifically tailored to their communities. We have set out proposals to reform the delivery of health services in England. They are contained in two White Papers, which I am sure Members are familiar with: one is for NHS services, and the other is for public health. Reducing health inequalities must, and will, be embedded in the reformed architecture that we propose.

[Margaret Hodge]

I believe that, in principle, all of us would support devolution of power, but I draw to the Minister’s attention constituencies such as mine—this is more a constituency point than a general point. My constituency, which is a working-class area, is quite uniform in class structure. The whole public service infrastructure is weak, whether one looks at education, health, public health, GPs or the voluntary sector. If there is devolution to the poorest areas with poor infrastructure, it will be extremely difficult for them to grow from within themselves the necessary capabilities to tackle some of these deeply entrenched problems. There is a role for the centre, through Government, to intervene and try to build capability so that we can achieve an impact. I am concerned that if the whole mantra is about devolution, we will leave large areas of the country with concentrations of poverty and need struggling to achieve the kind of outcomes that she and we would want.

[Anne Milton]

I thank the right hon. Lady for that intervention. She is absolutely right to mention capacity building. There are areas where there is weakness across the board, and that is certainly something that we need to address. However, it is quite interesting what local areas can do with good leadership and the right levers and safeguards in place. I believe that it was out her way that I visited a scheme in an area with a high incidence of domestic violence. The local authority connected the council’s noise nuisance helpline and the domestic violence team, on the basis that where there is noise from neighbours there will probably be violence in the home. After a certain number of calls about a certain address, the domestic violence team is alerted and then goes in—a simple intervention, and a kind of capacity. Some of that is down to the confidence of the people working in the area, some of it is to do with expertise, and some of it—general practice has been mentioned quite a lot—involves putting in incentives to ensure that we get people with the skills that are needed to build that capacity.

I was not going to mention this, but we have made, for instance, a commitment to increasing radically the health visitor work force. One of the modules in health visitor training that we are looking at is about teaching new health visitors how to build capacity in communities. It is a nebulous thing, but it is important that we understand it. There is no doubt that communities, Governments and even empires have struggled for donkeys’ years with the question of how to improve public health. The hon. Member for Hackney North and Stoke Newington mentioned that in 1948, the NHS itself was a major public health advance. It secured health services for all, regardless of ability to pay. I make no apology for giving a history lesson. I am not a history scholar, but it is important to take on board the history of public health. At the same time, local authorities were given responsibilities for the health of children and mothers, and for the control of infections. At the same time, they retained their role in planning, sanitation and overseeing the health of their local population through medical officers of health.

In the NHS reforms of 1974, further unification of health services resulted in the transfer of some of those health functions from local government to the NHS, including many that we would recognise as public health functions. I draw Members back to the comments of the hon. Member for Hackney North and Stoke Newington about the status of public health. One of the reasons why the medical profession at that time pulled public health out of local authorities was to do with status, and the clout that they felt they had. Clearly, if one looks at what we are doing now, that was probably a mistake, but there were issues to deal with. The Government have to be clear about how we want the public health profession to look.

That period coincided with advancing knowledge that allowed us to identify the causes of chronic disease and health inequalities. All of those things needed to be tackled as they became apparent. The hon. Member for Blaenau Gwent (Nick Smith) mentioned the Black report, which was published in 1980. It showed that although there had been a significant improvement in health across society, there was still a relationship between class and infant mortality, life expectancy and access to medical services. It is shocking that one could write the same thing today, 31 years on.

That report was followed by the first public health White Paper, “The Health of the Nation”, which recognised that there were considerable variations in health by area, ethnic group and occupation. A new public health agenda was set, and it provided a foundation for action over the past 30 years. There has been a great deal of work, with the best of intentions. I do not doubt the previous Government’s intentions. As I said in my opening remarks, it is important to have some humility and understand that the intent was there. However, we did not get the results that everyone wanted.

We need a new approach, and that is backed up by recent data from the London Health Observatory and from the Marmot review team, which show that although life expectancy is increasing in all socio-economic groups, it also reinforces inequalities. The data also show the variation in life expectancy at birth between men and women and between local authorities, and the pronounced inequalities even within local authority areas including, for example, Westminster, which has the widest within-area inequality gap, at just under 17 years for men: a man born in one part of the borough can conceivably expect to live almost two decades longer than his friend born a short distance away.

