Kettering General Hospital

Philip Dunne Excerpts

Thursday 29th June 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

Let me start by congratulating you, Madam Deputy Speaker, on the resumption of your rightful place in the Chamber. It is a delight to serve under you in what I think is the first Adjournment debate that you have chaired in the new Parliament. I am delighted that you are looking after our proceedings this evening.

Let me also join in the congratulations of all who have spoken in the debate—apart from his usual modest self—to my hon. Friend the Member for Kettering (Mr Hollobone), who has been so gracious in encouraging me to take a personal interest in the hospital in his constituency. He was forthright in inviting me to join him last year when we previously debated the hospital, and I was pleased to be able to take up his invitation. Invitations have been flowing around the Chamber once more this evening from his neighbours, who show a consistent and collegiate approach to managing health issues in their constituencies and Northamptonshire in general.

When I visited Kettering in April, I was delighted to see my hon. Friends the Members for Corby (Tom Pursglove) and for Wellingborough (Mr Bone) taking such a close interest in the primary acute facility serving their constituents. I feel that the area is well represented by its Members of Parliament, who take such an active interest in health.

One thing that disappointed me about the speech made by my hon. Friend the Member for Kettering was the fact that his detailed grasp of the issues confronting the hospital was almost as good as that of the officials who helped me to prepare my speech. I therefore may not tell him too much that he does not know already, but it is a tribute to his perspicacity that he has such a good grip.

My hon. Friend raised a number of detailed issues relating to Kettering general hospital, and I shall try to address as many of them as possible in the time that is available to me. He concluded his remarks by making it clear that his No. 1 priority was to see progress on securing funds for the development of an urgent care hub at the hospital. I am pleased to join him in welcoming the progress that has been made since our debate last October. In particular, the foundation trust has secured funds from the Department of Health, with agreement from NHS Improvement, to enable the production of an outline business case, which, in the NHS approval system, is a necessary precursor of any significant capital investment.

A mobilisation meeting was held only last week to discuss the preparation of the outline business case, which is a welcome development. The initial draft of the outline business case is expected to be shared with NHS Improvement in August. The current intention is for the trust board to approval a final outline business case by the end of the year, provided it is satisfied with the progress that has been made, before a formal submission is made to NHS Improvement. I hope that that gives my hon. Friend some idea of the pace of the process. I am talking about a period of months, but I am afraid that that is the nature of the world we are in. It must be ensured that all appropriate internal procedures are followed correctly in order to give the proposition the best prospect of success.

The business case is intended to create a long-term solution for the hospital: a 10 to 15-year proposition that will take into account the significant increase in house building envisaged in the local plans, and the accompanying population growth to which my hon. Friend referred. In the meantime, the trust has put in place as a temporary facility a modular unit—a Portakabin —which we visited a couple of months ago. The outline business case will include plans to replace it with a permanent structure in due course.

More immediately, I am delighted to join my hon. Friend in welcoming the solution to the current challenge, which was very evident to me when I visited, that faces staff and patients trying to gain access to the hospital. The challenge of finding somewhere to park for anyone arriving by car was such that I had to be plucked out of the queue waiting to get into the car park by the chief executive herself, who had come to find me. Otherwise I might have spent my entire allotted time for the visit trying to get into the car park. The good news, as my hon. Friend has identified, is that work begins next week on the construction of the second level of the car park. The additional tier will provide an extra 240 spaces. I am told that the work will be completed by mid-November, which sounds like pretty pacey progress. This will cost some £1.3 million over five years, and the funding has been found by the trust from its own resources, which is very welcome.

My hon. Friend made reference to various pressures affecting the hospital. NHS England is working closely with the two local clinical commissioning groups to ensure that local care homes, general practices and the ambulance service are supported to care for patients outside the hospital, when that is appropriate. That is designed to help to reduce pressure on the hospital, and it was referred to in the interventions from my hon. Friends the Members for Corby and for Wellingborough.

In the longer term, the draft Northamptonshire sustainability and transformation plan, which was published last December, proposes an early focus on improving the urgent care system to reduce the pressures on A&E. Part of that will include introducing more front-door clinical streaming at Kettering general, with plans to put in place a seven-day discharge capability to help patient flow through the hospital. However, I have heard the comments in this debate about the quality of the STP, particularly from my hon. Friend the Member for Wellingborough. The STPs are being assessed by the Department of Health, and we will be making some comments before the summer recess on their relative attributes. We will see where Northamptonshire comes out in the context of the others.

[Tom Pursglove]

As part of that work in the Department, will the Minister take away from this debate the significance of the Corby urgent care centre to our local health economy, particularly in the context of how it relieves the pressure on Kettering A&E? Will he also acknowledge that there are significant healthcare needs in the Corby community that that facility helps to address?

[Mr Dunne]

I was not going to allow my hon. Friend the Member for Corby to leave without passing comment on the Corby urgent care centre, so I shall do that now, as he raised the matter so specifically. As we have heard, the STP does not perhaps place as much emphasis on what is to happen outside the acute hospital setting as hon. Members would like, and I shall take that away.

One of the issues that we need to address is the urgent care centre in Corby. As I understand it, the current service expires at the end of September. A new contract will be let as a caretaker arrangement for the ensuing 12 months to ensure that the existing facility continues, thereby allowing time for the CCG to engage with the public about the future shape of urgent care services in Corby, which will help to inform the development of the STP plan for the long term. The intent is that public engagement will lead to a proposal for an enduring longer-term contract to be procured in the next calendar year—during 2018—which will take into account the additional population around Corby. As we have already heard, the population is extensive around Kettering, but that is not unique to that part of north Northamptonshire. I am reassured by the CCG that the temporary arrangement will continue to provide the highest standards of patient care and safety for Corby’s population. My hon. Friend should not be concerned; this is a short-term contract extension that is facilitating a much longer-term solution.

My hon. Friend the Member for Kettering referred to the better care fund and how services are being provided in the community beyond the acute setting. As he knows, the fund supports programmes not only at Kettering general, but at Northamptonshire general. The better care fund and what we are describing as the improved better care fund—a similar pot of funding for the current financial year—are being used to fund both non-elective admissions and discharge to support at Kettering general, which is aimed at relieving pressure on the hospital.

My hon. Friend mentioned the special measures regime, which was the immediate trigger for my visit in April, the time of the publication of the CQC report that rated the trust as inadequate. I was pleased that he welcomed the introduction of special measures, because they provide an opportunity for focus across the NHS on areas that have been rated as not performing as we would all like. The evidence thus far is that trusts that go into special measures get considerably more attention not only from NHS Improvement, but from right across the NHS and up to a ministerial level. Special measures have a significant impact on improving performance within a hospital. I see that as a positive step, and I was pleased that he welcomed it. NHS Improvement has agreed an initial package of support. It has allocated an improvement director who will be working with the trust from next month. NHSI is also setting up “buddy trust” arrangements with highly rated trusts.

Kent & Canterbury Hospital

Philip Dunne Excerpts

Thursday 22nd June 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

It is a pleasure to serve under your chairmanship as Deputy Speaker, Sir David. I hope that that will not necessarily be as temporary as suggested by Mr Speaker when he sought the leave of the House to appoint you. It is also a pleasure to respond to my hon. Friend the Member for Faversham and Mid Kent (Helen Whately), who has been on her toes in securing Mr Speaker’s consent to have this debate so early in the parliamentary Session. I am pleased that she has secured the support of many of her constituents, some of whom have come to witness her championing their interests in relation to Kent & Canterbury hospital. She has done that not just this evening, but consistently over the past few months with our mutual friend Sir Julian Brazier, who is sadly no longer with us in the House. However, I congratulate his replacement, the new hon. Member for Canterbury (Rosie Duffield).

I worked closely with Sir Julian when we were Ministers in the Ministry of Defence, and both he and my hon. Friend the Member for Faversham and Mid Kent have been doughty champions of the population of mid- Kent, particularly those in the areas surrounding Canterbury, in fighting for healthcare services given the challenges that she quite properly describes at Canterbury hospital. I pay tribute to them for that, and they are doing the right thing in ensuring that such issues are brought to Ministers’ attention. I know that she wrote to the Secretary of State only last week, and I am pleased to hear her arguments, which were so eloquently put today. I will say what I can in response to the questions and challenges that she posed, but I must say at the outset that I do not stand here tonight with all the answers to all the questions because, as she will appreciate, many of the things that she is calling for are decisions that will be taken and led by clinicians in Kent. It is not for Ministers to prescribe the provision of services in Kent. Many such decisions will take place over a period of time; it will not be instant decision making.

I will start my response by providing a little context for what has happened over the past few years, and this week in particular. As my hon. Friend pointed out, the board of East Kent Hospitals University NHS Foundation Trust agreed to relocate some services from its Canterbury site, Kent & Canterbury Hospital, this Monday. The change happened overnight from Sunday into Monday and came in response to legitimate concerns raised by both the General Medical Council and Health Education England over a period stretching back to as early as 2014, when they raised concerns about the standard of training available at the Canterbury site, in particular the quality and safety of junior doctor training.

