NHS Bursary

Maria Caulfield Excerpts

Monday 11th January 2016 Westminster Hall

[Maria Caulfield (Lewes) (Con)]

I welcome the opportunity to speak in such an important debate. I acknowledge that the changes affect all sorts of healthcare professionals, including midwives, physios and speech therapists, but I will keep my remarks mainly to student nurses because I am a qualified nurse and have worked in the NHS for more than 20 years—I was even working as a full-time NHS nurse until just after the last general election.

I trained under the bursary scheme. I was one of the second intake, after the scheme was introduced in the early ’90s, so I have first-hand knowledge of how it works. I have met student nurses, the Royal College of Nursing—the RCN—and qualified nurses to discuss some of the issues that the changes raise. I have also met the Minister to express my concerns, and have been reassured that alternatives to a student loan mechanism for entering nurse training are in the pipeline. These might be better than the nurse bursary scheme, and they will certainly be better than the proposed student loan scheme.

Let us not pretend that the bursary system is ideal—I speak as someone who went through that method of training. It started in the early ’90s as a replacement for the old-style nurse training system in which student nurses were part of the workforce and were on the payroll. Let us be honest though, the students were used as a spare pair of hands and often there was not a huge opportunity for them to learn on the job. At that time, there were two ways for someone to become a nurse. They could do a two-year course to become a state-enrolled nurse, in which role they could do only so much, or they could do a three-year course and become a fully qualified state-registered nurse, taking on all aspects of the role of a registered nurse. The bursary scheme, when it was introduced, was a move to make nursing more academic, and to create supernumerary student nurses. Or rather, that is what is supposed to happen. As my hon. Friend the Member for Sutton and Cheam (Paul Scully) pointed out, in practice, student nurses are still used as a spare pair of hands and are rarely supernumerary when they are on placement.

Student nurses were, however, taken off the payroll and the bursary scheme was introduced as a sort of income to acknowledge that, although the students were not counted as part of the workforce, they still had to do a huge number of hours while on placement, including night shifts and weekend and evening work. The bursary was supposed to compensate the students for their loss of income, but a bursary is not a wage, and it certainly does not reflect the number of hours student nurses put in during their training.

Let us not miss the point. Someone can do a three or four-year academic nursing degree, but unless they do the clinical placement hours, they cannot register as a nurse. That is the crux of the matter. In addition, a bursary certainly does not reflect the increase in experience and skills that students gain as they go through their training. A first-year student nurse gets exactly the same bursary as someone who has almost qualified and is practically working—under the supervision of a qualified nurse—as a qualified nurse.

The bursary system undervalues the contribution that student nurses make, and it means that student nurses across the country live on little more than £3,000 a year. The system has changed over time—it was not means-tested when I was doing my training, but it is now. Let us not pretend, therefore, that the system is ideal. The bursary has never adequately supported student nurses, and I welcome the chance to change it. Let us look at other professions. I certainly do not want people sitting in the Public Gallery to suddenly rush out and change profession completely, but a trainee police officer has a starting salary of £19,000 and a trainee firefighter starts on £21,000. Airlines are now moving to in-house training. A new pilot with no flight experience training with British Airways is on £23,000 and Virgin has a similar policy, with Richard Branson saying that he welcomes those with no experience to be part of the Virgin family from day one. Yet for student nurses, who take similar life and death decisions every single day, we propose not just that they work in clinical areas for free but that they pay for their training as well.

I believe Ministers when they say that this is not a cost-cutting exercise, because the money will instead increase the number of student nurse placements. Currently, more than 50% of people who apply to become student nurses are turned away simply because the places are not there in the universities. The RCN’s figures from only last year show that there were 57,000 applications, of which 37,000 were rejected.

[Ruth Cadbury]

Will the hon. Lady give way?

[Maria Caulfield]

I will not, if the hon. Lady does not mind, just because I know that so many Members want to speak.

Although not all of those 37,000 will have been rejected because of a lack of places, a significant number of them will. The current system restricts the number of student nurses that enter the profession so, in theory, the changes should increase the numbers of qualified nurses in a few years’ time. From my clinical practice I know, however, that what works in theory will have the opposite effect in reality.

My main concerns about moving from a bursary scheme to a student loan scheme are, first, that many nurses go into a degree system simply because there is no other way to become a nurse. They do not necessarily want a degree in nursing; they want to be a qualified registered nurse. If we commit to a student loan scheme, we are committing them to take on debt for years to come. As we have heard, many of them—more than 30%—are mature students, and by mature students we do not mean people in their 40s and 50s. They are people in their mid-20s and early-30s. They have young families; they are single mums; and they have a first degree and have to take on a second one just to become a nurse. It is a crazy situation. For someone who already has a student loan, and/or a mortgage and/or childcare to pay for, the thought of taking on more debt will definitely put them off entering nursing, and to say otherwise is madness.

The difference between student nurses and other undergraduates is that the starting salary for a nurse is £21,000. Most nurses will only ever be a band 5 or 6, and the maximum they can earn as a band 6 is £34,000—that is if they do not have a break to have children or go part time for some other reason. They will never be in a position fully to pay off their student loan. Student nurses are different, therefore, from other undergraduates, and that has not been recognised in the debate. An issue in the wider debate about graduates is that a graduate is, on average, £100,000 better off than a non-graduate, but that is not the case with nurses. Other graduates earn, on average, more than £40,000 a year, but nurses do not earn anything like that and that difference needs to be recognised when decisions are made.

We have heard how much time student nurses spend on clinical placements—more than 50% of their course, including nights, weekends and evenings—which makes it almost impossible for them to get any other income from part-time work. We must recognise that. Being dependent on a loan is not a great way of life either, but other students are able to supplement their loans by working in pubs and shops, and doing other evening work. Student nurses are not in a position to do that.

