Community Pharmacies

Debate between Maria Caulfield and Philippa Whitford

Wednesday 2nd November 2016 Commons Chamber

[Dr Whitford]

We recently debated STPs and the potential they provide. The danger is that at the moment we are seeing finance-centred care, instead of patient-centred care. Going back to place-based planning, which is what we have kept in Scotland, where we still have health boards, means that we can look at integrating services, and pharmacies definitely need to be part of that. They have the potential to be a significant front-line player.

[Maria Caulfield (Lewes) (Con)]

I am interested in the experience in Scotland, although we do not have the same system in England. What does the hon. Lady think about moving pharmacists into GP surgeries? I think that it is a mistake. I would much prefer the approach that is being taken in Scotland, where pharmacies are expanding by having consulting rooms of their own.

[Dr Whitford]

Scotland actually has both. We do have pharmacists who are in a consulting room within a practice, and our Government have put £85 million into taking on an additional 140 pharmacists who work in primary care with GPs. We are not, as has been done in the past, saying, “Everyone on drug A must change to drug B because it is cheaper,” without giving any thought to how that affects the patient. We are consulting patients, who are often on 10 or 15 medications, all of which interact and have different side effects, and then rationalising that and giving the patient advice. We are therefore providing a clinical service rather than just a changeover service.

Our community pharmacy system has been running for 10 years, so it is quite mature. Patients register with a pharmacist in the same way as they register with a GP. The aim is for all people to be registered with whomever they consider their local pharmacist to be, as that means that they can access minor ailment treatment. It also means that people who are on chronic medication have a chronic medication service, with their prescription sent electronically to the pharmacy, which then keeps track of when it is due and therefore ensures that patients do not run out of medication. The pharmacies also provide an acute medication service for people who have not signed up to the other service but suddenly find they have no tablets, as they had not thought to re-order them with their GP. If they are regulars at the pharmacy, a single round of drugs can be prescribed for them there so that they do not have a gap in their treatment. The important thing is that our vision is to have all our pharmacists as prescribers by 2023, and to have our public registered with pharmacists by 2020.

Access to Medical Treatments (Innovation) Bill (Money)

Debate between Maria Caulfield and Philippa Whitford

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)

Debate between Maria Caulfield and Philippa Whitford

Monday 14th September 2015 Westminster Hall

[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.

A&E Services

Debate between Maria Caulfield and Philippa Whitford

Wednesday 24th June 2015 Commons Chamber

[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.