Budget Resolutions

Paul Williams Excerpts

Tuesday 30th October 2018 Commons Chamber

[Dr Paul Williams (Stockton South) (Lab)]

I am grateful, Madam Deputy Speaker, for the opportunity to speak in this most important debate on public services and the Budget. It is a pleasure to follow the hon. Member for Sleaford and North Hykeham (Dr Johnson). I agreed with her comments about children’s mental health. As co-chair of the all-party group for the prevention of adverse childhood experiences, I agree that tackling the causes of children’s mental health problems is vital.

Today, however, I wish to talk about community safety and the public service that our police provide. My constituency of Stockton South desperately wanted a better response from the Chancellor than a Budget that ignored community policing. I cannot really imagine how it must feel to be frightened in my own home. I have heard many people’s stories of the fear that they feel, but how many Members really know what it is like? How many of us know what it is like to be woken in the night by people loudly bashing on the door looking for someone to sell them drugs; what it is like to know that, if we were to go out to walk the dog, someone might break in and steal our possessions; and what it is like to have to listen to sex workers being threatened by clients through a flimsy adjoining wall when we are lying in our beds in the early hours of the morning?

Hon. Members have probably heard these sorts of stories from looking in their email inboxes, engaging on social media and meeting people at their surgeries, but yesterday those affected were ignored by the Chancellor. Cleveland police, which covers my constituency, has dedicated professionals working hard under the exceptional leadership of Police and Crime Commissioner Barry Coppinger, a new chief constable, and a team of hardworking officers, police community support officers and support staff. I pay tribute to everyone working in our police forces to keep our communities safe. They are the people who pick up the pieces during a crisis. I thank them for everything that they do. No police officer goes to work each day not wanting to help, not wanting to prevent crime, not wanting to respond to need and not wanting to engage with communities, but our community can see that the policing in Cleveland is not adequately meeting their needs. In the past eight years, the actual cash—not real terms—budget for Cleveland police has fallen by more than 10% from £148.5 million in 2010 to £134.6 million in 2018. The money that remains buys much less today than it did in 2010. Inflation, pay awards, national insurance increases and the apprenticeship levy all increase the cost of policing.

In real terms, Cleveland police force is £39 million worse off than in 2010, and we have 500 fewer police officers as a result, but is that not the same picture as in the rest of the country? No. This Government are widening social divides by making the greatest cuts to policing in the areas of highest need. The least impact of the Government’s police cuts has been experienced in Surrey, where residents have seen an overall funding increase of 1% since 2010. Recorded crime is nearly 60% higher in Cleveland than in Surrey. If Cleveland had received the same increase, my local police force would have gained an extra £15 million a year instead. I am genuinely pleased that the people of Surrey have had a 1% increase in their police funding, but if it is good enough for Surrey, why is it not good enough for Stockton South?

Why is my community different and why is Cleveland so special? Cleveland is a great place to live. Our communities are strong, and we are a good place in which to do business, but policing our area is a challenge. We have particularly high needs: the highest levels of antisocial behaviour in the country; the second highest levels of domestic violence; an increasing level of recorded crime; the highest levels of drug abuse in the country; high deprivation; and serious and organised criminals involved in the supply of drugs. The Government promised us a Budget to end austerity, but the fact remains that Cleveland police is now £39 million a year worse off than it would have been, with more cuts to come.

Austerity has always been a political choice. Over the past eight years, time and again, the Conservatives have been able to find giveaways and sweeteners for a few people at the top while leaving communities in places like Stockton South to pick up the pieces. Think about the woman in Parkfield in my constituency who contacted me in tears because she says she has no choice but to sell her home just to get away from a small number of criminals in the area who act with impunity. Or think about the police officer who got in touch and offered me a picture of a force working its hardest, but unable to do its job, with low staff morale and significant concerns about a loss of public trust. “We desperately need the support of Government,” the officer told me. There is crime that officers want to tackle—crime that they want to fight—but it carries on with impunity because they do not have the numbers to be there when they are most needed.

Since 2010, Cleveland police has lost about 500 officers, yet next year the Government plan to make Cleveland’s thin blue line even thinner, with a further cut of an even greater £9 million. Nine million pounds of cuts means even fewer police officers at a time when our communities have never felt less safe. If the Chancellor really wanted to end austerity, he would give Cleveland police their £9 million back. Police in our county need the resources to be able to do their job. My constituents have a right to feel safe in their community and to know that the police will be there for them when they are needed.

The Conservatives used to call themselves the party of law and order. How can Conservative Members carry on saying that with a straight face to some of the people who visit me at my surgeries, and probably theirs too? This Government will carry on fighting among themselves long after the grand gestures of Budget week have been forgotten; I and my Labour colleagues will carry on fighting for the proper funding that our local police forces need to keep our constituents safe.

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[Alex Cunningham (Stockton North) (Lab)]

The financial health of industry in my area is absolutely critical. The attempts yesterday by the Chancellor to bury the bad news for industry, in particular energy-intensive industries, did not help at all. He did not mention it, but he did not bury the news very deep either: it is there for all to see on page 47 of the Red Book. If the changes in carbon taxes materialise in response to Brexit, it will cost individual firms millions of pounds. The carbon emissions tax is significantly higher than the average emissions trading scheme price over the past 12 months, which was just £12.30. This would increase the cost of carbon for UK installations across the country, currently covered by ETS, by 30%.

The Chancellor acknowledges the increasing high total carbon price, but proposes to freeze it at £18 a tonne of carbon dioxide for 2021. He might think that that is an ambitious move, but these plans come with little notice and a particularly high cost for industry. Firms like CF Fertilisers in Stockton are significantly exposed to the additional extra costs. The EU energy trading scheme is a market-based instrument for which companies had developed a strategy over time to ensure they were able to comply. Now, on top of the perfect storm of high electricity and gas prices, this carbon tax, coupled with the doubling of the gas climate change levy, is a very real issue for energy-intensive industries.

The Government did publish a document on this last night. It betrays a fundamental change in policy since the Brexit vote, with no consultation with industry along the way. In the worst Brexit scenario of all, EIIs are being given an expensive fait accompli with no notice, no discussion and no impact assessment. This makes industry very nervous. Rolled together, all this serves to make the UK an unattractive place for EIIs to do business in the future.

The Chancellor could have helped an industry facing such a dilemma by giving some indication of Government support for carbon capture, use and storage, but he did not. As I have said on numerous occasions, Teesside is ripe for investment in carbon capture, use and storage. The industry needs some indication that the Government are capable of making the right call on this matter. Perhaps once the task group on CCS reports we will hear something more positive from the Chancellor in the new year.

This is my ninth speech in a Budget debate, and in every single one I have talked about health inequalities in my area and the need for a 21st century hospital in Stockton to help tackle them. Stockton was promised a new hospital, but in 2010 the coalition Government scrapped it while making sure that similar plans went ahead where there just happened to be Government MPs of both the blue and yellow. Let me outline why we need to solve the social care crisis and build a new hospital in Stockton.

Nationally, on average, a boy born in one of the most affluent areas of England will outlive one born in the poorest parts by 8.4 years. In Stockton, where life expectancy for a man in the town centre ward is 64, that gap is around double at 15 years. Incidentally, that life expectancy age is the same as in Ethiopia. Our children in these inner-city areas are living in poverty. They are more likely to be undernourished, more susceptible to all manner of illnesses and more likely to end up in care. Older adults are more likely to be ill, given a lifetime of hard work in the heavy industries. One in five babies in Stockton is exposed to cigarette toxins in the womb because their mother smokes while pregnant. That was in 2015-16. That year, there was a significantly higher rate of hospital admissions attributed to smoking than the national average. According to the British Lung Foundation, people in the north-east have the highest chronic obstructive pulmonary disease mortality ratio in the country. The English average for children achieving a good level of development at five years old is at 60%. In Stockton, this is just 50%.

[Dr Paul Williams]

Does my hon. Friend agree that the cuts to public health funding have had a significant impact on Stockton Council’s ability to deal with some of those health inequalities, and is he as disappointed as I am not to have heard about increases in public health funding in the Budget?

[Alex Cunningham]

Most certainly. My hon. Friend and I represent between us some of the most difficult areas in Stockton, with high levels of smoking and drinking that make the national average pale into total insignificance. We desperately need that additional funding, so I most certainly agree with him.

Our local North Tees hospital does an exemplary job in the most difficult circumstances, yet it could do so much better in a modern building with services that are required cheek by jowl and where people can be treated in wards rather than converted corridors. That is why we need a new hospital in Stockton and why I will mention that in every Budget speech I ever make until I get it.

Still on health, the police and crime commissioner for Cleveland has been doing excellent work on the introduction of heroin-assisted treatment in neighbouring Middlesbrough—a project that the experts believe will help to save lives and money and reduce crime across Teesside—but he needs Government support to make it the best that it can be. I hope that there will be a full Government commitment to that initiative.