My second concern is that, if I am completely wrong and we suddenly have a huge increase in the number of student nurses, the placements will not be able to cope. To qualify as a student nurse, not only does someone have to pass their exams and essays and do the required hours, they also have to be clinically assessed by a registered nurse—not just any old registered nurse, but someone who has done their mentoring and assessing course. I know that there are student nurses now who struggle to find placements because there are not enough qualified nurses able to assess them. That needs to be taken into account as well. It is not just about increasing the numbers; it is about having the support services in place.

When I met the Minister, I was hugely reassured by what he said about other schemes that are being proposed. My plea is that he outlines those schemes so that student nurses are reassured that, in order to qualify, they will be able to use schemes other than the student loan system. Routes such as nursing associates and nursing apprenticeships are being proposed. I am probably getting a little old now—

[Stephen Pound]

No!

[Maria Caulfield]

I thank the hon. Gentleman for his intervention. Those routes sounds like the state-enrolled nurse or state-registered nurse route again, and they worked pretty well in years gone by.

[Fiona Mactaggart (Slough) (Lab)]

Will the hon. Lady give way?

[Maria Caulfield]

I have almost finished, so I will not take any more interventions. The Minister told me that those routes are alternatives to the proposals that have been put forward today. I urge him to highlight those alternative routes and to give a timescale. If those alternatives are realistic, they need to be in place as the bursary system is phased out, if not before, so that student nurses have choices on how they become nurses. When I was running a clinical team, we used the assistant practitioner role effectively and made some great progress. Some of those assistant practitioners are in the process of becoming qualified nurses themselves.

I have a couple more points to make. One thing that we are missing is a return-to-nursing scheme. Under the proposals, money will be saved from the bursary scheme. Huge numbers of nurses go off to have children or take a break from their career, like me, and they have to do a six-month course and pay for that themselves. An efficient way of building up nursing numbers quite quickly would be to fund return-to-nursing courses, so that we can easily and quickly increase the number of nurses who can get back into the profession. They have huge amounts of experience.

It is hard to be a student nurse. Although it was a long time ago, I still bear the scars of my nurse training. Not only do student nurses have to learn and take exams, but their placement changes every eight to 12 weeks. They go to a new ward, new day unit or new community placement, and they never really feel part of any team. As soon as they start to get that feeling, they are moving on to the next team. They are struggling to survive on less than £4,000 a year and have to rely on family and friends. We are now asking student nurses to take on more debt to do their training. They may or may not come to nursing with a lot of life experience, but they are telling people that either they may die or their loved ones are dying. Student nurses witness death at first hand—sometimes that death is expected and sometimes it is not. They are kept going, however, by the thought that one day they will be a qualified nurse with that bit of paper that says, “You are registered.”

We have an extremely high turnover of student nurses. Many are leaving before they are qualified, and my concern is that, if we add to their financial pressures, the turnover will be even higher. We are spending nearly £12,000 a nurse to recruit from overseas and fill our vacancies, and I would prefer to see that money being used to sponsor nurses to get into their nurse training, whether that is through the associate route, the apprenticeship route, which sounds exciting, or through encouraging and paying nurses to come back into nursing. We need to have that Virgin philosophy, where a student nurse is part of the team from day one. I hope the Minister can give us some positive feedback from the petition.

Oral Answers to Questions

Maria Caulfield Excerpts

Tuesday 5th January 2016 Commons Chamber

[Alistair Burt]

I am grateful to my hon. Friend not only for his question but for previous questions in relation to this area and his obvious interest and concern about it. He is right. Nationally, the numbers of looked-after and abused children in the new prevalence survey—the first since 2004—would be relatively small. We have therefore asked the statisticians to look at different ways of assessing the data and the numbers so that we can address this issue. I hope to be able to report further on that later in the new year after I have had that meeting.

[Maria Caulfield (Lewes) (Con)]

13. What steps he plans to take to increase the availability of nurse training in the NHS.

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

I thank my hon. Friend for asking this question. I can tell her that we have made significant steps. In the past two years, there has been an 11% increase in nurse training places, and I anticipate that that increase will continue this year. We are providing over 23,000 full-time-equivalent additional nurses by 2019. We expect there to be an additional 10,000 nurse training places as a result of the announcements made by my right hon. Friend the Chancellor last year.

[Maria Caulfield]

Speaking as a nurse, I would struggle to undertake my nurse training given the proposed changes to the bursary scheme. I know that the Minister is working very hard on this, but will he outline what additional routes into nursing are planned to help mature students and those on a low income to gain access to nurse training?

[Ben Gummer]

My hon. Friend is right to point out that there are different ways into nursing. Just a few weeks ago, we announced a massive expansion in apprenticeships across the NHS, and I anticipate that a significant number will be for those going into nursing. The new post of nursing associate is a vocational route into nursing via an apprenticeship. In addition, our reforms to bursaries will ensure that there is a 25% increase in funding to recipients, bringing it into line with the rest of the student cohort. That cohort has seen a considerable expansion in the number of students coming from disadvantaged backgrounds as a result of the reforms that we undertook in 2011 and 2012.

Mental Health

Maria Caulfield Excerpts

Wednesday 9th December 2015 Commons Chamber

[Maria Caulfield (Lewes) (Con)]

I want to highlight the importance of preventive work in dealing with mental health issues. I am not saying that my constituency does not need more funding or resources for preventive work or the acute mental health setting, but I want to highlight some good work happening locally already.

In my constituency, Sussex police were, until recently, at the forefront of dealing with those in mental health crisis. For those who do not know my constituency, it is on the beautiful Sussex coast, and I have the picturesque spot of Birling Gap lying right next door to Beachy Head, both of which are suicide hotspots. Until recently, the police, along with the Beachy Head chaplaincy team, had to deal with people standing or sitting on those cliffs contemplating suicide. Since last year, mental health nurses have been out with Sussex police on these and other calls to ensure that people suffering acute mental health crises get the help they need when they need it. Previously, Sussex police were detaining more people under the mental health legislation than any other police force. They had no other way of looking after those people. That was far from ideal, because a prison cell, rather than a hospital bed, is not conducive to supporting vulnerable adults.

I ask Opposition Members, therefore, to look at some of the great work being done. I am not saying we do not need more funding and resources, but there is some great work being done in the field of mental health.

