Ambulance and Emergency Department Waiting Times

Peter Aldous Excerpts

Wednesday 6th July 2022 Westminster Hall

[Peter Aldous (Waveney) (Con)]

It is a pleasure to serve with you in the Chair, Mr Stringer. I congratulate the hon. Member for Bath (Wera Hobhouse) on securing this debate. I will focus my comments on the work of the East of England Ambulance Service NHS Trust and the James Paget University Hospitals NHS Foundation Trust, which together serve north Suffolk and east Norfolk, including the Waveney constituency.

The staff and management of both NHS trusts are under enormous pressure at the current time and are working incredibly hard to meet a challenge that is largely not of their own making. The East of England Ambulance Service has faced a number of institutional and cultural challenges over the past decade, which the current management are addressing. During that time, for the most part, it has provided the local community with a good service, although there have been three occasions when it has not done so: in 2012, when the system broke down very badly, at around Christmas time in 2017-18, when the then management failed to properly plan for seasonal pressures, and today, as it works against a very difficult backdrop.

For the week ending 26 June, the average arrival-to-handover delay at the James Paget was one hour 30 minutes. For the previous week, it was one hour four minutes. For the week before that, it was 49 minutes. The trajectory is very much upwards. The worst individual case that has been brought to my attention is a wait of 16 hours, and I am also aware of the situation with poor triaging.

Working collaboratively and in a co-ordinated way, the ambulance service and the James Paget hospital are putting in place a range of measures to relieve the pressures. The hospital has expanded its emergency department, launched a new surgical assessment unit and invested £900,000 in a new GP streaming service aimed at providing care for patients who attend A&E and who need a doctor rather than hospital treatment. For its part, the ambulance service is putting more ambulances on the road, developing co-responses with the fire services and local communities, and staffing cohorting areas at the Paget with its own HALOs—hospital ambulance liaison officers.

Those initiatives are welcome, and the two trusts should be commended for putting them in place, but they are, in many respects, a sticking plaster. They do not address the root cause of the current crisis, which is the logjam caused by the difficulty that the James Paget and other hospitals are facing in discharging patients to free up beds.

The Paget regularly has an average of 100 patients—the equivalent of four wards—who are ready for discharge, but have nowhere to go. They have opened 22 beds at the Carlton Court Hospital, a facility that the Paget now shares with the mental health trust, but there is an urgent need for more beds to be made available in the community, whether at home, or in care and nursing homes.

The problem with care at home, which in many respects is to be preferred, is that councils such as Suffolk County Council and its social services department are struggling to recruit carers and agencies to go into people’s homes to look after them after they have left hospital. In the long term, there is a need for strategic workforce planning in both the health and care sectors.

In the short term, Government need to work with councils such as Suffolk, with the East of England Ambulance Service and with hospitals such as the James Paget hospital—as well as with the wider care sector—to remove the blockage that is impacting all the way along the ambulatory care pathway. I look forward to hearing from the Minister the Government’s plans for doing that.

NHS Dentistry in England

Peter Aldous Excerpts

Wednesday 22nd June 2022 Westminster Hall

[Peter Aldous (Waveney) (Con)]

It is a pleasure to serve under your chairmanship, Mr Stringer. I congratulate my hon. Friend the Member for St Ives (Derek Thomas) on securing the debate. Access to NHS dentistry remains an enormous problem right across England, from his constituency, which is the most westerly, to the Waveney constituency that I represent, which is the most easterly. There is not only a so-called perfect storm, but also a perfect symmetry, which hits the most vulnerable hardest.

The Government have brought in measures to address this crisis, which have had some partial success; but what is needed is a long-term strategic plan for NHS dentistry, which I would suggest should meet the following criteria. First, a secure long-term funding stream. Secondly, a strategic approach to recruitment and retention. Thirdly, replacement of the dysfunctional NHS dental contract. Fourthly, a prevention policy, promoting personal oral healthcare. And fifthly and finally, transparency and full accountability, through the new emerging integrated care systems.

The issue on which I wish to focus falls in the last of those categories. It is the procurement of NHS dentistry, which at present is opaque and has, over a long period, led to some outcomes that are not in the best interests of local residents and do not meet the standards of probity that one is entitled to expect in the award of public contracts.

In 2009, the late Dr David Johnson, a much-loved local dentist with a thriving practice in the high street of Lowestoft, was refused a contract to continue to offer a service that he had provided to the local community for many years. That happened in highly unsatisfactory circumstances, which caused much personal upset and ultimately led to units of dental activity being taken away from Lowestoft, where they were much needed, and reallocated elsewhere.

More recently, approximately two years ago, a contract was awarded for the out-of-hours service in Norfolk. The company that won the contract still does not have either regular dentists or premises, and does not work anywhere near the hours stipulated in the contract.

[Dr Poulter]

My hon. Friend is absolutely right when he speaks of the challenges that patients face throughout Suffolk in accessing NHS dentistry. Does he agree that there is availability of emergency out-of-hours dentistry, but that some companies are not taking the correct steps to provide it—and that some dentists are not opening up the number of slots that they are contractually obliged to, to provide it?

[Peter Aldous]

I thank my hon. Friend and neighbour for that intervention. He is correct, and the example I have just provided illustrates that point.

On the issues with the probity of procurement arrangements, I will move forward to the present. It is welcome that a new, long-term NHS dentistry contract has been awarded for the Lowestoft area, and the locally based Dental Design Studio will deliver the contract to a high standard for the benefit of local people. However, before DDS was awarded the contract, it was initially won by a limited company with no local presence, no dentists and no premises. That company then offered the contract to local practices, seeking bids, initially of £400,000, which it then reduced to £250,000. When it was unable to sell on the contract, it withdrew from the process.

Procurement arrangements that allow such blatant profiteering are quite clearly not fit for purpose. There is also a worry that the process is skewed against partnerships, which have been the traditional means of providing primary healthcare in local communities. Only single legal entities and limited companies are able to tender for NHS dental contracts, with partnerships excluded from doing so. The feedback that I am receiving is that the tender documents are far from straightforward and discourage some local NHS dentists who remain in practice from bidding for contracts.

The transfer of responsibility from NHS England to the new integrated care systems, which will start operating in just over a week’s time, provides an opportunity to carry out root-and-branch reform of the procurement and oversight arrangements for NHS dentistry. We need to ensure that they are fair, transparent and in the best interests of local people. It is vital that we seize this opportunity.

