Oral Answers to Questions

Matt Hancock Excerpts
Tuesday 24th July 2018

(5 years, 8 months ago)

Commons Chamber
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Alan Mak Portrait Alan Mak (Havant) (Con)
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1. What recent progress has been made on providing patients with online access to NHS services.

Matt Hancock Portrait The Secretary of State for Health and Social Care (Matt Hancock)
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It is a great honour to be here, Mr Speaker.

There is good progress in patients using online services in the NHS—about a quarter of patients are now registered to access general practitioner online services, up from about a fifth a year ago—but there is much more to be done to use technology in the NHS for the benefit of patients and clinicians alike.

Alan Mak Portrait Alan Mak
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I congratulate my right hon. Friend on his appointment. Healthcare delivered by app is increasingly popular with patients in Havant and across the country. Will my right hon. Friend reconfirm his Department’s commitment to the first ever NHS patient app, and update the House on the timetable for its roll-out?

Matt Hancock Portrait Matt Hancock
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The roll-out of technology right across the NHS and, indeed, social care is good for patients and good for clinicians. I have seen countless examples of that in just my first two weeks in this job. I pay tribute to the Centre for Policy Studies report, which was launched by my predecessor and authored by my hon. Friend, which demonstrates how apps can be useful for making healthcare easier to access for patients. Apps are popular with patients, and I cannot wait to drive that forward.

Helen Goodman Portrait Helen Goodman (Bishop Auckland) (Lab)
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22. May I congratulate the Secretary of State on his new appointment? Another new technology that really matters is MRI scanners. We have had a big fundraising campaign in Bishop Auckland for ours, but the problem with such fundraising campaigns is that they are of course easier in wealthy areas than in poor areas. Will the Secretary of State pay attention to evening out this uneven distribution of resources?

Matt Hancock Portrait Matt Hancock
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Yes, of course I will. I pay tribute to the hon. Lady for her work to raise funds for the MRI scanner in Bishop Auckland, which benefits from great levels of philanthropy in some areas. The whole purpose of having a national health service is that, wherever people live in the country, they can get high-quality healthcare, free at the point of delivery, according to need. I stand by that principle, and I honour it.

Sarah Wollaston Portrait Dr Sarah Wollaston (Totnes) (Con)
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I welcome the Secretary of State to his post. He will know that no regulator is prospectively examining the safety and effectiveness of diagnostic apps in use in the NHS. I wrote to his predecessor recently following concerns that were raised with me about Babylon’s apps, which could be missing symptoms of meningitis and heart attack, for example. What steps will the Secretary of State take to ensure that, as these technologies are rolled out, patients have can have absolute confidence that they have been properly evaluated for safety and effectiveness? Will he set out how he will take that forward?

Matt Hancock Portrait Matt Hancock
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The Chair of the Health and Social Care Committee makes a really important point. There is no greater enthusiast for technology than me—as you well know, Mr Speaker—but the thing about new technology is that the rules sometimes need to be updated to take changes in technology into account. The response when there are challenges such as the one my hon. Friend raises is not to reject the technology, but the opposite: to keep improving the technology so that it gets better and better, and to make sure that the rules keep up to pace. I spoke to Simon Stevens at NHS England about this only this morning—we have had a series of conversations in the past couple of weeks since I have been in post—and he is reviewing this exact question. I am absolutely sure that we will get to the right answer.

Andy Slaughter Portrait Andy Slaughter (Hammersmith) (Lab)
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Is the Secretary of State familiar with the “GP at hand” online service? It is a partnership between a private company and a Fulham GP surgery, and it has poached thousands of profitable patients from GPs all over London, to the alarm of the British Medical Association and of GPs generally. My clinical commissioning group is investigating it, and in the meantime CCGs have blocked Babylon’s expansion to Birmingham on safety grounds. This is creating a two-tier system for GPs, so will the Secretary of State investigate it?

Matt Hancock Portrait Matt Hancock
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I am acutely aware of the question that the hon. Gentleman raises, not least because I am a user of the Babylon service myself—it is my GP. The important thing is to ensure that the rules are kept up to date so that we can get the benefits of the new technology, but make sure that it works in a way that ensures everybody gets high-quality primary care.

Theresa Villiers Portrait Theresa Villiers (Chipping Barnet) (Con)
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Warm congratulations to the Secretary of State.