The situation was brought to a head following a visit in March this year. The recruitment and retention of key medical staff has been an ongoing challenge for the trust, and there is a shortage of consultants to provide the required training and supervision of junior doctors posted to Kent & Canterbury hospital. On Sunday 18 June, 38 junior doctors were reallocated from Kent & Canterbury to other sites operated by the trust. The removal of these junior doctors has required the trust to relocate some of the services it provides, to ensure safe and sustainably staffed services for patients.

My hon. Friend’s constituents will still receive good service provision. The clinical commissioning group has facilitated this development by acquiring some 40 additional care packages to support effective discharge from the Ashford and Margate sites, to free up some 75 beds to allow for this temporary service change to take place, along with an additional 20 ambulances, supplied through SECAmb—the South East Coast Ambulance Service NHS Foundation Trust—to cover the additional journey times from the Canterbury area. Replacement services at nearby hospitals in Ashford and Margate are being monitored to ensure that they are safe and effective, given the additional pressure on those hospitals from the move.

Unfortunately, I cannot say today how long this temporary closure will last. The GMC has made it clear that

“if there is evidence that appropriate and sustainable action has been taken to make the Urgent Care Centre a safe environment for doctors in training once more, HEE will review reallocating trainees to the site”.

No decision has been made about the long-term future of the service and no decision will be made without full public consultation. I can give my hon. Friend that reassurance.

[Helen Whately]

My hon. Friend mentions that there is monitoring of the provision of care for the services that have been moved to William Harvey and Queen Elizabeth the Queen Mother hospitals. May I ask him to take a personal interest in that monitoring? I have heard reports from staff who are really worried about how care is being provided following the transfer of the services. They are very concerned that patients might be at risk.

--- Later in debate ---

[Mr Dunne]

One of my ministerial responsibilities is to support the Secretary of State in having an oversight of trusts that are in special measures. The East Kent trust has been in special measures and is currently in financial special measures, so I take a close interest in what is happening in that trust. In view of my hon. Friend’s request and the events that have happened this week, I assure her that I will take a particular interest to ensure that the existing facilities at Ashford and Margate are up to scratch to cope with the increased demand they will undoubtedly have to manage.

I want to make it clear to the House and to the representatives on both sides who look after constituents in Kent that this issue is about maintaining the supervision of junior medical staff and ensuring that we have safe staffing levels for patients from central Kent; it is not about clinical practice or the competence of the hard-working staff in the hospital. I have been assured that before taking this decision every effort was made to identify appropriate senior staff cover from neighbouring trusts. The challenge has been to ensure that an adequate number of consultants were on duty at Kent & Canterbury hospital to allow junior doctors to have senior colleagues to refer to in the event of issues they felt uncomfortable dealing with. The problem that the trust has had is that it has been over-reliant on locum consultant cover in the hospital and there has been an inability to recruit to substantive posts in the hospital over a prolonged period, which has given rise to this concern on the part of HEE and the GMC that the training conditions for junior doctors were not adequate. That is what has led to this decision, rather than any criticism of the individual doctors or other staff members in the hospital.

I am also assured that the concerns of both HEE and the GMC are being addressed as quickly as possible. That will form part of any public consultation that follows from the development of the STP that is being worked up for the area.

I will not go into any great detail about the specifics of what has happened over the last few days as my hon. Friend the Member for Faversham and Mid Kent has already done so, but our expectation is that this temporary relocation is likely to affect approximately 50 of the 900 patients who visit Kent & Canterbury hospital each and every day. It is important to recognise that there has not been a full A&E unit at Kent & Canterbury hospital since 2005, when services at the trust were reconfigured, and it was established as an emergency care centre. Trauma and general surgical emergency cases had already been sent to sites in Margate and Ashford for some time prior to the recent temporary changes, and I believe it was in 2016 that the emergency care centre itself was turned into an urgent care centre, which again had an impact on services at that time.

I am advised that local NHS leaders have fully explored the risks of temporarily relocating services and have put in place mitigating action and contingency plans when required. The decision has been an exercise in the balance of risk: it is clearly not desirable, and nor is it either common or unique, for the regulators to take action such as this when they have concerns about both patient and staff safety, and it is not a decision taken lightly or comfortably, but the trust has come to the view that the risk to patient safety outweighed maintaining the status quo and seeking to continue with, frankly, unsustainable levels of senior support.

My hon. Friend rightly raised concerns that this might presage a future closure of the site, and I want to try to reassure her: the trust board has been left in no doubt whatsoever that it should not regard this as a step on the road to a permanent solution and that it needs to consider the requirements of the population of mid-Kent in the round when looking at the provision for the future to be undertaken through the STP. The hon. Lady raised a perfectly reasonable concern that the STP horizon of five years is not long enough. If the STP were to consider a more wide-ranging reconfiguration, that absolutely would have to look at the long-term horizon for healthcare provision in the area and not just at meeting the immediate objectives of the next five years.

[Charlie Elphicke]

I thank the Minister for making this important speech, but may I gently press him on the issue of a new hospital? Is there not a cost-benefit analysis between the efficiency savings to be had from a new, state-of-the-art hospital, which can operate much more efficiently and do much more with much better use of resources, versus the cost in capital? How would the Minister and his Department strike that balance, and can they carry forward a feasibility study to look at the very interesting case being put by my hon. Friend the Member for Faversham and Mid Kent (Helen Whately)?

[Mr Dunne]

I was going to come on to the suggestion of my hon. Friend the Member for Faversham and Mid Kent about both allocation of capital and the possibility of a new hospital. I was starting to develop the point that this matter needs to be assessed in the light of the overall requirements of the healthcare economy of mid-Kent and the East Kent trust through the STP process. Capital is currently constrained throughout the NHS. As hon. Members will know, in the March Budget we announced a capital allocation of some £325 million over the next three years to support the first phase of STPs. Fairly shortly, we should have made sufficient progress in deciding which of the STP proposals should be supported to secure that capital. Other capital pots are available to the NHS for what we refer to as business as usual, and there are always opportunities for trusts to make capital proposals to the NHS.

Right now, it is not appropriate for me to explain the basis on which future capital allocation decisions will be made. One can look to the recent past to identify some significant new hospital builds that are now in progress. There is currently a significant capital investment not far around the coast from Kent, in Brighton, and there is another closer to my constituency, in Sandwell in Birmingham. Such builds are few and far between, and bearing in mind the kind of major capital investment we are talking about, I think both my hon. Friends from different parts of Kent are arguing for space to undertake a study to consider whether a major build is appropriate to meet the needs of the mid-Kent population.

Generally, as can be identified from the two significant builds that are currently under way, which have been allocated hundreds of millions of pounds of capital each, a certain density of population is required to be served. Such builds are therefore most likely to occur in major cities rather than in less densely populated areas. That said, it is not for me to make suggestions as to what would or would not be appropriate. I urge my hon. Friend the Member for Faversham and Mid Kent to discuss the matter, as I know she has already, with her STP leaders. If there is a desire among Kent MPs and the Kent community to consider whether in future a more holistic approach to satisfying healthcare needs should be taken in the county as a whole, perhaps my hon. Friend should work in conjunction with other hon. Members.

The right forums are the STPs, which are bringing together NHS providers and commissioners from throughout their regions to try to arrange provision to meet the future healthcare needs of their populations. Whether or not my hon. Friend is successful in persuading the STP that a new hospital in Canterbury is the right solution, that is a matter for her to take forward with the STP. Such an effort would carry more weight were it supported by other colleagues from the area.

[Helen Whately]

It needs to come from the top that, when a bid is put forward that makes the case for significant investment, capital will be forthcoming. That message is currently not coming through and it is deterring people from making that case. It needs to shift.

[Mr Dunne]

I am conscious that I am close to running out of time, and I want to address the other point my hon. Friend raised, but I will say that capital is allocated by the Department of Health on the basis of the strength of the proposals, which need to meet the criteria on meeting the needs of local populations. That has to be balanced against the amount of capital that is available throughout the country, where there are competing needs.

My hon. Friend also raised the idea of a medical school, which she has discussed with me previously. She is aware of the consultation the Department ran on allocating new medical school places. That consultation has completed and we are considering our response. I am grateful to her for her submission. We wish to encourage some development of new medical schools, but again, that is subject to regulatory approval by the General Medical Council and other bodies. Any universities that wish to establish a new school need to meet the regulators’ criteria. I encourage my hon. Friend to see what progress is being made in that direction.

In conclusion, I again congratulate my hon. Friend on securing this debate and reassure her that I will be taking a close interest in how events unfold in the East Kent trust. I expect we will have an opportunity to discuss this matter again before too long.