On policing, I am really worried, like my colleague next door in Stockton South, about policing in our area. Like most others, the Cleveland police force area has been short-changed by this Government over many years and the police know that they can no longer deliver the full service that is needed. As my hon. Friend said, over the last eight years, the Government grant for policing and crime in Cleveland has been cut by around 24%. He also outlined in detail why we need that extra money, yet Cleveland is harder hit by cuts than most other forces because of how it is categorised. The county is largely rural, but the vast majority of the population is in inner-city areas, with the same challenges of the cities, yet we do not get the same level of funding. Let me be clear: there will be severe repercussions for public safety and criminal justice in Cleveland if the people do not get more funding.

On education, the Chancellor announced some one-off funding for schools to pay for little extras, but it is teachers and action on pay that they need. Stockton’s branch of the National Education Union visited my surgery on Friday. It wants to see the Government fund the full pay award rather than leave schools to do it. It also wants all teachers treated fairly, which the pay award fails to do. I hope that they will hear something better from the Government in future.

I simply plead again with the Chancellor to do the right thing by Stockton: help us to tackle the health inequalities that we have; help us to deliver the public health programmes that help to educate people about the choices that they have in life; and please find a way to build us a new hospital.

Oral Answers to Questions

Paul Williams Excerpts

Tuesday 23rd October 2018 Commons Chamber

[Steve Brine]

As I said, we are spending £16 billion of our constituents’ money during this spending review period on public health grants. Decisions about where we go in future are of course not a matter for me but for the Chancellor in the spending review. This House decided in the Health and Social Care Act 2012 to make every upper tier local authority a public health authority. We believe that it is right for local authorities to make those decisions, with the funding that we give them.

[Dr Paul Williams (Stockton South) (Lab)]

How many health visitors have been lost since 2015? How will the Minister ensure that important investments are made at the start of life to reduce health inequalities?

GP Extended Access Services: Privatisation

Paul Williams Excerpts

Wednesday 17th October 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

I beg to move,

That this House has considered privatisation of GP extended access services in Stockton, Hartlepool and Darlington.

It is a pleasure to serve under your chairmanship, Mr Hosie, as we explore the important issue of the privatisation of local health services. Before I begin, may I bring to your attention my entry in the Register of Members’ Financial Interests? I have worked in the local extended access service. I have been employed as a GP since my election to Parliament, and before that I was chief executive of Hartlepool & Stockton Health, which is a GP federation established by all local GPs as a non-profit-making venture to allow collaboration between practices and other parts of the NHS. I resigned my position when I was elected, and I served my notice. My partner, Vicky, is a nurse in the local NHS and she derives some income from the GP federation.

As the Minister will know, the Government’s ambition is for all patients to be able to access evening and weekend GP appointments, which is a good thing. It is difficult for each individual GP practice in any area to open every evening and weekend, but it is achievable if GPs work together. In Stockton South in April 2017, Hartlepool & Stockton Health started to deliver extended access appointments between 6.30 pm and 8 pm on weekday evenings, for three hours on a Saturday, and for two hours on a Sunday. Local GPs did that as a collective through their federation.

The federation was set up as a private company—there is as yet no NHS GP federation organisation that it can belong to—but it was designed as a not-for-profit organisation because local GPs insisted on it. They did not want to make any profit out of collaboration. All the money earned by the organisation is reinvested into local primary care—I know the detail of that because it was my job before I came into Parliament to set up and run the organisation.

Evening and weekend GP services have now run for 18 months and they have been a success by all measures. Patients like it:

“Every aspect of my visit was excellent…it was prompt and professional…a lovely experience”

are three of the many comments received as feedback. During the past year, there have been 26,000 extra GP and nurse appointments for routine care. That has not just been good for patients; it has also reduced pressure on local practices. Teesside has one of the highest patient-to-GP ratios—we are an under-doctored area.

Down the road in Darlington, Primary Healthcare Darlington has run an extended access service in the evenings and weekends since 2015 when it received Prime Minister’s Challenge funding. According to all the reports I have received, it has run an equally good service for the people of Darlington. So far, so good. However, in September this year the local clinical commissioning group launched an invitation to tender with two lots—one to run an extended access service in Darlington, and the other in Hartlepool and Stockton. The tender documents requested that organisations bid to run one and a half hours of general practice each evening and a bit longer at the weekends. The bidding process is under way and I am sure the Minister will not want to say anything that might prejudice the process.

I have initiated this debate to ask some big questions. Biggest of all is this: how does privatising this service benefit local patients—the acid test for any NHS change? When local GPs work together to deliver this service, and when the local NHS has all partners collaborating so well, how can it possibly be right to bring in a new private sector provider?

[Alex Cunningham (Stockton North) (Lab)]

I congratulate my hon. Friend, my next-door neighbour, on securing this debate. One thing that concerns me is the potential loss of good will from GPs across the Tees valley who are currently delivering the service. Does that concern him too?

[Dr Williams]

I will come later in my remarks to some of the reasons why the system works well at the moment, and to some of the potential threats that could arise from introducing a private sector provider.

Before I expand my point, let me establish my position so that there can be no confusion or misinterpretation. As I said, extended access services are a good thing. I worked hard before my election to establish them, and they are good for patients and for the NHS. I congratulate Hartlepool and Stockton-on-Tees CCG and Darlington CCG on delivering extra GP services for local patients over the past few years in Darlington and for the past 18 months in Stockton. They have done a good job. I also know that most GP practices are technically private organisations with a contract with the NHS, but there is an important difference between a local GP who is doing the work and making money from that, and a private corporation whose shareholders profit from the NHS.

Having said that, I am on the record as having said that GPs should be employed by the NHS, and I believe that the time has come for the NHS to set up community providers to integrate GPs, community nursing, social care and community health services. GPs should be offered employment in those organisations. The farce that I am describing today makes the case for that type of organisation stronger.

While setting out my credentials, I am also pragmatic and not dogmatic about private and voluntary sector provision within the NHS. Our local counselling services in Stockton are better for having multiple providers. Patients like getting hearing tests on the high street at Specsavers instead of going to the hospital audiology department. What I am describing today, however, is privatisation for privatisation’s sake. It is privatisation because the “rules” say privatise, and not because anyone thinks that privatisation is good for patients. It is probably even privatisation by accident.

For me, the most important test of any change in the NHS is: how does this benefit patients? The NHS is there to improve health. I have huge respect for all the staff who work in our NHS, and I thank everyone for their efforts, but fundamentally local health services must meet the needs of local patients. How could bringing in a private GP company for an hour and a half each day possibly make things better for patients in my constituency? If there were a list of 101 things to do to improve the NHS in Stockton South, finding a new provider for GP extended access would not be one of them.

Children’s mental health services are in crisis and health inequalities in Stockton are the most stark in the whole country. Our local authority is struggling to deliver effective public health services because of the cuts, and waiting times for autism diagnosis for children have been four years, even though our health and wellbeing board, council and CCG have good plans to reduce that. For general practice, in some parts of Stockton South patients tell me they have to wait four weeks for a GP appointment. Fixing those things should be the priority for our CCG, not being forced to spend time and money on an unnecessary privatisation.

GP extended access is one part of the local NHS that is working well. The model has energised local GPs and, to an extent, local nurses. Eighty-five doctors and 25 nurses have worked in the service. Three years ago, before I was in Parliament, I led a workshop for GPs, and the No. 1 thing they asked me not to introduce was an extended access service. However, working together with the CCG, a model was created that people wanted to work for—one that works for staff and patients. Since GPs own the organisation that they work for, the things that matter are prioritised. The GP federation has a culture lead—an employee of the federation whose job it is to promote a happy, healthy working environment and reduce the pressure on frontline GPs. GPs working in that service are not motivated by profit. They are working as a collective and taking responsibility.

Extended access has also allowed new models of care to be tried, and pharmacist, physiotherapist and counsellor appointments are directly bookable at the weekend. The scheme is popular with patients—96% of GP and 70% of nurse appointments have been used. In short, the service works well. Although most people said at the start that it would not work, the service is popular with patients and well led. Why privatise it? What on earth could be gained? One and a half hours a day of private general practice—it is ridiculous.

More good collaborative things are happening in Hartlepool and Stockton. The local GPs are already working in partnership with the local hospital and the local ambulance service to run the local urgent care centre. Local services are integrated, everyone is talking to each other and most people are happy. Most areas would be delighted to have such a level of engagement and co-operation and such leadership. The service has been put out to tender simply because of the law. The Health and Social Care Act 2012 mandates competitive tender for certain contracts worth more than £615,000 a year.

In this case, I contend that the law is not working. It does not work for patients, it will not work for doctors or NHS leaders and I suspect it is probably not even what the Minister wants. There is hypocrisy here—a fundamental difference between what the Government are saying and what they are doing. I will quote from NHS England’s “Next steps on the NHS Five Year Forward View” document, published in March 2017, which says that it will:

“Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care…hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access.”

That is what the NHS five-year forward view says will happen: GPs will work together to pool responsibility, which is exactly what is happening in my area. If private companies are invited to competitive tender for that, every GP has something to fear from the collaboration. They will do the work of setting up the services and somebody else will then come in and run them.