--- Later in debate ---

[Maria Caulfield]

We are looking at the issue of clawback. Obviously we are in negotiations, so I cannot say what the final outcome will be. However, on the point that the hon. Gentleman makes about clawback during the last quarter, when the omicron variant was a particularly significant factor, we made clear to commissioners and dentists that if there were issues arising from omicron—patients who could not attend their appointments, or dental teams that were unable to be at work—they would not be subject to clawback. I would be disappointed if dentists who could not undertake their units of dental activity for covid-related reasons were penalised with clawback for that, because we made it very clear that there needed to be a flexible mechanism to mitigate some of those issues. If the hon. Gentleman has examples of that, I would be happy to take them away and ask officials to look into them.

[Peter Aldous]

There is some ambiguity about where the negotiations stand. Can my hon. Friend clarify whether a letter has gone to the BDA to start the negotiation process, or whether there are finalised heads of terms ahead of an announcement on a new contract?

[Maria Caulfield]

The negotiations started back in March and there have been a number of meetings with the BDA. The BDA has been sent final recommendations, but we have not yet heard back, so I encourage the BDA to respond.

I will touch on a number of other issues that have been raised, the first of which is overseas dentists. For obvious reasons, no overseas registration examinations took place during the pandemic, creating a backlog of over 800 overseas dentists waiting to take their exams. Exams restarted earlier this year, and extra sessions are being held to get through that backlog of dentists so that we can get them into the system and working as dentists as quickly as possible.

We have also been working with the General Dental Council, which is the regulator, on recognition of overseas qualifications. The GDC did a consultation on regulation and recognition of overseas dentists, which I think closed on 5 or 6 May. We are waiting to hear the feedback from that consultation, but we are happy to lay regulations in this place—if necessary, we can do so by the end of the year—to give the GDC the power to mutually recognise overseas dentists according to its judgment. It is not for the Government to mutually recognise qualifications; it is for the regulator. However, we are happy to give the GDC the power to do so, and we look forward to its feedback on the consultation it undertook, because our overseas dentists are a rich source of the talent and skill that we need.

When it comes to getting more dentists into certain parts of the country—obviously, one of those areas is the south-west, whether that is Cornwall, Devon or Plymouth —significant work is going on. I met with Health Education England this morning to look at how we can set up centres for dental development. Those centres are different from dental schools, which are often very expensive and take a long time to set up, and, as was said during the debate, there are not always dentists available locally to supervise the training. Centres for dental development can be much more flexible and meet existing local needs while also looking at what needs could develop.

As such, we will be working up a programme, looking at what we can do in those specific parts of the country with the greatest need. In Norfolk, I recently met a group of local MPs and representatives from the local university and the local enterprise partnerships, all of whom are willing to work together to make that happen. I am going to Portsmouth on Monday, to Gosport, to see exactly the same thing—dentists coming together to come up with local solutions that will make a difference.

Access to GP Services and NHS Dentistry

Peter Aldous Excerpts

Tuesday 21st June 2022 Commons Chamber

[Peter Aldous (Waveney) (Con)]

With regard to access to GP services, there is a significant challenge that must be met head-on. The solution must address patients’ ongoing concerns, involve long-term strategic workforce planning, and respect, not abuse, the GPs themselves.

The issue that I wish to focus on is access to NHS dentistry, which after 18 months retains the unenviable and scandalous position of being No. 1 in my postbag. It is quite clear that the situation is replicated for colleagues across the House. Access to NHS dentistry is a problem that has been brewing for a long time. It can be likened to a house built on shallow and poor foundations, which—with the earthquake of covid—have led to the house falling down.

The impact on people is profound: millions unable to find a dentist; thousands in agony, resorting to DIY tooth extraction; as yet untold numbers of undiagnosed mouth cancers; children suffering and having whole mouth replacements; and the poorest hit hardest. The solutions are fivefold: a secure, long-term funding stream; a strategic approach to recruitment and retention; replacement of the dysfunctional NHS dental contract; a prevention policy promoting personal oral healthcare from the cradle to the grave; and transparent and full accountability through the new emerging integrated care systems.

To be fair to the Government, measures have been put in place to address the crisis. Locally in Lowestoft, funding has been provided for an established dentist to attend to emergencies. The practice has responded heroically and prevented the system from collapsing. A new long-term NHS contract has been awarded to Lowestoft-based Dental Design Studio. That is welcome, although given that it was not possible to commission similar contracts elsewhere in Suffolk and Norfolk, there is concern that demand for NHS dentistry across the region will continue to outstrip supply, and that the new service could have a large and unserviceable catchment area.

The Government’s announcement in February of a £50 million dental “treatment blitz” was welcome, but there is concern that the take-up of that funding has been limited because dentists have been too overstretched to take on the extra work. In the long term, the fact that the feasibility of establishing a dental school in Norwich is being considered is also very much welcomed.

Those initiatives are a step in the right direction, but the underlying causes of the dentistry crisis are yet to be tackled. In May, the Association of Dental Groups’ report highlighted the emergence of dental deserts across the country, where there is almost no chance of ever seeing an NHS dentist. There is a real risk of them merging to form an area of Saharan proportions. The British Dental Association is concerned that the negotiations to reform the NHS dental contract framework are yet to begin in earnest.

I have mentioned the importance of prevention. Back in February, I attended an event in Lowestoft at which community dental services and Leading Lives—a Suffolk-based not-for-profit social enterprise—launched a toolkit to help improve the oral health of young people with learning difficulties. Leading on from that, Lowestoft Rising, which promotes collaboration between statutory authorities and the voluntary sector, got together with local councillors and supermarkets to buy toothbrushes and toothpaste for primary school students. The initiative is to be applauded, but the feedback that I have received is that so much more could have been done if the group had not had to pay 20% VAT; surely this is a Brexit dividend that is looking us right in the eye.

As we have seen with the zero rating of women’s sanitary products, we now have more flexibility to vary our fiscal regime. If necessary, such a VAT exemption could apply to children’s dental products in much the same way as it does to children’s shoes. Children’s toothpaste and toothbrushes are distinct and different from those products used by adults. Such a strategy would embed good oral healthcare at an early age, and help to prevent the traumatic and expensive whole mouth replacements that hospitals increasingly have to carry out. Such a policy could form part of the new long-term plan for NHS dentistry that is so badly needed right across the country, and which I look forward to the Government rolling out at the earliest possible opportunity.

Health and Care Bill

Peter Aldous Excerpts

Consideration of Lords amendments
Monday 25th April 2022 Commons Chamber

[Daisy Cooper (St Albans) (LD)]

I will speak to the workforce amendment and the amendment on the social care cap.

