Diabetes-related Complications

Paula Sherriff Excerpts

Tuesday 7th June 2016 Westminster Hall

[Paula Sherriff (Dewsbury) (Lab)]

I beg to move,

That this House has considered diabetes-related complications.

It is a pleasure to serve under your chairmanship, Mr Pritchard. I am particularly pleased to have secured a debate on this topic because of its profound importance to all those with diabetes, and because support for those with long-term conditions is vital to the future of the NHS.

There are 4 million people living with diabetes in the UK today, and it is estimated that more than half a million people are undiagnosed, living with the condition without being aware they have it. Since 1996, the number of people diagnosed with diabetes in the UK has more than doubled, from 1.4 million to almost 3.5 million. About 700 people a day are diagnosed with diabetes, which is the equivalent of one person every two minutes. The NHS spends about £10 billion on diabetes every single year, which equals around 10% of its budget. Critically, it is estimated that 80% of that cost is spent on complications that are largely avoidable through better care.

[Ms Margaret Ritchie (South Down) (SDLP)]

I congratulate the hon. Lady on securing this important debate. She referred to the fact that 80% of NHS spending on diabetes is on avoidable complications. Does she agree that a greater focus on early intervention is needed, to ensure that the budget, resources and staffing are better targeted?

[Paula Sherriff]

I thank the hon. Lady for her intervention, and I absolutely agree. As with so many other conditions, early intervention is crucial.

The total direct and indirect costs associated with diabetes in the UK are estimated at £23.7 billion. That is predicted to rise to £39.8 billion by 2035. Earlier this year, the Public Accounts Committee said that the cost of diabetes to the NHS would continue to rise.

[John Howell (Henley) (Con)]

I thank the hon. Lady very much for the speech she is making and for securing the debate. I want to take her up on the point she has just made. There is a belief that diabetes is not curable; actually, diabetes is curable. It is curable by the individual going through a process of losing fat around the liver, which takes away the—

[John Howell]

The hon. Lady is shaking her head. I am a living example of someone who has cured diabetes. I wonder whether more patient-centred education would be a big help to the NHS.

[Paula Sherriff]

I thank the hon. Gentleman for his contribution. While I acknowledge that some people may be cured of the condition, we must not be complacent about the causes of it or, indeed, the impact it can have on many people’s lives.

--- Later in debate ---

[John Howell]

I did mean type 2 diabetes.

[Paula Sherriff]

I thank hon. Members for their contributions, and I will now try to make a little progress.

Earlier this year, the Public Accounts Committee said that

“the costs of diabetes to the NHS will continue to rise. In order to control these costs, the Department and NHS must take significant action to improve prevention and treatment for diabetes patients in the next couple of years.”

The wider impact on people’s health is significant. One in five hospital admissions for heart failure, heart attack and stroke are among people with diabetes. The condition is responsible for more than 135 amputations per week. It is the leading cause of preventable sight loss in people of working age and the single most common cause of kidney failure.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Lady on securing the debate. I declare an interest as a type 2 diabetic. I lost almost 4 stone and I am still a type 2 diabetic. I still need tablets to keep me right, and many type 2 diabetics are the same. Experts at Queen’s University Belfast are spearheading a new major research project aimed at ascertaining why thousands of diabetics around the world suffer kidney failure, which she referred to. They have examined DNA samples from 20,000 diabetics to help identify the genetic factors in diabetic kidney disease. The project could enable personalised procedures for those at risk. Does she agree that such research is the key to unlocking life-changing advances for diabetics?

[Paula Sherriff]

I absolutely agree, and it is encouraging to learn that such research and development is being carried out. I will later share details of a visit that my hon. Friend the Member for Heywood and Middleton (Liz McInnes) and I undertook recently, which proved very interesting.

[Julian Knight (Solihull) (Con)]

The hon. Lady has been most generous in taking interventions. I congratulate her on securing this vital debate. Does she agree that education is a key part of ensuring that individuals with diabetes can manage their condition and limit the complications that she mentions? In my constituency we have a diabetes support group that was established way back in 1994. It meets nine times a year, often hears from experts, and provides advice and support. Will she reflect on the role of support groups in helping people to combat diabetes?

[Paula Sherriff]

I thank the hon. Gentleman for that relevant contribution, and I absolutely agree. It is worth noting that, as with many conditions, education is often the key, and I will allude to that later in my speech.

[David Simpson (Upper Bann) (DUP)]

Will the hon. Lady give way?

[Paula Sherriff]

I will make some progress and then take further interventions.

The starkest figure of all is that every year, more than 24,000 people die prematurely due to diabetes and its complications. However, there is significant room to improve diabetes care, which would reduce the risk of diabetics developing complications and tackle the rising costs of diabetes to the NHS. First, we could take action to reduce avoidable amputations. There are more than 7,000 diabetes-related amputations every year in England alone, and foot ulcers and amputations cost £1 of every £150 spent in the NHS. I am sure hon. Members will agree that that is quite an incredible statistic. In 2013, the Secretary of State for Health committed to reducing the rate of diabetes-related amputations by 50% over five years, but the national amputation rate has since remained steady.

Action could be taken to meet that commitment. For example, the Government must ensure that clinical guidance is properly implemented and followed. The National Institute for Health and Care Excellence recommends that all people with diabetes have their feet checked every year, but in the worst-performing clinical commissioning groups, one in four people still are not receiving that annual foot check. There also appears to be a significant disparity in what the annual foot check actually means. Those at increased risk of foot problems should be referred for an assessment by a foot protection service. Having multidisciplinary foot care teams in place can reduce the risk of amputation, but almost one third of hospital sites do not have one.

That is of particular significance to me, because along with my hon. Friend the Member for Heywood and Middleton, who will no doubt have more to add during the debate, I recently visited King’s College hospital diabetic foot clinic here in London, which provides some of the best diabetic foot care in the country, if not the best. Care such as that provided at King’s is unfortunately not universal. There are currently no national drivers to lower the rate of amputations across the country, of which we believe about 80% are avoidable. With the right care in place, such as acute multidisciplinary foot teams and a robust care pathway, amputation rates could be significantly reduced. Not only would that have significant cost-saving benefits for the NHS, but more importantly, the people involved would not need to go through such a life-changing experience.

