Epilepsy

Martin Horwood Excerpts

Thursday 26th February 2015 Commons Chamber

[Martin Horwood (Cheltenham) (LD)]

I commend the hon. Members who secured this debate, and the Backbench Business Committee for bringing this very serious issue to our attention. I have found the debate genuinely shocking.

The statistics are shocking enough: 600,000 people in this country have epilepsy. That puts it on the same scale as dementia and Alzheimer’s disease, but it receives far less attention, perhaps because we feel that we are used to epilepsy and it is not that serious. Another shocking statistic is that 1,000 people a year die of epilepsy-related deaths, and most shockingly of all—this was mentioned by the hon. Member for Walsall South (Valerie Vaz)—42% of those deaths are preventable, in many cases with little more than good communication.

The debate is all the more shocking and upsetting for me because of the case of Emily Sumaria. Emily went to my junior school in Cheltenham, and attended the secondary school of the right hon. Member for Chesham and Amersham (Mrs Gillan), Cheltenham Ladies college. From there, she did work experience in Parliament with me for several weeks. I remember her as a brilliant young woman who had the kind of smile that lights up a room. Her mum, Rachel, describes her as

“a bright, beautiful and funny girl with her whole life ahead of her. Her epilepsy was totally under control and she lived a perfectly normal life.”

Indeed, I had no idea she was epileptic. She went on to get four good A-levels and then started at Leeds university, but she never graduated.

On 4 December 2012, Emily was found dead in her bed by her university housemates. Her mum says:

“Neither she nor I were ever told about the possibility of dying and had never heard of SUDEP”—

sudden unexpected death in epilepsy. The explanation was tragically simple: Emily’s university GP practice prescribed the wrong dosage of her medication when she moved from her home GP, which meant that when she missed one day of her tablets, she did not have enough in her bloodstream to prevent her from having a seizure. That one and only seizure, after almost two years, killed her. Rachel says:

“Knowledge is power and maybe if Emily or I had known about SUDEP then we could have taken additional steps to minimise her risk. This totally avoidable death has had devastating effects on a huge number of people. The ripple effect of Emily’s death has been enormous.”

SUDEP Action, the charity which looks into sudden unexpected death in epilepsy, states that being

“open and honest with patients about their level of risk, allows them to make educated choices as to their ongoing care and management”,

but that GPs in primary care lack confidence with epilepsy, and that even specialist services “do not routinely discuss” with patients the level of risk and much more serious risks of which some of them may not be aware. One of the families who contacted SUDEP Action said:

“There is nothing worse than losing a child but to feel that [our son] did not have all the information he needed to make informed decisions makes it especially cruel.”

There is also an issue about information for bereaved families after death has, tragically, occurred. NICE guidelines state:

“Where families and/or carers have been affected by SUDEP, healthcare professionals should contact families and/or carers to offer their condolences, invite them to discuss the death, and offer referral to bereavement counselling and a SUDEP support group.”

Yet SUDEP Action says that that is not happening. It is aware of many people bereaved by epilepsy who find no specialist support and who are often left struggling to understand what has happened to them and why.

In 2013, SUDEP Action launched—with, I am pleased to say, Government support—the epilepsy deaths register. It is not only an amazing research resource, but of enormous value to families, which the Government should be congratulated on supporting. It offers a means for bereaved families to express what has happened to them. SUDEP Action says:

“The bereaved families are robbed of the chance of saying goodbye; of saying the things that they always wanted to, and didn’t. They are robbed of opportunities, future hopes and dreams.”

The register is therefore an important outlet for the families:

“It is somewhere to leave their story; a way to feel that the information they give will be used for the benefit of others for years to come. The impact of these deaths is not yet fully understood, but in our experience is captured by one of the families reporting to SUDEP Action’s Epilepsy Deaths Register: ‘The physical pain and guilt are overwhelming, and we are only just becoming able to talk about him to each other after 16 months has passed. The impact is total and devastating, and has affected both the physical and mental health of the whole family.’”

SUDEP Action and families such as Emily’s are calling for better information. That means better information at primary care level. I know that this is a constant theme with GPs and that they cannot be experts in everything, but it is particularly important in the case of epilepsy because people do not understand the potential seriousness of the condition. There must also be better communication about risk that is communicated properly by specialist services and better information after death for bereaved families.

We as policy makers have little power to offer much comfort to families such as Emily’s, but if we can take action that saves even one more life from sudden unexpected death in epilepsy, it would matter a great deal to Emily’s family and friends, among whom I feel proud to have briefly counted myself.

Francis Report: Update and Response

Martin Horwood Excerpts

Wednesday 11th February 2015 Commons Chamber

[Mr Hunt]

Yes. We have set out new guidelines. The right hon. Member for Cynon Valley (Ann Clwyd) helped us a great deal when we were looking into how to improve the NHS complaints procedure, in particular advising people about how to complain and ensuring they knew that they could talk to someone independent if they needed to. I try to look at a letter of complaint about something that has gone wrong in the NHS every day before I start my work, and I make sure that the trusts are aware of that.

[Martin Horwood (Cheltenham) (LD)]

Before Christmas, I alerted Ministers to attempts by Gloucestershire Hospitals NHS Trust to prevent a governor from expressing concern to the local media about the care of local people. Does the Secretary of State agree that gagging governors is also unacceptable, and that the new spirit of openness should apply to governors and board members as well as staff?

[Mr Hunt]

I do, and I think it important to bear in mind the role of the press as a last resort for whistleblowers. Many of the problems of which we are aware have come to light because people have spoken to the press, and that is to be welcomed, but I think we would all agree that it is a real shame if things have to reach that stage. We need a culture in which people are listened to straight away. That governor should have felt that he or she could talk to someone in the hospital who would do something about the problem, rather than having to go to the press.

UK Ebola Preparedness

Martin Horwood Excerpts

Monday 5th January 2015 Commons Chamber

[Mr Hunt]

I have spoken to several European Health Ministers, and the Under-Secretary of State for Health, my hon. Friend the Member for Battersea (Jane Ellison), who has responsibility for public health, is in regular touch with them about the international effort. The hon. Lady is right that no one country can solve this on its own, and we collaborate well with others—perhaps most closely with the French, who have taken responsibility for the fight against Ebola in Guinea.

[Martin Horwood (Cheltenham) (LD)]

I declare an interest, as my wife worked for Public Health England. I am sure that all PHE staff will appreciate the Secretary of State’s calm and supportive words today.

Local directors of public health have traditionally formed part of the response to such incidents, not least in reassuring the general public—perhaps the hon. Member for Kettering (Mr Hollobone) as well—so is the Secretary of State confident that they still have the resources and organisational support to do this effectively now that they are part of local government, not the NHS?