Question put and agreed to.

Health Service Medical Supplies (Costs) Bill

Philip Dunne Excerpts

Tuesday 25th April 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

I beg to move, That this House disagrees with Lords amendment 3B.

[Madam Deputy Speaker (Mrs Eleanor Laing)]

With this it will be convenient to discuss Government amendments (a) and (b) in lieu.

[Mr Dunne]

When we last debated the Bill, I reminded the House of its importance. I do not intend to go over all that ground again, save to note the three primary purposes of the Bill: first, to give powers to align broadly our statutory scheme for the control of prices of branded medicines with our voluntary scheme, by introducing the possibility of a payment percentage for the statutory scheme, which could deliver £90 million of funding for the NHS every year; secondly, to give us stronger powers to set prices of unbranded generic medicines where companies charge unjustifiably high prices in the absence of competition; and, thirdly, to give us stronger powers to require companies in the supply chain for medicines, medical supplies and other related products to provide us with information. We intend to use that information to operate our pricing schemes, to reimburse community pharmacies for the products they dispense and to assure ourselves that the supply chain or specific products provide good value for money for the NHS and the taxpayer.

We agreed with 23 amendments made by their lordships during the passage of the Bill through the other place. Those, we accept, have made this a better Bill. We rejected just a single amendment. Despite the strength of our arguments, the other place has now made amendment 3B, which to all intents and purposes has the same effect as the original Lords amendment 3. It would introduce a duty on the Government, in exercising their functions to control costs, to take into account the need to promote and support a growing life sciences sector and to ensure that patients have access to new medicines. As I explained previously to this House, the amendment, which is no different in its effect from previously, would undermine one of the core purposes of this Bill: to enable the Government to put effective cost controls in place.

In our view, the amendment could encourage companies to bring legal challenges where the cost controls have not in themselves promoted growth in the life sciences industry. That could significantly hinder the Government’s ability to exercise their powers effectively to control costs. That would have a particularly detrimental effect if the Government were to take action to control the price of an unbranded generic medicine where it was clear that the company was exploiting the NHS—a point on which there was cross-party agreement when we debated the matter. That is because the Government might be challenged, not on the basis that the action was inappropriate, but on the basis that it did not promote the life sciences sector. Nevertheless, as I am sure all Members would agree, such action could be the right thing to do for the NHS, patients and taxpayers. The powers in the Bill that enable such action have received universal, cross-party support in both Houses.

Through debate on the issue in the other place, we have clarified that their lordships did not intend to undermine the core purposes of the Bill. Rather, the intent was to ensure a mechanism, laid out on the face of the Bill, to ensure that the Government pause to reflect on the impact of any proposed price control scheme on the life sciences industry and access to cost-effective medicines. With this clarity, the Government are now proposing amendments in lieu of Lords amendment 3B that will achieve that intent without undermining the core purpose of the Bill.

Consultation requirements prior to the implementation of any new statutory price control scheme for medicines are already set out in section 263 of the National Health Service Act 2006. Our amendment (b) in lieu would amend the 2006 Act to include particular factors that must be consulted on before proceeding with a new statutory scheme. They are:

“(a) the economic consequences for the life sciences industry in the United Kingdom;

(b) the consequences for the economy of the United Kingdom;

(c) the consequences for patients to whom any health service medicines are to be supplied and for other health service patients.”

The requirements are framed in that way to allow us not only to consider the economic consequences for the life sciences industry and for patients who may benefit from new medicines, but to balance those factors against wider considerations. I am sure the whole House can agree that while a thriving life sciences industry and access to new medicines are highly desirable, they must not come at any cost. It is the Government’s responsibility to achieve the right balance, and, indeed, to be held to account for it.

--- Later in debate ---

[Mr Dunne]

I had not intended to make a significant response in the light of this debate, but other colleagues have taken advantage of this being their final appearance at the Dispatch Box or speaking for their party in this Parliament and I cannot resist the opportunity to join the club.

I follow the hon. Member for Ellesmere Port and Neston (Justin Madders) in thanking Members for their work both in Committee and on the Floor of the House during the passage of this Bill. He gave us a valedictory, perhaps hinting that he may not be returning to this House, which in some respects I would welcome and in other respects I would regret because he has been a co-operative colleague on this Bill.

Again, I place on record my thanks to the hon. Member for Central Ayrshire (Dr Whitford) for her contribution to the passage of the Bill. I also briefly thank my Parliamentary Private Secretary, my hon. Friend the Member for Kingston and Surbiton (James Berry), who has been a stalwart supporter throughout the Bill. I also thank the departmental Whip, my hon. Friend the Member for Beverley and Holderness (Graham Stuart), who has also joined us today, for his efforts in this Parliament to help the work of the Department of Health, which is not always the smoothest ride for Government Whips.

The hon. Member for Ellesmere Port and Neston spoke about the budget impact test, and he challenged me to identify whether certain specific drugs will be caught by it, which is a nice try. The test applies for new drugs, of course, so drugs that are already licensed and on the list will not be caught because they are already licensed and in use. The intent, which came through in the consultation that concluded in January, is that this should not be seen as a threshold that will have a direct impact on the applicability of these drugs; it was designed to provide an opportunity for the NHS to have negotiating scope to try to get a better price on prospective drugs that will have a significant cost.

Although the hon. Member for Central Ayrshire is concerned about the delay resulting from the Bill and the delay from the potential loss of the EMA, we do not necessarily see it impacting in quite that way. We think it will have on impact on one in five new medicines that are brought forward for use in this country. As we have said repeatedly, we have a strong desire to see a vibrant life sciences industry in this country. There have been some significant investments by life sciences companies in this country since the referendum on 23 June, with this Bill in prospect, so we do not share the fears expressed today.

Finally, the hon. Member for Wolverhampton South West (Rob Marris) was here for the previous debate, but he served on the Health Service Medical Supplies (Costs) Public Bill Committee. He has had a distinguished career in this House and served on Finance Bill Committees with me ad nauseam. I was therefore pleased but somewhat trepidatious to see him put himself forward to serve on the Health Service Medical Supplies (Costs) Public Bill Committee. He lived up to all expectations, and I wish him well.

Lords amendment 3B disagreed to.

Government amendments (a) and (b) made in lieu of Lords amendment 3B.

Department of Health Arm’s Length Bodies

Philip Dunne Excerpts

Thursday 20th April 2017 Written Statements

[The Minister of State, Department of Health (Mr Philip Dunne)]

The Department of Health has completed its triennial reviews of the Human Fertilisation and Embryology Authority, the Human Tissue Authority and the Committee on Mutagenicity of Chemicals in Food, Consumer Products and the Environment and is today publishing the associated reports. A copy of each review report can be found online. Additionally, the review of the NHS Pay Review Body and the Review Body on Doctors’ and Dentists’ Remuneration will be subsumed within a cross-cutting review of the classification of the Department of Health’s advisory non-departmental public bodies.

Each review, which took place during 2015-16, consulted with a wide range of stakeholders and concluded that the organisations perform necessary functions effectively. The reports contain recommendations intended to support each organisation’s future performance, efficiency, and governance.

Attachments can be viewed online at: http://www. parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2017-04-20/HCWS599/.

[HCWS599]

Rare Diseases Strategy

Philip Dunne Excerpts

Tuesday 28th March 2017 Westminster Hall

[The Minister of State, Department of Health (Mr Philip Dunne)]

Mr Pritchard, I am grateful for your generosity and guidance. You are chairing the debate admirably, as usual. I congratulate my hon. Friend the Member for Bath (Ben Howlett) and the other members of the all-party group on rare, genetic and undiagnosed conditions on securing the debate and on producing a timely and informative report. My hon. Friend rightly pointed out that the Under-Secretary of State for Public Health and Innovation would have been the Minister responding to the debate, but I am sure he will understand why she cannot be here: she was invited to accompany the Prime Minister elsewhere today. I regret, for him, that that proved an invitation hard to resist. It has, however, given me the opportunity to learn more about rare diseases and I am grateful to my hon. Friend for that. I hope to be able to address some of the comments that he and other hon. Members have made.

As has been acknowledged, the UK strategy for rare diseases was published in 2013 and set out a high-level framework that aimed to improve the lives of those affected by rare diseases. The Government remain committed to implementing the strategy by 2020 and are aware that the real test of success will be tangible improvements experienced by patients with rare diseases and their families. Last month’s publication of the all-party group report is a timely reminder that there is still much to do, as has been mentioned by all speakers today. However, it is important not to forget just how much we have achieved.

NHS England has been actively working to raise the priority given to rare diseases. In particular, advances in genomics are already having a positive impact on patients with rare diseases. NHS England has embarked on a world-leading project to establish genomics in mainstream healthcare, establishing a network of 13 genomic medicine centres that will underpin the delivery of genetic medicine over the years to come. The Government have also made a clear commitment to developing genomics, and that is best demonstrated by the £500 million investment in the 100,000 Genomes Project, which is the biggest national sequencing project of its kind in the world.