I do not apologise for using figures, because when we talk about health inequalities, people glaze over and are not terribly sure what it is about. They think it is something to do with obesity, smoking or something like that, but the figures tell the real story. The smallest inequality gap for men is in Wokingham in Berkshire, at less than three years, and for women the smallest gap is in Telford and Wrekin, at slightly less than two years—so we all know where to move. It is worth repeating that those are the smallest differences in the entire country, so even in the areas with the best outcomes, we are still talking about differences in years.

It stands to reason that a community in Lancashire, for example, might face different health problems from one in Hackney, where I used to work. The public health White Paper therefore sets out a new way of working. It gives a different flavour to how we view public health, looking at our lifecycles and highlighting the points where we can intervene to make a difference. It is a way of working that shifts power away from central Government and into the hands of communities.

We had a short discussion about devolving power, and it is a brave Government who devolve authority for something for which they will be held responsible in the end. That is why I disagree with my hon. Friend the Member for South Norfolk, who said there has been a yo-yo between local devolution and centralised power; there has not. All Governments like to centralise things and keep control, because at the end of the day at a general election they will be blamed or otherwise for what has happened. It is quite brave to devolve power, but sometimes it is the right thing to do.

The new way of working will enable local areas to improve health throughout people’s lives, reduce inequalities and focus on the needs of the local population. The White Paper also underlines the priority we have given to tackling inequalities in supporting the principles of the Marmot review, which is important. The White Paper recognises the value of an approach that sees the importance of starting well, even before a child is born. Life chances are set well before someone pokes their head out into the world.

The new body, Public Health England, will have an important role. It will bring together what I suggest is a rather fragmented system and will span public health; it will improve the well-being of the population, targeting the poor in particular; and it will protect the public from health threats, which have not been mentioned, but they are an issue. There are inequalities in public health threats and, without a doubt, there are inequalities worldwide. Public Health England will need to work closely with the NHS, to ensure that health services continue to play a strong role and that NHS services play an increasingly large part in that mission. There has been a tendency for NHS services to see themselves simply as services to cure an immediate problem, rather than as part of a wider, more holistic approach to improving individuals’ health.

[Anne Milton]

The hon. Lady is right to raise the issue. That is what has happened. On a more general point, cherry-picking is a problem. It is very easy to get certain people to lose a couple of stone—[Interruption.] Actually, sometimes it is quite hard to get them to lose a couple of stone and go down the gym. To be rather crass and non-specific, it is easier to get the middle classes to go to the gym and to eat a better diet.

The hon. Lady is absolutely right to highlight the fact that some areas are very disparate and disconnected. I am an optimist, and I believe that there is social capital. Central Government are very poor at delivering in local areas. I have worked in the most deprived part of the country and lived in the most affluent, and there is a world of difference. It is extraordinary to see—they could be different planets. Central Government is a clumsy tool to deliver something that is very difficult to bring about on the ground, so we must ensure that we have levers and build social capital.

I mentioned health visitors as an example, and a universal health visiting service is extremely important. When we think about hard-to-reach communities, we forget just how hard to reach they are. For some people, the only interaction they have with any health or social service is when they have their baby. Their kids might not go to nursery school or might frequently play truant from school, and they are extremely difficult to get hold of. To be honest, a universal health visiting service is probably the single most important measure we have announced, because it will get hold of those families who are so difficult to reach.

There has been talk of increased health funding. I will not deny that the previous Government put a significant amount of money into health, and I welcome the rather cross-party approach in this debate to acknowledging that that did not always produce returns, certainly not in public health. One problem was that the budget was not ring-fenced, but it will be ring-fenced now. I will return to some points made on ring-fencing and localism and the tension between them. It is important that local government be given the responsibility and freedoms to make a major impact on improving health, backed by ring-fenced budgets.

The right hon. Member for Barking gave an interesting example about the ineffectiveness of one-to-one smoking cessation programmes. More generally, she said that it is extraordinary that we do not drive or back up with evidence what we do in health, which to most people is a science-based discipline with science-based professions. I may have a higher opinion of local government than my hon. Friend the Member for South Norfolk. I think that local government knows a lot about its local area and is often better at dealing with evidence than health services are.

The size of the ring-fenced grant will be important, because when the money was not ring-fenced it was an easy pot from which to pinch. The trouble is that the tabloid newspapers—I hesitate to mention one in particular—do not come out screaming about the poverty of the public’s health, although they come out screaming when services go. It was too easy to pinch the money, which is why it needs to be ring-fenced. It must also be based on relative population health need and weighted for inequalities, so that the areas with the greatest need will get the most.