[Mr Hunt]

To date, no issues have been raised about resourcing for those very important responsibilities, but we will keep an eye on that. Every local area has had a resilience exercise to ensure it is prepared for what happens if someone contracts Ebola in its area, and so far we have been satisfied with the response, but obviously we will keep it under review.

A and E and Ambulance Services

Martin Horwood Excerpts

Thursday 18th December 2014 Commons Chamber

[Mr Hunt]

My hon. Friend is right about that. Just as this Government have taken a very robust attitude towards poor care in hospitals—we now have 6,000 more nurses on our hospital wards following the Francis report—we need to take an equally robust attitude towards what is provided in people’s homes, to make sure that we have proper care. It is a false economy to cut back on out-of-hospital care to pay for hospital care, as we need both.

[Martin Horwood (Cheltenham) (LD)]

rose—

[Paul Burstow (Sutton and Cheam) (LD)]

rose—

[Mr Speaker]

An absolutely delicious intellectual beauty parade. Mr Martin Horwood.

[Martin Horwood]

Mr Speaker, your festive generosity equals only that of Father Christmas.

Gloucestershire hospitals have been under severe pressure in recent days, but is not one complicating factor that, in Gloucestershire and elsewhere, every unplanned GP admission to hospital goes via the emergency department? Although such cases may be relatively urgent, they are not necessarily what most of us would understand as an accident or an emergency.

[Mr Hunt]

The hon. Gentleman is absolutely right to make that point. There has been a lot of support for the NHS today from Liberal Democrats. If they are ever considering which is the best partner to back the NHS at any hypothetical time in the future, they should know that there is only one party that can provide the strong economy to fund a strong NHS.

Ebola

Martin Horwood Excerpts

Monday 13th October 2014 Commons Chamber

[Mr Hunt]

The hon. Gentleman is right in what he says. This morning, my hon. Friend the Under-Secretary spoke to Alex Neil, the Scottish health Minister, and on Wednesday we will have a Cobra meeting with the devolved Administrations to test how resilient the structures are between the constituent parts of the UK. That is a very important part of our effort.

[Martin Horwood (Cheltenham) (LD)]

Perhaps I should declare a non-pecuniary interest, Mr Speaker, as my wife works for Public Health England. I join the Secretary of State in applauding all of her colleagues and the others who are putting themselves in harm’s way in the front-line battle against Ebola. Given his predecessor’s reorganisation of the NHS and of public health, does the Secretary of State need to check whether there are now sufficient local directors of public health in post and whether they have sufficient resources, qualified staff and seniority within local authorities to take a local lead, should that be necessary, in the fight against Ebola?

[Mr Hunt]

We are absolutely checking that, and it is all in hand.

Mitochondrial Replacement (Public Safety)

Martin Horwood Excerpts

Monday 1st September 2014 Commons Chamber

[Mrs Glindon]

I agree. There is probably not enough understanding within the House, either.

The Minister had previously said:

“licensed fertility clinics are only required to report instances of OHSS to the authority that require a hospital admission with a severe grading, although in practice clinics often report moderate OHSS as well.”—[Official Report, 24 June 2014; Vol. 583, c. 157W.]

The figures that do exist indicate there has been a small recent increase both in the total number of recorded cases and in those cases categorised as “severe” rather than “moderate”. About 50,000 women go through IVF in the UK each year. The fact that we do not collect proper data on a potentially life-threatening condition that may affect a third of them, seems an astonishing oversight in the collection of official health statistics. Mandatory reporting of all cases is an essential first step in this process, but should only be the start of more effective and careful collection of statistics.

This issue has a particular pertinence at present because of proposed changes to the law on mitochondrial transfer and the Government’s stated intention to allow the creation of three-parent embryos. I am sure that many Members may be struggling to get to grips with the details of this procedure, but simply put both of the techniques used in mitochondrial transfer require a significant supply of donor eggs. Any such eggs will have to come from women who have been through controlled ovarian hyper-stimulation, with all the attendant risks.

[Martin Horwood (Cheltenham) (LD)]

Will the hon. Lady give way?

[Mrs Glindon]

I will not. Sorry. There is not time.

It appears that very little consideration has been given to this fact in any of the various consultations and Government position papers that have emerged over the past two or three years. No in-depth questions about the physical health of women donating eggs were addressed in the HFEA’s own briefings. Will the Minister assure the House that she will take the matter back to her Department for consideration? In the light of the safety concerns we have heard today associated with the proposed techniques, such action would appear to be urgent, for the sake of the vulnerable women involved.

--- Later in debate ---

[Jim Dobbin (Heywood and Middleton) (Lab/Co-op)]

As a former NHS scientist, I would like to speak in support of the motion proposed by the hon. Member for Congleton (Fiona Bruce). Whatever our personal views on the ethics of mitochondrial transfer, it is remarkable from a procedural point of view that the Government are considering putting these regulations before the House before the critical pre-clinical tests by their own body, the Human Fertilisation and Embryology Authority, have been performed, written up and peer reviewed. I am not against research. I support scientific research, but scientific research that is safe. That is the situation in America, where this was put on the back burner basically because of the issue of safety.

In my humble opinion, it is scientific practice to presume that tests will yield positive results. That has had the whiff of manipulating the evidence to fit the hypothesis. In this case, however, it is even worse, as the necessary evidence has yet to be produced. Such a methodology would not stand up in the scientific community, and if it is not good enough for the scientific community, it is not good enough for this House. We must wait for these results and examine them in detail. After all, we are talking about the possibility of permitting techniques which could be—I repeat, could be—disabling to the children who are created through them. As Members of Parliament elected by the people, we should be made fully aware of the risks and safety concerns surrounding these new techniques before voting on whether they should be allowed.

There are three camps in this debate. There are those who oppose mitochondrial transfer for ethical reasons and those who are strongly in favour, but there is another group: those who are in favour but are concerned about safety. The votes of this third group will be determined by the available evidence. That evidence has not yet been produced. I am not talking about the more stringent evidence asked for by the world-renowned US Food and Drug Administration in its recent report on the subject, but the few tests that the Human Fertilisation and Embryology Authority—a clear and obvious supporter of the techniques—recommended as the critical bare minimum to be completed before progressing. We do not have the results of those tests. Does the Minister agree that it would be a subversion of due process to ask Parliament to vote pre-emptively on them?

[Martin Horwood]

Does the hon. Gentleman appreciate, though, that the HFEA’s expert panel is commending these techniques, and that if the regulations are passed, the responsibility for safely licensing each application will still rest with the HFEA, so the safety process will still be in place? This is a permissive step.