The Minister’s colleague, the Minister for Health, the hon. Member for North East Cambridgeshire (Stephen Barclay), recently gave evidence to the Health and Social Care Committee inquiry into integration in the NHS. When he was asked about privatisation, he said that

“there are a number of checks and balances in the system in the requirement for CCGs to consult their local populations, their health and wellbeing boards and their oversight and scrutiny committees. On top of that, there are safeguards at a national level of CCGs going through the integrated support and assurance process. Actually, there are a lot of checks and balances as to the fact that this is not privatisation.”

I ask where the checks and balances were to stop the CCG having to put these services out to tender. Why did the Minister not intervene, when it is plain to everybody that it is a ridiculous idea to bring a private company in for an hour and a half each day?

[Alex Cunningham]

What concerns me is that this tender document sounds as though it will lead to a reduction in service, and the working people who access those extra clinics and appointments will not have the same level of service that they currently do. The Minister must intervene to ensure that we at least have the level of service that we have now.

[Dr Williams]

I thank my hon. Friend for highlighting the potential risks to local patients. This is not about defending the interests of the staff who work in the service, however important they are; it is about ensuring that it is the best service for local patients.

Finally, I quote from the 2017 Conservative election manifesto; I am afraid I do not keep my own copy, but it is still available online. It says:

“We expect GPs to come together to provide greater access”.

It also says:

“If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes. This includes the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy. So we will review the operation of the internal market and, in time for the start of the 2018 financial year, we will make non-legislative changes to remove barriers to the integration of care.”

I ask, then, what the Minster has done and how he has acted to remove barriers to integration of care in Stockton.

GPs in the NHS in Darlington and in Hartlepool and Stockton are doing everything they have been asked to do by this Government and the NHS. They have organised themselves into collectives, and together they are delivering social prescribing and pharmacists in practices, promoting nursing in general practice, introducing new technologies, helping physicians’ associates and training. Those are all good things that I am sure the Minster would support. Integration works. Integration is the right strategy: collaboration, not competition.

Why privatise now, and what is the risk of a private company running this service? The tender encourages competition on price. The lower an organisation’s bid, the more likely it is to win the contract. Cutting costs means less money to pay for things such as the culture lead I mentioned, so the kindness, the looking after staff, the encouragement and the “thank you” cards go, and with them much of the goodwill they bring, which my hon. Friend the Member for Stockton North (Alex Cunningham) talked about.

Would local doctors and nurses want to work for a private organisation motivated by profit? Remember, I said that most local GPs were opposed to extended access only three years ago. Their participation has been carefully nurtured; they have ownership of the organisation delivering the service and they now really care about making it a success. How will the tender process take account of that? Today, we have doctors and nurses working in a service motivated by patient care. How can a for-profit company answerable to remote shareholders recreate that ethos? We have seen this Government’s privatisation failures over and over again, with Circle, Serco and Carillion. This Government are saying one thing about NHS collaboration, but doing another.

I have three questions for the Minister, and I will give him plenty of time to respond. First, why did he let this happen and why did he not intervene to stop it? Secondly, what is he going to do to stop this happening again in other parts of the country? What changes to the law does the Minister think would be helpful? Thirdly, how can he expect the public to trust the Tories on their new integrated care system idea if he cannot guarantee that these new multi-million pound contracts to run all the local health services will not be put out to tender in exactly the same way?

In the Minister’s response, I ask him to either defend this ridiculous privatisation of 1.5 hours of GP services a day, risking a great service being taken away from local GPs and given to a private company, or perhaps to concede that this type of privatisation—a consequence of the Conservatives’ 2012 Act—does not help patients and runs counter to the aims expressed in his party’s election manifesto, the stated aims of his ministerial colleagues and the strategy of NHS England. Maybe he will agree that the law needs to be changed. I look forward to his response.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is a pleasure to serve under your chairmanship, Mr Hosie—it is the first time we have done this. I congratulate the hon. Member for Stockton South (Dr Williams), who I always enjoy listening to, on securing this debate on an important issue for him as both a Member of Parliament and member of the important Health and Social Care Committee, and—as I think he is still—a practising GP.

We know that primary care literally, by definition, comes first. It has always been and always will be the bedrock of the national health service. The Secretary of State and I have made that absolutely clear, and the long-term plan, when it is published later this year, will make it even clearer. As the hon. Gentleman rightly says—I think there is unanimity—we are committed to ensuring that everyone can see their GP at a convenient time by increasing the availability of routine evening and weekend appointments. Millions of patients have already benefited thanks to our investment of some £2.4 billion into general practice by 2021. I join him in paying tribute to his colleagues for making the leap and making that available to his constituents.

We have asked all clinical commissioning groups to ensure by March next year that patients have extended access to general practice across the whole of their registered population. That includes ensuring that access is available during peak times of demand such as bank holidays, and across the Easter, Christmas and new year periods. We have made great strides in delivering extended access, with the vast majority of England now offering weekend and evening appointments. Apologies to you, Mr Hosie—this of course is a devolved matter and we are talking about the English health service. That extended access will, as the hon. Member for Stockton South rightly says, help to reduce the pressures on general practice—it is not all squeezed into the original sessions—and, importantly, to reduce pressures across the wider NHS ahead of winter, which is creeping up on us.

Good access is key to improving quality and is not just access for access’s sake. Problems with access make it harder for people to get the right care from the right person at the right time. It is a publicly funded health service and it is there for the public, and that is what the public say they want. However, for us improving access is not simply about all GPs working seven days a week or doing more of the same. There was certainly a comms failure with the 2012 Act, in that it was allowed to be presented as saying that we just wanted GPs to just do more and to work seven days a week. Many people work seven days a week—all MPs certainly do—but improving access was not just about asking GPs to do more of the same. It can be and often is about practices coming together to offer services to a larger population—I have seen it most recently at the brilliant Granta surgery in Cambridge, which does it very well—using technology in different ways to make it easier for patients to access services, and broadening the skills mix. The hon. Gentleman and I have talked about the multidisciplinary team many times. It is also about working smarter in greater partnership across the health and social care system. The Secretary of State was at Granta just last week.

The hon. Gentleman mentioned the Health and Social Care Act 2012 and asked in effect why we do not just do away with the requirement in that Act—the section 75 rules—so that CCGs are, as he says, no longer required to tender for contracts. Let me assure the hon. Gentleman and you, Mr Hosie, that any fears of privatisation of our NHS are, we think, completely groundless. I do not accept the title of the debate on the Order Paper. The Government are fully committed to the NHS as a public service that is free at the point of need, as it has been since day one in 1948—70 years ago this year, of course—whether care is provided by NHS organisations, as the vast majority is, or by the private, voluntary or social enterprise sectors. That guiding principle remains absolutely the case today. The mechanisms for deciding who provides what service may vary, but the basic structure of our NHS remains exactly the same. The key question is, and will remain, the pragmatic one: how do we best secure the outcomes that we want for patients and the best possible value for the taxpayer? I completely respect the fact that the hon. Gentleman started his speech by saying exactly that. He is spot on, of course.

We should avoid the blanket assumption that one form or other of provision is always the best or worst, as the evidence does not support that sort of sweeping conclusion, which the hon. Gentleman understands. As long as patients receive care that is high quality, timely and free at the point of use, the status of the provider is of little if any significance. That has been the policy of successive Governments for many years. It was certainly the policy of the last Labour Government and was what Tony Blair believed when he was in office. I know that many Opposition Back Benchers do not share the ideology of those on their current Front Bench, which is to make those sweeping conclusions that one form of provision is bad and one good. Where healthcare is free at the point of use, people are not as concerned about who provides the care as we think and often hear in the House. The British social attitudes survey showed that 43% of people had no preference whatever between a private provider, an NHS provider and a not-for-profit organisation.

A clear framework for public sector procurement is both necessary and, we think, desirable, just as it has been since it was introduced in 2006, under a previous Government, to implement the EU procurement directive. It is necessary to ensure that where a local, clinically led CCG decides that it is in the interests of patients and taxpayers to look at a range of potential providers for a service, it is able to do so. That is in the best interests of patients and taxpayers. Securing the best possible treatment for a patient is what we all want to achieve, but we also have to use NHS resources for the good of all patients. Achieving value for money is not just about making the numbers add up. It is about how we ensure that everyone gets the quality of treatment that they deserve.

[Dr Paul Williams]

The Minister has said that the CCG puts things out to procurement when it decides that that is in the interest of patients. Do I understand from his words that the local CCG had the option within the law of not going out to procurement on this service?

[Steve Brine]

I might have to send the hon. Gentleman a note on that, but I will repeat what I said, just for the purposes of accuracy—I know he is seeing the relevant people later this week. Where the clinically led CCG decides that it is in the interests of patients and taxpayers to look at a range of potential providers for a service, it is able to do so. Those are the words I have for him. What we need and have is a sensible, proportionate framework that effectively balances the need of commissioners to secure the best-quality service at the best price with their need to ensure the security and sustainability of supply. It has worked that way and worked well for the past 12 years.