Whether it is online consultations or more traditional, face-to-face ones, will the Secretary of State join me in thanking all the NHS staff who do fantastic work in taking care of my constituents in Chipping Barnet?

Matt Hancock Portrait Matt Hancock
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I certainly will. I pay tribute to the NHS workforce and the social care workforce who, every day of their working lives, give up their time to serve their community, to serve their fellow man and woman, and to ensure that we have the healthiest nation we possibly can. I love the NHS, as does everybody in the House. Almost everyone is touched by the NHS at some of the most difficult times in their lives. I pay tribute to the workforce.

Julie Cooper Portrait Julie Cooper (Burnley) (Lab)
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I, too, welcome the Secretary of State to his new position. I note his intention to extend online NHS services, but I hope that he will provide more detail about how he intends to guarantee patient safety, given that the Care Quality Commission reported this year that 43% of online GP and pharmacy services are currently unsafe. Will he reverse the cuts to capital funding so that safe technology can be installed? Furthermore, what steps will he take to ensure that elderly and vulnerable patients, who find it difficult to access online services, will still have the certainty of sustainable community surgeries?

Matt Hancock Portrait Matt Hancock
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Those are really important questions. On funding, I announced only last week £487 million to improve technology and technology services to ensure that they can be as high quality as possible. On patient safety, the key is to keep improving technology so that it gets better and better. On universal access, we must use technology in such a way that patients who want to access services through technology can do so, as that frees up resources so that more can be done for those who do not want to use technology, meaning that we preserve universal access.

Ronnie Cowan Portrait Ronnie Cowan (Inverclyde) (SNP)
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2. What recent discussions he has had with the Home Secretary on policies to tackle drug-related harm.

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Caroline Johnson Portrait Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
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14. What steps he is taking to reduce rates of childhood obesity.

Matt Hancock Portrait The Secretary of State for Health and Social Care (Matt Hancock)
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We published the second chapter of our world-leading childhood obesity plan on 25 June. It builds on the progress we made since the publication of chapter 1 in 2016, particularly on the reformulation of products that our children eat and drink most. We will continue to take an approach that is based on evidence and we are determined to act.

Nigel Huddleston Portrait Nigel Huddleston
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I warmly welcome the Secretary of State to his post. I am sure that he was as alarmed as I was to learn that the proportion of 11-year-old children who are obese is now greater in the UK than the US. What more can we do to educate children and their parents about the benefit of a balanced diet and healthy life start?

Matt Hancock Portrait Matt Hancock
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I pay tribute to my hon. Friend’s work at the Department for Digital, Culture, Media and Sport on this matter. It is critical that we have a cross-Government approach. The obesity plan is led by the Department of Health and Social Care, but it is a cross-Government plan. There is a whole range of actions we need to take—from education through to culture and broadcasting—to make sure we get it right.

Caroline Johnson Portrait Dr Johnson
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One of the reasons why tackling obesity in children is so important is the fact that it has such long-term detrimental effects on health. Now that the Government have published chapter 2 of their childhood obesity strategy, will the Secretary of State outline how it will have a long-term impact on children’s health and tackle issues such as diabetes and heart disease?

Matt Hancock Portrait Matt Hancock
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My hon. Friend is absolutely right that obesity, especially in children, is one of the underlying conditions that often leads to much worse long-term health conditions. Some 22% of children aged four and five in reception are overweight or obese; that number is too high and we have to act.

Barry Sheerman Portrait Mr Barry Sheerman (Huddersfield) (Lab/Co-op)
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I welcome the Secretary of State to his new post, which is one of the toughest jobs in Parliament. Having worked with him on other things in the past, I am sure that his energy will come through in the Department.

I have a vested interest in the welfare of young children as we are expecting our 11th grandchild in October. Will the Secretary of State look closely at the relationship between obesity in later childhood and the diet of mothers during pregnancy? Early research shows that there is a link, so will he look at it carefully?

John Bercow Portrait Mr Speaker
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A veritable football team of Sheermans.

Matt Hancock Portrait Matt Hancock
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I am sure that they will grow into that, Mr Speaker.

I pay tribute to the work that the hon. Gentleman has done, which I have watched with admiration from elsewhere. I will certainly look at the point that he raises, which is very important, and we will take a fully evidence-based approach.