[Jim Dobbin]

I understand the hon. Gentleman’s point, but may I refer him to Dr David King, director of Human Genetics Alert? He is sympathetic to this process but fears that science is racing ahead of ethics. He says that we are in danger of creating designer eugenic babies, and we do not know where we are going in future.

Denying Parliament the opportunity to examine these results seems difficult to defend. In effect, it would be asking the House to vote blind on the safety of techniques that the House might reject outright on the basis of the results. Let us be clear and honest about this: the results could not be published and peer reviewed in time for the rumoured vote in the autumn. I end with a clear and simple question to the Minister: do the Government intend to ask Parliament to vote on these regulations before the HFEA’s suggested critical tests are performed, written up and peer reviewed; and if so, why?

Cervical Cancer Screening

Martin Horwood Excerpts

Thursday 1st May 2014 Commons Chamber

[Martin Horwood (Cheltenham) (LD)]

It is an honour and a pleasure to follow the hon. Member for West Ham (Lyn Brown), as well as other Members, particularly my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) and, indeed, the hon. Member for Wirral South (Alison McGovern), whose speech was a moving tribute to Sophie Jones—her constituent—and her family. I also congratulate the hon. Member for Liverpool, Walton (Steve Rotheram) on securing this timely debate.

I welcome the Government’s work on cancer in general. Their Be Clear on Cancer campaigns, which began in 2011, have been producing good work, which is now being done in conjunction with Public Health England. I should probably declare a non-pecuniary interest here: my wife is the director of one of Public Health England’s regional centres.

I feel some sympathy with the Minister. I am sure that her instinct was to trust her brief from the Department, and its representation of the risks and statistics attached to cervical cancer and screening. I suspect that, being a member of the coalition, I have a similar brief before me now. I have to say, however, that deeper examination of those risks and statistics casts grave doubt on the Department’s current interpretation of them.

I have benefited from some forensic research carried out by my constituent and friend Mel Gladwin. Mel works for an organisation in Cheltenham that is well known for its forensic examination of data, but she contacted me in connection with today’s debate because in 2003, at the age of 22, she was diagnosed with a very aggressive form of cervical cancer. I am delighted to say that she is now perfectly healthy, and has a bouncy seven-year-old son. Her life was saved by effective treatment. The treatment was effective because Mel’s condition was diagnosed early, and it was diagnosed early because she was part of a routine screening programme for those aged under 25. Mel, her family and I are all pretty well convinced that she would not be with us today if that routine screening programme had not existed.

Mel tells me that in 2009, the Advisory Committee on Cervical Screening cited two specific reasons for not restoring screening for those aged under 25. One was that it caused significant anxiety. That view appears to have been based not on any recent evidence, but on evidence dating back to the 1970s and 1980s, when survival rates generally were much lower, a much greater stigma was attached to cancer, and, I suspect, anxiety levels were higher. I believe that cancer now constitutes a largely curable disease in the public imagination, and that anxiety levels may not be quite the same. In any event, I think that when anxiety is balanced against the risk of death, most people would rather be sure that they were safe, even if the cost of that was some anxiety.

The principal reason given by the ACCS for its decision was the potential risk of premature birth if the women concerned had children later in life. That evidence was presented to the committee by Professor Peter Sasieni of Queen Mary, University of London—the self-same Peter Sasieni who conducted the much more robust 2012 study referred to by hon. Members today. It was a study of 44,000 women, including 2,000 to 3,000 under the age of 25, and was much larger than the earlier studies and based in England, whereas the others were done in Scandinavian countries where the incidence was different and the treatment appears to have been somewhat different. Therefore, this research is much more robust and relevant.

Although my right hon. Friend the Member for Sutton and Cheam presented the results in quite a qualified way, actually, the British Medical Journal was pretty robust in its conclusions when it published them:

“After adjusting the results to account for the type of treatment and whether it had occurred before or after the birth, the researchers found that there was no increased risk associated with treatment. The researchers concluded that the increased risk of preterm birth in women who have been treated for cervical disease was due to common factors that increased the risk of both cervical disease and preterm delivery, and not to the treatment itself.”

The BMJ could not really have been clearer, yet that evidence has never been formally reviewed by the ACCS.

That suggests that there is no strong reason not to screen women under 25, but perhaps we should balance that against whether there is a strong reason actually to screen women under 25, because the Department must also take that into consideration. Mel comes from a talented family. Her father, as luck would have it, is a mathematician and computer scientist at the university of Kent’s school of computing. He has looked at research produced by Cancer Research UK on the incidence of diagnosis of cervical cancer in various age cohorts. The statistics are very strange. The incidence of diagnosis at 25 has tripled in just the last few years—a huge spike in the statistics—and is many times the incidence at 24 and lower ages, which appears, strangely, to have reduced. It is also higher than the incidence at 26, so something very odd is happening. What was previously a gradual increase in incidence of diagnosis by age cohort now contains a massive spike.

Peter Welch, Mel’s father, is not medically qualified but he is a statistician and knows his statistics. His conclusion was pretty clear:

“The figure shows a dwindling of diagnosed cervical cancers in the 20-24 year group since they stopped being screened and a massive spike in those aged 25 (discovered on their first screen). That dwindling is very unlikely to be because the prevalence of cervical cancer has dwindled. The huge spike—approximately 10 times the counts for the individual year groups 20 through 24 and 3 times the counts for the year groups 26 through 29—is most likely because of cancers that would have been prevented by screening now developing and cancers that would have been found earlier now being found late.”

In other words, withdrawing routine screening has suppressed the numbers at 25 and younger, and massively increased them at age 25. That is a very serious conclusion. If it is true and the conclusions of the second batch of Sasieni research are true, the inescapable conclusion is that we have denied screening to young women whose lives would have been saved, and increased the risk at the age of 25 and above of people having had undiagnosed cancer before then.

I am very glad that Mel is happy and healthy, but she clearly attributes her survival to the routine screening programme. This issue is now in urgent need of review. We are not talking about vast numbers of young women —there were about 45 in 2010, according to the most recent available statistics—but their lives might be being put at risk each year, and the Government must reflect urgently on the issue and reconvene the ACCS to look again at the most recent and robust research.

--- Later in debate ---

[Jane Ellison]

Indeed, and I will be guided by you, Mr Deputy Speaker.

Like others, I start by paying tribute to Sophie Jones and her brave battle against cervical cancer. I also offer my sincere condolences to her family who have conducted themselves with such dignity in recent weeks and months. I assure all Members that I will try to address the important issues that they have raised. There is a lot to say, so if I do not get through it all, I will respond to them afterwards.