I will briefly reflect on a gentleman my hon. Friend and I met during our visit to King’s College hospital. He was due to have an amputation at another hospital within 48 hours. He was then referred to King’s College for a last chance to have his condition reviewed, where he was told that he did not need any surgery, nor an amputation. When we saw him, he was almost completely cured of his foot problems. A huge amount of money and a huge amount of distress to that man were saved. Will the Minister please confirm that the Government are still committed to the 50% reduction that the Secretary of State spoke about and tell us when they expect to see figures showing year-on-year decreases? Will she tell us what they are doing to ensure that CCGs meet the NICE guidance, and how they can ensure that multidisciplinary teams such as that at King’s operate much more widely across the NHS? The benefits we saw that morning were absolutely clear.

There is a similar need to improve in-patient care. One in six people in hospital now have diabetes, but one in three hospitals have no diabetes specialist nurse and an unacceptable number of in-patients experience diabetes-related harm while staying in hospital. Diabetes UK has pointed to evidence showing that specialist diabetes in-patient teams save three times what they cost the NHS to provide. Specialist teams make fewer prescribing errors and deliver better outcomes for their patients, so there are fewer expensive complications in hospital and shorter stays. Although most hospitals report increasing referrals and patient contacts, there has been no increase in staffing levels in diabetes teams.

I do not think that the number of in-patients who suffer diabetes complications while in hospital is acceptable, and I hope the Minister agrees. The national diabetes in-patient audit showed that 38% of in-patient drug charts had at least one diabetes medication error and 22% had at least one prescription error; that 30% of in-patients had one or more hypoglycaemic episodes, with nearly a third being severe; that 33% of people with diabetes did not think the staff looking after them knew enough about the condition; and that one in 10 hospital sites did not have any consultant time for diabetes in-patient care. Will the Minister tell us what action she intends to take to reduce those figures, assuming that the Government do not think they are acceptable?

[David Simpson]

We have heard education and early intervention mentioned. Does the hon. Lady agree that in order to help patients, and especially children—there is a reluctance for teachers to give insulin to young people within nursery provision and at primary school level—the mindset needs to change? We need to make sure that there is preventive medication as well as early intervention for children.

[Paula Sherriff]

I thank the hon. Gentleman for that intervention; once again, I agree with those points.

It makes sense both clinically and financially to improve access to diabetes self-management education. Managing diabetes well is time-consuming and can be complicated, but 69% of diabetics said they did not fully understand their condition. On average, people with diabetes spend only three hours a year with a healthcare professional. For the remaining 8,757 hours they manage their diabetes themselves, for which they need the right skills and knowledge—not to mention confidence. Diabetes self-management courses empower people with diabetes to take charge of their own care. Nine out of 10 people with diabetes who attended a course stated that they felt more confident about managing their diabetes afterwards.

Evidence collated by Diabetes UK shows that diabetes education courses reduce an individual’s risk of developing serious and costly complications and prove very cost-effective. However, more than a third of CCGs do not currently commission specific courses for people with type 1 and type 2 diabetes, despite national guidance, and less than 2% of people newly diagnosed with type 1 diabetes—and just 5.9% with type 2 diabetes—attend a diabetes education course. Investing in diabetes education is the big missed opportunity in diabetes care. Will the Minister agree to look at what can be done to ensure that we do not continue to miss it?

[Mr Jamie Reed (Copeland) (Lab)]

My hon. Friend is making a fantastic case. I speak as somebody who is a type 1 diabetic, the father of a type 1 diabetic and the uncle of a type 1 diabetic. Does she agree that when we look at providing the education that she has talked about, we also need to give regard to the fact that such courses require a basic level of numeracy and literacy, so provision needs to be made for people accessing those courses to be given help in those disciplines in some cases?

[Paula Sherriff]

I thank my hon. Friend for his contribution; he speaks with a great deal of experience, having experienced diabetes himself. That is an incredibly interesting point, and I hope that the Minister will give her views on that issue.

Finally, we must tackle the significant variations in the care and support received by people living with diabetes. The postcode lottery is exacerbated by additional differences according to age and the type of diabetes. People of working age with type 1 diabetes receive considerably worse routine care than other people with diabetes. For example, although 41% of people with type 2 diabetes achieve the three treatment targets—on blood pressure, HbA1C, or haemoglobin A1c, and cholesterol—less than 20% of people with type 1 diabetes achieved them in 2014-15. Because of that variation, far too many people are experiencing short and long-term complications that have a huge impact on their health and quality of life and prove incredibly costly to our NHS.

The universal provision of healthcare is one of the founding principles of the NHS, and we have warned of the impact of wider Government policies on that, but there is also a specific issue in the case of diabetes. We should acknowledge that the Government have recently made some steps to improve care and address wider problems through the new improvement and assessment framework, but those measures will require sustained resources and national leadership. I hope that the Minister will outline not just a commitment, but some detail on how she will ensure that those intentions result in long-term action. In particular, will she tell us more about what support will be provided to CCGs that are identified as poor performers as part of the new improvement and assessment framework?

As well as better care to reduce complications and enable people with diabetes to live long and fulfilling lives, urgent action is needed to tackle the rise in type 2 diabetes. Nearly 12 million people are currently at increased risk of developing it. As obesity accounts for 80% to 85% of the risk for type 2 diabetes, the main strategy for reducing the rising prevalence of type 2 diabetes must be to tackle the rise in obesity. I welcome the NHS diabetes prevention programme—a joint commitment from NHS England, Public Health England and Diabetes UK—which will identify those at high risk of developing type 2 diabetes and refer them to evidence-based behaviour change programmes to help reduce that risk.

The first wave of 27 areas in that programme covers 45% of England’s population, with the aim of supporting 20,000 individuals to reduce their risk of type 2 diabetes. Can the Minister give us any assessment of the programme’s record to date? Will she confirm that it is due to cover the whole country by 2020 and that she still expects a full 100,000 places to be available on the programme each year?

The Obesity Health Alliance identifies three other priority areas for action that should be fundamental components of the forthcoming governmental childhood obesity strategy. They are restrictions on unhealthy food marketing, including a 9 pm watershed for TV advertising of junk food; the implementation of independent and mandatory reformulation targets to reduce the sugar, saturated fat and salt content in our foods; and the implementation of a levy on sugary drinks manufacturers. We have, of course, recently had some progress on the last of those, although the levy that the Chancellor of the Exchequer is implementing perhaps does not quite match up to that envisaged by public health campaigns. Perhaps the Minister can tell us more about that strategy and about the Government’s views on the other policies put forward by the alliance.