Directors of public health will lead on action to address health inequalities. Public health physicians have done tremendous work. The public health observatories have done fantastic work, but they have tended to work in a cupboard and do not feel that they are getting their message across. Locating them in local authorities will bring together the threads that influence health, not only health care itself, but other determinants such as housing, transport, employment—the causes of the causes of poor public health, if you like.

There will be financial rewards for progress, and greater transparency so that people can see the results achieved. The new health premium will provide an incentive to reduce health inequalities and reward progress. That does not necessarily mean cherry-picking the easy cases. The programme will be designed to reward instances where progress has been made, and those places that have seen the greatest impact in areas with a poverty of outcomes in reducing inequalities. Almost by definition, those will be the areas where health inequalities are greatest.

[Margaret Hodge]

I understand the thinking behind the incentives and rewards, but my point was about the other side of that coin. Will there be penalties for those high-need areas with huge health inequalities that fail to perform? Although it is good to reward the good performers, that does not help people living in communities where there are bad performers. What are the Government’s intentions on that point?

[Anne Milton]

The right hon. Lady is right to raise that point. I was trying to stress that the healthiest areas will not necessarily be those that receive the most money. In theory, those areas that start from the lowest base should have the greatest opportunity to get those rewards.

Perhaps I can connect the right hon. Lady’s point with that made by the hon. Member for Hackney North and Stoke Newington. This debate is slightly premature because a consultation on the outcomes is currently under way, and we are also looking at the finances, at how much each local authority will have and at the size of the health premium. We are acutely aware—as I am sure are all Opposition Members—of the problem of unintended consequences.

Let us take an obvious example of A and E waiting times. It is right to want people not to wait in A and E for very long, and indeed they did not. If that is given as a target, the health service is good—as are most professionals—and it will fulfil that target. It will get people out of A and E. However, what was never measured was whether people got the care they needed. Did they get better or were they just transferred up to a ward sooner than they should have been? It is important to look at that. To some extent, this matter is a work in progress and we are keen to learn and listen to what people have to say. It is important not to have perverse incentives but to put in place the levers that we need to produce the right results in areas where there is possibly poor capacity, or areas that need building up or contain inequalities.

In some areas there are difficult cultural issues. To return to the issue of domestic violence, sometimes those working in the health service will collude with some of the men who perpetrate that violence. It gets very complicated and we need a system that takes account of all those issues.

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[Margaret Hodge]

I thank both Front Benchers—the Minister and my hon. Friend the Member for Hackney North and Stoke Newington (Ms Abbott)—for their contributions, and I thank you Miss Clark for chairing our debate so well. It is the first time that I have heard the hon. Member for Guildford (Anne Milton) speak as Minister. I am sorry that it is always so difficult to keep other Members in this place on Thursday afternoons. None the less, it has been a quality debate, and I am grateful for the remarks made by hon. Members on both sides of the Chamber. We will return to the subject because, as the Minister said, it unites parties and is of huge importance to the people. I look forward to being able to say, “And we are making progress.”

Question put and agreed to.

Health and Social Care Bill

Margaret Hodge Excerpts

Monday 31st January 2011 Commons Chamber

[Ian Lucas (Wrexham) (Lab)]

Will the Secretary of State give way?

[Margaret Hodge (Barking) (Lab)]

Will the Secretary of State give way?

[Mr Lansley]

In a moment. I have just answered one question.

Why did spending more not deliver better results? We know why that is—[Interruption.] No, better results should have been achieved. Opposition Members need to realise this, because it has been at the heart of their failure in public service reform over the past decade: the Office for National Statistics said a few weeks ago that productivity in the NHS fell in every one of the past 10 years. It fell by 1.4% a year in hospital services.

Despite a huge amount of money rightly invested in the NHS, taxpayers and patients were not getting the service that they should have had. Billions of pounds have also been wasted on an ever-growing bureaucracy, taking money away from the front line and away from patient care. The number of managers doubled under Labour. I give way to the Chair of the Public Accounts Committee.

[Margaret Hodge]

I thank the right hon. Gentleman. He is right to draw attention to the fact that productivity has fallen in the past 10 years, but should he not consider whether it is wise in those circumstances to distract people from driving up productivity and achieving savings by the unnecessary institution of reform? That is just taking people away from the thing that they should be concentrating on.

[Mr Lansley]

The right hon. Lady should understand, as I will go on to explain, that we are not distracting the NHS from the need to improve services for patients. We are enabling the NHS to improve services for patients. In her role on the Public Accounts Committee, she should understand that right across the public services, one of the consequences of dealing with the deficit is that we will have to reduce the costs of bureaucracy and administration.