The Lords have compromised on the workforce amendment—they have now asked for projections every three years instead of every two, and they no longer require independent verification of the projections—so it is deeply disappointing that the Government have not moved to meet them halfway, especially when outside the Government there is so much cross-party consensus that the amendment is badly needed. I know from my constituency of St Albans, as I am sure many Members know from theirs, that our NHS and care staff are burnt out. They are understaffed and overworked. Those people, who continue to turn up every single day, need to know that the cavalry is coming, and without this workforce amendment, they simply will not.

There have been worrying reports that NHS trusts have been silenced when they have tried to talk about the numbers of staff that they need to recruit, so will the Minister address this question in his response: if the Government will not produce workforce planning numbers, will they at least commit to not interfere with or silence any part of the NHS or care sector that decides that it wants to produce its own workforce projections? I look forward to hearing the Minister’s assurances on that point.

When it comes to the social care cap, Ministers have stated time and again that their changes would save the Treasury £900 million a year by 2027-28, but that saving comes at the expense of people with fewer assets and savings, including those who will have been paying five years of increased national insurance contributions, which were put in place partly to fund these care reforms. The Government continue to say that that improves on the current situation, but they conveniently ignore that it is much worse than their original proposal. The social care cap provision does nothing to generate more care; it does nothing to give protections to unpaid carers, who are often on lower incomes but save the Government millions of pounds; and it does nothing to help the social care workforce. I know from my constituency that hospitality, the NHS and social care are all fighting for the same people, and nothing in the Bill will help to improve that situation.

[Peter Aldous (Waveney) (Con)]

I am grateful to have a few minutes to say a few words on the cap on care costs and on workforce planning.

With regard to the care cap, it is important to congratulate the Government on tackling a problem—or attempting to defuse a ticking time bomb—that all their predecessors shied away from. However, there is concern that the proposals are a rushed tag-on to a Bill that was designed for a different purpose: the integration of health and social care and the setting up of integrated care systems. I accept that there is a clear correlation, but the legislation that addresses the problem of people being forced to sell their homes to pay for their care should have been considered and scrutinised separately and carefully, with the objective of putting in place a system that has political consensus and will stand the test of time. That is what the Dilnot proposals and the Care Act 2014 achieved, and they should be the foundation stone on which we build this new system.

My concerns are twofold. First, clause 140 is extremely unfair to those with limited assets and modest incomes. The changes may save the Government hundreds of millions of pounds, but they do so at the expense of those on low incomes and those who live in parts of the country where house values are lower, such as Lowestoft in my constituency. Secondly, there is a worry that working-age adults with disabilities will be unfairly penalised, hence the introduction by the other place of a provision to address it. I acknowledge the Government’s worries about the cost implication of that additional provision, but that iniquity needs to be addressed.

On workforce planning, there is a staffing crisis both in the NHS, where there are 110,000 full-time equivalent vacancies, and in social care, where there are another 100,000 vacancies, high staff turnover and very limited respite for unpaid and family carers. Those deficiencies cascade through the health and care system, creating bed-blocking in hospitals and impeding the efforts made to reduce waiting lists. There is an urgent need for strategic planning to address this crisis. There is concern that framework 15 is not working because of inadequacies in the collection of data, lack of assessment of workforce numbers, and unresponsiveness to societal shifts.

Since we last considered the issue last month, the other place has sought to address the Government’s concerns and, as we have heard, has made reasonable concessions. There is a crisis that must be addressed, and I hope that at this very late stage the Government will accept this reasonable amendment, so that we can get on with this much-needed work.

[Margaret Greenwood (Wirral West) (Lab)]

Amendment 29B goes much further than the Bill’s current provisions on workforce reporting, which are extremely weak. It would require the Government, at least once every three years, to lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of health, social care, and public health services in England. What could be more reasonable? One has to wonder why the Government do not support amendment 29B. Surely any Government who were committed to running the NHS as a public service would see these provisions as crucial.

The Royal College of Physicians has pointed out that clause 35

“will not set out how many health and social care staff are needed to meet demand”

and has stated that, without long-term projections, which amendment 29B would provide, there is no way to assess how changes in workforce trends, such as retirements or working part time, will impact the delivery of healthcare. The Royal College of General Practitioners has spoken of unsustainable pressures driving GPs out of the workforce and threatening to destabilise general practice.

Just a few weeks ago, the Royal College of Nursing said that nursing staff are exhausted and that staff shortages are undermining their efforts to give safe and effective care—a sentiment reflected by a nurse I met on bank holiday Monday. That is hugely concerning. As the RCN has said, there is a clear evidence base showing that staffing levels have a direct impact on the safety and quality of patient care. When I met members of the RCN last year, they made clear to me the increased stress levels that nurses are experiencing as a result of staff shortages and the impact that is having on the care they so desperately want to deliver.

According to the Health Foundation:

“In the next 25 years, the number of people older than 85 will double to 2.6 million”

in England, so demand for social care is increasing and we need to know that there will be enough doctors, nurses and social care workers to meet people’s needs. The “Strength in Numbers” campaign, a coalition of more than 100 health and care organisations, says that we must put

“measures to adopt a sustainable long-term approach to workforce planning on a statutory footing.”

Without credible, up-to-date numbers, the system cannot plan.

I support Lords amendment 29B. I urge the Government to think about those NHS staff who are working so hard and are so stretched by the amount of stress they are under because they do not have enough colleagues around them, and to listen to the clinicians who are calling on the Government in this regard.

Health and Care Bill

Peter Aldous Excerpts

Consideration of Lords amendments
Wednesday 30th March 2022 Commons Chamber

[Edward Argar]

It is a pleasure in discussing this set of amendments to be facing the shadow Secretary of State, the hon. Member for Ilford North (Wes Streeting), although I might not say that after he has made his contribution or challenged me. I am grateful for the opportunity to speak to this important set of amendments, and I again put on record my gratitude to their lordships for the work they have done in scrutinising this Bill. This group is about accountability and makes it clearer that the Government are committed to ensuring that the NHS is transparent, accountable and effective.

Lords amendments 42 to 47 ensure that the procurement regulations will have to include provision for procurement processes and objectives; for steps to be taken when competitively tendering; and for transparency, fairness, the verification of compliance and the management of conflicts of interest. They also require NHS England to issue guidance on the regulations. It behoves me to pay tribute to the shadow Minister, the hon. Member for Bristol South (Karin Smyth), who served on the Bill Committee throughout. Although we did not always agree, she brought her expertise and forensic skills with issues such as this to that Committee. Even if she did not always agree with the conclusions, she made sure we were well informed in the conclusions we reached.