The full potential for genomics can be realised only with continued research into rare diseases, and the National Institute for Health Research has established a Rare Diseases Translational Research Collaboration to make maximum use of its significant research infrastructure. I welcome the support given by the Opposition spokesperson, the hon. Member for Washington and Sunderland West (Mrs Hodgson), to that initiative. It is supported by a £20 million investment and has already recruited more than 15,000 patients to support 56 projects related to rare diseases.

I am pleased to say that the UK is a recognised leader on many rare diseases. We are an active member of the International Rare Diseases Research Consortium and have been actively involved in the establishment of 24 European reference networks—ERNs—for rare disease, six of which we are leading on. I was at an informal meeting of EU Ministers early last week, where our role in punching above our weight for the ERNs was widely acknowledged.

An important element of our plans will be to continue to look for ways in which the UK can work with international partners. The all-party group, along with hon. Members present in the debate and a number of external groups in the rare diseases community, have raised concerns about the perceived impact of the planned changes to the methods used by the National Institute for Health and Care Excellence for the evaluation of highly specialised technologies. That is one of a set of proposals being introduced by NHS England and NICE following the recommendation in last year’s Public Accounts Committee report on specialised services that the Department of Health and our arm’s length bodies should better consider affordability when making decisions, including on rare diseases. NICE and NHS England have consulted on the proposals, and I can assure hon. Members that they have listened carefully to the responses and made substantive changes.

The planned changes to NICE’s methods, as amended following the consultation, recognise the unique position of patients with very rare diseases and the need to pay a premium for their treatments. The changes introduce a clearer framework for the assessment of drugs for very rare diseases, which will better enable commercial discussions between NHS England and the pharmaceutical companies, in line with the recommendations of the accelerated access review. The consultation originally proposed the introduction of a threshold of £100,000 per quality-adjusted life year. In response to feedback, that single threshold has been replaced by a sliding scale, which means it will be possible for transformative treatments that offer significant health gains to be approved up to £300,000 per QALY. That is 10 times greater than NICE’s threshold for treatments considered by its mainstream technology appraisal process.

My hon. Friend the Member for Bath can speculate, but I gently say to him that it is not possible to predict how likely any individual new drug is to be recommended by NICE under the changes in the future, and we cannot retrospectively apply the new framework to past decisions. Furthermore, it is important to stress that even when NICE is not able to recommend a drug for the full patient population, NHS England may still be able to fund a drug for a subgroup of patients who will most benefit from treatment.

The hon. Member for Linlithgow and East Falkirk (Martyn Day) referred to the co-operation of Scotland, along with the other devolved nations, in collaborative work. We acknowledge and welcome that, and we acknowledge that Scotland has published an implementation plan. My hon. Friend the Member for Bath referred to four examples of drugs that NICE had approved for use for rare diseases in England, and they are available for use in Northern Ireland. The hon. Member for South Down (Ms Ritchie) asked about that. In particular, Translarna was approved for Duchenne muscular dystrophy, which she referenced. I gently say to the hon. Member for Linlithgow and East Falkirk that those four drugs are not yet available in Scotland—at least, not according to my briefing—other than one that is available for restricted use. Although we wish to continue co-operating with Scotland, the system in England has some advantages thus far.

I am confident that the planned changes create a framework that will enable truly transformational new drugs for patients with rare diseases to be made available where companies are willing to set prices that fairly reflect the added benefit they bring.

[Mr George Howarth (Knowsley) (Lab)]

I congratulate the hon. Member for Bath (Ben Howlett) on securing this debate. I welcome the progress that the Minister has described, but one thing that has been touched on in several speeches is the difficulty people have as a result of the nature of rare diseases. When they are trying to get a diagnosis in the first instance, medical practitioners often have no experience of the disease. As he develops his speech, or as the Department develops the policies and framework for delivering more services, will consideration be given to how that knowledge can be more widely spread?

[Mr Dunne]

The right hon. Gentleman anticipates something that I will come to shortly in my speech, but we acknowledge that challenge and we recognise that there will continue to be concerns among patient groups and Members. I hope that my hon. Friend the Member for Bath in particular will understand that the proposed changes are intended to put in place a fairer, more transparent framework for the evaluation of technologies for very rare diseases as they are developed.

I want to respond specifically to the challenge posed by my hon. Friend and the shadow Minister on the real need to ensure that the commitments set out in the UK rare disease strategy are fully realised. It is right that last week in the House, my hon. Friend the Under-Secretary of State for Public Health and Innovation made a personal commitment to that effect in her response to my hon. Friend’s oral question, and I am happy to reiterate that commitment today. I can confirm to the House that I have agreed with the chief executive of NHS England that by the end of this year he will deliver an implementation plan for those of the 51 commitments of the UK strategy for rare diseases for which NHS England has lead responsibility. For those commitments that fall outside NHS England’s remit, the Department will work collaboratively across stakeholders to contribute to the implementation plan. I am sure my hon. Friend will agree that the development of that plan will be a significant step in the journey.

[Ben Howlett]

indicated assent.

[Mr Dunne]

I welcome my hon. Friend’s acknowledgement of that. We are absolutely clear that we need to ensure that the proposals are used to drive real action and make tangible improvements for patients affected by rare diseases. It is not only about having a plan but about ensuring that the plan has effect for sufferers of these conditions. That is why we have recently reconfigured and strengthened the governance arrangements and formed a more streamlined UK rare disease policy board to monitor and co-ordinate progress in implementing the strategy.

In addition, we have strengthened the patient voice with the appointment of two patient representatives to the policy board. To make our work more transparent, a broad online stakeholder forum will operate in collaboration with the policy board to allow a more meaningful dialogue with the rare disease community. The rare disease policy board will be supported by clearly defined task and finish groups to examine progress objectively and to consider in particular the diagnostic odyssey that my hon. Friend referred to, which can be so frustrating for those who are still unable to determine their condition. That issue is a considerable worry for anyone affected by a rare disease, who will be familiar with the problem.

I will conclude slightly ahead of schedule by confirming that the lives of patients with rare diseases can be improved only by means of concerted and co-ordinated action. I take this opportunity to reaffirm the Government’s aims to drive real improvements in the care and treatment of those affected by rare diseases by working with stakeholders to deliver the standard of care and treatment that all patients deserve and to ensure that the implementation plan for England is delivered by the end of this year.

Oral Answers to Questions

Philip Dunne Excerpts

Tuesday 21st March 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

Many NHS bodies work with their international peers, and each makes its own assessment about the effectiveness of intended collaboration, rather than any determination being made at a national level. Trusts should only pursue opportunities that deliver value for money and do not impair their ability to deliver NHS services.

[Charlotte Leslie]

A team of clinicians at Southmead hospital in my constituency, led by Professor Tim Draycott, have developed and are now exporting internationally a system of maternity healthcare that is transforming maternity safety and childbirth. What is the Department doing to provide further support and ensure that the evidence base the team have developed is embedded and incorporated in policy making in this place?

[Mr Dunne]

My hon. Friend will be aware that the professor to whom she refers has presented his findings to the Secretary of State. Partly in response to that, we have set up an £8 million innovation fund to help to take such initiatives forward and to spread best practice throughout the country.

[Keith Vaz (Leicester East) (Lab)]

May I endorse what the hon. Member for Bristol North West (Charlotte Leslie) said? In the area of diabetes, for example, our country has some of the best clinicians in the world. Will the Minister ensure that the next time the Prime Minister goes on an official delegation she takes one of these professors with her to show the rest of the world what we are able to do for conditions such as diabetes?

[Mr Dunne]

The right hon. Gentleman is an acknowledged expert on diabetes. I have visited facilities around the world, including in Abu Dhabi, where Imperial College London has a joint venture with the diabetes centre there. The UK is an acknowledged expert, and we are launching the national diabetes prevention programme, which will roll out across 10 pilot sites for type 2 diabetes prevention work. I shall encourage the Prime Minister to consider the right hon. Gentleman’s proposal that we expand that work on other trade visits, certainly those for health, around the world.

[Paula Sherriff (Dewsbury) (Lab)]

5. What steps his Department is taking to reduce the number of mental health patients having to travel out of their local area for treatment.

--- Later in debate ---

[Sir Nicholas Soames (Mid Sussex) (Con)]

10. If his Department will take steps to introduce the enriched culture medium test for group B streptococcus for pregnant women; and if he will make a statement.

[The Minister of State, Department of Health (Mr Philip Dunne)]

My right hon. Friend will be aware that Public Health England published a paper in June 2015 precisely on this subject, but it concluded that within the currently accepted clinical guidelines there are no clinical indicators for testing women using enriched culture medium methods. This test is not, therefore, recommended for routine use at present.