Palliative Care

Maria Caulfield Excerpts

Wednesday 4th November 2015 Commons Chamber

[Maria Caulfield (Lewes) (Con)]

I am pleased to have secured this debate tonight on the important topic of access to palliative care for those who are dying. There are three key reasons why this debate is so timely and so important. First, it follows hot on the heels of the assisted dying debate that we had here on 11 September. No matter how Members voted, there was cross-party support for the movement for better access to palliative care in this country. Secondly, it is an important subject because from my experience as a cancer nurse working in one of the best cancer units not only in the country but in Europe, I have seen at first hand the difference that good palliative care can make, not just to patients and their families at the time of death, but in the last few weeks and months, making patients’ lives as fulfilling as possible.

Thirdly, the debate is important and timely because it fits in with the discussion of the Access to Palliative Care Bill in the other place. That Bill aims to ensure that wherever people are in the country and whatever disease they are suffering from, palliative care services are available to them. It would put palliative care services into the mainstream for the many, not the few.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I congratulate the hon. Lady on securing this debate. Should we not see palliative care in its broadest sense, including medical care as well as social care? That co-ordinated approach could make end of life far more tolerable and would mean that people had to go into hospital to a far lesser extent.

[Maria Caulfield]

I agree, and I will highlight that point later in my speech.

For me, palliative care is about support and services that help to achieve a good death and underpin the care in someone’s final weeks and months of life. What happens now is that all too often the provision of palliative care is distributed on the basis not of need but of availability, and depends on the diagnosis, where the person is treated, and sometimes even their age, leading to a patchy and ineffective service. We heard during the Adjournment debate on Monday night about the impact of not having good bereavement services, which stays with relatives not just at the time someone dies but for years afterwards, and may never go away if they have had a bad experience.

This patchy service continues despite all the hard work in recent years reviewing palliative care provision across the country. As far back as 2008, an end-of-life care strategy was produced, and in 2011 the National Institute for Health and Care Excellence produced quality standards, yet palliative care services remain patchy. To highlight that further, let us look at a few more statistics.

Unfortunately, we know that 100% of us will die eventually, and that three quarters of those deaths will be expected. That means that three quarters of the population could benefit from palliative care, but currently only 48% of people who have palliative care needs receive palliative care support. Of the 500,000 deaths that occur in this country every year, 82.5% are among the over-65s, yet fewer than 15% of that group have access to palliative care. That tells us that those who need it most often have the hardest job accessing it. For older people, death is often seen as inevitable and not something that palliative care should be helping with.

More shockingly, between 50% and 70% of people who are dying say they would like to die at home, but only 30% actually do. Most people end up dying in hospital—just over 50%. Hospitals are amazing places, but they are acute settings helping to deal with urgent and emergency cases. While they do need to do more to provide better palliative care, we need to invest in our excellent hospice movement and facilities so that if people want to die in a hospice, they can. We also need to support our community outreach programmes so that if people want to die at home, they can have that choice too.

[Jim Shannon (Strangford) (DUP)]

The need for palliative care always comes at a time when people and their families are feeling vulnerable. The importance of charities and Churches at that time is something that we all know very well. The hon. Lady referred to hospice care groups and organisations. Does she agree that their role should be recognised more by Government and by the authorities so that they can take better advantage of hospice care and do better for those people through it?

[Maria Caulfield]

I thank the hon. Gentleman. I absolutely agree. That point is picked up in the Bill.

The most shocking statistic concerns the diseases that people are suffering from. The London School of Economics says that 92,000 people a year miss out on palliative care help. At the moment, 88% of our palliative care provision goes to people with cancer. As a cancer nurse, I am certainly not saying that that needs to be reduced, but the majority of deaths are due to other diseases. Only 29% of people die of cancer, with 28% of deaths due to heart disease, 15% due to respiratory illnesses, 10% due to stroke, not to mention Alzheimer’s disease, motor neurone disease and multiple sclerosis. Until we ensure that palliative care provision is mainstream, and not just for patients with cancer, the majority of people will be denied access to a good death.

The Bill introduced in the other place comes up with solutions to resolve this situation and place the responsibility firmly in the hands of local clinical commissioning groups to ensure that all patients, no matter where they want to die or what disease they have, will get access to palliative care services. That will take the pressure off existing acute facilities that are currently having to provide them. The Bill makes some key practical proposals. The first is about the ability to admit people directly to palliative care facilities. This happens really well in a lot of places, but it does not happen everywhere. That goes back to the point made by the hon. Member for Strangford (Jim Shannon) about investing in our hospices to ensure that it can happen more widely. The Bill talks about support for healthcare professionals in all settings, so that whether they are an intensive care unit nurse or someone who works with motor neurone disease, they have a signposted facility to access specialist palliative care that helps them to help patients manage their symptoms.

The Bill fits very firmly into the Government’s seven-days-a-week NHS in calling for the availability of seven-days-a-week palliative care services. As I know only too well, it is at 4.30 pm on a Friday that a patient will phone up in pain and say they cannot cope, when pharmacies are closed and it is possible to get a prescription but not a drug. Someone who is breathless and needs a chest drain often has to wait until the Monday morning, in the meantime being admitted to A&E or a medical assessment unit and then finding it very difficult to be discharged to go home. This is why we need a seven-days-a-week palliative care service.

The Bill calls for some really basic things that should exist now but do not, such as sufficient equipment for our community services. It is unbelievable that a ward nurse who wants to discharge someone with a morphine pump cannot do so because the pump belongs to the hospital. Unless the community has a spare pump, that patient will not go home. That is why only 30% of people are dying at home—they are stuck in hospital because communities do not have the necessary equipment to look after patients. There are shortages of mattresses and feeding pumps, which would make a crucial difference if they were available.

[Sarah Champion (Rotherham) (Lab)]

I congratulate the hon. Lady on calling this debate on such an important and often overlooked issue. I support what she is saying 100%, but does she agree that it is not just the NHS, the community and the charitable sector that need to join up? Joining up health and social care would enable the seamless transition she is talking about.