We recognise those key aspects as vital. While it was always our intention to include them in the new provider selection regime, the amendments add clarity and clearly signal our intentions. Furthermore, Lords amendment 47 makes the regulations subject to the affirmative procedure. We are grateful for the input of the Delegated Powers and Regulatory Reform Committee in advising that, and we have listened.

Lords amendment 55, supported by the Scottish Government, makes it clear that any powers or duties conferred on Scottish Ministers in relation to their role in collecting information for medicine information systems can be treated in the same way as other NHS powers or duties in Scotland and be delegated to health boards in Scotland.

Lords amendments 56 and 58 to 64 relate to the power to transfer the functions of arm’s length bodies. Following constructive engagement with the devolved Governments, these amendments enable us to proceed on a UK-wide basis. Lords amendment 56 clarifies that the powers in part 3 of the Bill in respect of special health authorities apply in relation only to England and cross-border special health authorities, and not Wales-only special health authorities. Lords amendments 58 and 59 remove devolved Ministers and Welsh NHS trusts from the list of appropriate persons to whom property, rights and liabilities can be transferred through a transfer scheme following a transfer of functions.

Lords amendment 60 creates a requirement for the Government to obtain the consent of the devolved Governments for any transfer of functions within the competence of their legislatures or which modify functions exercised by the Welsh Ministers, Scottish Ministers or a Northern Ireland Department. Finally, Lords amendments 61 to 64 are consequential upon the changes made by Lords amendment 60.

I am also asking the House to disagree with several amendments made in the other place. First, Lords amendment 29 relates to the workforce, and I reassure the House that the Government are committed to improving workforce planning. We recognise the importance of having a properly trained workforce in sufficient numbers and in the right places. We are already taking the steps we need to ensure we have record numbers of staff working in the NHS. While we recognise the strength of feeling behind the amendment, we simply do not think it is necessary in its current form, and we urge the House to reject it.

[Peter Aldous (Waveney) (Con)]

I am aware that the Government have put in place their own plans for NHS workforce planning, but can my hon. Friend address the concerns that framework 15 has inadequacies in terms of data collection, does not provide an assessment of workforce numbers and is not responsive to societal shifts?

--- Later in debate ---

[Edward Argar]

I hope that I can give the hon. Lady reassurance. When we refer to “carers”, we intend that to be a broad term, rather than a narrowly drawn one. She is absolutely right to highlight young carers; they are carers. They also face particular challenges, because they often juggle school and similar things with caring. It is our intention that all carers will be covered by this duty on trusts and foundation trusts to involve carers during adult discharge planning. That would apply to all adults who are being discharged, where a carer is involved. I hope that that gives the hon. Lady some reassurance. We would look to ensure that these points were suitably emphasised in guidance and in the advice we give to ICBs and ICSs. As she will know, the Department works with NHS trusts and NHS England, and has various mechanisms for guiding and informing trusts. I recognise the importance of the issue.

We ask that this House rejects Lords amendment 80, and that it reintroduces the clause that the Government originally inserted on Report in this House, alongside further amendments to support the operation of charging reform that were originally tabled in the other place. The Government have set out their plan for a sustainable social care system. We want to end unpredictable care costs for everyone by introducing a universal £86,000 cap on an individual’s personal care costs. I pay tribute to the Minister for Care and Mental Health, who, since taking up her post last September, has made driving this agenda forward a personal priority. I should also pay tribute to her predecessor, my hon. Friend the Member for Faversham and Mid Kent (Helen Whately), for her work in this area.

We entirely recognise and respect that there are strong views on this issue across the House, and it is vital that our approach is fair. The Government believe that the fairest version of the cap would be based on what people contribute towards their care, rather than our counting local authority contributions as well. It simply cannot be fair that two people living in different parts of the country, contributing the same amount, progress towards the cap at different rates because of the differences in the amount that their local authority is paying.

[Peter Aldous]

The Government’s plans are regressive when compared with the proposals under the 2014 Act. They are less equitable to those with moderate assets, including those living with dementia and working-age adults with disabilities. It would be fairer to keep to the original Dilnot proposals, but can the Minister outline how the £900 million saving that, it is estimated, will result from the Government’s proposals and the use of means-testing will better protect those with lower-value properties?

[Edward Argar]

I am grateful to my hon. Friend, who has been open and consistent in expressing his concerns about this issue. He cites the 2014 Act, but it is important to note that those proposals were never implemented and were not deemed to be financially sustainable or deliverable. There were other proposals, including in 2015, but although no proposal is perfect, the proposals before us are a dramatic improvement, in terms of the protections offered and the crippling care costs that many face under the existing regime. This is an important step forward. Let me make a little more progress, after which I may touch on some of my hon. Friend’s other comments.

Access to NHS Dentistry

Peter Aldous Excerpts

Thursday 10th February 2022 Westminster Hall

[Clive Efford (in the Chair)]

Before we begin, I remind Members to observe social distancing and to wear masks. There is clearly a lot of interest in the debate. We will work out roughly how long people have to speak, but I do not intend to impose a strict time limit, unless people abuse the timings. We will give you an indication of how long to speak for, and if you could roughly stick to it that would be really helpful. I call Peter Aldous to move the motion.

[Peter Aldous (Waveney) (Con)]

I beg to move,

That this House has considered access to NHS dentistry.

It is a pleasure to serve under your chairmanship, Mr Efford. I thank the Backbench Business Committee for granting this debate. I am grateful to the hon. Member for Bradford South (Judith Cummins) for her work in helping to secure it.

NHS dentistry has been the No. 1 issue in my inbox for the past nine to 10 months. This is a national crisis, though the problem in my constituency—in Lowestoft and Waveney—is acute. Dentists have retired, which has led to resources and dental capacity being taken away from the area, notwithstanding the increased need and demand following the pandemic. Many of the remaining practices are experiencing difficulties in recruiting and retaining dentists, and the situation has been exacerbated by a lack of funding, with net Government spending on general dental practice being reduced by a third over the past decade. That said, the overall situation locally has improved since I first raised concerns in an Adjournment debate on 25 May last year, and I will outline the improvements later. They are welcome, but I am concerned that they might be a short-term sticking plaster and might not provide a long-term solution.