Although I am not able to comment in detail on individual clinical cases, we understand that Sophie’s case was one of misdiagnosis rather than of screening, to which the hon. Member for Liverpool, Walton alluded. Thankfully, cases of cervical cancer in her age group are extremely rare. I understand that the medical director for the Cheshire, Warrington and Wirral area team has requested that the GP practice undertake a significant event analysis to review the case, and ensure that all appropriate procedures are followed and that any lessons learned are put into practice. Once that is completed, it will be agreed with the practice how that will be shared. I can assure the House that I fully expect NHS England to keep the family and local MP fully informed as the investigation progresses.

Despite the tragic circumstances in this case, I reassure the House that the NHS cervical screening programme is one of the most well regarded in the world. More than 3 million women are screened every year. Experts estimate that the programme saves up to 4,500 lives in England alone. However, it has to be based on the best available evidence. The best independent evidence shows that routine screening of women under 25, on balance, does more harm than good. The UK national screening committee reviewed the age of cervical screening in 2012—although some Members have said that the last review was earlier or later than that—and confirmed the English policy of not screening those aged under 25 as it has no impact that can be seen on the detection rates of cervical cancer in young women and gives rise to a high number of false positives, which cause anxiety and, more importantly, lead to unnecessary investigations and treatments that can have side effects.

The UK NSC review in 2012 followed a review of the age at which cervical screening starts by the Advisory Committee on Cervical Screening, or ACCS, which is made up of experts in a range of disciplines, third sector representatives from Jo’s Cervical Cancer Trust and patients. The ACCS review took place in May 2009 to consider the raising of the screening age from 20 to 25, and it confirmed that decision. The 2012 review was partly a response to the Jade Goody effect mentioned by some hon. Members today and was intended to reconsider that decision. The ACCS was unanimous in deciding that there was no reason to lower the age from 25, which is in line with World Health Organisation guidelines.

Some of the reasons behind that decision have been mentioned. The research presented showed that there was little or no impact on detection rates in those aged up to 30, no clear evidence of an increase in the incidence of cervical cancer following the change to the screening age in 2004, no new scientific evidence was available to support the reintroduction of screening and one in three young women aged under 25 would have an abnormal result when screened, as opposed to one in 14 from all women who are screened. That shows a lot of false positives in young women.

[Martin Horwood]

Will the Minister give way?

[Jane Ellison]

If the hon. Gentleman is going to draw my attention to the statistics he presented, I am happy to look at them in detail and, indeed, I have a partial answer to some of his questions.

[Martin Horwood]

indicated dissent.

[Jane Ellison]

I will give way very quickly, but I need to get through my speech.

[Martin Horwood]

I was interested to know when in 2012 the UK NSC met. The second Sasieni research was only published in August 2012 and the Cancer Research UK statistics were published in the BMJ in 2013, so they have not been reviewed as far as I know.

[Jane Ellison]

As I said, the hon. Gentleman presented quite a detailed statistical submission and I shall respond to him after the debate rather than off the cuff. His statistics deserve better than that.

Cervical cancer is thankfully very rare in women aged under 25. As has been said, there were 47 cases in England in 2011, the last year for which we have figures. That is less than 2% of all cases and there were two deaths. Obviously, we will consider the statistics presented by the hon. Member for Cheltenham (Martin Horwood), but we are aware that in 2009-10—this also relates to the points made by other hon. Members, and most strongly by the hon. Member for West Ham (Lyn Brown), about health inequalities—an extra 600,000 women came forward for screening, many as a result of the publicity surrounding the death of Jade Goody. Many of those women were from lower socio-economic and hard-to-reach groups, and they are more often at risk. That is an important statistic and we need to consider that again.

It may help the House if I briefly run through the science behind the abnormal screening results in younger women. Primarily, they are caused by the fact that they have a high rate of HPV infection, as the cervix in young women is more prone to infection with transient HPV, both because it has not yet matured and because younger women might be exposed more often to different types of HPV. Furthermore, some of the few cancers found in young women are unusual and rare tumours that differ from the type we screen for, such as small cell tumours that can develop rapidly and are very dangerous. However, some are HPV-associated tumours that develop at a young age and sometimes simply as a rapidly developing cancer. The key thing in such cases is rapid referral and an appropriate medical response.

In its 2009 report, the ACCS was concerned that young women presenting to primary care with symptoms of cervical cancer were not always given the best advice. I know that that will be a concern not only to Sophie’s family but to all of us in this House and to the NHS. We know that for many GPs, seeing a patient with cervical cancer is rare, and potentially only one GP in 16 will see a new case each year. That is quite a statistic. To help GPs make the right clinical decisions, new guidance for primary care on the management of young women with gynaecological symptoms was developed and sent to all GPs in England in March 2010. The guidance was developed by a multi-disciplinary group, and supported by all the relevant royal colleges. I undertake to raise the issue again with the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners to explore the best way to remind GPs of the guidance.

I reiterate that whatever her age, if a woman is concerned about abnormal symptoms she should contact her GP, who will be able to examine and refer her urgently to a gynaecologist if clinically appropriate. The House might not be aware that the guidance is explicit that in any case where a woman is showing symptoms, best practice is that she should not be referred for screening. That is because a cervical screening test is aimed at women without symptoms. It is a screening, not a diagnostic test, and waiting two weeks for the result could delay examination by a gynaecologist. That is a really important point to bring out in the debate. If someone has symptoms, we want to get them urgently from symptom to diagnosis via a referral, and a screening test could further delay that.

I want to talk a little, as others have, about the human papilloma virus, or HPV. Many Members have mentioned the fact that we have identified high-risk types of the virus and that the vaccination programme sprang from that identification of risk. The programme was introduced in 2008 for girls aged 12 to 13. Its aim was to prevent cervical cancer related to the HPV types covered by the vaccine, which covers about 70% of all cervical cancers. The programme has been a big success. More than 7.8 million doses have been given so far in the UK since 2008, and we have among the highest rates of HPV vaccine coverage in the world, with 86% of girls eligible for routine vaccination in England in the 2012-13 academic year completing the three-dose course, and 90% receiving at least two doses.

It may be of interest to Members to hear that the Merseyside area team reports a higher than national average take-up of the HPV vaccine, with 87.8% of girls vaccinated with all three doses in 2012-13. In Wirral and Sefton, that figure was 90%. However, we cannot be complacent and we want to get the fullest possible coverage. That is something about which MPs, as well as Ministers, can do a lot to spread the word. When we go into schools, a good question to ask might concern the coverage and whether there are particular groups of parents or people from particular backgrounds who do not take up the vaccine.