[Maria Caulfield]

Absolutely. I am touching on some of the Bill’s highlights, but we also need to incorporate social care, because that is often the kind of support that carers need in order to be able to look after relatives.

The Bill also highlights the fact that medication is not available at all times. I know only too well that if a patient’s pain needs to be better controlled, they can get a prescription but they cannot get the drugs on a Saturday or Sunday or during the night. Once again, they are admitted to A&E for help in managing their pain. That is not acceptable.

Practical solutions are available to enable people to choose where they want to die. I was disappointed by the response of Lord Prior of Brampton in the other place when he dismissed the Bill so easily by saying that we did not need to legislate for good palliative care. I strongly disagree. If we can legislate for a charter of budget responsibility, which I strongly supported because it is important for this country to run a surplus, and if we can legislate to freeze VAT and national insurance because that is also vital to this country, and to charge 5p for every carrier bag, why can we not legislate to provide good palliative care for every person who needs it?

I urge the Minister to consider the Access to Palliative Care Bill, which is currently going through the other place, as a way to improve access to palliative services and to support patients, families and NHS staff.

[Mims Davies (Eastleigh) (Con)]

On legislation, does my hon. Friend agree that it gives us as individuals and families the opportunity to start thinking about the unthinkable, to improve the process and to shape the palliative care we will want in the future?

[Maria Caulfield]

I completely agree with my hon. Friend. We need to make death a normal part of life, but until palliative care is available to everyone it will still be seen as something that happens in dark corners in hospitals, when it should be happening at home.

The NHS is supposed to be there from cradle to grave, but this country is not getting death right. People are going abroad to commit suicide because they cannot face a natural death. We are doing something fundamentally wrong. I therefore ask the Minister to consider legislating on access to palliative care. Years of reviews have not solved the problem. With 100% of us facing death, we need to ensure that end-of-life care is treated as a priority.

Access to Medical Treatments (Innovation) Bill (Money)

Maria Caulfield Excerpts

Tuesday 3rd November 2015 Commons Chamber

[Dr Whitford]

Of course the Bill is well intentioned, and its title will attract support from people who think that it means getting access to drugs to which we do not currently have access. It is not that any doctor can prescribe anything—we cannot. We can prescribe drugs that are licensed and recognised, and have a basic safety profile. In Westminster Hall we often debate access to expensive, innovative, brand-new treatments, but that is not about our right as a doctor to prescribe them; it is about who will pay for them because some of those drugs are expensive. As the Minister has said, that would still be an issue. In what sense would a commissioning group have evidence to allow a doctor to prescribe a drug that has absolutely no basis, but that would have to be funded?

The Bill is basically a bit of a mess. What problem is it trying to answer? People think it means that they will get earlier access to new drugs, but drugs should be taken forward on the correct path to protect patients and doctors. Doctors need to know that what we are doing is right, and not some random thing that has been on a database after somebody tried something once and it seemed to work. We know that there are placebo and random effects.

[Maria Caulfield (Lewes) (Con)]

I support everything the hon. Lady has just said. I was a research nurse in cancer care for more than 10 years. We observed good clinical practice standards, and the standards of the Medicines and Healthcare Products Regulatory Agency and the FDA, because mistakes happened. Those safeguards are in place for a reason. The No. 1 reason is to protect the patient.

[Dr Whitford]

I did my MD thesis in the late ’80s on the use of monoclonals in breast cancer, which was then totally blue-sky thinking. What became Herceptin was found at that time. I remember speaking at a conference in America where people presented their research. At that time, they thought they had to put a toxin on the back of an antibody to make it work. They were using ricin, which was used in the Bulgarian umbrella murder, and—surprise, surprise—almost all their patients died. They got around that in America by going to Mexico and to prisons. It is not the case that everything a doctor thinks might work will be good for patients. We have developed a safe system over decades and we give it away at our peril.

NHS (Contracts and Conditions)

Maria Caulfield Excerpts

Monday 14th September 2015 Westminster Hall

[Helen Jones]

We made our policy quite clear in the last Parliament. In particular, we opposed the Government’s decision to curb 1% pay increases for NHS staff who were gaining increments. The hon. Gentleman really has to think about this: if there are fewer and fewer nurses in our hospitals—in particular, employment in the most senior grades is down by 3%—and we are spending millions on agency staff, something is going badly wrong. Hospitals are being forced to recruit nurses from abroad or spend on agency staff when we have thousands of people in this country who want to train as nurses but simply cannot get the training places that are available.

[Maria Caulfield (Lewes) (Con)]

Will the hon. Lady give way?

[Helen Jones]

In a moment. I want to make a little progress and finish this point.

That is a false economy. I make no criticism of the skills of the nurses we recruit from abroad, but it—

--- Later in debate ---

[Helen Jones]

I am grateful to the hon. Lady for reading that out, but I referred to nurses in hospitals. The number of nurses working in hospitals has fallen under this Government, particularly in the top grades. The failure to train and recruit enough permanent staff is putting a great strain on those staff already in post, who are having to deal with agency staff all the time to make sure that they know how things work in a particular hospital or ward. That does not offer continuity of care for patients.

[Maria Caulfield]

I declare an interest as a former NHS nurse—in fact, I still work as a nurse. I do not want to be political about this, because I want progress to be made on supporting the NHS, and particularly staff, but one of the single biggest factors in demoralising nurses and leading many skilled nurses to leave the practice was the last Labour Government’s change to the skill mix. That was crucial, because we were forced to cut our budgets, particularly on the wards, and junior nurses were left in charge of wards, instead of experienced senior staff nurses and sisters—

[Valerie Vaz (in the Chair)]

Order. I remind Members that interventions should be brief.

[Maria Caulfield]

Can I just say that it is the change to the skill mix that has demoralised nurses, and that did not happen under this Government?

[Helen Jones]

I am afraid that I do not agree with the hon. Lady. What has demoralised most of the nurses I see is the cuts they have to cope with day in, day out, as well as the shortage of sometimes even basic equipment and the—

--- Later in debate ---

[Helen Jones]

Yes. I thank the hon. Lady for that useful suggestion. I will do so.