As we emerge from covid, the situation both locally and nationally has reached crisis point. Locally, that is due to covid, as well as retirements in two NHS dental practices in Lowestoft and the closure of the mydentist practice in Leiston, in the constituency of my right hon. Friend the Member for Suffolk Coastal (Dr Coffey). That practice closed due to the difficulty of recruiting dentists to work in the NHS in the area—a theme that is repeated across the country.

Access to NHS dentistry is a problem that has been brewing for a long time. The situation can be likened to a house built on shallow and poor foundations. The earthquake of covid has led to that house falling down. There are now parts of the country—particularly in, though not confined to, rural and coastal areas—that are dental deserts.

[Mr Khalid Mahmood (Birmingham, Perry Barr) (Lab)]

I thank the hon. Gentleman for securing this important debate. On that point, my constituents in the city of Birmingham have hugely suffered through the covid. People like myself, who suffer from diabetes, have had huge issues with dental treatment. I hope that we can move forward and return to treating people in the best way possible.

[Peter Aldous]

While there are particular problems in rural, coastal and more peripheral locations, which it is difficult to get dentists to move to, it is clear from looking around the Chamber today that the problem is not confined to such areas and is an issue in metropolitan areas as well. Sir Robert Francis, chair of Healthwatch England, has commented:

“Every part of the country is facing a dental care crisis, with NHS dentistry at risk of vanishing into the void.”

I believe there are five issues that need to be tackled to address the problem. First, a secure, long-term funding stream must be provided. Secondly, we need to step up the recruitment and retention of dental professionals. Thirdly, it is vital that work on the new NHS dental contract, which has been being developed for more than a decade, is completed as soon as practically possible. Fourthly, it is important to highlight the role that water fluoridation can play. Finally, there is a need for greater accountability and for dentistry to have a voice in the emerging integrated care boards and partnerships.

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

I congratulate my hon. Friend on securing this important debate. Another point that needs developing is that in Helmsley, in my constituency, the commissioners have still not recommissioned services after 20 months. The commissioning of dental services by the NHS is simply too slow and too bureaucratic. It is a real deterrent for new dentists to take these contracts.

[Peter Aldous]

I thank my hon. Friend for that intervention, and he is right. There has been a recent procurement process in East Anglia, but it has been only half successful. There are places that have not been able to get dentists to fill those voids.

Figures published in March 2020, before the pandemic, show that 25% of patients new to practices in England could not get an appointment. The situation has got worse: the most recent figures, from 2021, show that that number has increased to 44%; in my area, it is 56%. Dentistry was locked down from March to June 2020 and the ongoing restrictions on dentists—fallow time between appointments—are still limiting the ability to see more patients.

The latest figures on workforce, published in August 2021, show that 951 fewer dentists performed NHS dental activity than 12 months earlier, with 174 of those losses in the east of England. Those figures confirm that parts of England are becoming dental deserts; beyond Suffolk and Norfolk, that includes the east Yorkshire coastline, Cornwall, Portsmouth and the Isle of Wight.

The lack of access to NHS dentistry has a fivefold impact on patients. First, millions are missing appointments. Secondly, there has been a significant increase in DIY tooth extraction. Thirdly, the poor are hit hardest. Fourthly, mouth cancers are going undiagnosed. Finally, children are suffering. This very serious situation has been confirmed by the “Great British Oral Health Report” carried out by mydentist.

I apologise for going on at length, Mr Efford, but it is important to emphasis the crisis we are facing. I will now briefly outline some of the solutions. The first issue that must be tackled is getting more dentists and dental practitioners working in the NHS. The Association of Dental Groups has put forward its “six to fix” proposals for solving the workforce crisis, which I will summarise. First, we need to increase the number of training places in the UK. That is a long-term measure. Secondly, in the short term, the Government should continue to recognise EU-trained dentists. Thirdly, there needs to be a recognition of other overseas qualifications. We have an opportunity to make more of our links with Commonwealth countries such as India, which has a surplus of highly skilled English-speaking trained dentists.

Fourthly, the process for overseas dentists to complete the performers list validation by experience—or PLVE—so that they can practise in the NHS must be simplified and sped up. Fifthly, whole teams in dental practices should be allowed to initiate treatments. The largest barrier to better use of the skills mix under the current NHS contractual arrangements is that allied dental professionals are unable to open a course of treatment, which means they cannot raise a claim for payment for work delivered.

Finally, the Government must create a new strategy for NHS workforce retention. The current contract through which NHS dentistry is provided was introduced in 2006 and for some time it has been widely recognised as not being fit for purpose. It is a major driver of dentists leaving NHS dentistry. Reforming the NHS contract is needed to deliver better access and preventive care so as to improve the nation’s oral health. Flexible commissioning, aimed at increasing access to vulnerable groups such as those in care homes should be an important part of the reform. The current dental contract is target-based, and it was accepted before the pandemic that it needed to be reformed. We must complete that reform as soon as possible. I would welcome an update from the Minister as to progress on that and when we might see a new contract.

It is important that NHS dentistry receives a sustainable long-term financial settlement and not a short-term fix. Additional funding is vital if long-term and sustainable improvements to NHS dentistry are to be secured. The pledge of £50 million on 25 January for a dentistry treatment blitz is welcome, and £5.73 million is available to the east of England. However, that is a time-limited one-off injection of funding that is available only until the end of March, and there is a concern that it will barely make a dent in the unprecedented backlogs that NHS dentistry now faces. The British Dental Association estimates that it would take £880 million per annum to restore dental budgets to 2010 levels.

Since my Adjournment debate on NHS dentistry in Waveney last May, there have been improvements to the local service, which it is important to acknowledge. A temporary contract was awarded to a Lowestoft-based NHS dentist to see additional patients, which has definitely helped prevent the situation from getting any worse. Tomorrow I shall be with Community Dental Services, which along with Leading Lives, a Suffolk-based not-for-profit social enterprise, is launching its toolkit to help improve the oral health of people with learning difficulties. It is also good news that from 1 July a contract has been awarded to Apps Smiles for the delivery of NHS dentistry in Lowestoft, but it is concerning that it was not possible to do that in nearby Leiston and across the border in Norfolk, in Fakenham and Thetford. It will be interesting to receive further details as to why that happened, but one can speculate dentists might not have been interested in those opportunities and might have been put off by the existing, unattractive contract.

I have concerns about the procurement process that go back a long time. I am concerned that it does not encourage traditional partnerships to put forward proposals. I urge the Minister to carry out a whole review of the procurement process.