The Government have also promised to take action to reduce childhood obesity, with the aim of publishing a childhood obesity strategy. The strategy was initially due for publication in autumn 2015 but has been delayed. The latest indication is that it is to be released in summer 2016, but quite frankly, they have been holding off for far too long already. Can the Minister give us a specific date for exactly when the strategy will be published?

I know that other hon. Members are keen to speak, so I will conclude by saying that, both as a former NHS worker for many years and as a member of the Select Committee on Health, I see this issue as absolutely critical for the future of our health service as a whole, as well as for the many thousands of my constituents who live with diabetes. There are a disproportionate number of diabetics in my constituency, so this is a big issue for the people of Dewsbury, Mirfield, Denby Dale and Kirkburton. I hope that the Minister has some answers today for them and for everyone who relies on our NHS.

--- Later in debate ---

[Jane Ellison]

I make no comment. Political momentum is important because it drives change in a way that is hard to pin down. We now have momentum on obesity and diabetes in a way that we did not a few years ago. The level of interest in this House is a good measure of that, so it is vital that we have such debates. It is also a measure of how seriously we take diabetes that we have included reducing diabetes care variation and preventing diabetes in the NHS’s mandate—it is right at the heart of our big asks of NHS England.

Before I continue, I take this opportunity to pay tribute to the many NHS staff who provide invaluable support to patients. Inevitably, in a debate where we are rightly stress-testing the system and asking where we can improve, it is easy to forget that masses of people out there are doing brilliant work. We have heard inspiring words today from two colleagues about their visit to see real specialists in action. Across the country there are people supporting patients with diabetes. There are also excellent third sector organisations such as Diabetes UK, with which we work closely, and JDRF, which does such great work on type 1. They both work with and independently challenge the Government, all with the aim of improving the lives of those with diabetes or at risk of it.

[Paula Sherriff]

Although I appreciate that the Minister undoubtedly has an incredibly busy schedule, I encourage her to contact the diabetes foot clinic at King's College hospital in London to arrange a visit. As my hon. Friend the Member for Heywood and Middleton (Liz McInnes) said, our visit was inspiring. I came away with much knowledge and real hope that we can make improvements.

[Jane Ellison]

I sat here thinking how interesting the visit sounded. My team has made a note of that. We had heard about the visit and how it had gone well, so it is great to hear that first-hand from the hon. Lady.

I will not repeat the shocking facts on diabetes, which have been well rehearsed and explained by Members in this debate, but suffice it to say that the impact is huge. My hon. Friend the Member for St Ives (Derek Thomas) and others have made notable contributions drawing out the human cost of diabetes. People tend not to understand how devastating diabetes can be for patients and families, as well as the cost to the NHS, which in England we estimate to be £5.6 billion a year.

We have to work together to address diabetes. Before I talk about the action we are taking now and the progress we need to make, it is worth noting that we have come a long way. I have discussed that in some detail with our national clinical director, Dr Jonathan Valabhji, over the past year. The progress we have made through the quality and outcomes framework over the past decade has driven a step change in delivering better management and care for people in GP practices. Last year’s National Audit Office report showed that the relative risk of someone with type 1 or type 2 diabetes developing a diabetes-related complication has not changed, and indeed has fallen for most complications, despite the growing number of people with diabetes, so we have made progress. Clearly, the question now is how we can go much further. Diabetes is a key priority for us, and we want to see a measurable difference in the lifetime of this Parliament. There are four main areas in which we are taking action.

Junior Doctors Contract

Paula Sherriff Excerpts

Thursday 19th May 2016 Commons Chamber

[Mr Hunt]

If I answer that question directly, I will dig myself into rather a deep hole. I echo my hon. Friend’s thanks to my hon. Friend the Member for Ipswich, who has done an outstanding job by my side at every stage throughout this difficult period. I can certainly say that we would not have had yesterday’s agreement without his strong help and support at every stage. It is true that there are A&E departments across the country that, in having to plan for the two-day withdrawal of emergency care, found that having consultants more visible to patients had some positive impacts. I know that studies are going on to see what lessons can be learned from that going forward.

[Paula Sherriff (Dewsbury) (Lab)]

I, too, welcome the opportunity for a negotiated settlement, but let us take just a moment to reflect on one of the fundamental principles of our NHS—providing high-quality patient care. Will the Secretary of State take the opportunity today to offer a heartfelt and sincere apology for the significant and severe distress caused to patients as a result of this prolonged dispute?

[Mr Hunt]

With the greatest of respect to the hon. Lady, it was not my decision to take industrial action—to ballot for industrial action without even being prepared to sit around the table and talk to the Government. We are seeing dramatic improvements in patient safety under this Government, as we face up to the many problems in care that we inherited, not just at Mid Staffs, but at many other places. I know that she cares about patient safety, so she should welcome the difficult changes we have made, one of which is to have a seven-day NHS.

Oral Answers to Questions

Paula Sherriff Excerpts

Tuesday 10th May 2016 Commons Chamber

[Mr Speaker]

The Minister is an endlessly noble fellow—I think we are very clear about that.

[Paula Sherriff (Dewsbury) (Lab)]

T2. During March, at one of my local trusts the A&E ambulance target was missed for 937 patients, and more than 4,000 patients waited for more than four hours in A&E. Staff and management agree that this is a trust in crisis, with many wards staffed to less than half the minimum safe staffing levels. Patient safety is being compromised every day. Will the Secretary of State please stop passing the buck and act to stop the downgrade of Dewsbury and Huddersfield hospitals, because it is clear that our local healthcare is in absolute crisis?

[Mr Jeremy Hunt]

The hon. Lady mentioned to me yesterday that she would raise this issue today. We are absolutely not passing the buck; the Under-Secretary of State for Health, my hon. Friend the Member for Ipswich (Ben Gummer), had a very productive meeting with her and local representatives to address these issues. She is right to have concerns about some of the safety indicators, but it is also true that summary hospital-level mortality for the trust has improved, and there are encouraging improvements in morale, as recorded through the NHS staff survey. However, there are worrying things, and we will continue to monitor them closely.

NHS Bursaries

Paula Sherriff Excerpts

Wednesday 4th May 2016 Commons Chamber

[Heidi Alexander]

I absolutely agree with my hon. Friend. Indeed, the bursary acts as an incentive to get those students into training and into the NHS.

A few weeks ago, the Government launched their consultation on the technical detail of the changes—not the principle, just the detail. In his foreword, the Under-Secretary of State for Health, the hon. Member for Ipswich, claimed that the proposals were

“good for students, good for patients and good for the NHS.”