People who are admitted to hospitals at the weekend are much sicker than those admitted on weekdays, because we do not have elective admissions at the weekend.

[Maria Caulfield]

Does the hon. Lady have any suggestion as to why people are sicker at the weekend? Is it perhaps because they have been unable to get hold of their GP in the evenings or on previous weekends?

[Helen Jones]

I have just said the Government should publish their research and delve deeper into the figures. [Interruption.] Look, the hon. Lady knows that people admitted at weekend are, overwhelmingly, emergencies. That is the point. Their death rates cannot be compared with death rates on weekdays, when there is elective surgery—that is a basic point, which she needs to grasp.

If the Government really believe these things are happening, they need to find out why. As I understand it, death rates are taken over 30 days, so someone can be admitted on a Sunday and die 28 days later, on a Thursday. The Government need to prove cause and effect before they can make the link between admissions at the weekend and death rates. So far, however, we have not seen that from them.

--- Later in debate ---

[Paul Scully]

In his King’s Fund speech, the Secretary of State talked about working with professionals, including the British Medical Association and other organisations, throughout September. That example is why we need to keep the dialogue going. I have seen nothing substantive in speeches by Ministers to pitch them into conflict with the vast majority of NHS staff. It is about change management. Change is always difficult, but change we must do. We can achieve much more together.

[Maria Caulfield]

Does my hon. Friend agree that staff morale has been an issue for decades? I worked in the hospital in his constituency during the previous Labour Government, and what demoralises staff most is the NHS being used as a political football. Opposition Members are screaming, “We have found data!” But it is not their data; it is patients’ data and the staff’s data. We need to work together. I commend my hon. Friend for saying that we need to work together and stop using the NHS as a political football.

--- Later in debate ---

[Maria Caulfield (Lewes) (Con)]

Thank you, Ms Vaz, for giving me the opportunity to speak in this debate. I am a passionate supporter of a seven-day-a-week national health service. That might take many formats; it is not a one-size-fits-all situation, so what works in my constituency might be different from what works in someone else’s.

I will not repeat what many of my colleagues have already said, but I think that we need an honest debate. There are difficulties to get over; my hon. Friend the Member for Totnes (Dr Wollaston) in particular has described them. We will have to work together and compromise on certain things, but if we do not debate the issue and find a resolution, patients will die from lack of access to good out-of-hours care. We need to tackle it. To be 16% more likely to die just because of the day of the week one is admitted to hospital is not good enough in this day and age.

However, it is not just about the impact on patients and their relatives; it is also about the impact on staff. Tribute has rightly been paid in this debate to staff, senior consultants and doctors who work long hours and come in at weekends. Many of them do so unofficially because they are dedicated, but I want to represent staff who work out of hours because it is part of their contract. I have been a nurse for more than 20 years. I have worked in the community on weekends, when patients without access to a GP have needed painkillers or an urgent dressing and it is difficult to get hold of a doctor. I have been in charge of wards on weekends and nights, when patients tend to be sicker because as medicine has progressed, patients who are well are often discharged earlier, so those left in hospital are often sicker than they would have been a decade ago.

Along with the reduced skill mix that I highlighted earlier, the pressure on nurses, healthcare assistants and other ancillary staff is huge. Two or three staff on night duty with a poorly patient who is septic might have one doctor on call handling four or five other wards, who might have 10 admissions that night to see to first. The staff will have expanded their skills so that they can cannulate the patient, take their bloods and send them off to the labs, but that is the limit of what they can do. It is hugely stressful. I know from having been in charge of a team of nurses on nights how difficult it can be.

That cannot continue. It is not good for patients—we know that their mortality and morbidity rates get worse—and it is not good for staff or for their morale. I have seen nurses in tears after a busy night shift during which we could not care for a patient the way we should have, because we had no access to senior medical advice. Yes, it is possible to phone the consultant on call and have a chat with them, but nothing beats having the advice of an expert who can interpret an X-ray or blood results and who can help junior medical staff prescribe the right antibiotics.

A great example introduced in the past couple of years is the acute oncology service, which has transformed out-of-hours care for cancer patients. As a sister in a research unit not far down the road, I know what a difference that has made to my patients. For some reason, patients tend to get really poorly at half-past 4 on a Friday afternoon, come what may. I have been so pleased with that service, which is now available up and down the country and offers trained senior nurses, doctors and a whole team of people who can assess a patient and get treatment going. For conditions such as sepsis, it is life-saving. Those with spinal cord compression can have a scan urgently and be started on steroids straight away. That is the difference between a patient being able to walk during the last six months of their life and being bed-bound.

That is out-of-hours care at its best, but of course difficulties and contentious issues will arise when renegotiating contracts. It is not just about consultants and senior staff. Proper out-of-hours care will require support services such as radiologists, radiographers and pharmacists. My hon. Friend the Member for Banbury (Victoria Prentis) spoke about the perfect week; I could talk to hon. Members day in, day out about how many patients we kept in hospital over the weekend because we could not access drugs to send them home. That is not a great use of hospital resources, but more importantly that is not a great experience for patients and their relatives.

Support services make a huge difference, but my plea is that we do not use the debate as an opportunity to score political goals. We have to work together. If we do not work cross-party on this, we will be here in 10 years’ time. Patients will lose out and their families will lose loved ones if we do not make a difference. It will not be easy. Nobody will be happy about working different hours. We are not asking people to work more than 40 hours a week; we are just asking people to work differently. We are not even just talking about how we work, but about a systems change in the culture of the NHS, so that the patient at half-past 4 on a Friday afternoon does not think, “What lies ahead for me this weekend?” I urge hon. Members on both sides of the House to be as constructive as possible.

[Helen Jones]

I am grateful to the hon. Lady; she has been most generous in giving way. She says that she is not expecting NHS staff to work more than 40 hours a week; did she mean to say that? Many of them already work more than 40 hours a week. Is it now Government policy that no one in the NHS should work more than 40 hours a week?