--- Later in debate ---

[Steve Brine]

Let me repeat that the local, clinically led CCG absolutely decided that it was in the interests of patients and taxpayers to look at a range of potential providers for the service that they wanted to be provided. That is the process that it is going through. The hon. Member for Stockton South rightly said that he would not expect me to wade into the middle of the procurement process. I cannot do that, but I will say that sensible, dynamic commissioning will be central to the NHS meeting the challenges that it faces today and in the future despite the commitment to increase the funding by £20.5 billion a year. That is vital to ensure that the NHS delivers on our triple aim of improving quality of care, cost control and population health which, as I am the Public Health Minister and absolutely focused on prevention, is one of my and the new Secretary of State’s key priorities. It is central. To achieve that triple aim, NHS commissioning will need to continue to develop as it has done since its inception. NHS England has designed a new commissioning capability programme to support commissioning systems. The programme provides tailored support delivered through place-based solutions to equip NHS commissioners with the skills they need to deliver on the challenges of today and the future.

Let me stress one of the fundamental principles of the 2012 reforms of the NHS—I served for many weeks on the Standing Committee that considered the Bill. That principle is delegating power away from Whitehall and Ministers such as me, who come and go with political cycles, to local clinical commissioning groups. They are led by fantastic GPs and other local health experts, who are best placed to make the important decisions that matter to local people. Darlington CCG and the Hartlepool and Stockton-on-Tees CCG are rightly making the decisions about how best to ensure that people in their areas have access to a GP when it suits them. Bids for local extended access GP services are currently being closely assessed with a view to the contract starting in April 2019. I have faith that those local commissioners will award this contract in a way that, as I have set out, improves access and quality for patients. Let me say that very clearly: I have faith that those local commissioners will award the contract in a way that I think the hon. Member for Stockton South will find satisfactory.

[Dr Williams]

rose—

[Steve Brine]

We still have two minutes, so I will let the hon. Gentleman come in again.

[Dr Williams]

If the Minister had been asked for his advice as the Minister with responsibility for primary care by the CCG about whether it should put this out to tender, what would his response have been?

Integrated Care

Paul Williams Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

It is a pleasure to serve under your chairmanship, Dame Cheryl.

I thank the hon. Member for Totnes (Dr Wollaston) for securing this debate and for her outstanding leadership of the Health and Social Care Committee. As a GP and a public health doctor, I have a lot of experience of care that has not been adequately integrated. Too many times, I have seen patients repeat their story again and again to different health and care professionals. Too many times, I have seen doctors, nurses, managers and secretaries waste time searching for information that has not been passed from one part of the system to another. Too many times, I have seen dedicated community nurses, social workers, GPs and therapists all providing care that either overlaps with or contradicts care provided by other health workers.

Integrated care, as the Committee has acknowledged, is a very laudable aim, and the Government have some credible plans on delivering more integrated care. I will use my speech to focus on where those plans need to be strengthened. I will talk about resource, about what success should look like, a little bit about legislation and governance, about keeping the NHS as a public sector organisation, and about leadership.

First, integrated care needs to be properly resourced. The new care models pilots have had significant resource to facilitate change, as the hon. Lady indicated, and that may be a key factor in any reported success. Greater Manchester has also had significant investment of extra funding. Can the Minster assure us that, as other areas move towards integration, we will not see what usually happens: the pilots get extra resources and then the roll-out fails because of a lack of extra resource?

[Dr Whitford]

I am glad that the hon. Gentleman has highlighted that problem, which we have been seeing for literally decades. Early adopters are well resourced and well supported and have the ear of the health board or the Government, but during roll-out, all the people who did not have that experience are told to do it out of existing budgets, and it fails.

[Dr Williams]

I thank the hon. Lady for emphasising that point.

My second point is on what the broader health goals of an integrated system should be. The NHS is focused on reducing unplanned hospital admissions. Although that is important—it is especially important because of the financial costs to the service of unplanned hospital admissions—I want to see integrated care providers trying to achieve broader health goals. Success should not be measured by a reduction in secondary care activity alone, although I agree that in many cases the use of unplanned secondary care is a failure of prevention. ICPs will provide healthcare for a population of people. They need to take a population needs-based approach to healthcare, and they need to be prepared to invest outside the traditional medical model of care, including investing in the voluntary and community sector. We know that loneliness, social isolation and bereavement can have a huge impact on health, and we need integrated care not to be integrated medical care, but integrated holistic healthcare. I consider that integrated care providers will have succeeded if resources are focused on improving the health of the members of our population who have the greatest health needs.

Health needs are often not expressed. The inverse care law tells us that those with the greatest needs often have the least access to healthcare. A clever healthcare system does not just react to the people who turn up; it works with communities to identify and address needs within communities. For example, many people with mental health problems simply do not access healthcare, and it is not only their mental health that suffers as a result; their physical and social health suffer, too. On average, people with learning disabilities die 15 years younger than those without. They do not die because of those learning disabilities; they die because they are not accessing healthcare, both preventive and curative. We know about the health issues suffered by people living in poverty and other vulnerable people, including those with substance misuse problems, homeless people, veterans and vulnerable migrants.

Overall, I will consider integrated care to be a success if the share of healthcare expenditure that goes to preventive care, community care and mental health care increases year on year. Also, prevention must be prioritised, and I am pleased it is one of the three named priorities of the new Secretary of State for Health and Social Care. We need prevention at all its levels: better early detection, better immunisation and screening coverage, better prevention of falls, and better prevention of mental health problems, including investment in prevention right at the beginning of life—the first 1,000 days—where it has the greatest impact.

My third test for success is that performance, quality and safety are all maintained within a system that is taking out competition. There is a genuine risk that taking away some of those internal market forces might take away some of the incentives to keep waiting lists and waiting times down and to improve quality. As we integrate care, we need to ensure that we maintain those things.

[Luciana Berger]

I am listening closely to my hon. Friend’s remarkably informed remarks. Taking him back to his second priority, prevention, does he agree that the Minister should be thinking about what he should be doing beyond his own Department? The Minister and his colleagues in the Department of Health will not on their own be able to do what is needed on prevention as well as tackle this country’s mental health crisis and increasing lifestyle-related disease. If we are to address those challenges seriously, it will also be about what happens in our communities, our schools and our workplaces. That comes from local government and is what will ultimately make the difference.

[Dame Cheryl Gillan (in the Chair)]

I remind colleagues that interventions are meant to be short. I hope Members will be able to keep them a little briefer.

[Dr Williams]

I thank my hon. Friend for her informed comments. I agree with her. We need a cross-governmental approach, particularly for children. There is a glaring absence of a cross-governmental strategy that would enable us to focus on all the things that have an impact on children.

The third area I want to mention is legislation. Under current rules, clinical commissioning groups will remain the statutory accountable bodies, even as the relationship between commissioners and providers starts to evaporate. At the moment, STPs, where the providers and commissioners are getting together, are making decisions—often behind closed doors—which are then rubber-stamped by the accountable bodies, which are the CCGs. That does not feel to me like particularly good governance. Legislation needs to follow the new provision arrangements.

We might also need to consider legislation to improve information sharing. The duty to share information—the eighth Caldicott principle—is often forgotten. In my experience the biggest barrier to integration is the fear that NHS providers have about sharing information with other parts of the system, and their resistance to do so. We are not necessarily doing enough in legislation to protect that duty to share information in the interests of providing good-quality clinical care.

The current situation on procurement is very difficult for CCGs. The law says that many services have to be procured if they are over a certain value. CCGs, as small organisations with accountability for their local pot of NHS funds, genuinely fear legal challenge. When they ask lawyers they are, unsurprisingly, advised that they have to follow the law, but the political and NHS England leadership strategy is to integrate care, which often cannot be achieved when care is fragmented by putting services out to tender, and provided by numerous different organisations. Many CCG governing bodies want and need to be cautious. They are just not going to take the risk given the current legislative framework.

Quite simply, if we, as elected politicians, want the NHS to collaborate, we should legislate for collaboration. In my view, the Health and Social Care Committee should be an enabler of that process. We would like to provide pre-legislative scrutiny, but we would like first to ask the health and care community what changes in the law would enable them to achieve their goal of providing integrated care to patients. I would like to know whether the Minister agrees with that proposition.

My fourth point is that integrated care providers should be NHS organisations—a recommendation the Committee made in its report. There is a well-founded concern in the health and care community that, under current legislation, private companies might bid to win contracts to provide significant chunks of our health services. That concern could be alleviated if it were made clear that integrated care partnerships need to be NHS bodies. In their response to our report, the Government did not accept that recommendation, arguing that ICP contracts could be held by GP-led organisations. It would be a very good thing to have GP-led organisations running primary and community care and other parts of the health service, but I see no reason why those GP-led organisations cannot be NHS organisations.