[Sir Nicholas Soames]

My hon. Friend will be aware from his reading of the British Paediatric Surveillance Unit report that the incidence of group B strep has increased by 30% over the last 15 years. Does he agree that this matter has gone on for far too long, and that the Government must come to a conclusion to prevent further tragedies?

[Mr Dunne]

As my right hon. Friend will be aware, the UK National Screening Committee is reviewing the evidence for antenatal screening, including the use of enriched culture medium tests for group B streptococcus, following a public consultation. I understand that its recommendation will be published very soon, and I assure him that I will consider the recommendation very carefully and write to him with my view.

[Anna Turley (Redcar) (Lab/Co-op)]

11. What steps his Department is taking to ensure that NHS England’s “General Practice Forward View” has the funding necessary to achieve its goals.

--- Later in debate ---

[Dr Tania Mathias (Twickenham) (Con)]

12. Which hospitals providing congenital heart disease services do not meet the standard for the co-location of paediatric services; and what plans his Department has to stop providing congenital heart disease surgery at those hospitals.

[The Minister of State, Department of Health (Mr Philip Dunne)]

Standards for paediatric co-location for congenital heart disease services are not currently met by the Royal Brompton, Leicester and Newcastle hospitals. NHS England is consulting on proposals to cease commissioning level 1 surgical services from the Royal Brompton and Leicester. No final decisions have been made on the proposed changes. Public consultation continues until 5 June 2017, and I encourage my hon. Friend to participate in that consultation.

[Mr Speaker]

I doubt the hon. Lady will require any encouragement.

[Dr Mathias]

Mr Speaker, you are absolutely correct in your comment.

Does the Minister agree that the standards review found that not all clinicians are in agreement about how essential the co-location of paediatric services is, bearing in mind that a child being treated right now at the Royal Brompton will have 24-hour access to all necessary medical specialties? Will he tell us what improvements co-location at the world-class Royal Brompton hospital would achieve?

[Mr Dunne]

My hon. Friend has considerable expertise, but I am advised that having all relevant children’s specialties on the same site is the optimal model of care for the most critically ill children. It promotes closer, more integrated ways of working between specialist teams, and ensures rapid access to key services, such as paediatric surgery, at the most critical times when they are needed.

[Andy Slaughter (Hammersmith) (Lab)]

Mortality rates for the treatment of congenital heart disease fell from 14% in 1991 to 2% last year. The Royal Brompton, where the service is threatened with closure, does better even than this. What evidence is there that the closure programme will produce any further improvement, and if there is none, why is it being pursued?

[Mr Dunne]

The hon. Gentleman is right to point out that we have some world-leading patient outcomes for congenital heart disease, and I recognise the statistics that he read out. This is being driven entirely by seeking to improve patient outcomes across the country—improving them even on that very good performance—and to ensure greater resilience of service in some areas where there are relatively low volumes and an over-reliance on locums. I accept that that is not the case at the Royal Brompton, but it is in some of the others.

[Greg Mulholland (Leeds North West) (LD)]

The Leeds heart unit is performing very well, and is free from the threat that it was facing, unfairly, a few years ago. Will lessons be learned, however, from the disastrous Safe and Sustainable review process, which pitted hospital against hospital and clinician against clinician? Can we find a much better way—I hope the Minister will tell us that this is happening now—to reconfigure such services?

[Mr Dunne]

I recognise that when the proposal was put forward back in 2012, it led to a process that we felt was wrong, and we therefore stopped it. This process, we hope, is being conducted in a more rigorous and fairer way, and will lead to outcomes driven, as I say, by improving patient experience.

[Tim Loughton (East Worthing and Shoreham) (Con)]

13. What the estimated cost of private finance initiative liabilities to the NHS is in (a) 2016-17 and (b) the subsequent three financial years.

[The Minister of State, Department of Health (Mr Philip Dunne)]

Labour’s legacy cost from the 103 hospital PFI schemes entered into between 1997 and 2010 was a public sector liability of £77 billion. The estimated total NHS PFI payments for the financial year ending at the end of this month is £1.97 billion, and the totals for the next three financial years are £2.04 billion, £2.11 billion and £2.16 billion.

[Tim Loughton]

Those are alarming figures, so what are the Government doing to support the trusts affected by those expensive and inflexible PFI and other deals reached under the previous Labour Government? What assessment has the Minister made of what the funds could be buying in the NHS now if it was not saddled by this Labour debt legacy?

[Mr Dunne]

My hon. Friend is right to point out that the Opposition constantly complain about the cost of the PFI programmes that they themselves initiated. The Government are making large efforts to support trusts in dealing with the PFI legacy. We are giving the seven trusts worst affected by PFI schemes access to a £1.5 billion support fund over a 25-year period. In 2014 alone, trusts negotiated savings worth over £250 million on their contracts.

[John Pugh (Southport) (LD)]

21. On the subject of financial liabilities, what assessment has the Department made of the potential effect of changes to the discount rate on the amount of compensation paid out by the NHS Litigation Authority?

[Mr Dunne]

The Department is urgently undertaking work to understand what the impact on the NHS will be. There have been regular meetings with the NHS Litigation Authority since the announcement. The Government will adjust the NHSLA’s budget to meet the additional costs associated with the change in the discount rate.

[Mr Speaker]

The hon. Member for Southport (John Pugh) shoehorned Question 21, which we did not reach, into a Question that we did reach. He blurted it out so quickly that it took us a while to notice that it had absolutely nothing whatsoever to do with the private finance initiative. Very naughty boy!

[Rob Marris (Wolverhampton South West) (Lab)]

PFI always was idiotic. It carried on under the coalition Government and has left a huge financial hangover. Will the Minister have a word with his colleagues in the Treasury, because the Treasury figures on hospital liabilities are different from the figures that some of the hospitals themselves produce? As there is a discrepancy, we do not even know what the liabilities are.

[Mr Dunne]

The hon. Gentleman has been assiduous, as is his wont, in trying to get to the bottom of the costs of the PFI impact on the hospital in his area. If he has a discrepancy, it would be very helpful if he pointed it out to me in writing. I will then respond to him.

[Rosie Cooper (West Lancashire) (Lab)]

14. What plans his Department has to increase the provision of social care for people with unmet needs.

--- Later in debate ---

[Sir Edward Leigh (Gainsborough) (Con)]

T9. As the Secretary of State knows, we have a crisis in GP recruitment in rural north Lincolnshire. Does he agree that the best way to enable doctors to get to know our glorious county would be to establish a medical school at Lincoln University, and will he join our campaign to make that possibility come true?

[The Minister of State, Department of Health (Mr Philip Dunne)]

As my hon. Friend will have heard from the Secretary of State earlier, a number of areas are competing to secure a new medical facility. One of our criteria will involve encouraging doctors to be trained in areas where there are shortages, and I am sure that Lincoln University will take that factor into consideration.

[Michael Dugher (Barnsley East) (Lab)]

The British Medical Association said recently that the funds for sustainability and transformation plans that were announced in the Budget would be completely inadequate for the task. Health trusts throughout the country are being forced to consider rationing treatment and ending or downgrading local services such as A&E, which will result in even longer waits and journey times to access care. Why do the Government not call STPs what they really are—secret Tory plans to decimate the national health service further?

--- Later in debate ---

[Mrs Flick Drummond (Portsmouth South) (Con)]

I welcome the new nursing associates role that is currently being piloted. Will other areas, such as Portsmouth, be able to offer the same opportunities in the future, and will the new role be open to older people wishing to return to the workplace?

[Mr Dunne]

As my hon. Friend knows, we are launching a second wave of nursing associates at the beginning of April. I am pleased to be able to confirm that Southern Health NHS Foundation Trust, which manages Portsmouth Hospitals NHS Trust, is one of the trusts that will receive nursing associates, and that the system is partly designed to give social care workers opportunities to upskill.

[Catherine West (Hornsey and Wood Green) (Lab)]

The Secretary of State will be aware of a recent High Court case concerning a surrogacy issue that has led to legal limbo. Does he agree that the existing legislation has let children down, and that reform is urgently needed?

Baby Loss (Public Health Guidelines)

Philip Dunne Excerpts

Tuesday 21st March 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

I congratulate my hon. Friend the Member for Colchester (Will Quince) on securing this debate on public health guidance and baby loss. I also congratulate you, Mr Speaker, on scheduling it on a day when the other business, inexplicably, was so curtailed, thereby enabling some very distinguished Members on both sides of the House who chair directly relevant all- party groups to make unusually—I would not say unprecedentedly, Mr Speaker, because you would be better placed than I to say whether it was unprecedented—long contributions in an Adjournment debate, and very welcome they were too.