It is expected that the programme will eventually save more than 400 lives a year from cervical cancer. The first indication that the programme is successfully preventing infection with HPV types 16 and 18 in sexually active young women in England was published in the scientific journal Vaccine, and showed that the proportion of infected rates in 16 to 18-year-olds fell from 17.6% in 2008 to 6.6% between 2010 and 2012. That is major progress, so the take-up of the vaccine is really important.

We encourage all girls, irrespective of religion or ethnic background, to receive the HPV vaccination. NHS England is responsible for making arrangements to implement the programme for eligible girls and young women in the local area, taking into account local circumstances, such as the number of independent or special schools and the number of girls who are not in school. Interestingly, I was informed that Surrey has a much lower take-up, so perhaps we need to consider how to deal with girls in independent schools, or other local circumstances. NHS England is also responsible for ensuring that local programmes meet the national specifications.

We are using our growing knowledge of HPV to modernise the NHS’s cervical screening programme by considering HPV infection alongside the screening programme and looking for abnormalities and seeing how they can interact. Public Health England is also promoting the use of the HPV test as a primary screen, which is very interesting. A lot of work is going on, and the first evaluation report of the pilot is due in spring 2015. Cancer Research UK has estimated that, when fully implemented, HPV primary screening could prevent hundreds of cancers a year.

There are some particular matters to which I would like to draw the attention of the House, as I have a little time. The Prime Minister’s £50 million GP access fund will support more than 1,400 practices covering every region to offer extra services for those who struggle to find appointments that fit in with family and work. That is important and responds to one of the points made by the shadow Minister.

I hope we can show that despite tragic cases such as Sophie’s, the age at which screening starts in England is based on sound evidence. It has been carefully considered by members of expert committees pretty recently. However, I am very aware that we need to keep all evidence under review. I have already had a brief conversation with the chief medical officer about this. Members may be aware that one of my fellow Ministers is a specialist in this area of medicine, so we will make sure that we look again at the points that have been made in the debate.

There is much we can do as a House and as a country to reduce the number of women who suffer from this devastating disease. I urge every woman invited to screening to take up the opportunity, as we know that 25% of women in the 25-to-30 age group do not. On screening, I do not have time to describe the work in detail, but I can assure Members that Public Health England has work under way specifically to look at low coverage in certain areas and to work on local action plans to improve that coverage.

I want to do more to urge employers to support their staff. Again, evidence from Jo’s Cervical Cancer Trust, representatives of which I met on Monday evening and discussed some of these issues with, suggests that many younger women do not want to ask an employer for time off for a smear test. I will look at what we can do through work that is already going on with employers to see how we can encourage them to make it clear to young women that they do not have to go through an embarrassing conversation to get time off for that. I will be looking at that further with Jo’s Cervical Cancer Trust.

If Members who called the debate and spoke in it have the appetite for it, I am happy to devote a special day in Parliament to what we can do on take-up of screening and of HPV vaccination. I would love to do that piece of work with hon. Members if they want to work with me on that, because much of this is down to local and specific community factors. A one-size-fits-all national programme is not adequate. As part of Be Clear on Cancer, we have a pilot programme on ovarian cancer which will be running this spring, so we are moving into those gynaecological issues. We will look at the review of that to see whether there is more we can do in this area. Work is under way, but there is so much more we can do working together.

Urgent and Emergency Care Review

Martin Horwood Excerpts

Tuesday 12th November 2013 Commons Chamber

[Mr Hunt]

The hon. Gentleman makes my point for me extremely eloquently. Under the previous Government, we had a top-down, ham-fisted policy of opening walk-in centres everywhere as a sticking plaster solution to the disasters with their GP contract. Sometimes they were valuable services, sometimes they were not. We are clearing up the mess, but sometimes, when those centres are useful and important for the public, we will keep them.

[Martin Horwood (Cheltenham) (LD)]

The origins of the recruitment crisis in A and E obviously predate this Government. Will Sir Bruce Keogh’s review highlight the local trusts, like that in Gloucestershire, which appear to have significantly worse recruitment and retention records than neighbouring trusts and have used it as a rationale for downgrading services—such as, in this case, those at Cheltenham general hospital?

[Mr Hunt]

I hope that it will. I hope that it will give clarity about the long-term future for A and E departments, which has been a difficult issue for this Government and for the previous Government. What people want is stability, and they want to know that there is a Government who are prepared to face up to difficult decisions. They want to know that they have a future, and I hope that tomorrow’s review is the first step towards providing that security.

Accident and Emergency Waiting Times

Martin Horwood Excerpts

Wednesday 5th June 2013 Commons Chamber

[Martin Horwood (Cheltenham) (LD)]

I am grateful to previous speakers, particularly the hon. Members for Lancaster and Fleetwood (Eric Ollerenshaw) and for Mitcham and Morden (Siobhain McDonagh), who made some of the comments I would have made and therefore saved me a good minute.

The crisis in emergency departments is multifaceted and we are facing a downgrade of the emergency department in Cheltenham general hospital. The rationale has not been funding pressures or extra admissions but, as the hon. Member for Lancaster and Fleetwood said, the shortage of emergency doctors. The College of Emergency Medicine recommends that we should have 20 emergency medical posts over the two A and Es in Cheltenham and Gloucester. The trust has only just managed to fill the 12th, so we are at not much better than half strength. That has obvious safety implications and has driven the trust’s recommendations for downgrading A and E at Cheltenham.

The staff shortages have their root in work force planning issues that date back many years. They must date back to the Secretary of State’s predecessor’s time and, clearly, to that of the previous Government, too. The hon. Member for Ealing North (Stephen Pound) was quite right, however, and we should not be playing a party political blame game. We should simply admit that we have a really serious problem and work out what to do about it.

The College of Emergency Medicine suggests that the initial recruitment to the discipline is quite respectable and that retention is the problem. Emergency medicine involves long hours, with a 24-hour cycle of shifts, and is an intense and stressful form of medical practice. I hate to accuse anyone of mercenary motivation, but of course those who work in emergency medicine cannot moonlight in private practice, either, which makes it less attractive from that point of view. So we do need a rethink nationally. I welcome the urgency with which the Government are now addressing that. It should have been done years ago.

In the meantime, changes inevitably are being proposed by local hospital trusts. I do not think we can blame them for that, but, as the hon. Member for Mitcham and Morden said, the process must be open, accountable and transparent. That was, after all, the idea of the new structures that the right hon. Member for South Cambridgeshire (Mr Lansley), the previous Secretary of State, foisted on us in the new system.