It is a barrier to progress in the NHS that there are not community-based NHS organisations that GPs can lead and work for. I urge the Government to look seriously at the recommendations in the Institute for Public Policy Research report “Better health and care for all”, published in June, which suggests the creation of integrated care trusts in communities and a right to NHS employment within such organisations, which would provide all non-hospital care in an area.

My final point is about leadership. My hon. Friend the Member for West Lancashire (Rosie Cooper), who is a member of the Health and Social Care Committee but cannot be here today, has done significant work shining a light on leadership failures within the NHS. Integrated care is possible only if we have the best and most talented managers in the NHS. As was evident in the failure of management in Liverpool Community Health NHS Trust highlighted by Dr Bill Kirkup, we are far from achieving excellence and need to be certain we have the right mechanisms in place to ensure that we have only the best and the brightest. Will the Minister assure us that the Kark review will be expansive in its remit and that those NHS leaders charged with fixing the mess in Liverpool have been consulted for their expert views?

To conclude, the purchaser-provider split has not always achieved the best NHS care for patients. I welcome the step towards integrated care, but I do not think it will succeed when the legislation promotes, and sometimes mandates, competition. There is political will—certainly from the cross-party Committee—to work with the NHS and care system, including the NHS assembly, on proposals to change legislation, keep integrated care providers within the NHS, improve governance and remove mandatory competition. I hope the Minister will respond positively to those concerns. Integrated care has the potential to transform the lives of millions of patients in our health service. I commend the Committee’s report, and I thank the Government for the changes they are making.

--- Later in debate ---

[Stephen Barclay]

The Prime Minister has set out that it will be for the NHS itself to come forward, rather than for the Government to specify legislative change in a top-down way. As part of the long-term plan, the NHS will determine what can be done within the existing framework and whether change is needed. That will flow from the work that comes forward later in the autumn from Simon Stevens, Ian Dalton and others in the NHS, who are best placed to lead.

[Dr Paul Williams]

In the short time the Minister has left, will he will address the invitation he was given categorically to rule out integrated care providers being private sector organisations? Does he accept that the language he has used—he said the NHS will continue to be free at the point of use—increases concerns about private sector provision?

[Ms Karen Buck (in the Chair)]

Order. Minister, in responding, will you be mindful of the time and the need to leave the Chair of the Select Committee a couple of minutes to respond?

Oral Answers to Questions

Paul Williams Excerpts

Tuesday 24th July 2018 Commons Chamber

[Caroline Dinenage]

I completely understand my hon. Friend’s concerns. She has been an incredibly strong advocate and campaigner on this very issue. As she knows, no permanent changes will be made until the work is carried out by the independent review panel, which is looking at attempts to recruit obstetric staff for her local services. I thank her very much for the offer of a visit; I am sure the Secretary of State will look at it very closely.

[Dr Paul Williams (Stockton South) (Lab)]

Dr Neal Russell volunteered to help in the fight against Ebola. Today he has returned his Ebola medal in protest at the healthcare hostile environment for migrants caused by a new charging regime, which has led to vulnerable pregnant women here in the UK being too afraid to get maternity healthcare. Will the Minister suspend her Department’s charging regime, pending the completion of a thorough and independent public health assessment?

[Caroline Dinenage]

That is incredibly sad news. We hate to hear of anybody who has done such incredible service in the pursuit of great healthcare around the world taking such drastic steps. We have an incredibly strong departmental ambition for NHS maternity to provide the safest, highest quality care in the world. That is something we will continue to aspire towards.

Perinatal Mental Illness

Paul Williams Excerpts

Thursday 19th July 2018 Westminster Hall

[Dr Paul Williams (Stockton South) (Lab)]

I beg to move,

That this House has considered perinatal mental illness.

It is a pleasure to serve under your chairmanship, Mr Davies. I and my colleague on the Select Committee on Health and Social Care, the hon. Member for South West Bedfordshire (Andrew Selous), are delighted to have secured this important debate, and I thank the Backbench Business Committee for granting it.

Nothing can prepare someone for the challenge of becoming a new parent—the sleepless nights, the new responsibility and the feeling that they suddenly have to put their old life on hold. As I have found since becoming a parent, a few months before my 40th birthday, raising a newborn child can be hugely rewarding. There is little that compares with the joy of seeing a child grow and develop. For most of us, it is a deeply fulfilling experience. Still, becoming a parent can have a dramatic impact on many people, in terms of both the stresses they experience and the impact it has on their relationships and their emotional wellbeing.

I will talk about how the Government can act to improve the lives of thousands of mothers in England who do not receive adequate support for perinatal mental health problems. The perinatal period is the time during pregnancy and the run-up to a birth, and the time immediately following the birth of a new baby. As a general practitioner as well as a parent, I have worked to provide mothers and newborn babies with the support and care they need in the perinatal period. It is a crucial time not only for the mother, but for the development of her child. It is also a time when great pressure is placed on mothers to care for their baby and simultaneously to be happy, excited and on top of life.

According to the mental health charity Mind, about one in five women experience mental health problems during pregnancy or in the year after they have given birth. Those mental health problems can come in many different forms—from eating disorders, to post-traumatic stress disorder, to anxiety and depression. If left untreated, the mental illnesses that these women experience can affect their whole lives, their ability to cope with being a parent and their relationships within and outside their families. The illnesses can affect attachment and bonding with the baby. At their extreme, perinatal mental health problems can lead to suicide and to long-term health problems for a child.

[Lyn Brown (West Ham) (Lab)]

I understand that one fifth of parents stated that they were not asked about their mental or physical health during the six-week post-natal check-up. Does my hon. Friend think that might be because GPs are massively overburdened and simply do not have the time to deal with this essential issue?

[Dr Williams]

I thank my hon. Friend for raising that point. I will refer to it later in my speech. I think the pressure on GP services that she has identified is one reason, but there are some other reasons to do with training and perhaps resources.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

I thank the hon. Gentleman for bringing forward this important debate. To support his case, I will describe the case of Libby Binks, a very brave constituent who came to my surgery. She described how she went through the six-week check without any consideration being given to her wellbeing, despite the fact that she was clearly in distress and had post-natal depression. A health visitor came in at a later stage and filled in a questionnaire with her, which clearly showed she had post-natal depression, but nothing whatever happened until her child’s first birthday. Does the hon. Gentleman agree that we need to make more of that six-week check in particular, to ensure that the mother’s wellbeing, as well as the child’s, is taken into consideration?

[Dr Williams]

I thank the hon. Gentleman for relating the experience of his constituent, which is, sadly, shared by too many other women. Of course, there are many dedicated health professionals who do identify mental health problems, but too many women say that they slipped through the net.

I will talk about why perinatal mental health problems are so important for a child. The first 1,001 days of a child’s life, from conception to the age of two, are absolutely crucial to their social, emotional and cognitive development. Put simply, those 1,001 days are when a brain is built and shaped. During that time, 1 million new neuronal connections are made every second in that child’s brain. When the environment the child experiences, whether inside or outside the womb, is happy, relaxed and stimulating, he or she learns and develops those connections in the brain. The baby grows and adapts in a positive environment.

However, many of the symptoms of mental health problems do not provide that ideal environment. Stress raises the level of cortisol, which can cross the placenta and affect a foetus. When someone is severely depressed, perhaps they do not smile, so a baby does not see the warmth, the love and the reciprocation that they need from their mother. When someone is anxious or has an obsessive compulsive disorder, a baby sees, learns and repeats actions from the environment they are experiencing from birth. They learn to behave like their mother.

A mum’s mental health problem can have such a significant effect on a baby that academics describe it as an adverse childhood experience. Adverse childhood experiences, or ACEs, are stressful events that occur in childhood.

[Mohammad Yasin (Bedford) (Lab)]

My hon. Friend is making a powerful speech. I was interested to hear the evidence put forward by the National Childbirth Trust to the all-party parliamentary group for the prevention of adverse childhood experiences that depression among 16-year-olds is usually linked to their mother’s pregnancy. I realise that the research is more complex, but given the worrying rise in the number of children and young people with mental health problems, is he as concerned as I am that one quarter of women are unable to access specialist perinatal services in the UK?

[Dr Williams]

I thank my hon. Friend for making several points, including that a child whose mum experiences mental health problems is more likely to develop mental health problems themselves. Despite significant Government investment in specialist perinatal mental health services, significant inequalities remain throughout the country and there are still areas where, as he said, one quarter of women with significant mental health problems are not able to access specialist facilities. I hope we will get the chance to talk more later about access to specialist services.

Other adverse childhood experiences include domestic violence; parental separation or divorce; being a victim of physical, sexual or emotional abuse; physical or emotional neglect; or growing up in a household where there are adults experiencing alcohol and drug problems. Mental health problems in a mother can have as significant an impact on a child as some of those other problems. The term ACEs was originally developed in the US, but other studies have reported similar findings in England and Wales. Those ACEs have, as my hon. Friend has said, been found to have lifelong impacts on health and behaviour. They are relevant to all sectors and involve all of society.