We know from families who have experienced baby loss that the silence that often surrounds the loss can make the experience much harder. For that reason, I join the tributes from the right hon. Member for Rother Valley (Sir Kevin Barron) and my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) to my hon. Friend the Member for Colchester for the work that he does in leading the all-party parliamentary group on baby loss and for bringing the experiences that he has suffered to bear on this issue a number of times.

Before I address the specific points made by my hon. Friend the Member for Colchester—I counted six challenges that he laid down in his speech, and I will try to address each of them—as I have the luxury of a little time, I will set the scene on the work the Government are undertaking to reduce adverse outcomes during pregnancy and the neonatal period.

My hon. Friend referred to the maternity transformation programme in England, which began a year ago. It provides an opportunity to shape services for the future. Improving women’s health requires a collaborative approach across the entire health system, including commissioners, primary care, maternity services, public health and local authorities, to meet the needs of women and their partners. The result of all that work is that England is a very safe country in which to have a baby. Sadly, a small number of babies are stillborn or die soon after birth but, according to the latest figures, stillbirths and neonatal deaths occur in 0.5% and 0.3% of births respectively.

We are absolutely committed to improving maternity care and recognise that every loss is a personal tragedy for the family concerned. As a result, it is our national ambition to halve the rate of stillbirths, neonatal deaths, maternal deaths and brain injuries that occur during or soon after birth by 50% by 2030. We are making considerable progress. The other day, I had the privilege of attending the Royal College of Midwives awards ceremony—one of the more enjoyable parts of my role in the Department of Health—where I was able to confirm that since 2010, the proportion of stillbirths is down by 10%, the proportion of neonatal deaths by 14% and the proportion of maternal deaths by 20%. Our plan is having some effect, which is very pleasing, but there is always more that we can do.

To support the NHS in achieving this ambition, we have a national package of measures with funding attached, including: an £8 million maternity safety training fund to support maternity services in developing and maintaining high standards of leadership, teamwork, communication, clinical skills and a culture of safety; a media campaign, “Our Chance”, comprising 25 animations and videos targeted towards pregnant women and their families to raise awareness of the symptoms that can lead to stillbirth; and a £250,000 maternity safety innovation fund to support local maternity services to create and pilot new ideas.

The fund was allocated in the past couple of weeks. One project that secured funding will develop a one-stop multidisciplinary care clinic for women with diabetes, hypertension, morbid obesity and epilepsy. Another project aims to develop a pathway whereby all women with high carbon monoxide breath test results—this was referred to by my hon. Friend—are referred for serial ultrasound measurements to provide them with more information about the potential impact of smoking on the child they are carrying. We are also investing £500,000 to develop a new tool to enable maternity and neonatal services to systematically review and learn from every stillbirth and neonatal death in a standardised way.

The Government are seeking to put in place infrastructure to improve maternal health, but clearly young mothers, partners and families have a role to play too. The evidence shows that the national maternity ambition cannot be achieved through improvements to NHS maternity services alone and the public health contribution will be crucial. It is vital that women and their families are made aware of and understand the lifestyle risk factors that can impact on the outcomes for them and their babies, and the changes they can make to increase their likelihood of positive outcomes. Hon. Members referred to a number of them.

As soon as a lady knows she is pregnant, she should be encouraged to contact her maternity service for a full assessment of health, risk factors and choices, so that a personalised plan of care can be prepared. Women with complex social factors, in particular teenagers and those from disadvantaged groups, do not always access maternity services early or attend regularly for antenatal care, and poorer outcomes are reported for both mother and baby. Maternity services need to be proactive in engaging all women.

Early in pregnancy, a midwife will provide a woman with information to support a healthy pregnancy. This will include information about nutrition and diet, including supplements such as folic acid and vitamin D as well as lifestyle advice, central to which is smoking cessation—on which my hon. Friend focused his remarks—the risks of recreational drug misuse and alcohol consumption, which my hon. Friend the Member for East Worthing and Shoreham focused on in his remarks.

When starting pregnancy, not all women will have the same risk of something going wrong, and women’s health before and during pregnancy are some of the factors that most influence rates of stillbirth, neonatal death and maternal death. We know that a body mass index of over 40 doubles the risk of stillbirth. A quarter of stillbirths are associated with smoking, and alcohol consumption is associated with an estimated 40% increase to stillbirth risk. In addition, the MBRRACE-UK perinatal mortality surveillance report, published in June last year, showed that women living in poverty have a 57% higher risk of having a stillbirth. Women from black and minority ethnic groups have a 50% higher risk, and teenage mothers and mothers over 40 have a 39% higher risk of having a stillbirth.

Those striking facts are why the Department of Health will continue to work closely with Public Health England and voluntary organisations to help women to have a healthy pregnancy and families to have the best start in life. Last year, NHS England published new guidance that aims to reduce the number of stillbirths in England. Building on existing clinical guidance and best practice, the guidance was developed by NHS England working with organisations including the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, British Maternal and Fetal Medicine Society and Sands, the stillbirth and neonatal death charity. The Saving Babies’ Lives Care Bundle includes key elements intended to significantly impact on stillbirth rates through reducing smoking in pregnancy, detecting foetal growth restriction, raising awareness of reduced foetal movement and improving effective foetal monitoring during labour.

I now come specifically to the challenges posed by smoking in pregnancy. My hon. Friend the Member for Colchester stole most of my thunder by declaring many of the statistics on the impact of smoking, but I am particularly pleased that he focused on the fact that the plan, as set out in the tobacco control plan for England in 2011, which set a target to reduce the number of women smoking in pregnancy to 11% or fewer, has now been achieved at the national level, with a rate of 10.6% for England as a whole. As my hon. Friend also pointed out, this masks wide geographical variations across the country, ranging from 4.9% across London to 16.9% in Cumbria and the north-east. There was an even greater difference at the level of clinical commissioning groups, from which I believe my hon. Friend collected his statistics. These range from 1.5% at the low end to over 26% at the higher end, which is clearly a totally unacceptable variation.

Although we have made progress in recent years, about 70,000 babies continue to be born each year to mothers who smoke—and more if we include exposure to second-hand smoke. My hon. Friend made an interesting observation about the impact of partners continuing to smoke while their partners are pregnant. My hon. Friend mentioned the figure of 25%, so for one in four pregnant women their partners continue to smoke. That is an area on which we need to focus our attention and seek to raise the awareness of the impact of passive smoking. I am grateful to my hon. Friend for raising that issue.

Smoking during pregnancy is the main modifiable risk factor for a range of poor pregnancy outcomes. It is known to cause up to 2,200 premature births, as my hon. Friend said, 5,000 miscarriages and 300 perinatal deaths every year across the UK. It also increases the risk of developing a number of respiratory conditions, attention and hyperactivity difficulties, learning difficulties, problems with the ear, nose and throat, obesity and diabetes. Pregnant women under 20 are six times more likely to smoke than those aged 35 or over. Specialist stop smoking support, while available to pregnant women, clearly needs to be targeted on those higher-risk groups. That provides much of the challenge that my hon. Friend set for us in his remarks.

We are looking to take considerable action to advance the cause of reducing smoking. My hon. Friend asked in particular when we intend to publish the next iteration of the tobacco control plan. He asked me to define a well-used parliamentary term—“shortly”. I regret to say that it is way beyond my pay grade to provide closer definitions of that term. There are others, including someone who recently arrived in the Chamber, who might have some influence on the speed with which plans emerge from the Government. I very much hope that we will be able to progress with the next iteration of the tobacco control plan in the next few months.

My hon. Friend referred to the babyClear programme, which is about informing pregnant women about the risks they run from continuing to smoke. It is an important programme that has been evaluated by Newcastle University, which published some findings last month. We think that this is closely aligned with the NICE guidance, which is appropriate. It builds on the point made by my hon. Friend and by the hon. Member for Belfast East (Gavin Robinson) about the sensitivity involved in giving advice to pregnant women. My hon. Friend the Member for East Worthing and Shoreham referred to the mental health challenges that pregnancy can cause for some women. I think there is a sensitivity involved in the delivery of hard-hitting messages to women who find it impossible to shake their addiction to smoking. We must be aware, in conveying the message that persisting in smoking during pregnancy may lead to long-lasting damage to the baby, that there may be mental health implications to which we need to be alert.

My hon. Friend the Member for Colchester mentioned the possibility of introducing an opt-out, rather than an opt-in, for carbon monoxide testing of women who present as pregnant to their maternity services. That is an interesting idea, and I am certainly willing to discuss it with NHS England and the Department. If it is possible for such a test to identify pregnant women who are smoking, it would be foolish of us not to introduce it.

My hon. Friend referred to the maternity transformation plan. I will write to him giving a specific response to his ideas and explaining how they might be used to embed smoking cessation in the nine elements of that plan. I cannot give him a similar reassurance about the training programmes for midwives, because they are determined independently by the Nursing & Midwifery Council and it is not for me to prescribe what should be involved in such training, but the debate will doubtless be heard by the midwife trainers.