The consultation in Gloucestershire has raised real questions. Why has not the trust even tried to pay more for emergency medical posts, as it has the freedom to do so as a foundation trust? Could it have looked more seriously at overseas recruitment? Why has it not been prepared to wait for the Keogh review, or the Secretary of State’s urgent review of recruitment, before making the changes permanent? Why was it not prepared to trial changes just for a year, as Liberal Democrat members of the health overview and scrutiny committee requested yesterday? I deeply regret the fact that Conservative councillors on that committee from all over Gloucestershire voted down that very modest compromise proposal and backed the downgrading of A and E in Cheltenham.

In my detailed evidence I raised issues of increased mortality, and of possible increases in health inequalities resulting from these changes, but I have no evidence that my submission, or the thousands of petition signatures that we gathered locally, have been properly considered at all. The primary care trust consultation website actually disappeared halfway through the consultation process because, of course, the primary care trust ceased to exist and handed over to the new clinical commissioning group. The obvious suspicion locally is that this was a foregone conclusion, and that it is only a matter of time before the trust proposes the outright closure of the A and E at Cheltenham.

That suspicion was strongly reinforced yesterday. Within hours of the health overview and scrutiny committee meeting, the trust issued a joint statement with the new clinical commissioning group, instantly announcing that the changes would now be going ahead on a permanent basis, despite the fact that the trust has not actually considered the outcome of the consultation exercise at either its board or the CCG’s board. That is not open, accountable and transparent, and it must be in future.

A and E Waiting Times

Martin Horwood Excerpts

Tuesday 23rd April 2013 Westminster Hall

[Martin Horwood (Cheltenham) (LD)]

I pay tribute to the right hon. Member for Cynon Valley (Ann Clwyd) for securing this debate on such a topical matter. I had not intended to speak, but since the opportunity has arisen I would like to make some points, because the matter is very relevant to my constituency.

Cheltenham is in an unusual situation. We have two district general hospitals within eight miles of each other, one in each of the almost twin cities of Gloucester and Cheltenham. Some years ago, the hospitals came under the management of a single NHS foundation trust, and there is an almost inescapable business rationale for the trust management always to try to centralise services in one hospital or the other. Some services, including oncology and cardiology, have been centralised in Cheltenham, but with emergency services there has been a slight drift towards Gloucester, starting with neonatal intensive care and then trauma. That might make business sense to the trust, but it poses a problem because they are services that people clearly want to get to in a hurry. They are a bit like maternity services, in that people value having them within their town and do not want to have to try to find them in a hurry in an unfamiliar setting.

The current situation in Cheltenham reflects exactly the national picture that the right hon. Lady described, and we have heard from the King’s Fund that in the final three months of 2012, 232,000 people nationwide waited more than four hours in A and E, a 38% increase on the previous quarter. Some of that is clearly a seasonal increase, reflecting winter issues, but it has certainly been the case in Gloucestershire, where the situation has been rather unequal, with waiting times significantly and regularly higher in Gloucester than in Cheltenham. People are, therefore, concerned about the further centralisation of services in Gloucester, because they fear that the capacity of the emergency department there to cope with the increase will be even worse.

The situation has been explained in a number of ways. There can be a seasonal explanation—there is always a winter upturn, and we have had a series of bugs and infections, including the winter vomiting virus. Those are known factors, which vary from year to year. There is, however, a new factor in the mix, which is the 111 out-of-hours service. I have anecdotal evidence from local GPs that far more referrals into hospitals and A and E departments are occurring as a result of the introduction of the 111 service. The GPs think that they ran a rather good out-of-hours service before, under a different NHS trust, and the new service is clearly causing problems if their accounts are to be believed.

We must gather reliable data, but the evidence that I have from doctors is that they are getting fewer requests to call patients back, through the 111 service, and that a number of individuals have been referred unnecessarily to A and E, partly because the initial triage is done by people who are not really medically qualified. They have a stock set of questions and the approach is not very sensitive, so it seems that the safest thing for the operators to say is, “The best thing is to go to A and E.” If that is responsible for part of the upsurge in cases, it is adding to our existing problems.

The other problem in Cheltenham and Gloucester is the shortage of, and the difficulty of recruiting, emergency consultants and registrars. The guidelines are that there are supposed to be 10 doctors in each emergency department, which would mean 20 for Cheltenham and Gloucester. Gloucestershire Hospitals NHS Foundation Trust has told me that it has managed to fill only 11 of those posts. That is true: I have had independent corroboration from people working in the human resources department of the hospital, who have occasionally advertised for emergency posts and had no applicants. There is clearly a significant problem that they say is part of the national picture of a shortage of trained emergency doctors available to be recruited to emergency departments, which is adding to management pressures and the difficulty of managing the flow of patients into A and E departments.

That raises some other questions. Gloucestershire Hospitals NHS Foundation Trust is, as the name suggests, a foundation trust. It has the freedom to advertise higher salaries, to apply a “hard to recruit” bonus and to try harder to attract more consultants and registrars to its emergency department. As far as I can see, it does not appear to be doing so at the moment. It may be that that does not make such good sense in business terms. Emergency is a relatively expensive function for a trust compared with others, such as orthopaedics, which appears to generate income for the trust. It would be worrying if such business considerations were interfering with a trust’s ability to take management decisions that might attract more consultants and registrars into an emergency department.

I want the Minister to address, first, the national issue of the shortage of emergency doctors, which is forcing difficult decisions on trust managements and, secondly, what she thinks trust managements’ best response might be. For instance, would it be better for them to wait for the outcome of the Keogh review into emergency services, rather than to take pre-emptive decisions now to take such actions as downgrading emergency services at Cheltenham general hospital?

The suggestion is not that that hospital will be closed outright, but simply that it will be downgraded so that bluelight referrals at night are diverted from Cheltenham to Gloucester. That seems like a small and not drastic change, but there have been a whole series of changes—to trauma, neonatal intensive care, children’s services and maternity—and each small change by the trust seems to justify another change. In itself, that is worrying, because who knows what will follow this decision. Will all bluelight referrals be diverted to Gloucester? In a few years’ time, will Cheltenham end up with simply a minor injuries unit for a town of 120,000 people, given that we instinctively know that had the management arrangements been different and two different hospital trusts were in existence, they would be fighting to keep the services open?

The timing of the consultation is very unfortunate, coming at just the moment of the changes to the NHS organisational structure. Perhaps I am a little cynical, but I cannot help thinking that the trust’s timing may not be entirely accidental. The primary care trust, which fought strongly to keep services at both Cheltenham and Gloucester reasonably level—it tried to serve both populations and keep a degree of equity between them—has been wound up and handed over to a clinical commissioning group that has failed to attract a single doctor from Cheltenham to serve on its board, so that a town of 120,000 people has no local voice on the main commissioning body. At the precise moment that it started—new and relatively experienced compared with the old PCT—the trust has chosen to launch changes to one of the services that is most controversial and most valued by local people, which is a very unfortunate coincidence of timing.