A vital strand of NHS dentistry should be the prevention of oral health challenges—prevention rather treatment. Fluoridation of water supplies can play a vital role in that, so it is welcome that the Health and Care Bill allows for it. There is also a need for greater accountability.

[Mr Mahmood]

I apologise for intervening on the hon. Gentleman twice, but I just want to make the point that John Charlton, with Severn Trent Water, has worked on getting fluoridation in water for the past 30 years. We should pay tribute to him for the great work that he has done.

[Peter Aldous]

I am very grateful that the hon. Gentleman intervened on me, because Birmingham is the model of how to do this. As a Birmingham MP, it is right that he highlights that, and I thank him for it.

[Duncan Baker (North Norfolk) (Con)]

As I will set out in my speech, my father was an NHS dentist for 23 years. He trained a long time ago in Manchester, and he told me that the advent of sugary foods and drinks had had an enormously detrimental effect on children’s teeth over the years. The one thing we can do to solve that problem is fluoridation of our waterstream. It has made such a difference, and I thank the hon. Member for Birmingham, Perry Barr (Mr Mahmood) for raising that point.

[Peter Aldous]

I am grateful to my hon. Friend for re-emphasising that.

[Sir Paul Beresford (Mole Valley) (Con)]

Birmingham is an interesting case. Not all of Birmingham is fluoridated, so when a child arrives, dentists can tell which part of Birmingham they have come from. No cavities, no fillings—fluoridated. Fillings and cavities—non-fluoridated.

[Peter Aldous]

I thank my hon. Friend for re-emphasising that case.

[Giles Watling (Clacton) (Con)]

I thank my hon. Friend for being so generous in giving way so many times.

There is another point that ought to be mentioned here. As far as I am aware—I hope my hon. Friend can confirm this—no detrimental effects from fluoridation have yet been found anywhere, and we ought to scotch any rumours to the effect that they have.

--- Later in debate ---

[Clive Efford (in the Chair)]

Order. Before the hon. Gentleman responds, I should just point out that a number of Members who have their names down to speak are intervening. To respect others who want to speak, could you please refrain.

[Peter Aldous]

I am grateful because, with those four interventions, we have re-emphasised the importance of fluoridation.

There is a need for greater accountability, and the Health and Care Bill can provide the framework within which that can be secured. It is welcome that the commissioning of dentistry is set to move to integrated care systems. That can make for a more transparent system, but there is a risk that dentistry and its impact on overall health could be overlooked in the integrated care proposals. It is important that dentists are properly represented on integrated care system boards.

At Report stage of the Health and Care Bill, I tabled new clause 18, which called on the Secretary of State to publish an annual report on access to NHS dentistry, to collect data on the length of waiting times for primary dental care treatment and, if necessary, to take action. The Minister for Health declined to accept the new clause. I do not know whether a similar clause will be introduced in the other place. If it is, I would urge the Government to give it serious consideration. Such a reporting mechanism can drive sustainable and meaningful improvement in access to NHS dentistry.

Mr Efford, you will be delighted to learn that I am coming to a conclusion. Tackling access for NHS dentistry, which has been neglected for 15 years, is an opportunity that we must grasp in order to demonstrate the levelling up of healthcare right across the UK. We must put in place an NHS dentistry system that is fit for the 21st century, instead of reversing into the 19th century.

[Clive Efford (in the Chair)]

I am grateful to the hon. Member. It looks like we have six minutes each for Back-Bench speeches. If anyone can deliver their speech in less time, it would be very helpful.

--- Later in debate ---

[Peter Aldous]

It has been a very interesting debate, and we have heard some great ideas. It has largely been consensual, although I welcomed the little bit of sparring, because it added to proceedings. One thing I did not do was thank the dentistry heroes during the covid pandemic. They are the people who have really been on the frontline.

I enjoyed the interludes into Shakespeare from my hon. Friend the Member for North Devon (Selaine Saxby) and the hon. Member for Bootle (Peter Dowd). Ian Fleming was also quoted, and I could cornily reply by saying the whole debate should leave us very shaken and stirred.

Some interesting issues on funding have been raised. I take on board a lot of what was said by my hon. Friend the Member for North East Bedfordshire (Richard Fuller), who is no longer in his place, about creating innovative funding solutions. He is right to say that there is not endless money, but I feel that NHS dentistry has been the Cinderella service when it comes to funding. I sense that part of the problem is that it has been shunted off into the sidings of the NHS.

We heard three very useful points from my right hon. Friend the Member for Basingstoke (Mrs Miller), who basically said that the health of our teeth is inextricably linked to our health service. The hon. Member for York Central (Rachael Maskell) said that our mouths are not divorced from our bodies. My hon. Friend the Member for Mole Valley (Sir Paul Beresford), whose contribution was really significant, said that dentistry and the mouth need to go back into the body. I sense that if we do that, the funding issue will begin to be solved. The primary and secondary parts of the NHS, and the mental health side, will realise that we need to get dentistry right, because that will have a positive knock-on impact on the remainder of the service.

Prevention is vital. It was striking that I had four interventions on the importance of fluoridation, innovative working such as supervised toothbrushing, and getting into schools and care homes—that is so important as well.

We keep coming back to the need for contract reform. It was striking that we heard that it is not a question of dentists going out into the private sector, having been lured by large sums of money. It is a question of their being driven out by the soul-destroying system under the existing contract. It was helpful to hear the Minister say that there were some quick wins being put in place and that the negotiations start in earnest in April.

We do not want to just go away, pat ourselves on the back and say that we have had a great debate. We want meaningful progress. When I proposed my amendment to the Health and Care Bill, one of the things that I wanted was annual reporting, to see where we are. My hon. Friend the Member for Worthing West (Sir Peter Bottomley), the Father of the House, talked about coming back in six months’ time for a progress report, and I hope that the Government will agree to that. We can look at how we do that—perhaps through another Backbench Business Committee debate.

Ms Ali, you are looking at me. I have summed up as best I can. It has been a great debate, but let us not stop here.

Question put and agreed to.

Resolved,

That this House has considered access to NHS dentistry.

Health and Care Bill

Peter Aldous Excerpts

Report stage
Tuesday 23rd November 2021 Commons Chamber

[Edward Argar]

My hon. Friend has made his point. He has made it to me before. I will not forget either him or unavoidably small hospitals, particularly in the Isle of Wight.

On the point made by my hon. Friend the Member for Aberconwy, we do recognise the importance of making sure that health and care data can be shared safely and effectively across the UK to support individual care and improve outcomes for people across the UK.

[Peter Aldous (Waveney) (Con)]

Will my hon. Friend give way?