My hon. Friend’s final request was for a warning on cigarette packets that would specifically alert people to the risks of smoking during pregnancy. Again, I am afraid that that is not in my gift, but it is a very interesting idea. As was pointed out by the right hon. Member for Rother Valley, there are already some stark and shocking images on cigarette packaging. We have just engaged in a major consultation that has led to the introduction of plain packaging. I suggest that my hon. Friend send his proposals to those who are responsible for monitoring the impact of plain packaging across Government.

I hope that I have addressed my hon. Friend’s points. Let me now respond to the requests from the right hon. Member for Rother Valley, who is the vice-chair of the all-party parliamentary group on smoking and health, in relation to e-cigarettes. He suggested that, as a research priority, we should ask Public Health England to consider whether they are helpful or unhelpful in encouraging pregnant women to stop smoking, and also whether the nicotine contained in them could lead to foetal damage in the future. I think that that is potentially an interesting subject for research, and I should be happy to pose the question to Public Health England.

I am pleased that my hon. Friend the Member for East Worthing and Shoreham was able to contribute to the debate, because he is very knowledgeable about these issues. He welcomed the progress that is being made in reducing smoking, and I am glad he recognised that. However, he focused many of his remarks on another aspect of public health guidance, in his capacity as chair of the all-party parliamentary group for foetal alcohol spectrum disorder.

[Tim Loughton]

I am not the chair. I am an officer.

[Mr Dunne]

I stand corrected.

Significant health messages are being sent about the consequences of continuing to drink while pregnant, and, again, progress is being made. I do not have the figures in front of me relating to the level of alcohol that pregnant women continue to consume, but the Government share my hon. Friend’s ambition. We must continue to bear down on alcohol consumption, because it has the potential to cause lifelong harm to babies.

My hon. Friend finished with a request that we consider once more the registration date for stillbirths, and his example of the twins falling either side of the 24-week definition puts the points very concisely and starkly. Again, I am not in a position to give him comfort on that issue here and now, but I will write to him, having consulted colleagues in the Department of Health on where we stand on it.

On that basis, I am very grateful to my hon. Friend the Member for Colchester for securing this debate and giving us the opportunity to spend almost an hour, I think, discussing this subject, which is unusual and welcome.

Question put and agreed to.

NHS Prescriptions, Dental Treatment, and Wigs and Fabric Supports: Charges

Philip Dunne Excerpts

Thursday 16th March 2017 Written Statements

[The Minister of State, Department of Health (Mr Philip Dunne)]

As at the start of previous financial years, regulations will today be laid before Parliament to increase certain national health service charges in England from 1 April 2017.

The prescription charge will increase by 20p from £8.40 to £8.60 for each medicine or appliance dispensed. To ensure that those with the greatest need, including patients with long-term conditions, are protected we have frozen the cost of the prescription prepayment certificates (PPCs) for another year. The three-month PPC remains at £29.10 and the cost of the annual PPC will stay at £104, allowing unlimited prescriptions within a specified time period. Taken together, this means prescription charges are expected to rise broadly in line with inflation.

Existing arrangements for prescription charge exemptions will remain in place, principally covering those with certain medical conditions like cancer, epilepsy and diabetes, pregnant women and new mothers, children under 16 and anyone over 60, and those on a low income.

As part of a two-year settlement announced last year, the patient charges for NHS dental care in 2017-18 will be as follows:

a band one course of treatment and urgent treatment will increase by 90p from £19.70 to £20.60;

a band two course of treatment will increase by £2.40 from £53.90 to £56.30;

a band three course of treatment will increase by £10.60 from £233.70 to £244.30.

The maximum band three charge is for the approximately 5% of treatments that include items such as crowns or bridges.

Charges for wigs and fabric supports will rise in line with inflation.

Full details of the revised charges for 2017-18 can be found online at: http://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2017-03-16/HCWS539/

[HCWS539]

Health Service Medical Supplies (Costs) Bill

Philip Dunne Excerpts

Ping Pong: House of Commons
Wednesday 15th March 2017 Commons Chamber

[The Minister of State, Department of Health (Mr Philip Dunne)]

I beg to move, That this House disagrees with Lords amendment 3.

[Madam Deputy Speaker]

With this it will be convenient to discuss Lords amendments 1, 2 and 4 to 24.

[Mr Dunne]

I remind the House of the importance of this Bill. NHS spending on medicines is second only to staffing costs. The NHS in England spent more than £15 billion on medicines during 2015-16, a rise of nearly 20% since 2010-11. With advances in science and our ageing population, the costs will only continue to grow.

The UK has a lot to be proud of: we have a world-class science base and an excellent reputation for the quality and rigour of our clinical trials and the data they produce. The UK has one of the strongest life sciences industries in the world, generating turnover of more than £60 billion each year. Indeed, it is our most productive industry. The Government are deeply committed to supporting it to flourish and, in doing so, to provide jobs and transform the health of the nation.

In the 2016 autumn statement, an additional £4 billion of investment in research and development was announced, specifically targeted at industry-academia collaboration. We expect the life sciences industry to be a substantial beneficiary. That comes on top of measures such as the patent box and the R and D tax credits that the Government have introduced to encourage investment from innovative businesses.

That determined action is reaping rewards. The UK ranks top among the major European economies for foreign direct investment projects in life sciences. Last month, the Danish drugs company Novo Nordisk announced a new £115 million investment in a science research centre in Oxford. That comes on top of an additional investment of £275 million announced by GSK last June and AstraZeneca reaffirming its commitment to a £390 million investment to establish headquarters and a research centre in Cambridge—it is good to see the hon. Member for Cambridge (Daniel Zeichner) in his place. Looking ahead, Professor Sir John Bell, the regius professor of medicine at Oxford, has agreed to lead the development of a new life sciences strategy for the long-term success of UK.

At the same time, it is important that we secure better value for money for the NHS from its growing spend on medicines and other medical supplies. I remind the House that, overall, the Bill will do three things. First, it will enable us broadly to align our statutory scheme for the control of prices of branded medicines with our voluntary scheme, by introducing the possibility of a payment percentage for the statutory scheme. That could deliver £90 million of savings annually for the NHS. Secondly, the Bill will give us stronger powers to set the prices of unbranded generic medicines if companies charge unwarranted prices in the absence of competition.

Thirdly, the Bill will give us stronger powers to require companies in the supply chain for medicines, medical supplies and other related products to provide us with information. We will use that information to operate our pricing schemes, to reimburse community pharmacies for the products they dispense and to assure ourselves that the supply chain of specific products provides value for money for the NHS and the taxpayer.

During the Bill’s passage through the other place, the Government tabled 23 amendments, following debate and discussion in this House and with peers. I firmly believe that those amendments make it a better Bill. However, I will start with Lords amendment 3 and set out the reasons why it does not improve the Bill.

Lords amendment 3 would introduce a duty on the Government, in exercising their functions to control costs, to have “full regard” to the need to

“promote and support a growing life sciences sector”

and the need to ensure that patients have access to new medicines. The amendment would undermine one of the core purposes of the Bill by hindering the ability of the Government to put effective cost controls in place. Controlling the prices of medicines cannot, in itself, promote the interests of the life sciences sector and deliver growth. Having such a requirement in legislation could encourage companies to bring legal challenges where the cost controls have not, in themselves, promoted growth in the life sciences industry. That could significantly hinder the Government’s ability to exercise their powers to control costs effectively.

For example, if the Government were to take action to control the price of an unbranded generic medicine, because it was clear that the company was exploiting the NHS—several examples of that have been raised throughout the Bill’s passage through this House—it could be argued that that action did not promote the life sciences sector, because every generic drugs manufacturer could argue that it is a life sciences company. Nevertheless, that would, of course, be the right thing to do for the NHS, for patients and for taxpayers. Lords amendment 3 would enable companies to challenge any action by the Government to control costs by arguing that proper regard had not been paid to supporting a growing life sciences industry. The amendment would therefore make it more difficult to control costs, including where companies seek to exploit the NHS over and above the interests of patients, clinicians and taxpayers.

I say gently to those on the Labour Benches that it is ironic that they talk tough on the pharma companies, which they claim in other forums routinely seek to exploit the NHS, when today they are arguing the cause of the industry by supporting an amendment that would provide it with a legal stick with which to challenge the NHS when it seeks to control the costs of drugs, some of which, as they acknowledge, are exorbitantly priced. I therefore have to ask the hon. Member for Ellesmere Port and Neston (Justin Madders): whose side is Labour on?

The Government are seriously concerned that Lords amendment 3 has the potential to impact negatively on our ability to control costs. I do not expect that that was the aim of well-intentioned Members in the other place. I hope both Houses agree that it would be damaging to the NHS if, on every occasion that the Government deem it necessary to use their powers to control costs, the Government could be challenged for failing to give full regard to promoting the interests of life sciences companies.