An ACE survey of adults in Wales found that, compared with people who had experienced no ACEs, those with four or more were more likely to have been in prison; develop heart disease; frequently visit their GP; develop type 2 diabetes; have committed violence in the last 12 months; and have health-harming behaviours, such as high-risk drinking, smoking or drug use

Children’s exposure to adverse and stressful experiences can have a long-lasting impact on their ability to think and to interact with others, and on their learning. Health and societal inequalities that develop during early years stick with children for life. That is why I chair the APPG for the prevention of adverse childhood experiences. It is also why the identification and treatment of maternal mental health problems is not only important for the individual mother but crucial for all of us in society.

National Childbirth Trust research shows that as many as half of new mothers’ mental health problems are not picked up by a health professional. That is not to say that health professionals are not asking—they often are. There are many fantastic nurses, GPs, midwives, health visitors and others who provide care during pregnancy and during the post-natal period. However, those services, as my hon. Friend the Member for West Ham (Lyn Brown) has said, are overstretched. We all know how hard-pressed GP services are. The Government have acknowledged the problem and have promised to recruit an extra 5,000 GPs by 2020. However, they are failing miserably and are struggling to even maintain GP numbers. NHS Digital reports a decrease in full-time equivalent GPs from March 2017 to March 2018.

Perhaps a little less well known is the dramatic fall in the number of health visitors. Since 2015, there has been a loss of more than 2,000—almost a 20% drop—so each health visitor has to work harder. I commend health visitors for the work they do but, overall, women are experiencing a drop in services.

Staff numbers are part of the problem, but there are many other reasons why the problems of almost half of women with perinatal mental health problems are not identified. Stigma, and the societal pressure to be seen to be coping, makes it hard for some women to disclose that they have a mental health problem. Also, as the hon. Member for Thirsk and Malton (Kevin Hollinrake) has said, health services do not always ask women about their mental health in the most sensitive way. That is sometimes because they are pushed for time and sometimes because they have not been trained to sensitively and gently probe behind the “I’m okay” response that people are primed to give.

As a result, the hidden half of new mums with mental health problems struggle on alone, often afraid to reach out for help. The overwhelming majority of women who experienced a mental health problem said that it had an impact on their ability to cope or look after their children, and also on their family relationships. The mother of a woman suffering from post-natal depression told me:

“As a parent, watching a child go through that and feeling unable to make it better is a horrible experience. Health professionals need to make sure that husbands, partners and the family know about the likelihood of such depression…and know where to get support and help.”

Perinatal mental illness has an immediate effect not only on mothers; it can have lasting consequences for relationships in the wider family. With the added pressure to be a perfect mother, and the expectations from many that come along with that, it is no wonder that so many women feel unable to cope. One constituent described this to me:

“I remember comparing myself to the younger mums who would turn up to the mother and baby groups looking fresh and without a care in the world, making motherhood look like a walk in the park. Although my son was thriving, I felt like I was failing, because I wasn’t like the young mums or the ones in those perfect baby ads. I didn’t want to share my feelings because I felt I’d been a failure in comparison to them. I believe the pressures of our professions and the guilt of parenthood traps us into a dark place.”

It is often the most vulnerable who receive the least support, with evidence suggesting that those in areas of higher deprivation are less likely to be asked about their mental health. In dealing with this issue, the Minister has the chance to fulfil two parts of her ministerial brief, because investing in perinatal mental health will help to improve mental health and reduce health inequalities.

I have described the problem, but what are the solutions? Identification is key. Regardless of what services may or may not be out there—from specialist mother and baby units, to secondary care perinatal mental health teams, to cognitive behavioural therapy and the prescription of medication—half of women with the problem are not even identified. That is where I believe we need to start.

The disinvestment in health visiting is significant; there can be no solution to the problem while health visiting is not properly resourced. Will the Minister say what she intends to do within her Department to ensure that local authorities are adequately funded and supported so that there is investment in crucial services for children aged 0 to 19, rather than the cuts that we have seen in the past three years?

However, there is another, relatively low-cost opportunity to identify the hidden half. About six weeks after giving birth, new mothers see their GP for a six-week baby check, with many practices also offering a maternal health check. Official National Institute for Health and Care Excellence guidance encourages doctors to do that and inquire about a mother’s emotional wellbeing, providing an opportunity for them to spot the development of any mental health problems. That check could be the last time a mother sees a health professional for a routine appointment in which there is the opportunity to focus on the mother, rather than her baby.

While some women get an excellent six-week check, showing its potential, other women miss out. A fifth of women questioned in a recent NCT survey said that they were not asked about their emotional or mental wellbeing at that appointment. Some women’s checks are all about their baby. Why do all women not get the check that they need? Despite the six-week baby check being part of the GP contract, for which they receive funding, doctors do not receive any funding for the check on the mum. It is a credit to many practices that they offer the checks without funding, but making the time for a full appointment can be challenging, meaning that there is little opportunity to encourage a mother to talk about how she feels, which takes time. A rushed appointment can make many, like the constituent of the hon. Member for Thirsk and Malton, feeling dismissed, or like it was a tick-box exercise.

One woman I heard from recently said her appointment made her

“feel like she was a burden”.

Another of my constituents spoke movingly of her experience:

“I knew there was something very wrong almost as soon as my son was born. Nothing I was ‘supposed’ to be feeling was happening. All I wanted to do was cry. I was feeding him and taking good care of him, but I felt empty inside, and so sad. I can’t remember anyone asking me how I was. I only saw my health visitor once, and that wasn’t in private so there was no opportunity to confide in her.

I told my GP I had postnatal depression and that I needed some help. He told me ‘you have a good family, you should be grateful—you need to pull yourself together.’ I don’t think I have the words to explain how damaging that was. I felt too ashamed to see him again so I changed to another medical centre. My first appointment was with a GP who listened to me. I found the courage to confide in her and she offered me support straight away. I remember very little of my child’s first year of life and I’m sure that is because of the trauma and deep depression I experienced.”

That could have been prevented if my constituent had been seen early on in the post-natal period, and if that first GP had delivered open, supportive questioning that reassured her, rather than made her feel ashamed.

Another constituent told me:

“I sat down with my GP, who had a check-list printed out and placed on his desk. He ran through the questions at a rapid rate, didn’t listen to my answers at all and placed ticks in the boxes after he asked the questions—not based on my reply. Hopefully a separate check for mothers can be achieved, as mothers just want someone to talk to who will not judge them for their feelings.”

About 30% of women diagnosed with post-natal depression still have depression beyond the first year of childbirth. If problems are not identified and treated early, they can worsen and develop into a much more severe mental illness. That underlines the need for an early check. If depression was recognised and treated appropriately within the perinatal period, it could prevent some effects that are much harder to treat in the long run.

[Lyn Brown]

I am sorry to intervene again. I intended to make a speech, but I am needed elsewhere, so I will ask a question. I have a lot of time for the Minister and I am wondering how we can help her to make the necessary case to the Treasury. Is it not true that if we look after the parent and the child as early and as well as possible, that will save massive amounts of money in the long term? This is an invest-to-save opportunity, and it would be welcome if the Government took it.

[Dr Williams]

I thank my hon. Friend for her intervention. I have avoided, as much as I can, talking about money in the debate—not all of this is about money, but there are many opportunities to make a massive difference. If we can draw a direct link between a mum’s experiencing mental health problems and the damage that that may do to her child—it increases the child’s chance of developing health problems and even of being involved in crime later in life—there are certainly opportunities to invest to save.

We must not forget, either, that perinatal mental illness has serious consequences for the mother. Suicide is the leading cause of direct maternal deaths occurring within a year after the end of pregnancy in the UK. It is at least possible that if an effective six-week check were in place, some of those deaths would be prevented. Of course, this is, as many hon. Members have said, a complex issue. Diagnosis and treatment are complex, but in addition some health services undoubtedly do not give women the care that they need. Women feel that they are still being dismissed, stigmatised and ignored. However, we should not blame the individual GPs and health professionals who carry out the checks; we should look to change the guidance, the system and the structure in place.

From its research, the NCT has made three recommendations. The first is to fund the six-week maternal post-natal check so that GP surgeries have the time and resources to give every new mother a full appointment for the maternal check. At the moment, although the check focusing on the baby is contracted for and there is funding available for it, there is no requirement for a six-week check on mothers. Checks on mothers, if they are done, are often compressed into the baby’s check, so conversations about mental health may be rushed or sidelined completely.

A constituent got in touch after I said that I was going to speak in this debate. Her response was surprising. She said:

“After the birth of my first child, I suffered terribly with post-natal anxiety—something I didn’t even know was a thing. I don’t remember anyone ever picking up on how I was feeling and no one ever really asked.

Then after the birth of my second child I believe I was depressed. When he was born I didn’t feel anything which then made me feel guilty”—

a common theme—

“and I struggled to bond with him over the first year.”