Nick Smith Portrait Nick Smith (Blaenau Gwent) (Lab)
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I, too, welcome the Secretary of State to his new job. Today’s figures show that levels of severe obesity in children are at a record high, so will the Government speed up their childhood obesity strategy to tackle this urgent public health challenge?

Matt Hancock Portrait Matt Hancock
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We published chapter 2 less than a month ago. There is further work to do, because that sets out a whole series of areas in which we are going to take action, and I am already working on pushing it faster.

Philip Davies Portrait Philip Davies (Shipley) (Con)
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I know that the Secretary of State has a track record of evidence-free, nanny-state policies from his time in DCMS. Can we expect more of the same in his new Department, or is he going to try out some Conservative principles, such as individual freedom, and individual and parental responsibility?

Matt Hancock Portrait Matt Hancock
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I am delighted to see that the teamwork between my hon. Friend and I is going to continue. You might be surprised to know, Mr Speaker, that there are some things on which my hon. Friend and I agree. One is the importance of individuals taking responsibility—a critical part of public health and tackling obesity—supported by an enabling state.

John Bercow Portrait Mr Speaker
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The Secretary of State is working extremely hard. I hope that he will take it in the right spirit if I say that I do not think he has yet quite secured the Shipley vote.

Luke Pollard Portrait Luke Pollard (Plymouth, Sutton and Devonport) (Lab/Co-op)
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Sarah, who runs the Devonport Live café in Devonport, one of the poorest parts of the country, used to provide cookery classes for local young mums, but she cannot do that anymore because of a lack of funding to provide the support, facilities and food to help young mums—especially those on low incomes—to get the skills that they need to cook healthy meals for their children. What support can the Secretary of State give to young mums and to people such as Sarah who want to provide cookery lessons to support tackling childhood obesity?

Matt Hancock Portrait Matt Hancock
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The hon. Gentleman makes an important point. Funding is available from lots of sources, not just taxpayers. Nevertheless, he will have noted that I have already started talking about the importance of getting funding out into the community, whether that is through social prescribing or wider public health efforts, to make sure that we try to tackle health problems at source and keep people out of hospital as much as possible, rather than spending all the money on sorting things out later in hospital.

Paul Beresford Portrait Sir Paul Beresford (Mole Valley) (Con)
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5. What assessment he has made of the potential merits of extending the provision of the HPV vaccine to boys.

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Patrick Grady Portrait Patrick Grady (Glasgow North) (SNP)
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17. What steps he is taking to tackle workforce shortages in the NHS.

Matt Hancock Portrait The Secretary of State for Health and Social Care (Matt Hancock)
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We now have more professionally qualified clinical staff working in the NHS: over 41,000 more since 2010, including over 14,000 more doctors and over 13,000 more nurses on our wards.

Peter Grant Portrait Peter Grant
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The majority of NHS staff in Scotland will benefit from a 9% pay rise over the next three years; their equivalents in England will get a much lower increase, and we do not even know if the funding for that is secured. Does the Minister have any concerns that nurses in England may choose to relocate to Scotland where they could be paid almost £1,000 more and work for a health service whose Government actually value its work?

Matt Hancock Portrait Matt Hancock
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It is interesting that the hon. Gentleman asks that question, because it is worth looking at some of the facts. Over the five years to 2017 health spending increased by 20% in England but by only 14% in Scotland. As a consequence, people are 30% more likely to wait 18 weeks for treatment in Scotland than in England, and the increase in the number of nurses and doctors in England has been higher than in Scotland. Perhaps the SNP should look at how we have been performing in the NHS in England and learn from that.

Patrick Grady Portrait Patrick Grady
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In that case, perhaps the Secretary of State will join the Royal College of Nursing in welcoming the action by the Scottish Government to enshrine safe staffing levels and ratios in law. Given that there are over 36,000 vacant nursing posts in the NHS in England, when will he follow the Scottish Government’s lead and bring forward legislation on safe staffing levels?

Matt Hancock Portrait Matt Hancock
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I have seen what has happened, and maybe the reason why the SNP has had to do that is that in England we have increased the medical workforce faster than in Scotland. When the performances improve in the Scottish NHS, we in England will start to take lessons, but until then I will concentrate on making sure we get the very best NHS right across the country.