I want us to hear, if we can, the Minister’s real plan for the future of emergency services, and to see whether there is any long-term vision about how local MPs and people can put a case to their trusts for the preservation of local emergency departments wherever possible. We need to deliver care to people as close as possible to their homes, and not drift into a situation of its being more and more centralised in particular locations, which may enable trust managements to have a rational case for attracting more sub-specialisms and doctors to their department, but leave a town the size of Cheltenham, with 120,000 people, with a much worse service.

That is causing great alarm, particularly in the context of the waiting times that we see, even as this debate goes on, right now. In Cheltenham, the wait is 38 minutes, according to the trust’s website. At Gloucester Royal hospital, it is 68 minutes—already more than an hour—at a time when demand should actually be very low. Those emergency departments are struggling to cope, and it seems to me that the waiting times are symptoms of a rather deeper and more difficult problem that we have to tackle.

--- Later in debate ---

[Grahame M. Morris]

I think that the Government are cutting the money that is spent on the NHS, not least with the costs of the reorganisation, which I have already mentioned. That money need not have been spent. We are giving back several billion pounds—some £2.5 billion to £3 billion to the Treasury—which could be spent addressing issues such as this. There are a couple of practical points that I want to raise with the Minister later, but I give way to the hon. Member for Cheltenham (Martin Horwood).

[Martin Horwood]

I agree with the hon. Gentleman about the reorganisation of the NHS. That time and effort would have been better spent trying to work out how to deliver health care more cost-effectively. But does not he rather undermine his case when pretending that there has been a cut to the NHS budget, when an objective analysis of the actual billions spent on the NHS clearly shows that it has gone up? The difference between a cut and an efficiency saving is that an efficiency saving is returned to the NHS budget.

[Grahame M. Morris]

I did not vote for the NHS reorganisation; I spent 40 sittings in Committee trying to resist what is now the Health and Social Care Act 2012 and the damaging changes it introduces. That includes those that are about to be implemented under section 75, on the introduction of competition, which will fragment the service and add to costs and complexities. I do not, therefore, accept the hon. Gentleman’s criticism, but I will press on because I want shortly to raise a couple of issues specifically about County Durham.

Part of our responsibility is to hold Ministers and, indeed, the Prime Minister to account. On waiting times—this was one of his five guarantees—he said:

“We will not lose control of waiting times—we will ensure they are kept low.”

Other Members have quoted the King’s Fund and patient surveys, and the figures clearly show that 32 foundation trust hospitals, out of 88 acute trusts in England with an A and E unit, missed the target in the last three months of 2012. I am not sure whether Kettering was one of them, but those figures should be cause for concern for everybody, including Ministers and the Prime Minister. That is double the number of trusts that missed the target in the same period last year, and four times the number that missed it in the previous quarter.

It is therefore clear that A and E waiting times are spiralling out of control. There have been various surveys, including one conducted by the Care Quality Commission, which found that one in three people spent more than four hours waiting for treatment. It also noted a large rise in the number of patients waiting for 30 minutes or more before seeing a doctor or a nurse.

In my area, The Northern Echo is campaigning on this issue, highlighting the alarming rise in the number of patients in the north-east waiting more than four hours for treatment. That number has almost trebled in the past 12 months. The paper has disaggregated figures from the Department of Health and found that more than 1,000 patients have waited longer than the target time, including 536 in County Durham and Darlington. Compared with 12 months ago, the number of patients waiting more than four hours has increased by 200% in County Durham and Darlington. South Tees and York have also seen increases in excess of 200%, compared with the previous year. However, at the Newcastle foundation trusts, the percentage increase is a staggering 630%. Alarm bells should be ringing for Ministers, because those figures are quite dreadful.

I was concerned by the Secretary of State’s responses at Question Time. One disturbing characteristic of this Government is that they are not taking responsibility or coming forward with proposals to address these issues. Specifically, in response to a question from my hon. Friend the Member for Manchester Central (Lucy Powell), the Health Secretary said:

“We are looking at the root causes of the fact that admissions to A and E are going up so fast”

—I think he quoted a figure of an additional million. The factors he blamed were that

“there is such poor primary care provision…changes to the GP contract led to a big decline in the availability of out-of-hour services…and…health and social care services are so badly joined up.”

He added:

“That is how we are going to tackle this issue”.—[Official Report, 16 April 2013; Vol. 561, c. 168.]

That really is not good enough. Indeed, Dr Laurence Buckman, who is chair of the British Medical Association’s General Practitioners Committee, has been quite dismissive and scathing about the Health Secretary’s decision to blame the increase in A and E numbers on the changes to GP contracts. He said it was “impressively superficial”—[Interruption.] Well, that is what the man said, Minister. He said that the decision was not based on any evidence. He went on to say:

“Most GPs were not providing personal access out of hours anyway; it was provided through a variety of out-of-hours routes and that has been the case for the past 30 years, so it would be nonsense to suggest that because GPs haven’t been personally responsible since 2004, therefore casualty is full of people. That is just such fatuous nonsense. I question the wisdom of the people briefing the Secretary of State.”

I tend to agree with him.

There is no magic bullet. With a complex organisation such as the NHS, we need a broad-spectrum antibiotic; we need to apply a number of measures. The fragmentation of the service is certainly contributing to the problem. There is also the issue of people not having access to their GP within 48 hours. Like many Members, I have, unfortunately, had experience of close family members and constituents being left with little alternative but to go to A and E, when the GP could have addressed the issue, had they been available in a reasonable period. This issue therefore requires a team effort.

I am also concerned about what the RCN is saying about the reduction in the number of community and district-based nurses, and I hope the Minister will refer to that. Information provided through freedom of information requests shows that the number of nurses in communities who are part of the rapid emergency assessment and co-ordination teams and the rapid response teams that help to keep elderly people, in particular, out of hospital, has been dramatically reduced.

--- Later in debate ---

[Mr Reed]

I note that the Minister prepared an answer, and I am grateful for that.

Major accident and emergency units—type 1 facilities, nationally—have missed the target for at least the last six months, and all A and E units, including minor incident units, have not hit the target for 12 weeks in a row. If anyone needs help analysing the figures, I would be happy to oblige. They are easy to find and they reveal some interesting points. For example, I wonder whether hon. Members know that only one trust with a major accident and emergency unit in England has hit its target every week since the Secretary of State took his position. That is relegation form, and if this were a football match the cry from the crowd would be “You don’t know what you’re doing.”