She then said:

“I believe I met you”—

meaning me, because I was working as a GP in the constituency at the time—

“at my six-week check with him and I remember you asking how I was feeling. After telling you I think I may have needed to”

get some extra help

“for more therapy, you agreed it was a good idea and told me to come back”

for follow-up. She continued:

“I think women need to know where they can go for help and what signs to look out for. I was too scared to tell anyone that I didn’t feel any bond with my son because I think there’s still such a stigma around mental ill health.

I do think the idea of a separate appointment for the mother would be a good idea and more signposting to support groups, how to self-refer, confidential information and advice.”

That experience with my patient, who is now my constituent, demonstrates the value of making time to identify and explore perinatal mental health issues. It might be argued that GPs should be doing that anyway, even if it is not contracted for. I would respond by saying that some are and some are not. GPs do many things that are not in their contract. But the only way of getting true national coverage and the time needed to do a proper job is to resource it.

[Kevin Hollinrake]

The hon. Gentleman will be aware that £365 million has been set aside for perinatal mental health services. He is not too far away from North Yorkshire himself, and North Yorkshire has just secured £23 million of that to help with perinatal mental health services for new and expectant mothers.

[Dr Williams]

I do give credit to the Government for making investments in this area of provision. We started from quite a low baseline. There has been significant investment. Too many women are still missing out on these specialist services; the coverage throughout the country is patchy, but I acknowledge that things are improving. However, if we are not identifying half the women with perinatal mental health problems, that is a significant problem in itself.

The investment required to identify problems through the six-week check is estimated by the NCT to be about £20 million a year. That is a very small amount in the grand scheme of the NHS’s budget, but it could make a huge difference to many new mothers. Secondly, in addition to the funding for the six-week check, the NCT recommends improved guidance for GPs on best practice on mental health, specifying a separate appointment for the maternal six-week check and the best methods of encouraging disclosure of maternal mental health problems.

A separate check involving supportive, open and encouraging questioning would provide an opportunity for women to come forward with any problem that they may be having. It might also help to eliminate some of the feelings of stigma or shame; 60% of women said that they felt embarrassed, ashamed or worried about being judged. Just because it is in a GP’s contract does not mean that a doctor has to do the work; with the right training in place, it can just as effectively be undertaken by a practice nurse or other suitably qualified healthcare professional. What is important is that it forms part of the ongoing relationship that a new mother has with her GP practice.

The third NCT recommendation covers NHS investment in and facilitation of GP education. It is important that GPs are trained to recognise the symptoms of post-natal depression and differentiate them from “the baby blues”, which resolve on their own; and it is crucial that mothers are reassured and valued, not dismissed.

These three relatively straightforward measures—a contractual obligation, guidance, and training—could make a huge difference to many women’s and children’s lives. They could eliminate some of the preventable problems encountered by women suffering from perinatal mental illness. The average cost to society of one case of perinatal depression is estimated at £74,000. With an already overstretched NHS under immense pressure, these measures could alleviate some of the stresses placed, later, on mental health services; they will inevitably have to deal with the consequences of undiagnosed and untreated perinatal mental health problems.

With this debate, we are already raising awareness and challenging some of the stigma surrounding perinatal mental health, but we also have a unique opportunity to do something practical to address the problem. Negotiations for the new GP contract begin in September, and by holding this debate today, we want to gain wider support for these important recommendations to be included in the new contract.

There are many other areas of perinatal mental health that I hope we get the chance to explore in this debate. We have already discussed the availability of specialist perinatal mental health services. I hope that we also talk about the variable access to psychological therapies, which are excellent in some parts of the country; in other parts of the country, women struggle to access those services, too. I am very grateful to the other hon. Members who have come today to speak and contribute.

I consider myself to be a fortunate father, one whose experience of parenting has so far been very positive. Many parents are not so lucky. When I hear the heartbreaking stories of women whose post-natal depression has blighted their and their family’s experience of parenthood, I am reminded of just how fortunate I have been. I am also acutely aware of how damaging it will be to wider society over the longer term if we do not improve the way in which we handle this issue. We need to bring the hidden half of these women out of hiding. Post-natal mental illness is not just a problem for new mums. If we fail to tackle it, we risk failing the next generation of children, too.

--- Later in debate ---

[Jackie Doyle-Price]

As I have often said, the real focus of the Green Paper is on schools and measures that we are taking with the Department for Education. However, the hon. Lady and others will be aware that we have committed to extra funding for the NHS and we are working with NHS England on what we can all expect with that extra funding. I am open to representations as we develop that 10-year plan as to what else we can do in this space. As we are in discussions with NHS England, I cannot make any commitments but this is exactly the time when we should rigorously be testing policy suggestions and interventions that we might be able to deliver.

[Dr Paul Williams]

It was reported in the Health Service Journal two days ago that the chief executive of the NHS, Simon Stevens, has outlined five priorities for the 10-year plan and that one is reducing health inequalities. Does the Minister think that a serious focus on reducing health inequalities—particularly those that are embedded from the beginning of life—should be a focus for the 10-year plan?

[Jackie Doyle-Price]

The hon. Gentleman earlier used the phrase “spend to save”, so the answer is yes, because obviously if we make interventions earlier and they help people to help themselves, there is a long-term saving to the NHS. That is the exact spirit in which we are entering the 10-year plan for the NHS. I look forward to hearing suggestions from the APPG—get in touch with us soon.

I thank everyone who has contributed to the debate and hope that we can go forward with the shared objective of doing the best we can for new mothers. By that I mean not only improving services, but giving support in general to women who are going through the experience of motherhood. As many Members have said, we are offered a fairy tale fantasy about how everything is perfect and wonderful, when actually there is a lot of associated vomit, pain and misery—joyful as the experience is overall. We need to tackle the taboo, because the fact that we think that everything is a perfect fairy tale means that the pressure on those women who are struggling makes them feel like failures. They are not: it is all entirely normal.

I am always struck by the fact that one in three women suffers from incontinence. People do not know about it, because everyone suffers in silence and just gets on with it. I often ask, “How would it be if one in three men suffered from incontinence?” We would hear about that a lot more. We need to be generally more open and give women the message: “Do you know what? It is normal to feel you are struggling, and feel miserable, because you have gone through a life-changing experience and a physical trauma. It is inevitable that it will affect your mental health.” Giving them the message that it is normal is half the battle, because they will realise that they are not a failure but just need to manage and work through the situation. We need the right services in place to help them.

--- Later in debate ---

[Jackie Doyle-Price]

I will write to the hon. Lady with some detail on the figures, but the point is that the access is there. Obviously, it will take time to become embedded. We have a good direction of travel to deliver against that commitment and we will continue with that. Community-based provision is key, but we also need to ensure that there are sufficient specialist perinatal mental health beds in mother and baby units for particularly severe cases. NHS England has taken a more strategic approach to commissioning, so that there is a level of access that does not involve wide-scale moving out of area.

As ever with transformation programmes, change takes time, but we are on track to meet our commitments. We are investing £63.5 million this financial year to support the development of those specialist perinatal mental health community services across England. Our pace of change is to enable 2,000 more women to access specialist care. Last year that was exceeded, so we should maintain the pace that we planned in the five-year forward view.

I have visited one of the new in-patient mother and baby units in Chelmsford, where there are four new beds. That centre is expanding its capacity. As well as opening new centres, we are expanding the capacity of existing ones to give more support. In Devon, the trust opened a four-bed mother and baby unit in a reused space in April this year while the new unit is being built, so we still have that provision even though there is not the physical space. By the end of this financial year, we will have expanded the capacity of those beds by 49% since 2015 and there should be more than 150 beds available for mothers and babies in those units.

We are also expanding psychological therapy services, which successfully treat many women who experience common mental health conditions such as depression and anxiety disorders during the perinatal period. We have set an ambition for at least 25% of people with common mental health conditions to access services each year by 2020-21, including extending provision to ensure swifter access for new and expectant mothers. However, as we have heard today, getting perinatal mental healthcare right is not just about expanding specialist services in isolation. Many professionals in different parts of the health and care system are well placed to support women in the perinatal period. NHS England is working with partners to ensure that care for women is integrated and joined up effectively. More than £1 million was provided in 2017 to enable the training of primary care, maternity and mental health staff, to increase perinatal mental health awareness and skills.

NHS England has also invested in multidisciplinary perinatal mental health clinical networks, which will include GPs across the country to support that strategic planning, working across services to ensure that those wider services are in place. The role of GPs is central in identifying when someone is suffering from perinatal mental illness, and to ensure that those women are directed towards treatment. The role includes monitoring early-onset conditions, including pre-conception counselling, referring women to specialist mental health services, including access to psychological therapies, and specialist perinatal community teams where necessary.