[Maria Caulfield]

The hon. Lady is being disingenuous.

[Helen Jones]

Answer the question.

[Maria Caulfield]

Of course. I have worked more than 40 hours a week; many staff do. We are not asking staff to work more hours—we have been very clear—but we are asking staff to work differently. I do not think that there is anything wrong with that if it provides a better service for the patient and takes the pressure off those front-line staff who are without radiology support, laboratory support and senior cover support. I ask the hon. Lady to support the measures and work with us, so that we can work with healthcare professionals to achieve that. They need senior support out of hours, because they need someone to interpret test results, make decisions to discharge a patient and break bad news when results are not good, and they need senior expertise to refer to others to move the process forward. My plea is that is we all work together.

I welcome the debate this afternoon. It is good to have it. I am pleased that healthcare professionals flag up issues, because I do not want policies to be steamrollered in, as they have been in the past, and for us to sit here 10 years later reaping the results. I welcome the seven-day-a-week initiative and the move to change the culture and the system, so that ultimately patients see improvement in patient care.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I declare an interest: I am a doctor and member of the British Medical Association, and I still work in the hospital.

We are talking about data showing that people admitted at the weekend are more likely to die within 30 days than those admitted on weekdays. It is important to listen to what Bruce Keogh said, which is that it would be misleading to assume that all of those deaths could be prevented. We use terms as if the deaths were avoidable or talk about people “dying unnecessarily”, but we do not know. We must understand what the data show. There is nothing wrong with the data and nothing that can ever be bigger, because the NHS is the biggest single health service in the world. Professor Freemantle has done the work twice and the pattern is there, but it is not people dying at the weekend; it is important to realise that his data show the reverse. They show fewer people dying on a Saturday or Sunday then dying on a Wednesday. What is higher is the number of people who are admitted, and we need to understand that. As the hon. Member for Totnes (Dr Wollaston) said, they are sicker people. On a Saturday, there are 25% more people in the most ill category and on a Sunday there are 35% more people in that category.

[Mrs Cheryl Gillan in the Chair]

It was said that there was an increased number of deaths among elective patients admitted on a Sunday, and people wondered why that was. As a surgeon with a Monday list, I can say that the norm now is that patients come in on the morning of surgery. So, for me to get permission for someone to come in on a Sunday, let alone a Saturday, means that that person has complex co-morbidity. If we are simply looking at additional populations, we cannot simply use a broad sweep and assume that all of this can be changed, because it cannot be; these people are inherently more ill, whether they are elective patients or emergency patients. Those data are absolutely there and they remain when we re-analyse them or try to balance them, so this issue needs to be tackled.

There are a few myths going around, including the idea that the opt-out clause is a major barrier. The opt-out clause that was cited was for routine work. Consultants do not get to opt out of emergency work at night or at weekends if they work in an acute service. If a consultant works in a service where acute provision is at all relevant, that acute provision is part of what they do and they do not get to opt out of it. Nine out of 10 consultants work out of hours and the other 10% are engaged in specialties for which there is not an acute service.

There has been talk about getting people to work for only 40 hours. My colleagues who are still up the road holding it together work for 48 hours and they simply cannot work more than that because it is illegal under the European working time directive to do so. Most consultants within the acute system work 48 hours a week, and I am sure that those of us who are married to them or simply aware of them will be well aware of that fact; indeed, we will have been told that in no uncertain terms in the last few months.

It is important that we focus what we do on trying to save the lives of those among those 11,000 people who can be saved. When I was a junior doctor, I was aware that getting scans out of hours or at weekends was very difficult, and so patients hit “pause” for a few days. I do not think there is that much difference in services; I find it hard to believe that there is. In Scotland, the situation has been changing for five or 10 years, not by threatening or cajoling people but simply by evolving. Our consultant radiologists cover the entire weekend; our stroke patients get CTs; and our heart attack patients go straight to get angiography, will get an angioplasty there and then, and will go home after breakfast the next morning. So this idea that we have big tracts of those in medicine sitting home watching “Coronation Street” is not true.

The NHS will be cash-strapped; it has to save £22 billion per year in the next five years, which is a big challenge. So now is not the time to say, “We can provide GP services eight to eight, seven days a week.” The pilots have not been successful. The uptake was 50% for Saturday and 12% for Sunday, and some of those pilots reported that there was great difficulty in covering the out-of-hours GP service, which people who feel unwell should be going to, because what was being talked about was totally routine.

Both in hospital and in primary care, we need to focus our attention on improving the access for people who feel unwell, which includes people being able to access a GP and not having to go to A&E with something that means they do not need to be there. That is recognised within the profession, but it is important for people to work together towards that aim rather than pulling out the pin and throwing a grenade at somebody, which is obviously how the profession regards what has happened during the summer. Like many people in Westminster Hall today, I was inundated by messages from colleagues, including from doctors south of the border who I do not know at all. They were very angry at the statement on 16 July that senior doctors do not work outside 9 to 5, which is patently not true.

We need to look at what we should do about these figures. One of the groups that shows the effect of this situation very strikingly is stroke patients. However, research by Bray looked at 103 stroke units, including units where there was seven-day consultant review through the day, and compared them. There was absolutely no difference between that seven-day service and units where there was a routine ward round and no ward rounds at the weekend. What made a significant difference was the ratio of fully trained registered nurses to patients. When that ratio was halved, so that there were twice as many nurses, the mortality was reduced by a third. So, before we go rushing into policy, even if we are working cross-party it is important to understand the data sufficiently to answer the question, “Do we need more doctors or do we actually need more nurses?” That is a pretty important question to answer before any moves are made.

It is also important to focus on the emergency side. People say, “Well, Tesco is open 24/7”. Actually, it is not open 24/7 totally. People will not find the fishmonger 24/7; the baker will not be making fresh bread; and there will not a butcher producing fresh cuts of meat. It will be the basic system that is open 24/7, so let us not confuse matters. And frankly, we can generate a person to work in Tesco, stacking shelves or operating the till, an awful lot quicker than we can create a GP, which will take 10 years because there are five years of medical school and then five years of training, or a consultant, which requires five years of medical school and—in my time—about 15 or 16 years of training.