We will do that in the NHS as much as anywhere else, but we will not do it in the way that the Labour party pressed us to do, which was to cut the NHS budget—[Hon. Members: “What?”] Yes, Opposition Members did exactly that. We will increase the NHS budget. As we set out in the spending review, we will increase the NHS budget by £10.7 billion over the life of this Parliament—investment that Labour opposed—and we are determined to get far more for British taxpayers’ money.

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[Malcolm Wicks (Croydon North) (Lab)]

The status quo in British health care is certainly no serious option. Improving the NHS is, of course, a continuing challenge, not least because of the ageing of our population, rising medical costs in many sectors and rising public expectations, which are sometimes fuelled by information on the internet. If one adds to that the new public health agenda and the need to bring health and social care into better alignment, one can see the scale of the challenge. However, that is not to say that a top-down reorganisation is the answer.

I want to ask Ministers some specific questions about how the Bill will impact on some of the values and underlying principles of the NHS. The first is the principle that the health service should be based on need, not income or wealth, which is perhaps the essence of the NHS. How do the proposals relating to private patients in hospitals relate to that ethical principle? The proposal is to remove any limit on the use of NHS beds and staff to treat privately paying patients. Unless the Government somehow envisage surplus hospital resources, spare staff and empty beds—a far-fetched proposition—will not more private patients create longer waiting times for NHS patients and/or poorer care? What is the Minister’s judgment on that?

My second question concerns the profit motive, which jars, at least for many of us, with the principle of patient care. Will Ministers confirm that private companies might in practice commission on behalf of GPs, possibly including US companies, while other companies will be awarded contracts? Have I understood that correctly? What is to stop companies competing on price for relatively straightforward procedures, perhaps initially cherry-picking as a loss-leader while leaving NHS hospitals with, frankly, the more difficult medical territories? What proportion of the NHS budget might effectively be in private hands? Of the £80 billion annual expenditure that we hear about, what sums might end up as profits for private shareholders? Ministers must have some idea of the answers to those questions, so I would be pleased to hear their answers or guesstimates.

[Margaret Hodge]

Does my right hon. Friend agree that there is another issue with privatisation? If a private, BUPA-run, hospital that provides health care gets into financial difficulties and is forced to close, does it not behove the commissioning body—the publicly run commissioning body—to take over the failing private hospital to ensure that the designated services are available to local people? Is that not an outrageous way of using public money?

[Malcolm Wicks]

Certainly, I can see that the commissioners might feel that someone had to look after the patients, and the financial implications of that pose another question for Ministers.

Given that the Bill allows for the new commissioning board to make payments to a commissioning consortium if performance is good, what happens exactly to that payment? Who benefits from it? Does it go to improved patient care, which is fine, or to bonuses for those working in the consortiums—the GP practices?

My third set of questions concerns accountability and parliamentary oversight. In this brave new world of competition, profits and privatisation, with the fearsome economic regulator, where does the NHS buck stop? Is the Secretary of State still responsible? Is he or she still accountable to this Parliament? If not, who is? If my Croydon constituent has to wait too long for surgery, are Ministers accountable? Can I ask questions? Will I get answers? If constituents cannot access mental health services, can MPs still expect Ministers to intervene and to act? Are they accountable? Will Parliament and public still be able to access the information, the data, the monitoring and the evaluative statistics to comment on performance? Is the publication and integrity of health statistics guaranteed by the legislation?

A further question concerns the relationship between patients and GPs. The Secretary of State and his colleagues wax lyrical about how decisions will now be taken by GPs and patients, and I remember that refrain during the general election, but what exactly does that mean for patients? How will those decisions be taken by patients as well as by GPs? How will patients be involved in commissioning? Will they be part of the commissioning body?

Moreover, will GP commissioners meet in public, like primary care trusts? If not, why not? Where is the accountability? If a patient wishes to complain about services, to whom do they complain—to their own GP, who does the commissioning? Where is the patient’s complaint procedure in all that?

This Bill—[Interruption.] There is no point in the Minister just whispering at me. We have a winding-up procedure, whereby serious questions can be answered— I would hope—rather seriously by the Minister. [Interruption.] She has not wound me up so far.

The Bill is somewhere between a relapse into market ideology and an untried, untested leap in the dark. For the national health service, it is a fearful time. As we have heard, the Government wish to cut public expenditure, yet they are embarking on this top-down reorganisation that no responsible body seems to welcome.

The Bill will also be shown to be a fearful leap in the dark for the Conservative party, just when in recent years it has been making some headway in convincing the British public that the national health service might be safe with it. It is a fearful step for the Conservatives, and they will learn that in the coming years.