The opposite is the case.

Before I set out why the plans are so bad, it is important to remind ourselves of why our country has a nursing shortage in the first place. Shortly after the 2010 election, the coalition Government cut the number of nurse training commissions in an attempt to make short-term savings. The cuts saw nurse training places reduced from more than 20,000 a year to just 17,000, the lowest level since the 1990s. As a result, we trained 8,000 fewer nurses in the previous Parliament than we would have done had we maintained commissions at 2010 levels. At the time, experts such as the Royal College of Nursing warned that the cuts would cause

“serious issues in undersupply for years to come.”

It was right, but it was ignored by Ministers who were too focused on the short term and no doubt too distracted by their plans to launch a massive reorganisation of the NHS.

Our health service is now suffering the consequences of those decisions. New analysis by the House of Commons Library released today shows that the number of nurses per head of population fell from 6,786 per million people in 2009 to 6,645 per million people in 2015. A Unison survey published just last week found that more than two-thirds of respondents felt that staffing levels had got worse in the past year, with a further 63% saying they felt there were inadequate numbers of staff on the wards to ensure safe, dignified and compassionate care. Because of these shortages, hospitals are forced to recruit from overseas or spend vast amounts on expensive agency staff.

[Paula Sherriff (Dewsbury) (Lab)]

In the years 2014 to 2015, the NHS spent £3.3 billion on agency staff. Does the short-sighted step of removing the bursary mean that beleaguered trusts may actually be more reliant on agency staff?

[Heidi Alexander]

My hon. Friend is completely right to point out that the problem of staff shortages leads to more agency staff having to be used, and that creates an enormous black hole in hospital finances. My fear is that the proposals will put off the next generation of nurses.

It now appears that the Government are making some of the same mistakes all over again. A report sneaked out on the day the House rose for the Easter recess revealed that the Government had commissioned only one-tenth of the extra nurse training places that experts said were needed this year. The report, from the Migration Advisory Committee, states:

“We were told that HEE—

Health Education England—

“has acknowledged that, on the basis of workforce modelling alone, they would have liked to commission an additional 3,000 places in 2016-2017. Funding constraints meant that they had only commissioned an additional 331 places; one tenth of what was actually needed”.

--- Later in debate ---

[Alistair Burt]

That is a good question. Yes, of course. At a time of change, there is a degree of uncertainty. My main point is about how the matter has been blown up yet again, as it was for student loans originally. The idea that people would be deterred from ever going to university, and that no one would go from disadvantaged backgrounds, has been proved false. Of course, the concerns are very much being addressed by the consultation that the Under-Secretary of State for Health, my hon. Friend the Member for Ipswich, is undertaking, and he is listening extremely carefully. The consultation process is very wide and genuine, and he is listening particularly to ideas on alterations and proposals. The consultations are not complete and the scheme is not complete, and he is keeping a close ear on those consultations.

There is recognition that there are different characteristics for those who go into nursing, midwifery and allied health professions, which is why we want to make sure that appropriate support is available. Department for Business, Innovation and Skills student support regulations give more support than the bursary; the Secretary of State retains the power to give discretionary funding in exceptional cases; and in the consultation, respondents can give examples of unique characteristics, so that the reforms can reflect that. Our position recognises that, as my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) said, more of the same will not do the job. The need for change is there. We need more nurses, and we need more nurses domestically trained. We are going to do something different, recognising what changes there might be. That is why we have the consultation. Unique characteristics will be reflected in it; that is what the consultation is about. Keeping the current system is not working and will not work in the future. That is why we need change.

[Paula Sherriff]

My local Mid Yorkshire Hospitals NHS Trust is, by its own admission, in the midst of a nursing crisis, with about half the wards staffed at below the minimum staffing level for nurses. Does the Minister think these proposals will help or hinder that?

[Alistair Burt]

I say in all honesty to the hon. Lady, who is knowledgeable about health matters and has been to see both me and the Under-Secretary of State for Health, my hon. Friend the Member for Ipswich, that the proposals help. At the moment, the problem with nurse training in this country is that it is limited. The universities cannot take all the people who want to be nurses; they have to turn them away—37,000 of them. This scheme opens up the opportunity for more people to train, and for more people to come into nursing through the nursing associates route. If the hon. Member for Dewsbury (Paula Sherriff) is looking for a straight answer on whether this will provide more nurses and help her local hospital, I can say: yes, it will. That is why these proposals are being made.

I wish to set out briefly the details of the basis for the reforms, just for those who were not able to attend the whole debate, and then answer one or two questions that were raised. To deliver more nurses, midwives and allied health professionals for the NHS, a better funding system for health students in England and a sustainable model for universities, we need to move nursing, midwifery and allied health students from grants and bursaries on to the standard student loans system. Putting more funding into the existing system was not a sensible or viable option for the Government, if we are also to increase the number of student places, live within our budget, and ensure that the NHS can use the extra £10 billion-worth of additional investment for front-line care by the end of the Parliament.

The subjects that we are talking about are extremely popular with students. In 2014, nursing registered as the fifth most popular subject on UCAS, and in that year there were 57,000 applicants for 20,000 nursing places. Rather than denying thousands of applicants a place to study health subjects at university, surely it is better that the new proposals ensure enough health professionals for the NHS, while cutting the current reliance on expensive agency and overseas staff, and giving more applicants the chance to become a health professional. Part of the reason why we need to modernise the funding system is that student nurses, midwives and allied health students currently have access to less money through the NHS bursary than students using the student loan system do. Under a move to the loan system, these health students will receive an increase of about 25% in the financial resources available to them for living costs during the time they are at university.

It is not possible to pick out all the speeches made today, but I would like to make reference to some. The hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) discussed issues affecting postgraduate students, which are important. The majority of healthcare students undertaking these courses will be able to access a BIS postgraduate masters loan, although we acknowledge in the consultation that some courses currently fall outside the BIS postgraduate loan package. We are working with BIS and the Treasury on their higher education and lifelong learning review, and we will address these matters in the Government’s response to the consultation, so she is right to raise that issue.

My hon. Friend the Member for Totnes (Dr Wollaston), the Chair of the Health Committee, said straightforwardly that we need to train more nurses. That is our bottom line; it is what we are trying to do. On transition, she said that it was important to listen to needs, and she spoke about getting more professionals away from the acute sector and into primary care. As she knows, that is a major interest of this Government, and these proposals will help in that regard.