There is no quick fix for this situation and we cannot afford to take on extra staff, but actually the money would be the easiest bit because we do not have the extra staff. The Government talk about 5,000 extra GPs and yet the British Medical Association shows that we will lose 10,000 GPs in the next five years. That means that we would need 15,000 GPs, and we simply cannot produce that number. So we need to ensure that we hang on to all the doctors we have, including the junior doctors, because that partly comes down to what those junior doctors see, including how they see their seniors working and what they think of that as a career. I say that because junior doctors have always gone to places such as Australia but they used to come back; now they are not coming back.

This whole matter could have been handled better, but the issue is working with people. The Scottish Government are also working towards seven-day cover, but they have been very clear that what they are talking about—the priority within that system—is seven-day cover for people who are ill. That means expanding the out-of-hours service for GPs and expanding what is available to us as senior doctors inside hospitals. That is the route that must be followed, and not the use of a grenade.

After the Francis report and the increase in the number of nurses being taken on to try to get the figures that are sought, what we had at the beginning of the summer was trusts that are struggling being told, “Cut back. Don’t use agencies. Don’t replace people unless they’re absolutely crucial.” We need to give serious thought about whether it is actually more nurses that we need before we rush in to bring in a whole lot—

[Maria Caulfield]

I welcome the hon. Lady’s thoughts and agree with a lot of what she has said. On the issue of nurses, does she agree that it is not just the number of nurses that matters but the skills mix? Because of budget constraints, what has happened over the past two decades is that the skill of senior nurses has been cut back, and those senior nurses are now often not on duty at nights and weekends, which has made a crucial difference.

[Dr Whitford]

I made the point that Bray’s paper talked about registered nurses—so, degree nurses—and that reflects the skill mix.

We need to know what the actual problem is rather than just running in and throwing ideas and policies around. Attacking staff who work very hard and for really long hours is not very fruitful. We need NHS staff to believe in the political decisions, the guidance and the direction being taken in the future, so I simply suggest that everyone in this House look at the way forward.

NHS Reform

Maria Caulfield Excerpts

Thursday 16th July 2015 Commons Chamber

[Mr Hunt]

We have big plans to recruit and retain staff, and those are being worked up by Health Education England. We think that we will need extra doctors to deliver seven-day care, just as we will need more GPs. We think we can afford that within the extra £10 billion that we are putting into the NHS, and we are ensuring that all the numbers add up. I am sure that I will inform the House once we have come to a conclusion.

[Maria Caulfield (Lewes) (Con)]

I declare an interest as an NHS nurse. Does the Secretary of State agree that the UK has one of the worst one-year cancer survival rates compared with the rest of Europe, with one in five cases being diagnosed as an emergency admission? Having a prompt diagnosis is very important. A seven-day-a-week service would be a major step forward, because patients should be seen when clinically indicated, not when indicated by the calendar. With a seven-day service they will be seen more quickly and be less poorly. Not only will that save money but—more importantly—it will save lives.

[Mr Hunt]

Absolutely. May I say how pleased I am to welcome my hon. Friend’s experience to the Conservative Benches? It makes a big difference. She is absolutely right. NHS England will be saying more about how we intend to deal with the problem of late diagnosis of cancer, which is critical if we are to improve our cancer survival rates. One point that links to the announcements I have made today is better collaboration between senior cancer consultants and GPs. If GPs are to be able to spot cancers earlier, they will need to link into the learning they can receive through closer contact with consultants and hospitals. That is something we need to think about.

Oral Answers to Questions

Maria Caulfield Excerpts

Tuesday 7th July 2015 Commons Chamber

[Mr Hunt]

What I can assure the hon. Lady is that we inherited deep-seated problems in the old South London Healthcare Trust and we have dealt with them. We have more doctors and nurses looking after her constituents, and care is getting better as a result of the difficult decisions we have taken.

[Maria Caulfield (Lewes) (Con)]

T2. Part of my constituency is served by Eastbourne District General Hospital, which is run by East Sussex Healthcare NHS Trust. The trust was recently deemed “inadequate” by the Care Quality Commission. Residents are obviously concerned, and both East Sussex County Council and Polegate Town Council have gone on record as saying that they have lost confidence in the hospital’s management. Will the Minister look into the matter urgently, in order to reassure my constituents?

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

My hon. Friend has been an extremely active champion of healthcare services for her local community, and I congratulate her on continuing to raise this matter. The CQC is due to publish the findings of its latest inspection of the NHS trust shortly, and we expect the trust to work closely with the regulators to deal with the concern that has been expressed. I know that there is concern locally, and I believe that Polegate Town Council will be discussing the matter soon.

A&E Services

Maria Caulfield Excerpts

Wednesday 24th June 2015 Commons Chamber

[Mr Reed]

My hon. Friend is absolutely right. Stoke deserves better, and no one has worked harder than him to ensure that it gets something better. Let us ensure that the Minister answers those points.

The understaffing crisis represents a dire situation that will only get worse unless the Government demonstrate an understanding of these issues and give them the attention that they deserve. We know that, as well as deficits this year, the“Five Year Forward View” is based on assumptions that the NHS can save £22 million by 2020. Will the Minister assure us that this will not result in any fewer medical staff or cuts to hospital or community services? Will he also commit to placing the analysis and the assumptions behind the efficiency plans in the public domain so that we can have an informed and honest debate about NHS funding? We do not want a programme of services being set up to fail and then being cut by stealth.

[Maria Caulfield (Lewes) (Con)]

I worked as a nurse under the previous Labour Government. That Government may have kept numbers the same, but they reduced the skill mix, which greatly affected the safety of patients both on wards and in out-patient facilities. Can the hon. Gentleman explain that?

[Mr Reed]

It is a matter of fact that we increased nursing numbers. The hon. Lady will be well aware that when we came into office in 1997, we were training 15,000 nurses a year, and when we left office in 2010, we were training 20,000 nurses a year.