Robert Courts Portrait Robert Courts (Witney) (Con)
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Barely two years after the shock closure of Deer Park medical centre in Witney, the people of Witney are now deeply concerned over the future of Cogges medical centre. Please will Ministers explain what they are doing to help with recruitment and retention of GPs in rural areas, and will the Secretary of State meet me to discuss the provision of GP services in our market towns?

Matt Hancock Portrait Matt Hancock
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I or the Minister of State would be delighted to meet my hon. Friend. Making sure that our GP services are of high quality and can respond to the health needs in the local community is absolutely mission-critical to getting prevention right, and I hope that my hon. Friend’s insights will feed into the long-term plan to guarantee the future of the NHS.

David Tredinnick Portrait David Tredinnick (Bosworth) (Con)
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I congratulate the Secretary of State and remind him that when he tours the high streets of Britain he will find an increasing number of acupuncturists, herbal medicine practitioners, reflexologists, yoga practitioners and many more, and they all have one thing in common: none of them is available on the health service. Will he introduce a review that takes into account patient experience and practitioner experience?

Matt Hancock Portrait Matt Hancock
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I pay tribute to my hon. Friend’s long campaign in this area, and I very much look forward to working with him on it to ensure that we get the right evidence-based approach to using all kinds of medicines and technologies for the benefit of patients.

Barbara Keeley Portrait Barbara Keeley (Worsley and Eccles South) (Lab)
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I welcome the new Secretary of State to his post. He has said that the whole workforce of the NHS and social care should have the chance to fulfil their potential, but the care workforce has an annual turnover of 27% and a vacancy rate of 7%, and, sadly, care staff learned last week that they would not even be paid the national minimum wage for sleep-in shifts, which will potentially drive even more people away from working in social care. Will the Secretary of State demonstrate the leadership that this Government have lacked on this issue and ask the Chancellor to change the regulations on the national minimum wage for sleep-in shifts, to show care staff that they matter?

Matt Hancock Portrait Matt Hancock
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I value every person who works in the NHS and in social care, because everybody plays a part in improving the wellbeing and the health of the nation. I care deeply about that. On the question of sleep-in shifts, I saw the decision by the court and I have already had conversations with the Department for Business, Energy and Industrial Strategy, which leads on this regulation, to ensure that we can get the rules right for the future.

Kwasi Kwarteng Portrait Kwasi Kwarteng (Spelthorne) (Con)
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10. What plans the Government have to improve support for the children of alcohol-dependent parents.

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Philip Dunne Portrait Mr Philip Dunne (Ludlow) (Con)
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18. What assessment he has made of the opportunity for artificial intelligence tools to improve the provision of healthcare.

Matt Hancock Portrait The Secretary of State for Health and Social Care (Matt Hancock)
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The Government believe that artificial intelligence and other digital technologies have the potential to transform health and care services. Our work on that includes investing over £400 million in tech transformation, which I announced last week. There is much more to do.

Philip Dunne Portrait Mr Dunne
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I also welcome my right hon. Friend to his new role. He will bring tremendous energy and enthusiasm, particularly into the information advantage that we know is needed to transform the NHS. Does he share my view that not only will this transform patient outcomes but we can use artificial intelligence to improve patient treatments? What are his initial views of the obstacles standing in the way of rapid uptake of such technologies?

Matt Hancock Portrait Matt Hancock
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There are huge opportunities for AI to improve patient outcomes and to make life easier for staff. In answer to the second part of my hon. Friend’s question, it is all about getting interoperable data rules and standards in place so that different systems can talk to each other in a secure, safe and innovative way.

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John Bercow Portrait Mr Speaker
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As the Clerk advises—his is the intellectual copyright—the hon. Gentleman has used his intelligence artificially to shoehorn his preoccupation into a question to which it has no other relation. But he has got away with it on this occasion, as it is the last day and we are all in a summer mood.

Matt Hancock Portrait Matt Hancock
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I welcome the power of new technologies to bring new drugs to the table. NHS England has made a very generous final offer to the manufacturer of Orkambi. Having spoken to those involved again over the past couple of days, I understand that a meeting has been offered to the company but not taken up. The company can break this impasse by accepting the very generous offer on the table.

Mary Robinson Portrait Mary Robinson (Cheadle) (Con)
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19. What steps his Department is taking to help protect children’s mental health from the harmful effects of social media.