My hon. Friend the Member for Morecambe and Lunesdale (David Morris) was straightforward. He talked about his trust recruiting from abroad, but said that it would like to recruit more at home. It will be able to do so under these proposals.

My right hon. Friend the Member for Hitchin and Harpenden (Mr Lilley) talked about what he discovered when he spoke to his local university and trust. He discussed the morality of taking more nurses, and student nurses, from overseas. It is important to recognise that our proposal will ease that situation to some degree. He also spoke about the important issue of the Ministers’ dilemma: of whether to put money into training now, knowing that the benefit will come some years later. It is important for any Government to recognise that more money must go into the training of doctors and of the people about whom we are talking today. There will be a return later.

I am conscious of time, and I am sorry that I cannot cover more speeches. Let me say this: the NHS never sleeps or stays still. As our country changes, so does the NHS; it must. It is always comforting to resist change, even when the status quo is not good enough; however, the need for innovation, which will be challenging and resisted, is imperative. This Government have given the NHS that commitment, and we will promote the finance, planning and innovation that were denied by the Opposition. We will not allow so many people to be denied the opportunity of becoming a nurse. We will not allow those on hardship funds and bursaries to fail to get access to more finance. We will not allow them to be—

Southern Health NHS Foundation Trust

Paula Sherriff Excerpts

Tuesday 3rd May 2016 Commons Chamber

[Paula Sherriff (Dewsbury) (Lab)]

Are the failures at Southern Health a symptom of the growing and unsustainable pressure being placed on the mental health and learning disability services? In the context of increased demand, significant pressure on beds, higher thresholds for care, staffing cuts and shortages, how can the Minister guarantee that mental health and learning disability trusts are able to do their jobs?

[Alistair Burt]

Let me point out that we have announced an increased resource for mental health of £11.7 billion. The extra £1 billion that the Mental Health Taskforce recommended being spent by 2020 will be spent, and it will be spent right across the board from perinatal mental health to crisis care. It will also improve baselines to ensure that the governance and quality of foundation trusts are good enough, and we are watching what CQCs are spending. Yes, we recognise that there has been historical underfunding from Governments of all characters, but we are determined to improve it and the money is there.

Junior Doctors: Industrial Action

Paula Sherriff Excerpts

Thursday 24th March 2016 Commons Chamber

[Ben Gummer]

My hon. Friend is right to point out that not all junior doctors are members of the BMA. In fact, a significant minority are not, which is why fewer than half have been turning out for industrial action. The number has been decreasing with each successive strike, and I have no doubt that as we move to the withdrawal of emergency cover, most junior doctors will say, “This is not something I went into medicine to do”, and will want to show their support for patients, rather than an increasingly militant junior doctors committee.

[Paula Sherriff (Dewsbury) (Lab)]

I plead with the Minister to respond to the comments from Jeremy Taylor, chief executive of National Voices, which represents 160 health and care charities and which has called on the Government to drop imposition and on both sides to get back around the negotiating table. In his words, if they do not,

“the only people who will suffer are patients.”

[Ben Gummer]

I disagree with the gentleman on two points. First, we have been trying to get around the negotiating table for over three and a half years, but it requires both sides to negotiate, and I am afraid the BMA has refused to do so. When only one party is at the table, negotiations cannot continue. Secondly, it is not just bad for patients; it is also bad for doctors in terms of their careers and what they want, which is to provide the best possible care for patients. That is why I urge all doctors not to withdraw emergency cover at the end of next month.

Mid Yorkshire Hospitals NHS Trust

Paula Sherriff Excerpts

Monday 21st March 2016 Commons Chamber

[Paula Sherriff (Dewsbury) (Lab)]

Let me start by paying tribute to the doctors, nurses and all the staff working in the Mid Yorkshire Hospitals Trust. As a Member whose constituency is covered by the trust, a local resident and indeed a patient, I have nothing but praise for their hard work, dedication and professionalism. Lord knows, the NHS may be up against it—and this trust perhaps more than most—but I am continually humbled by the quiet and determined way that all the staff at Dewsbury and District hospital, Pontefract hospital and Pinderfields hospital go about providing care and support in the face of what must seem at times like overwhelming odds.

[Jo Cox (Batley and Spen) (Lab)]

I congratulate my hon. Friend and neighbour on securing this critical debate on our local hospital. I back her in what she says and recognise that doctors and nurses and other staff at the hospital have been working in crisis mode for 15 months now. It is difficult to overstate how hard it must be for staff to go to work every day, knowing that they will miss key targets and not be able to give the care and attention that they so want to give.

[Paula Sherriff]

I thank my hon. Friend for her intervention. I absolutely agree with her. We must also pay tribute to our incredible junior doctors.

Whatever difficulties the trust is facing, there can be no doubt that those working there on the frontline are blameless, and deserve our full backing. As Members of Parliament, we owe it to them to make sure that they are given all the support they need.

The trust and its staff have to work in a challenging environment. In the area covered by the trust, the overall health of the population is below the average for England. Deprivation is higher than average, and nearly 20% of children are living in poverty. Life expectancy is lower than the national average for both men and women.

The Care Quality Commission inspected the trust in July 2014, with a follow-up inspection in June 2015. An unannounced inspection of Pontefract hospital emergency department took place in July 2015. A second unannounced inspection took place in August 2015 at Pinderfields hospital, focusing on staffing levels, with a follow-up visit to Pinderfields in September.

Although there were some improvements between the two main inspections of 2014 and June 2015, there were also areas in which the trust’s performance had worryingly deteriorated, and there were still serious concerns about staffing levels. The CQC noted that there was still a significant shortage of nurses, which was having a knock-on effect on patient care, particularly on the medical care wards, in community inpatient services, in the specialist palliative care team and in end of life services.

Two weeks ago, my hon. Friend and I met the trust’s new interim chief executive. We were both very grateful to him for his candour. He told us that the leadership team has effectively been in crisis mode for the past 14 months. He said that the trust had recently put in an additional 120 beds across the trust to cope with increasing demand, but the 100 extra staff who should have accompanied that expansion are nowhere to be seen. The posts simply have not been filled.

[Sue Hayman (Workington) (Lab)]

Does my hon. Friend agree that the NHS’s problems in recruiting and retaining staff is one of the most critical issues facing our national health industry and our ability to manage our hospitals properly?

[Paula Sherriff]

I thank my hon. Friend for that intervention. I will come to that point later.