On social care, under this Government, 300,000 fewer older people are getting the care they need, with more and more people being forced to stay in hospital. But that is only part of the story. When someone who needs care cannot get the help they need, it increases the risk that they will struggle or fall ill and have to go to accident and emergency. That is clearly demonstrated in the increasing number of older people arriving at A&E by ambulance. Almost 100,000 extra patients over the age of 90 were brought to accident and emergency by ambulance last year. That is an indictment of Government policy towards older people, and the problem is further exacerbated when the true scale of the damage to social care is revealed.

Before the election, the National Audit Office published its report on the impact of Government cuts on local council budgets. The report found that 40% of the total savings between 2013-14 and 2014-15 were made through reducing adult social care services.

The Association of Directors of Adult Social Services has calculated that a further £1.1 billion will be cut from adult social care over this financial year, and the president of the association said:

“Short-changing social care is short-sighted and short-term.”

The number of patients ending up in A&E because they cannot get the care they need to help them stay healthy outside hospital is clear evidence of this short-termism.

Cutting the social care budget is clearly a false economy, as thousands turn to A&E as a result. That is bad not only for the patient, but for the taxpayer. If a patient is not getting the care they need, their condition will deteriorate, which means that more complex interventions will be needed. A recent poll commissioned by the Care and Support Alliance found that nine out of 10 GPs believe that deep social care cuts are responsible for the overcrowding in our accident and emergency departments. The Government need to get a grip and address the crisis in social care in order to relieve the pressure on A&E departments and GP surgeries. Instead, they have chosen to risk putting more pressure on the heath system at all levels by announcing further cuts of £200 million to the public health budgets of local authorities without any idea of whether they can be made without harming vital services—services that potentially save money.

--- Later in debate ---

[Maria Caulfield (Lewes) (Con)]

I congratulate the hon. Member for Dewsbury (Paula Sherriff) on her eloquent maiden speech. It is great to see another strong woman in the House.

I am mindful of the time constraints in the debate and, although I would love to talk about GP access and hospital finances, I shall concentrate on accident and emergency targets and, in particular, the target of 95% of patients being seen within four hours. I speak as a nurse who has worked in A&E under the last Labour Government when the four-hour target was introduced. I hope that my clinical experience will be used to inform the debate and take it forward.

I want to make four key points on A&E targets and the four-hour wait. First, like the hon. Member for Central Ayrshire (Dr Whitford) and my hon. Friend the Member for Totnes (Dr Wollaston), I am not a fan of targets. As a healthcare professional, I found them increasingly frustrating. They are great as a tool, but they are being used as a political stick with which to beat healthcare workers and the system. There was no clinical rationale for choosing the four-hour target. There is no evidence that the morbidity or mortality of someone who waits for four hours and 30 minutes is compromised. Similarly, there is no evidence that the healthcare received by someone who has waited for three hours and 30 minutes is any better than that received by someone who has waited for four hours. The four-hour target is actually not that helpful.

[Karin Smyth]

Will the hon. Lady give way?

[Maria Caulfield]

I will not take any interventions owing to the restriction on time.

I shall give the House an example. When I worked as a nurse in A&E—under the Labour Government—an elderly gentleman was brought in during a busy night shift. He had fallen at home and broken his hip, and he was put in a corridor to wait. After three hours and 30 minutes, he called me over, saying, “Nurse, I desperately need to go to the toilet.” I had nowhere to put him. The best thing I could do was to wheel a curtain around his trolley, and there, in the middle of a busy hospital corridor, that elderly gentleman with war medals on his chest went to the toilet. He was seen within four hours. That box was ticked and he was deemed to have had good healthcare, but I was not particularly impressed with that care. Let us not kid ourselves that meeting that target always means that the patient experience is good or that the outcome is any better.

My second point, which relates to my worry that this debate is being used as a political football, is that the four-hour target is not being seen in the context of the bigger picture. Other targets show that, even with the increased numbers attending A&E, more and more patients are getting their treatment within four hours. Similarly, the clinical outcomes—surely the most important factor—relating to diseases such as heart attacks show that morbidity and mortality rates have improved. There have also been better outcomes for people who have had strokes and for trauma victims. So outcomes for patients are improving despite the four-hour target not having been met during the past 100 weeks. We should welcome that and congratulate our NHS staff on achieving it.

Thirdly, if this is a serious debate about A&E services throughout the whole of the United Kingdom, which we are surely all here to represent, why are we not looking at the rate in Scotland of only 87%, in Labour-run Wales of 83% and in Northern Ireland of 79%? This debate is a political one, and as a healthcare worker, I find that distressing. It is interesting that those Members who have worked in the NHS believe that the four-hour target is a useful tool but that it should not be used as a political stick.

[Dr Philippa Whitford]

I would like to know where the hon. Lady got her figure of 87% from. Our figure is 92.6%, and we measure it every week.

[Maria Caulfield]

I was given the figure by the Nuffield Trust.

[Dr Whitford]

Not by the NHS?

[Maria Caulfield]

It is an NHS figure.

I shall attempt to move the debate forward with my fourth point. If we are serious about tackling the issues resulting from the number of patients using A&E services, we need to acknowledge that 15% of patients who go to A&E could receive treatment elsewhere, in local community facilities. We need to look seriously at the Government’s proposals for seven-day-a-week health service, and if Opposition Members are serious about working with healthcare professionals to improve the experience of patients, they should surely welcome the introduction of out-of-hours services to take the pressure off A&E.

The thing I find most distressing about the motion is that it is full of criticism and complaints but offers no solutions. My plea to Opposition Members is that we should work together for the benefit of patients. We cannot continue to have patients whose care is being compromised even though they have ticked the four-hour box. We have only to look at the example of Mid Staffs, where the four-hour target was met time and again while terrible incidents were happening behind the scenes. Let us stop using the NHS as a political football; let us start working together. I would welcome the efforts of all Members to work together with the Government to deliver out-of-hours services and take the pressure off A&E units and the staff who work in them.