Before the Minister attempts yet again to dismiss those statistics, I hope she will take a moment to attend to what has been said by the chief executive of the Royal College of Nursing, by Dr Clifford Mann of the College of Emergency Medicine, and by David Behan of the Care Quality Commission. Earlier this month, Dr Peter Carter, of the Royal College of Nursing said:

“These figures are yet more proof of a system running at capacity, and patients are suffering as a result. Our members are regularly telling us that pressure on the system is rising while staffing levels fall, and as a result any increase in demand results in unacceptable waits for patients who are already going through a difficult time.”

Dr Clifford Mann, of the College of Emergency Medicine said:

“We are seeing...ambulances queuing outside departments, and patients waiting too long on trolleys before they can be admitted to hospital.”

The Care Quality Commission said:

“It is disappointing that people have said they have to wait longer to be treated than four years ago. People should be seen, diagnosed, treated and admitted or discharged as quickly as possible”.

Like me, the Royal College of Nursing, the College of Emergency Medicine and the Care Quality Commission will be appalled that the key performance indicators for the NHS, such as A and E waiting times, are getting steadily worse. In the past six months, 582,811 people waited more than four hours in major A and E units, compared with 420,921 for the same period in the previous year. That is an increase of 161,890 people. That is not silly: it is a question of people’s lives. Those figures relate to people in need who did not get treatment in the time when they needed it. They represent more than 500,000 extra waiting hours in one year. People will find it hard to stomach the fact that there are now about 5,000 fewer nurses than there were in 2010, at a time when, as hon. Members on both sides of the House have mentioned, demand in our A and E units is increasing.

One way to get the figure down—it has been touched on already in the debate—would be to offer services for people with non-emergency ailments, so that they do not feel the need to travel to an A and E department. However, instead of NHS Direct being used as a tool for easing pressure on A and E departments, the roll-out of NHS 111 has turned into a trade marked Government shambles. Patients calling the new 111 service wait hours for advice. One patient waited 11 hours and 29 minutes for a call back. No wonder they feel that they have to go to A and E, when they cannot trust a telephone service with such an inadequate response rate.

Accident and emergency departments are a litmus test, or a barometer, for the performance of the NHS as a whole. If people are waiting in A and E, it means that there are too few beds or too few staff to cope with demand. That is just a fact of health service planning. If there are too few beds, it is because community services are being cut and patients who should be at home are kept in hospital. That reverberates back through the entire system. If patients who could be at home are in hospital, beds are occupied. If beds are occupied, A and E staff cannot admit patients. If A and Es are full, paramedics cannot hand over patients. If patients are queuing in the back of ambulances, those ambulances cannot respond to a potentially serious call-out. One failure leads to another. Each compounds the other. That is what is so serious about the debate. It is not just about the patient sitting in A and E for hours on end; the statistics I have highlighted show much more than that—the experiences of patients throughout the entire system.

[Martin Horwood]

In my remarks I suggested another possible factor in the current problems of emergency departments: the difficulty in recruiting emergency doctors. That may have something to do with the attractiveness of emergency medicine as a specialty—the long hours, and so on. However, it also obviously dates back to the training numbers that I am afraid prevailed under the Labour Government. Does the hon. Gentleman accept that there may be some such responsibility, dating back several years, in relation to attracting sufficient numbers into training for emergency medicine?

[Mr Reed]

I expect the Minister to talk about new doctors in the NHS when she replies to the debate; and, of course, we trained those doctors. We commissioned, paid for and put in place the training of those doctors, so I take what the hon. Gentleman says seriously. I also commend him for being the only Member of Parliament from either of the coalition parties to attend the debate to defend the Government’s record.

The statistics highlight more than the simple numbers: they show the experience of patients throughout the system. One person waiting in A and E can reflect one person in a bed on a ward and another waiting at home for an ambulance. I hope the Minister will acknowledge and accept that, and explain what the Government plan to do. It is essential that they explicitly acknowledge the problems faced by accident and emergency in England. Constant denials do them no credit. They must acknowledge the scale of the problem before any solutions can be introduced.

The NHS in England is completely different from the NHS in Wales. I expect the Government will be tempted to compare the two, but I want to address the issue head on. The reality is that Welsh Ministers are dealing with a £2.1 billion real-terms cut to their budgets. Yet, despite that, they have still managed to protect NHS services. There are now more GPs working in Wales than in 2010, and the number of nurses, midwives and health visitors has remained consistent. That is in stark contrast to England, where nurse numbers are falling. I am sure that hon. Members who have heard such tired comparisons over and over would be interested to know that there are differences in the way A and E waiting times are measured in the two countries, and in how frequently performance is measured.

Before any comparison is made—and I hope that none will be—I want to point out that it is misleading to try to make a direct comparison. However, it is fair to say that all parts of the UK are experiencing increased pressures on A and E. The key difference is that in Wales, Labour are doing something about it, whereas in England the coalition is sitting on its hands. In Wales, 270 additional beds were opened this winter to cope with demand, easing pressure throughout the system. The Welsh Government have also agreed an all-Wales action plan for unscheduled care, which means that health boards must ensure that they have sufficient capacity to meet demand.

Will the Minister inform us today what the Government plan to do to help A and E services in England? When and where will they start to provide such help, and how much will it cost?

That aside, will the Minister also answer a few important questions on A and E waiting times? First, will she explain why, when demand is clearly so high and the current services are at breaking point, the Government have handed P45s to almost 5,000 nurses? Will she also explain why the Secretary of State chose a period of intense demand and structural reorganisation to roll out the 111 service when it was clearly not ready to be rolled out?

May I tempt the Minister to speculate on the causes of that rise in A and E waiting times? Does she agree that a combination of inadequate staffing levels, a distracting reorganisation of the NHS and deep cuts to council care budgets is the principal reason for the sharp increase in A and E waiting times? If she does not agree that they are having a major impact on the NHS, can she explain why the Government think that fewer nurses and a distracting reorganisation have improved services?

The problems that others and I have outlined today are well known to many, but they are still sadly neglected by the Government. Despite its imperfections and its many real challenges, the NHS remains one of the best models of national health care in the world. It is filled with dedicated professionals who believe passionately in the aims and values of the service, but it is clear that an expensive, unwanted and unloved reorganisation, combined with Government-induced staff shortages, are causing and have caused deterioration in performance. That is unfair on health care professionals, and, far more importantly, it is unfair on patients. I look forward to the Minister explaining in detail how her Government intend to get a grip and bring all A and E services in England back up to national standards.