To make things more complex on the administrative side, the monthly staffing reports are found to be overly detailed, generally running to over 100 pages, making it difficult to identify the most urgent risks. Likewise, there are concerns that policies and procedures for the escalation of staffing risks were not always followed when they were identified. The trust aims for a ratio of one nurse to every eight patients on adult in-patient wards. The Royal College of Nursing recommends 6.7 patients per nurse on adult wards as a maximum, so one to eight is not too far wide of the mark, though not ideal. However, the CQC found that even the 1:8 ratio was very inconsistently met. During its unannounced visit to Pinderfields hospital in August, of the 17 wards only one was staffed to safe staffing levels. Ten were at minimum level and six were actually below the minimum. Indeed, records show that in August 2015 only 71% of nursing hours were achieved. Staff on the trust’s spinal injuries unit at Pinderfields are constantly reallocated to other wards, in essence robbing Peter to pay Paul. A nurse even told a patient that because they were so short-staffed, if two patients got into respiratory difficulties, which is not uncommon on a spinal injuries ward, the nurses would have to choose which patient they were to save.

The problem is particularly acute at the community in-patient sites at Monument house and Queen Elizabeth house, where between May and June last year 96% of shifts used at least one non-permanent member of staff, either agency staff or staff redeployed from other areas of the trust. Indeed, two shifts had only a single registered nurse on duty. The trust as a whole breached the Department’s cap on charges for agency staff, on average, 132 times a week during December. While it is absolutely right to prioritise patient safety over the Government’s financial targets, that is a clear indication that there has been a failure in long-term workforce planning and that it is struggling to attract and retain appropriately qualified staff.

To give credit where it is due, the trust has been making efforts to address the staffing issue. After the unannounced inspection, a risk summit was held under the leadership of NHS England to look at the actions the trust needs to undertake and the support needed from the wider healthcare community. The high number of registered nurse and care staff vacancies is now noted on the corporate risk register. The trust is looking at a range of different structures for nursing teams to get the best out of the available staff. It has invested in safety guardians to provide support and safeguarding for patients with mental health issues, freeing up time for registered nurses. It is putting extra effort and resources into filling gaps by looking to recruit nurses both locally and from Europe, proactively recruiting rather than waiting for staff to leave.

The CQC rated the safety of services provided by the trust as “inadequate”, largely due to the shortage of staff. For instance, between May 2014 and April 2015, 258 serious incidents were reported, of which 206 were cavity-like grade 3 pressure ulcers. That sort of thing is indicative of nursing staff being rushed off their feet, unable to provide the level of patient care that they would like. Concerns were also raised about patients who required one-to-one care not receiving it, and fluid balance monitoring and nutritional assessments not being properly completed, with charts often not kept fully up to date. In January, 81.4% of accident and emergency admissions were seen within four hours; the target is 95%. More than 2,000 patients waited on A&E trolleys for more than four hours, including six who waited more than 12 hours at Pinderfields.

When looking at such statistics on patient care, we have to be very careful to remember that each number—each percentage point—represents real people. They are people who may be in pain, or vulnerable, worried or nervous. They may be upset or distressed. By any reckoning, the NHS is our nation’s most prized institution, and when people have to make use of it, they rightly expect a certain level of service. NHS staff want to give that level of service, and when they cannot the result is more than just a delay in treatment—the dignity of patients is also compromised.

A few weeks ago I received an email from one of my constituents. Her 84-year-old father had been admitted to Dewsbury hospital with stroke-like symptoms. He was on a trolley in A&E for 14 hours. After he had been admitted to a ward, his daughter came back to visit him. She found that his bed was a complete mess and covered in food, and her father was naked from the waist down. When she asked why he had on only a pyjama top and was sitting on an incontinence pad, she was told that it made it easier when he needed to urinate. When she came back later that afternoon, his bedding had still not been changed, which in the end she did herself. That is a basic outline of one case, but it is by no means the only such correspondence that I have received from concerned constituents. At the moment I receive similar emails more than once a week, which is alarming.

All that, of course, has an inevitable knock-on effect on staff motivation. The results of the 2015 NHS staff survey show just how low morale has sunk. For every key indicator the results are depressing and fall well short of national averages. Only 54% of staff felt that the care of patients was the trust’s top priority, compared with a national average score of 73%, and 55% felt that the trust acts on concerns raised by patients, whereas the national average is 72%. Just 41% of people would recommend the trust as a place to work. Perhaps most damningly of all, only 46% of people would be happy for a friend or relative to receive care at the trust.

The amount of disciplinary action being taken against staff has risen in recent months, which is generally due to staff making minor mistakes or not being able to follow procedures through fully for want of time. That is a symptom of the shorthandedness that has been experienced on the wards, and it contributes to the general air of despondency as staff are effectively penalised for not being able to be in two places at once. I have spoken to a number of past and present members of staff in the trust, who informed me that they have failed to whistleblow for fear of retribution.

The feeling of being worn down is affecting staff at all levels. I was told by the interim chief executive last week that the board has effectively been operating in crisis mode for the past 14 months, which, of course, is now taking its toll. There is a general feeling of chaos, tempers are fraying, and there is severe instability in the personnel in management teams—a sure sign that the trust is struggling to get its problems under control, which is a challenge in itself.

To be fair, there have been some slight improvements recently. The CQC’s follow-up visits noted that staff were more confident than they had been previously, and that senior management were taking some concerns on board and trying to get to grips with the issues. However, that feeling was by no means universal, and that slight improvement from such a low base is hardly a cause for celebration.

On the underlying causes of these problems, the Government must take the lion’s share of the blame. Going right back to slashing nursing training places in 2010, they have failed to ensure that the NHS has the levels of staff it needs to provide a safe and caring service. Thousands of nurses who should have begun training between 2010 and 2012 and would now be qualified—thereby helping to alleviate the difficulties in Mid Yorkshire—are just not there. Applicants for nursing courses outnumber the available places by more than two to one.

The whole ethos of the NHS has been warped from one of service and care to one of financial management. Of course the health service must keep on an even keel, but when a cash-strapped trust feels that it is appropriate to hire city consultants such as Ernst & Young, alarm bells should start ringing. Thankfully, that contract finally came to an end last September, but not before the trust had stumped up more than £15 million. Given that staff are still struggling to keep their heads above water, they could be forgiven for questioning whether that was money well spent.