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Patrick Grady Portrait Patrick Grady (Glasgow North) (SNP)
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T2. If he will make a statement on his departmental responsibilities.

Matt Hancock Portrait The Secretary of State for Health and Social Care (Matt Hancock)
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We have proposed £20 billion more funding for the NHS to guarantee its future, and I am looking forward to working with everyone in the NHS and the social care system on a long-term plan to ensure that that money is well spent. Today, we have published for the House the 2018-19 pay settlement for doctors and dentists. It represents the highest pay settlement since 2008. I regard it as a first step and look forward to a wider conversation on pay and improvements to help to make the NHS the best employer in the world.

Patrick Grady Portrait Patrick Grady
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Will the Secretary of State update the House on the progress of Baroness Cumberlege’s review of the use of mesh implants? Will he confirm whether the inquiry will liaise with the Scottish Government and whether it will hold any evidence sessions in Scotland? There are plenty of women, including some in my constituency, who had operations in England but now live in Scotland. Their voices must be heard in the inquiry.

Matt Hancock Portrait Matt Hancock
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Yes, the hon. Gentleman is absolutely right. We published information on this issue just last week. We absolutely will consult the Scottish Government and all interested stakeholders. It is a very important matter to get right.

Tim Loughton Portrait Tim Loughton (East Worthing and Shoreham) (Con)
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T5. Last year, 7.3 million people were prescribed antidepressants, including more than 70,000 children. That is an increase of more than 500% in the past 20 years. In welcoming the Secretary of State’s announcement on social prescribing, may I, as co-chair of the all-party group on mindfulness, ask him what part mindfulness and other evidence-based non-drug options will play in the strategy? Would he like to undertake a mindfulness course, and in doing so join the now more than 150 other MPs and Lords who have done so at Westminster?

Matt Hancock Portrait Matt Hancock
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I would be absolutely thrilled to. I have previously participated in mindfulness training. In fact, the former chairman of my local Conservative association became a mindfulness instructor, which shows how much we take it seriously locally. I pay tribute to my hon. Friend’s work on this issue. He will have seen that, even in my first two weeks in this role I have already spoken out in favour of moves towards social prescribing and the broader prescribing of less intervention and less medicinal methods, where possible, because medicines do of course have their place. The work that he has done on this issue over many years is to be applauded.

Jonathan Ashworth Portrait Jonathan Ashworth (Leicester South) (Lab/Co-op)
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I welcome the Secretary of State to his post. May I take a moment to thank all the NHS and social care staff who are caring for vulnerable patients in this intense summer heat?

The new Secretary of State inherits waiting lists at 4.3 million, with more than 3,000 patients waiting more than a year for an operation. He inherits a situation in which 1,700 patient requests for hip and knee operations have been refused, and in which patients in Sussex are now expected to endure “Uncontrolled, intense, persistent pain” for six months before they receive hip or knee treatment. Does he consider such increased rationing to be fair?

Matt Hancock Portrait Matt Hancock
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I am grateful to the hon. Gentleman for his welcome. Like him, I pay tribute to the work of NHS and social care staff in this summer heat. There are of course pressures on the NHS—I fully acknowledge that—and he raises a couple that I have already raised with NHS England. What he did not mention was that since 2010 there are 6,000 more operations every day and 1,800 more emergency admissions every day.

Jonathan Ashworth Portrait Jonathan Ashworth
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Since 2010, the NHS has suffered the biggest financial squeeze in its history, and the rationing that I referred to is a consequence of that squeeze.

Let me ask the Secretary of State about general practice, which he will know is facing a severe workforce crisis, with GP numbers down by 1,000 and many GPs worried about the patient safety implications of the Babylon app, which we have already discussed this morning, and its funding implications for their model of practice. When Babylon itself admits that it is still testing it out, when Hammersmith and Fulham CCG says that

“there is evidence of concern regarding the risk to patient safety”

of expanding the service, and when Birmingham and Solihull CCG questions whether Babylon can operate in an effective and safe manner, why does the Secretary of State dismiss concerns about patient safety and say that the rules simply need to be updated? Will he tell us what specific rules will be updated to allay concerns about patient safety?