--- Later in debate ---

[Margaret Hodge (Barking) (Lab)]

I speak both as Chair of the Public Accounts Committee and as the MP for Barking. As PAC Chair, my concerns have not been allayed by the evidence sessions that we have held on these issues. I do not want to be saying in three years’ time, “I told you so.” I urge the Government to think again before they introduce changes that have not been thought through properly, that are incredibly risky, and that could result in long-term damage.

There has been insufficient focus on the risks of the changes. The NHS chief executive said in evidence that

“the risk is higher. If you try and reorganise, the risk becomes higher. I think we’d be kidding you to say that it wasn’t”.

Making Monitor an economic regulator forces it to concentrate on competition, not quality. Its purpose will be to drive down costs, not drive up health outcomes. If the spotlight is on price, the risk is that patients will lose out. The NHS chief executive agreed in his evidence that lowering tariff prices could endanger patients. Opening the health market to any willing provider will undermine the viability of many NHS foundation hospital trusts, which face immovable fixed costs, such as their private finance initiative costs. Again, that risk has not been assessed properly.

The Government appear to be driven by an ideological mission. The NHS needs pragmatism, not dogma. I fear that there is no firm grip on the costs of reform. The NHS already faces the unprecedented challenge of finding £20 billion of savings and its record is poor. Over the past decade, despite assurances to the Treasury, NHS productivity declined, with hospital productivity declining by 1.4% annually. The NHS should therefore concentrate its efforts on the enormous financial challenge, and should not be diverted by an unprecedented organisational challenge. Quality and productivity, not reorganisation and privatisation, should be the priorities.

[Robert Flello (Stoke-on-Trent South) (Lab)]

My right hon. Friend is making a good-quality speech, as usual. Surely in areas such as Stoke-on-Trent, where the cost of laying people off in the PCT will be tens or hundreds of millions of pounds, the risks that she describes already exist.

[Margaret Hodge]

Indeed, and I was going to come to that point. As I understand it, Ministers have set aside £1.7 billion to finance their reforms, but as my hon. Friend says, if the costs of redundancy are higher than planned, or if people carry on attending A and E rather than seeing their GP, the costs of reform will spiral and front-line services will have to be cut. I am not convinced that Ministers have transition costs properly under control.

Nor has anybody sorted out to our satisfaction the issue of accountability for public money. For instance, foundation trusts are supposed to be directly accountable to Parliament. With 167 trusts accountable to the PAC and the House, if there is financial failure or poor quality of care, will that accountability be good enough? In the past, Monitor could sack the board of a trust, but under the Bill it will lose that power. How can we hold the permanent secretary to account when there is a plethora of new quangos or new responsibilities for quangos? We have to know where the buck stops. I seek Ministers’ reassurances tonight that there will be clear, practical accountability that enables Parliament to hold the Executive to account.

The Government do not have effective plans to deal with failures, and there will be failures—hospitals bankrupt, GP commissioning consortia overspending. Ministers must explain how they will deal with failure, so that local services will be maintained even when trusts and consortia collapse. So far, officials have been unable to provide us with the confidence that we need to feel that the Government have got a grip.

That matter is of particular importance to my constituents. For years, our NHS trust has been in terrible trouble, and last week it was named and shamed by the Audit Commission for systematic failure on its finances. It has failed to balance its books for years, and it has a projected deficit of £29 million this year. The quality of care has deteriorated, too. In the week of the general election, 99% of people at our King George A and E and 92% at Queen’s hospital were treated within four hours. By 2 January this year, that had dropped to 83% at King George and just over 61% at Queen’s. More than 1,000 people were forced to wait for more than four hours, ambulances were queuing around the block and all but the most urgent cases were turned away. In one case, a patient died because she was sent home.

That hospital trust is not fit to become a foundation trust. Despite a stream of new chairs and chief executives, the underlying problems persist. Now, the only answer that NHS London has is to try yet again to close the A and E at King George. That is health vandalism at its worst, with patients’ needs sacrificed at the altar of financial cuts.

What would happen to my constituents under the proposed NHS reforms? King George A and E would go, forcing my neediest and poorest constituents to spend hours on three buses to get to a hospital. Queen’s hospital would become unviable, and what then? Where is the local hospital ready to meet local needs? Who would want to consider merging with a hospital trust struggling with an impossible financial burden, and even if anyone did, would they ensure that our services remained local? The current health care reforms should put the patient at the heart of the NHS, but it does not feel like that is happening in Barking. I urge the Government to think again before they act to damage the health care of the people who need it most, the people I represent here in Parliament.