[Jo Cox]

My hon. Friend makes a powerful and personal case. Does she agree that the Government have responsibility for this issue? They have cut public health funding, and there is a social care crisis locally and problems with the junior doctors contract. The Government must take responsibility for this crisis and not pass the buck to an embattled NHS trust.

[Paula Sherriff]

I absolutely agree that the buck must stop with the Government, and we must see action, not platitudes.

I have now been told several times that the solution to the problems lies in the plans to downgrade Dewsbury’s A&E and maternity services, which will be centralised at Pinderfields. I say that that is putting the cart before the horse. Nearly 70% of in-patient beds will be lost in Dewsbury, and the simple fact is that this will put lives at risk. Leaving aside the arguments about whether the proposed reforms are necessary, it is just not safe to attempt this sort of major restructuring right in the middle of a major staffing crisis.

Once again, financial considerations are overriding clinical concerns. The trust is currently consulting on proposals to bring forward the reconfiguration. I say absolutely unequivocally that, while the trust is in a state of flux, discussions must focus solely on improving safety and quality. I urge the board to abandon these plans.

I have written to the Secretary of State about the serious worries in relation to what is going on at Mid Yorkshire Hospitals NHS Trust. The Minister has kindly agreed to meet me and other concerned MPs next month to discuss this in more detail. However, I want to reinforce the point that we are in danger of forgetting the lessons learned from the Mid Staffordshire situation about the absolute priority that must be given to safe staffing levels. Unless we can crack this by getting the qualified staff we need, no amount of reorganisation will make up for poor care. We must break the spiral of demoralisation and overwork so that we can help both the patients and the staff who are currently getting the short end of the stick.

On this day exactly 70 years ago, Nye Bevan announced his plans for a national health service. His vision of universal healthcare free at the point of delivery and funded collectively is just as valid today as it was then. Bevan said:

“The NHS will last as long as there are folk left with the faith to fight for it.”

We must stand together now for the NHS, and we must support the staff who go above and beyond for the NHS every day. It is our duty as parliamentarians to continue the fight for those who, yet still, have faith in those founding principles—an NHS for all, based on clinical need and free at the point of delivery.

--- Later in debate ---

[Paula Sherriff]

Given that Ernst & Young’s services were used, at some considerable cost, and that some of the matters it considered were staffing issues and staff forecasts, it is relevant to point out the contract has now ended after about four or five years. Does the Minister agree that it is quite worrying to find ourselves in this position after spending somewhere in the region of £15 million?

[Ben Gummer]

As a constituency MP, I, too, have been frustrated by consultancy contracts, both before and after the 2010 election. Across the service, we have managed to bear down on consultancy spend considerably. It is for the hon. Lady and her consultants to determine whether the trust has got good value for money. It is not for me to pass comment on that, except for the fact that all hospitals should account to their local people and to the trust and local authority responsible for making sure that money is being spent wisely.

I completely agree with the hon. Lady in that behind the statistics of poor performance that she identified, there are people who are not receiving the care they require. That was picked up by Professor Sir Mike Richards in his report into the quality of care provided at the hospital. He was very clear about it, saying

“we found medical care, end of life services and community inpatients either hadn’t improved or had deteriorated since our last inspection.”

He found areas of significant staffing shortages affecting patient care, especially on the medical care wards, community in-patient services and in the specialist palliative care team. He said that there was a shortage of medical staff for end of life services. He came to the same conclusion as the hon. Lady did.

The difference here is that I hope we have made progress since the Mid Staffs tragedy that the hon. Lady identified, and are now able to be more open about this. There will not be a culture of denial from the Government Benches about problems where they exist. Clearly, there is a problem here; it has been identified by the Care Quality Commission. The distressing story of the hon. Lady’s constituent that she raised with the Secretary of State in the Chamber and in the letter and again just now has been supplemented with additional stories that her colleagues have brought to the attention of the Department, and these make it clear that things need to be done in Mid Yorkshire.

What, then, is the solution to the problems that the hon. Lady has identified? The first is a local one, and all these problems have to be addressed locally, but I of course take the hon. Lady’s point that the Department has to take a degree of responsibility. Of course the Secretary of State and I take responsibility for everything that happens in the health service—that is ultimately our duty—but we cannot micromanage every hospital. It is for the local team to ensure that they are universalising the best and implementing the kinds of changes in their trust that have made such a success of hospitals not very far from the hon. Lady’s own. If they are able to do that, they will already be able to bring considerable improvements to the quality of the care that they can provide.

I can obviously do additional things as a Minister to give the local team the tools to do the job, as I can for other hospitals across the country. That includes ensuring that they have the best guidance to enable them to roster their staff properly. Lord Carter’s review is being conducted with the Care Quality Commission and with NHS Improvement. It is a tripartite review of safe staffing ratios that will give hospitals cutting-edge support to roster their staff according to the acuity of their patients to ensure maximum safety and efficiency, learning from best practice across the globe. Salford Royal Infirmary has already been looking at this particular model in one guise.

[Paula Sherriff]

My hon. Friend the Member for Batley and Spen (Jo Cox) and I share considerable concerns about the senior leadership at the trust. We have regular monthly meetings, but we were made aware only at the last meeting—we now have an interim chief executive—of some of the chaotic things that were going on at the trust, although we had been aware of anecdotal stories. We would therefore appreciate some support from the Department of Health team to ensure that communication channels between us as elected Members are as effective as possible.

[Ben Gummer]

I shall certainly impress that upon NHS Improvement, which will be taking over the functions of the NHS Trust Development Authority in the next few days. I expect that it will keep an even beadier eye on the quality of management than has been the case so far. It will do so under the watchful eye of Jim Mackey, its chief executive, who ran one of the best hospitals not only in England but in the world. He is now running NHS Improvement and I know that he will be able to provide the support that the hon. Lady wishes to see. I will tell him later this week about the discussion that we have had tonight and I will ensure that he provides hon. Members with the kind of resource that they are asking for so that they can ensure that their local leadership is doing the right thing.

On the wider issue of staffing, the fact is that the nursing numbers in the service, which were found wanting at the time of the Mid Staffs scandal, could have been addressed only by significant changes in commissioning levels not two, three or four years ago but 10, 15 or 20 years ago. The service has failed under successive Administrations to predict the number of staff that it needs for the future. One of the more extraordinary functions that I possess is to have to sign off every year the commissioning of staff that will be required in 20 or 30 years’ time. My officials are a wise and brilliant group of people, but no one can behave like Nostradamus and expect to know what the service will require after that period of time.