[Edward Argar]

I am afraid that I cannot give way, because I literally have two minutes. Forgive me, but if my hon. Friend catches me afterwards, I will happily speak to him.

We are already committed to working with officials across the devolved Administrations, noting the devolved nature of health and care policy, but my hon. Friend the Member for Aberconwy is right and makes a very powerful case for data interoperability and clear data standards. I am happy to speak with him further on this issue if he feels that that would be helpful.

I ask the hon. Member for Bootle (Peter Dowd) to forgive me for yesterday. I heard what he said about self-care and I will continue to look carefully at that. I did not ignore him.

I fear that, in the time that we have, there is little more that I can say.

[Peter Aldous]

Will my hon. Friend give way on that point?

[Edward Argar]

Okay, my hon. Friend has 10 seconds.

[Peter Aldous]

The No. 1 issue in my inbox is access to NHS dentistry. New clause 18 provides a framework for addressing that. May I urge the Minister and the Government to consider accepting it?

[Edward Argar]

While we cannot accept that new clause as drafted today, I or the Minister for Dentistry will meet my hon. Friend, if that is helpful, to discuss in more detail the concerns sitting behind his intervention.

Question put and agreed to.

New clause 62 accordingly read a Second time, and added to the Bill.

--- Later in debate ---

[Peter Aldous]

I am grateful to you for giving me time to speak, Madam Deputy Speaker. I would have liked to speak on new clause 18 on Report, but that was not possible.

Access to NHS dentistry is a problem that has been brewing for a long time and has been exacerbated by covid. There are now parts of the country, particularly in rural and coastal areas, that have dental deserts. It is invariably children from poorer backgrounds and vulnerable adults who suffer the most. The crisis is acute in Suffolk and Norfolk, but is not confined to East Anglia. Sir Robert Francis, who chairs Healthwatch England, commented:

“Every part of the country is facing a dental care crisis, with NHS dentistry at risk of vanishing into the void.”

There are five issues that need to be tackled to address the problem. The Bill can provide the framework to ensure that that happens without delay or prevarication. First, funding must be increased. Secondly, it is vital for the new NHS dental contract, which has been being developed for more than a decade, to be rolled out next April. There are rumours that it will be kicked into the long grass, and I should be grateful for confirmation that that will not happen. Thirdly, we need to step up the recruitment and retention of dental professionals. Fourthly, it is important to highlight the role that water fluoridation can play in improving the oral health of future generations, and in that context clauses 132 and 133 are to be welcomed. Finally, there is a need for greater accountability, and for dentistry to have a voice on integrated care boards and partnerships.

People are currently pulling out their own teeth, while children are having whole-mouth replacements and early signs of cancer are going undetected. We need to act now to put in place an NHS dentistry system that is fit for the 21st century, instead of reversing into the 19th. My hon. Friend the Minister has advised that the Government will not accept new clause 18, and I should therefore be grateful if, without delay, my right hon. Friend the Secretary of State could ensure that his Department comes up with a clear plan for addressing a crisis that is affecting people throughout the country.

GP Appointment Availability

Peter Aldous Excerpts

Tuesday 26th October 2021 Westminster Hall

[Peter Aldous (Waveney) (Con)]

It is a pleasure to serve with you in the Chair, Mr Robertson. I congratulate my hon. Friend the Member for Beaconsfield (Joy Morrissey) on securing this debate and on her graphic and very personal assessment of the current position.

Over the past two to three months, I have received a great deal of correspondence on this issue, with constituents very upset that they have not been able to secure face-to-face appointments with their GPs. Late last month, I had a virtual meeting with GPs practising across the Waveney area, who themselves are very upset at the abuse that they have been receiving—something that they and their staff should not have to put up with.

There is clearly a major problem, and, at a time when the pressures on the NHS are growing at an exponential rate, there is a need to work together to find a solution. In the Norfolk and Waveney clinical commissioning group area, notwithstanding the enormous demand for GP services, the position with regard to appointments is positive, although it is recognised that more needs to be done. In August 2019, there were 478,160 GP appointments, and this August that figure increased to 482,993. The proportion of patients being seen face to face is increasing. This August it was 69%, compared to 67% in July and 66% in June. More patients are being seen face to face in Norfolk and Waveney than in other parts of the country: the August figure of 69% compares with a national average of 58%.

That said, it is recognised that a lot of people are very distressed, and in many cases very worried, that they have not been able to see their GP. The pandemic has meant that there is now an enormous increase in demand for GP services, with people on growing waiting lists needing support, and with those who were unable to see their GP during the pandemic wanting an appointment in order to highlight something that is causing them a lot of worry and distress.

The increase in demand for GP services has been happening for some time, but there are severe capacity constraints on the number of patients who can be seen face to face. The current infection, prevention and control measures that are needed to keep patients and staff safe mean that in-person appointments take much longer. Social distancing means that, at practices with smaller waiting rooms, people have to wait in their cars and staff have to go and get them when it is time for their appointment. Additional cleaning arrangements are also required between patients. There is a need to improve and standardise the way that remote appointments are operated and to adopt a whole-team approach, as there are many cases where a patient does not always need to see their GP and can often be cared for better by a physio or pharmacist.

[Margaret Greenwood]

The hon. Member is making some very interesting points. Does he agree that it is important that the Government review the outcomes of patients who have been consulted remotely? I have heard harrowing stories from my constituents. One woman thought she had a very minor ailment—she did not get seen by a GP, and she ended up with life-changing surgery. She will never be the same again. It is important that there is a national review of what has happened to such patients, rather than assuming that everything is all right because a patient does not come back.

--- Later in debate ---

[Peter Aldous]

I am most grateful to the hon. Member for that intervention, and I agree wholeheartedly with her. The more evidence we have, the more we can get remote forms of working to operate much better.

I previously mentioned the abuse that GPs and their staff receive. I should emphasise that it comes from only a small number of patients, but it is nevertheless making general practice a less attractive, and often quite unpleasant, place to work. That risks making GPs and practice staff harder to recruit and causing existing staff to retire early, to choose to work elsewhere in the NHS or even to leave the health service altogether.

The Government’s plan for improving access for patients and supporting general practice is largely to be welcomed, but there needs to be an emphasis on collaboration and working right across the NHS, which is something that the integrated care systems will hopefully achieve. It is also vital for the Government to see through our manifesto pledge to increase the number of GPs and other primary care professionals. There will be an increased emphasis on information technology, and the necessary investment in that infrastructure must take place right across the country in a way that is easy to operate and, most importantly, straightforward for all patients to access.