Matt Hancock Portrait Matt Hancock
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It is almost as if it was not just my hon. Friend the Member for Hitchin and Harpenden (Bim Afolami) who popped out, but the shadow Secretary of State, who obviously was not here for the earlier discussion. Getting more resources and increased resources into primary care and to GPs in particular is absolutely mission critical to the long-term sustainability of the NHS. I am delighted that there is record GP recruitment at the moment and that the work that has been done to increase GP training is bearing fruit. On the question of new technology, as we discussed over a series of questions earlier, yes, it is important to make sure that it works well and that the rules are right but, if we turn our backs on new technology, we are turning our backs on better care.

Robert Halfon Portrait Robert Halfon (Harlow) (Con)
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I congratulate my right hon. Friend on his new position. Despite having incredible NHS staff, our hospital in Harlow, the Princess Alexandra Hospital, is not fit for purpose in terms of its building. We desperately need a new hospital. Will he visit Princess Alexandra Hospital as Secretary of State and will he please make sure that we get the new hospital that we urgently need in the constituency of Harlow?

Matt Hancock Portrait Matt Hancock
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I pay tribute to the work that my right hon. Friend has done over many years making the case for his hospital, which I have heard loud and clear. I always enjoy visiting Harlow, especially when I am his guest. I hear the case that he puts and look forward to visiting soon.

Lilian Greenwood Portrait Lilian Greenwood (Nottingham South) (Lab)
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T3. Last month, a constituent contacted me about the care of her adult son who needed to be admitted to hospital under the Mental Health Act 2007. She was told that no beds were available anywhere in the country. The following day, a bed was identified but when, after three hours’ wait, the ambulance had not arrived, the bed was filled by another patient. Three days later, he was finally admitted to hospital. The head of mental health at Nottingham City Council told me that this is not an infrequent occurrence. Secretary of State, how is this an acceptable standard of mental healthcare?

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Chris Green Portrait Chris Green (Bolton West) (Con)
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I welcome the Secretary of State to his position, especially given his background in data and digital. What is he going to do to improve NHS data management to enable its use to develop the next generation of drugs and medical technologies to deliver better health outcomes?

Matt Hancock Portrait Matt Hancock
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That is a great question. Not only can technology improve in health settings; there are even greater opportunities on the research side. Getting the data structures right is mission critical, but there is so much more that we can do.

Nick Smith Portrait Nick Smith (Blaenau Gwent) (Lab)
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T7. To help to reduce childhood obesity, 76% of people support a ban on junk food adverts before 9 o’clock, but the consultation on this is going into the middle distance. Critics would say that the Government are dragging their feet. By when will we see this ban finally put into place?

Matt Hancock Portrait Matt Hancock
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We announced that we will be consulting less than a month ago. I have been closely involved in this in my previous role, as well as in this one. We will ensure that we take an evidence-based approach, but I am determined that we proceed.

Huw Merriman Portrait Huw Merriman (Bexhill and Battle) (Con)
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Will the Secretary of State come down to East Sussex to view the Better Together partnership, which puts health and social care together?

Matt Hancock Portrait Matt Hancock
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How could I say no? The integration of health and social care is vital and long awaited, and there is so much to do.

Ann Clwyd Portrait Ann Clwyd (Cynon Valley) (Lab)
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As someone who is about to have a knee operation, may I tell the Secretary of State that it is a painful thing to wait for and that people should not have to stay on waiting lists for long periods of time? My question is about hospital medical staff. Western Mail carried out a survey to look at the effect of EU nationals leaving the national health service because of Brexit. It found one health board saying that there were 1,200 more nurses than there were four years ago, and another saying that there were 1,400 fewer. No one seems to be able to tell us with absolute certainty the numbers of these staff in the health service.

Matt Hancock Portrait Matt Hancock
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I listened carefully to the right hon. Lady because she has long been a campaigner on health issues, and I very much take her point about knee operations. Of course, the number of EU nationals working in the NHS in England has risen by over 4,000 since the referendum. I know that there are concerns in specific areas, but I hope that we can all take reassurance from the fact that that number has continued to rise. We are determined to ensure that the NHS has the workforce that it needs.

Anne-Marie Trevelyan Portrait Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)
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I welcome the Secretary of State to his place. I encourage him to visit the most rural part of England, up in Northumberland, to see for himself the challenges to healthcare provision due to the lack of a real rural financial formula. Will he update my constituents and the Save Rothbury Hospital campaign on how the review for that community hospital is going? That sort of low-level care is what makes the difference.