That is why we have come to the conclusion that we need to increase significantly the number of places commissioned. Within the current spending envelope, however, it is simply not going to be possible to achieve the numbers that we wish to see. I think that Governments from both sides would have found that very difficult—in fact, impossible. That is why we came to the conclusion that we should release those places by transferring nurse graduates on to a loan system. I know that that is unpopular with Labour Members, but I hope that they will understand the rationale behind our doing so. It will allow us to add 10,000 additional places between now and the end of this Parliament. Those are 10,000 places that we will then be able to feed into additional nursing places, which will in time solve the underlying issues that parts of the country such as the hon. Lady’s have suffered for decades.

One final aspect that I wish to bring to the hon. Lady’s attention, which I hope she will be pleased with, is that of the new role of nursing associate. It is supported by the Royal College of Nursing and to some extent by Unison, although it has reservations—a consultation is starting soon on this. It will provide a ladder of opportunity to healthcare assistants to move through an apprenticeship level up to the midway point of a nursing associate, and then on to being a full registered nurse. At present that is a course that healthcare assistants cannot take; it is not open to them.

I know that other parts of Yorkshire have no problem at all hiring healthcare assistants, but find it very difficult to hire registered nurses. That is a particular local difficulty. What I have proposed is a mechanism to give an opportunity to healthcare assistants to progress themselves, which they have many times missed out on because they did not have access to the decent formal education that we aim to provide now under the reformed education system. We are now offering, through an apprenticeship route that would not be open to them otherwise, a ladder of opportunity to a much wider group of people in the NHS, and at the same time helping to solve staffing issues where there are traditional, historical difficulties in hiring nurses.

I hope that with those general measures we will be able to do far more in the long term to solve the issue that the hon. Lady has identified. On the specific issues, I will ensure that she gets the reassurance she requires, not just on the reconfiguration, but on the leadership of her trust. I thank her and her colleague for bringing this important matter to the attention of the House.

Question put and agreed to.

NHS: Learning from Mistakes

Paula Sherriff Excerpts

Wednesday 9th March 2016 Commons Chamber

[Mr Hunt]

It is so good to have someone with nursing experience in the House, and I hope that my hon. Friend will make an important contribution for many years to come. She knows what it is like on the front line, and why it is important to get this culture change. She also knows how important it is not to run down the NHS, which is doing extremely well.

[Paula Sherriff (Dewsbury) (Lab)]

Last week I received an email that was frankly heartbreaking. My constituent’s 84-year-old father, a proud and dignified man, was admitted to hospital with symptoms of a stroke, and he had to wait 14 hours for a bed. She went to visit him later that day and found him in bed wearing clothes on only his top half. He needed the toilet, and she was given a bottle to help him urinate.

[Madam Deputy Speaker]

Order. I am sure that the hon. Lady will quickly come to her question.

[Paula Sherriff]

That was no dignified way to treat that man. Will the Secretary of State agree to an urgent investigation into safe staffing levels at Mid Yorkshire Hospitals NHS Trust, because the nursing staff told my constituent that they did not have time to fulfil her father’s basic nursing needs?

[Mr Hunt]

I am more than happy to look into that case, which is exactly the kind of thing that we are trying to stop with the measures we are bringing forward today.

Community Pharmacies

Paula Sherriff Excerpts

Tuesday 23rd February 2016 Westminster Hall

[Derek Thomas]

I hope to make the point that we need clarity about how the money will be found, if it must be found. I believe that there are other ways to save money, particularly involving the use and waste of drugs.

Community pharmacists are unsure about their future and unclear what support they can expect from the Government. The letter sets out the £170 million reduction in support for community pharmacists and asks them to prepare for the cut, but gives little detail about where the money will be cut, who will lose and what services can no longer be funded.

[Paula Sherriff (Dewsbury) (Lab)]

Does the hon. Gentleman agree that local pharmacies are part of the fabric of local communities? That is particularly the case for independent pharmacies, which are embedded in communities and whose owners and staff often come from those communities. Perhaps the Minister can tell us what impact assessments have been undertaken in terms of health and economic and social wellbeing by individual constituency.

[Derek Thomas]

I welcome that intervention, but I am concerned that the hon. Lady might have read my speech, and I have not yet put it on my Facebook page. In my constituency, I have several community pharmacists, and I am not sure that I have too many. It is simply that my patch is large and includes areas of social deprivation, which has an inherent impact on health. A car journey from the north to the south of my constituency takes an hour. The journey from the most westerly point to the most southerly point takes an hour and nine minutes. In a rural area such as mine, community pharmacists provide invaluable access to the NHS and invaluable support to vulnerable people.

To follow on from the hon. Lady’s helpful intervention, over and above their obvious healthcare roles, I see community pharmacies’ input into society as comparable to that of post offices, police community support officers, libraries, local churches or chapels, local pubs, village shops and our postmen and women. They all play an important part in local communities. They are the glue that holds communities together, the people and organisations that know when things are not as they should be, and the people who look out for our elderly, the sick and the vulnerable. Although it is difficult to put a price on the work they do, without those people and institutions, society would be a poorer place and the added strain on public services would be significant. It is perverse that we judge reducing support for services such as community pharmacists to be a saving.

Junior Doctors Contracts

Paula Sherriff Excerpts

Thursday 11th February 2016 Commons Chamber

[Mr Hunt]

We want more doctors and more nurses in the NHS, but in the end, if we are putting extra money in to recruit these extra doctors and nurses, it is fair to the public who are paying for their salaries to have reforms that mean their care gets better. That will apply to the hon. Lady’s constituents in Hull, who want a seven-day NHS, just as my constituents in Surrey do.

[Paula Sherriff (Dewsbury) (Lab)]

The Health Secretary repeatedly accuses the BMA of misleading junior doctors, yet 98% of them voted for industrial action. Without exception, every doctor I have spoken to said that the last thing they wanted to do was to go out on strike. Doctors are some of the brightest and most intelligent people we have in our country. Does the right hon. Gentleman really believe that they cannot make up their minds for themselves?

[Mr Hunt]

It is interesting that when that vote was held, the BMA had not sat down and talked to the Government, despite repeated invitations. I personally met Johann Malawana, the leader of the junior doctors committee, and invited him to talks. Despite those repeated invitations, they refused to talk; they decided to ballot for industrial action. How serious are people about reaching a negotiated settlement if that is what they do?