Health and Care Bill

Peter Aldous Excerpts

2nd reading
Wednesday 14th July 2021 Commons Chamber

[Peter Aldous (Waveney) (Con)]

Generally, the Bill is to be welcomed as it seeks to promote collaboration and the integration of local health and care services. It aims to give local people, local clinicians and those running local NHS and care services more control over the way that health and care services are delivered. The King’s Fund highlighted that the Bill will remove “clunky” competition rules and make it simpler for health and care organisations to work together and deliver more joined-up care to more people. That said, it is important to recognise that the last 16 months have been very challenging and very exhausting for those working in health and care, and in many respects, the last thing that they now need is yet another NHS reorganisation. Groups such as the BMA have concerns and I urge the Government to look at those closely in Committee.

I wish briefly to highlight two issues. First, I urge the Government to retain the existing boundaries, with the Waveney area remaining in an ICS with Norfolk. To change the boundaries to make them coterminous with the two counties would be highly disruptive and an unnecessary distraction, and it would demotivate hard-working staff. It would place at risk the health integration that has taken place in the area in recent years. To achieve better collaboration with care services, it is better to build on the existing foundations rather than to dismantle them. In many respects, boundary wars have been going on behind closed doors for the past seven to eight months, though I am grateful to both the Secretary of State and the Minister for listening to my concerns in recent weeks. I urge them to retain the status quo.

Secondly, the health issue that has taken up most of my time in recent weeks is NHS dentistry—or rather the lack of it. Many of my constituents are in agony and local NHS dentists urgently need the funds to see more patients. We are gradually moving towards a short-term solution, but it has taken far too long. In the longer term there needs to be greater accountability; dentists need to have a voice on integrated care boards; dental budgets should be protected; and steps must be taken to tackle the staffing crisis.

In conclusion, the Bill provides a statutory footing to ways of working that are in many respects evolving naturally. However, there are potential pitfalls, particularly —from my perspective—the changing of ICS boundaries, which I urge the Minister to avoid at all costs.

NHS Integrated Care System Boundaries

Peter Aldous Excerpts

Tuesday 29th June 2021 Commons Chamber

[Sir Bernard Jenkin]

My hon. Friend anticipates what I might say later.

The foundation trust for the Ipswich and Colchester hospitals will have two different commissioners, or Suffolk will have to take over the commissioning role for Colchester Hospital, leaving north-east Essex GPs, mental health services and so on with a different commissioning authority from that of the local hospital. NHS England told the MPs:

“We still do not know how the funds will flow”.

We certainly will not have all the partners sitting around a single table. The constituency of my hon. Friend the Member for Waveney (Peter Aldous) will be reabsorbed into Suffolk, even though it is half of the wider Great Yarmouth and Waveney place.

[Peter Aldous (Waveney) (Con)]

My hon. Friend is making a very good point. The Waveney area of Suffolk has been in a health administrative area with neighbouring Great Yarmouth for a very long time, and with the rest of Norfolk for a reasonable time as well. Any change would be highly disruptive, a distraction and demotivating for hard-working staff. I have written three long letters to the Department of Health and Social Care and have had a meeting with the Minister for Health, my hon. Friend the Member for Charnwood (Edward Argar), but does my hon. Friend the Member for Harwich and North Essex share my concern that there is a perception among those working in health and care in the local area and East Anglia that changing the boundaries is a done deal? Can the Minister confirm in his response that that is not the case?

[Sir Bernard Jenkin]

I very much hope that my right hon. Friend the Minister will confirm the latter; I have been assured that it is not the former, which is why I thought it was worth having this debate. The problem that my hon. Friend the Member for Waveney has is that the local population will continue to have acute services commissioned and provided from Norfolk. The imposition of separate Norfolk and Suffolk ICSs would compromise place-level integration for that population.

The west Essex population, which may be close to your heart, Madam Deputy Speaker, has acute services commissioned and provided predominantly from Hertfordshire, London or Cambridgeshire, and very little from the rest of Essex. That means west Essex will become part of an Essex ICS when it does not even include many of the key partners responsible for delivery of acute services to that population, and of course there is to be a new hospital, which may well be outside the Essex border. The proposed county-based arrangements would fragment NHS commissioning for places in north-east Essex, Waveney and west Essex. There might be different commissioners for acute, community and primary care. These places can only fully realise the benefits of integration if they have the flexibility to align all NHS commissioning. Other parts of the country will be similarly affected.

The idea of coterminosity for the administrative convenience of county councils is, I am afraid, a bit like the tail wagging the dog. In 2018, across the UK as a whole, we spent £149 billion on the NHS, but only £22 billion on social care. How can it make sense to align NHS commissioning with social care boundaries? That is not integration with social care; it is disintegration of NHS commissioning, and why do it now, of all times? We would be destabilising our health and care infrastructure while we are not yet out of the pandemic, let alone free of the aftermath.

The focus needs to be on the recovery of services. Elective treatment waiting lists increased to 5.12 million in April—a record high. There are other options for Essex and Suffolk, and I dare say in other parts of the country as well, such as a two-county proposal, as many Essex and Suffolk MPs set out in our letter to the Secretary of State two weeks ago.

In conclusion—I want to give time for others to contribute—the new legislation could provide the opportunity for ICSs to build on their successes, but that will be impossible with the level of disruption that a change of boundaries would bring about. Conservatives should have learned the lesson that NHS reorganisations usually fail to deliver the benefits promised. That will be especially true if reforms are rushed through again, tearing up what has been so recently established. Boundaries are the contentious part of the reforms. It would be better to allow the current ICSs to implement the new legislation and then look at whether boundary changes are necessary, rather than trying to do both at the same time.

So often I have seen it happen: structural and organisational reform is imposed from above as a substitute for a full understanding of what is really going wrong and why. It is always hard to improve leadership and to promote the right attitudes and behaviours in large and complicated organisations, particularly the NHS, but the slowest way to achieve this is to have another structural organisation. Everyone stops thinking about the job they are doing and thinks only about what new job they are applying for. After the reorganisation everyone has to re-learn how their job works and to re-establish new relationships, but nobody has challenged the attitudes and behaviours, which are still holding the organisation back. So often the problems are about poor leadership, poor employee engagement and lack of stability, which yet more structural change just makes worse. I therefore urge my right hon. Friend to delay the decision concerning future ICS boundaries until after the pandemic, and to consult and explore alternative boundary proposals after the legislation has settled down.