I am aware of the NCT’s #HiddenHalf campaign; I am grateful for its campaigning on this important issue. The National Institute for Health and Care Excellence recommends post-natal checks for mothers and new-born babies. NHS England expects commissioners and providers of maternity care to pay due regard to the NICE guidelines. My hon. Friend the Member for South West Bedfordshire raised this issue and said that, since this was part of what we should expect from GPs, it seemed anomalous that so many mothers and babies were not getting such checks. We make clear to GPs what we expect of them, as part of their contract, but ultimately we rely on clinical commissioning groups to ensure that GPs deliver against the obligations that we expect of them. This is not the only case where this happens—many GPs are not delivering learning disability health checks either. We need to be clear with NHS England that we expect that obligation to be delivered.

[Dr Paul Williams]

The hon. Member for South West Bedfordshire referred to a maternity additional service that only four general practices have opted out of. Is the Minister aware of what period of time that additional service covers?

[Jackie Doyle-Price]

I will come back to the hon. Gentleman, but this area requires further exploration because we need to be clear about how we deliver on those things.

[Dr Williams]

I will gladly tell the Minister: the period of time covers pregnancy but ends 14 days after birth. Whereas it may be very appropriate for a GP to provide care during that time, the additional service that the hon. Member for South West Bedfordshire referred to ends 14 days after birth. We are talking about a different issue: the opportunity to do a check six weeks after birth. There is no commissioning of that check at the moment. It is helpful that the Minister says that she expects commissioners to commission that check, but is that a commitment from the Government to ensure that commissioners are funded to be able to commission that six-week check?

[Jackie Doyle-Price]

I was coming to that—I was just dealing with the point made by my hon. Friend the Member for South West Bedfordshire.

Moving on from the NICE guidelines, we clearly expect GPs to do their part in identifying and supporting women. We are aware of the campaign, but any changes to GP contracting arrangements to specifically include the six-week check-up would need to be negotiated with the GP committee of the British Medical Association. Those negotiations are taking place and will be completed by September. I cannot give any firmer commitment than that, other than to say that we obviously want to see GPs make their contribution.

--- Later in debate ---

[Dr Paul Williams]

I thank all the Members who stayed here to contribute to the debate. I also thank the organisations—particularly the National Childbirth Trust—that contributed to filling our minds with useful information. I am proud to have brought this issue to Parliament as a man. As many Members said, this is not a women’s issue—it affects us all, and it needs to be taken really seriously. As the hon. Member for South West Bedfordshire (Andrew Selous) said, it is everyone’s business.

We have discussed a very vulnerable time in a woman’s life—the time when she is most likely to develop a mental health problem. We heard about the impact of such problems on a woman, her family and particularly her child. It is heartening to hear that the Government are listening, and I hope that that continues to manifest itself in action—particularly on the GP contract negotiations, but also on the many other things that could be done to improve the lives of these women, their families and their children.

Question put and agreed to.

Resolved,

That this House has considered perinatal mental illness.

NHS Long-Term Plan

Paul Williams Excerpts

Monday 18th June 2018 Commons Chamber

[Mr Hunt]

As usual, my hon. Friend speaks very perceptively. When he was a Minister in my Department, he did a fantastic job in getting our capital funding and our workforce planning into a much, much better place. He is right. Although this is a big opportunity for the NHS, we must not make the mistake of solving yesterday’s problems tomorrow. A huge data and tech revolution is about to happen in healthcare all over the world, and we must make sure that we are at the forefront of it.

[Dr Paul Williams (Stockton South) (Lab)]

How does the Secretary of State plan to lead the transformation from reactive hospital care to preventive community care? He has presided over a fall in community nurses, a fall in GP numbers, cuts to public health and social care, and widening health inequalities. How are the next five years going to be any different from the past five years?

[Mr Hunt]

Let me tell the hon. Gentleman what I presided over: 10,100 more doctors; 14,300 more nurses; the Commonwealth Fund saying that our healthcare system is the best in the world; the biggest expansion in mental health provision; and improved outcomes for cancer, heart attacks, strokes and nearly every other disease category. I can do that because this Conservative Government have put the economy back on its feet. Everyone in the NHS knows that, in the end, that is how we get more resources into it.

NHS Outsourcing and Privatisation

Paul Williams Excerpts

Wednesday 23rd May 2018 Commons Chamber

[Dr Paul Williams (Stockton South) (Lab)]

I refer the House to my entry in the Register of Members’ Financial Interests: I work as a GP.

There may be people listening to this debate who work for private or voluntary sector organisations, providing services to patients or to the NHS. Most of them do a fantastic job. They are not employed by the NHS, but they do help our NHS, and I thank them for the work that they do.

When local people and local commissioners agree that it is in the best interests of local patients to use non-NHS services to deliver NHS care, that should sometimes be enabled. In the fields of medical technology and devices, pharmaceuticals, information management and many others, good private sector companies are working to support the NHS. But private sector involvement can also lead to a race to the bottom. When subsidiary companies reduce terms and conditions for workers, that is bad for us all; when privatised community services ignore the hardest-to-reach patients, that can widen health inequalities; and when private sector treatment centres cherry-pick the least-risky patients, do not contribute to training, and then expect the NHS to pick up the pieces when complications arise, the NHS loses.

All that is without mentioning the private Primary Care Support England contract, run by Capita. It is total disaster. The main function of support services is to enable clinicians to get on with the job of looking after patients, but GP registrars are not being paid on time, GPs are not added to performers lists, and one practice manager told me that it took four months and 16 emails to transfer a GP from being salaried to being a partner. This work needs to be taken back by the NHS; Capita has failed.

What vision do I think we should have for our NHS? I endorse the Government’s goal of integrated health and care services built around patients’ needs. That is the only way to meet the health challenges of this century. The Health and Social Care Committee, on which I serve, has looked in detail at moves towards the integration of care through sustainability and transformation plans, accountable care organisations and integrated care systems. We have seen real potential to improve the quality of care for patients, to make the strategic shift away from reactive care to proactive care and to transfer more NHS resources into keeping people well rather than just fixing them when they get sick. The need to bring together primary care, community care and social care has widespread support in the NHS, but we should do that within a health and care service, run by the NHS, owned by the NHS, and led by the NHS.

There are understandable concerns about the integration agenda being used to encourage more private sector involvement. The Government and NHS England say that that is not their intention, but speculation could easily be dispelled by legislating to make accountable care organisations—if they happen—NHS bodies. I am talking about NHS-owned and NHS-led organisations running health, and even care services, for whole populations. What a great legacy that would be, with procurement not being forced on commissioners, with the private sector being used only when it enhances the ability of the NHS to help patients and with no cherry-picking and no dilution of hard-won employment rights for any staff providing services to and for the NHS.

The Government should bring forward legislation to repeal section 75 of the Health and Social Care Act 2012; accountable care organisations should be cemented in primary legislation that makes them NHS bodies; and the Primary Care Support England contract should be brought back into the NHS.

Oral Answers to Questions

Paul Williams Excerpts

Tuesday 8th May 2018 Commons Chamber

[Steve Brine]

I think that is what is known as a back-handed welcome. We have made great progress on improving access to dentistry in England, but we know that there are parts of the country, including the hon. Gentleman’s area, in which we can do more. That is why NHS England in Yorkshire and the Humber—with which I liaise on matters raised by a number of Opposition colleagues—is finalising plans to improve access to dentistry throughout the region, paying particular attention to 20 areas. Bradford East is one of those areas and, as the hon. Gentleman said, will shortly receive additional recouped funding to support his constituents.

[Dr Paul Williams (Stockton South) (Lab)]

Why are dentists, such as my constituent Peter Sharp in Thornaby in Stockton South, funded less per unit of dental activity than his colleagues who are working in more affluent areas? Surely, to reduce health inequalities, it should be the other way round?

[Steve Brine]

That goes to the heart of why we are reforming the dental contracts. Our 73 high street dental practices are continuing to test the preventive focused clinical approach to a new remuneration practice. [Interruption.] Someone on the Opposition Front Bench has just said “when” from a sedentary position. It will be when we have got it right.

Breast Cancer Screening

Paul Williams Excerpts

Wednesday 2nd May 2018 Commons Chamber

[Mr Hunt]

I thank my hon. Friend for the work that he did on cancer when he was working at the Department of Health, and for his broader work in supporting the hospital sector. He is absolutely right: additional people will come forward for treatment, so one of the other matters that we have been looking into is our treatment capacity. We certainly intend to ensure that people are treated within the normal short period if a cancer is detected, and the first step in that process is to ensure that everyone has a scan in the next six months. During that period, we will make certain that they are able to look forward to the same rapid treatment that all other people whose cancers are detected can be confident of receiving.

[Dr Paul Williams (Stockton South) (Lab)]

We have an ethical duty to get screening right, because we are inviting well people into our health service and offering them an intervention. May I ask the Secretary of State whether the uptake of screening by 68 to 71-year-olds during the period concerned was any lower than expected? If it was less than expected, why was that not properly analysed?

[Mr Hunt]

I do not know the answer to that question, but I will look into it. If we find that the uptake was lower than expected in that age group, it will be a very important clue about something that may have gone wrong, and I am sure that the review panel will want to examine it. The overall uptake rate is about 80%, but I agree with the hon. Gentleman that we should look into what the rates were in specific age cohorts.