The second part of Lords amendment 3 requires the Secretary of State to have full regard to the need for NHS patients to benefit from swift access to innovative medicines that have been recommended by the National Institute for Health and Care Excellence through its technology appraisals. However, NHS commissioners are already legally required to fund drugs and other treatments recommended in NICE technology appraisal guidance, normally within three months of final guidance. The Secretary of State’s power to control costs is a completely separate process. Therefore, this part of the amendment would not achieve anything.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

The Minister is of course absolutely right on the primacy of NICE in this matter, but today the NICE board will be imposing a budget threshold of £20 million a year, which would have the effect of at least delaying or possibly preventing the roll-out of new medicines. Does he share my concerns, particularly in relation to cancer drugs?

[Mr Dunne]

My hon. Friend is right to point out that NICE is considering today in its board meeting thresholds for the introduction of new medicines. What I would not do, however, is share his concern that it will necessarily lead to delay in their take-up. In essence, it will provide NHS England with greater commercial flexibility to negotiate with drugs companies that propose to introduce a drug that may cost more than £20 million in a full year. It will give NHS England more time to negotiate a lower price with the pharma company. That should not, in and of itself, lead to either delay or less take-up.

I am aware of the concerns, expressed by my hon. Friend, other Members and some charities in a national newspaper today, about the joint NICE and NHS England consultation on the proposed changes to the appraisal and adoption of new technologies. There have been suggestions by Opposition Members that this is rationing of NICE-approved medicines. I assure the House that that is not the case. Patients will continue to have the right to NICE-recommended drugs, as enshrined in the NHS constitution. The proposals are intended to ensure that patients benefit from even faster access to the most cost-effective treatments, while addressing issues of affordability as well as effectiveness.

Let me be very clear: Lords amendment 3 would not impact on the proposals; the NHS will continue to fund a product approved by NICE, in line with NICE recommendations. I also remind Members that NICE and NHS England are making the changes to address concerns about the affordability of high-cost new drugs and other technologies that were raised by the Public Accounts Committee, which is chaired by the hon. Member for Hackney South and Shoreditch (Meg Hillier).

I have read the suggestion by the Opposition that the NICE and NHS England proposals would be contrary to our intent to increase the uptake of new medicines. As I said to my hon. Friend the Member for South West Wiltshire (Dr Murrison), that is false. In reality, last year saw spend on medicines grow more quickly than in any of the past 10 years, as we seek to secure rapid access to new medicines for patients.

Access to medicines is primarily dependent on clinicians’ choices about what is best for their patients. Clinicians need to be aware of new medicines and persuaded that they may be a better option for their individual patients, taking into account other conditions each patient may have and other medicines they are taking. We need to change the culture and behaviour of those clinicians who may be reluctant to use innovative medicines, and legislation is not the right way to effect behaviour change in the NHS.

[Bob Stewart (Beckenham) (Con)]

I want to ask a layman’s question: if NICE approves a drug, is the NHS necessarily required to buy it?

[Mr Dunne]

The short answer is yes, it is. That is set out in the NHS constitution. The measures considered by the NICE board today provide some additional flexibility for NHS England in its handling of negotiations with the drugs companies over the introduction of new technology.

Let me conclude on amendment 3 by saying that the Government strongly believe that it would have a negative impact on the Government’s ability to operate price controls, so I ask Members to disagree with it.

I will deal briefly with the other amendments. Lords amendments 1 and 2 and amendments 4 to 24 were made in the other place. They are all amendments that the Government brought forward, having worked constructively with parliamentarians on improving the Bill.

Amendments 1 and 2 relate to the remuneration for persons providing pharmaceutical services in England and Wales respectively. The amendments provide for new regulation-making powers in respect of special medicinal products. These are unlicensed medicines that can be manufactured or imported to meet a patient’s individual needs when no licensed product is available.

The unique nature of specials—the hon. Member for Central Ayrshire (Dr Whitford) mentioned them during our consideration in this place—and their manufacturing arrangements mean that we need to do more to ensure that the prices paid by the NHS represent value for money for all these products. These amendments would enable England and Wales to develop options that will secure improved value for money—for example, by using a quotes system that has been trialled in Scotland, but there are also other options. We will consult the community pharmacy representative body on how best to take this forward.

Amendments 4 to 7 introduce a consultation requirement on the Government with regards to medical supplies. Again, the hon. Member for Central Ayrshire helpfully pointed out that such a requirement was in place for medicines, but not for medical supplies. I thank her for engaging with me and my officials, which has helped to improve the Bill.

The Government have listened to concerns in the House of Lords and in this House about the Government’s power to control the prices of medical supplies. These amendments would ensure that the first order to control the price of any medical supply would be subject to the affirmative procedure, giving both Houses an opportunity to discuss that order.

Amendments 8 and 9 and 15 to 17 are amendments to the information powers in the Bill. Responding to concerns from industry about the potential burdens of the proposed information power, they introduce an additional hurdle for the Government to obtain information by requiring them to issue an information notice whenever they require companies to provide cost information related to individual products, which can be appealed by the company concerned.

[John Redwood (Wokingham) (Con)]

One problem in coming to a fair price for a new drug—we want to reward the company for its innovation, but without being ripped off—is knowing what kind of production run or demand there might be for it. Is there any way that the NHS could get better at forecasting what its volume might be, as that might drive the price down?

[Mr Dunne]

As ever, my right hon. Friend, who is a champion of market solutions to some of these tricky problems, lights on an important point. We need to be better at trying to predict the take-up of medicines. Of course, until a new medicine has been introduced, it is very difficult to assess that, because it requires clinicians to get behind the product and to choose to prescribe it. He is absolutely right that we need to look at the way in which we model in order to have a negotiation with the pharmaceutical company that ensures that we build in as good a volume as we are expecting to maximise our prospects of getting the best price.

Let me return to Lords amendments 8, 9 and 15 to 17. When the Government ask a company to provide straightforward information about prices and other transaction costs or overall costs, there is no need for an information notice. The rationale is that there could be a significant burden on companies to provide product-level cost information. Any such request should be made only in exceptional circumstances—for example, in order to set the price of an unbranded generic medicine, when the Government would need insight into the costs and profits associated with the specific product.

Health and Social Care Budgets

Philip Dunne Excerpts

Tuesday 14th March 2017 Westminster Hall

[The Minister of State, Department of Health (Mr Philip Dunne)]

I congratulate you on chairing this substantial debate so efficiently, Mr Bailey. Some 31 colleagues were present—that is a very high turnout for Westminster Hall—of whom 18 spoke, including three distinguished Select Committee Chairs and two Opposition spokesmen. Certainly I have not attended such a significant debate in Westminster Hall, and it reflects our common interest in ensuring that the NHS and social care services in this country provide as high-quality a service to the public as possible.

Virtually all speakers welcomed the developments in last week’s Budget, and I welcome that broad consensus across the Chamber. Only one discordant note was struck—reference was made to a march in the streets of London led by the shadow Chancellor, the right hon. Member for Hayes and Harlington (John McDonnell). That march obviously demonstrated a degree of concern, but it happened before the Budget, which, as I shall touch on, responded to many of the concerns that have been raised.

We all recognise that the NHS faces a significant challenge, given the increasing demand for health services as a consequence of our ageing and growing population, new drugs and treatments, and safer staffing requirements, and that in turn is increasing the pressure on social care services. We know that finances are challenging for both areas, which is why we have ensured that spending on the NHS has increased as a proportion of total Government spending each year since 2010.

We backed the “Five Year Forward View” as part of the spending review in late 2015. That ensured that real-terms NHS funding will increase by £10 billion by 2020-21 compared with the year before the spending review. Some hon. Members said that they wanted to see a plan. We have supported the NHS’s own plan—the “Five Year Forward View”—and announced that we will publish a Green Paper this summer looking at how social care is funded in the long term, which hon. Members have welcomed, so it is churlish to deny that this Government are providing long-term strategic thinking about the way we fund both those services. I remind colleagues that the NHS budget was £98 billion in 2014-15 and will be £119.9 billion in 2020-21. That is a £21.8 billion increase in cash terms, which seems to get lost from time to time in these discussions.

We are almost at the end of the financial year. The NHS received a cash increase of more than £5 billion in 2016-17. That was front-loaded, as NHS chief executive Simon Stevens requested. For the year that starts on 1 April, there will be another significant increase in funding once the mandate is settled. The hon. Member for Bristol South (Karin Smyth), who is a member of the Public Accounts Committee, asked when we will see that document. It has to be published by the end of this month, and I assure her that it will be.

The measures announced last week, which many hon. Members referred to, have three features. I will not go into them in detail, because they have all been covered. Much of the focus has been on the additional £2 billion that we will provide for social care over the next three years, half of which will start to come in next month, when the new financial year begins.

Some hon. Members are aware of the numbers for their areas and some are not, and one colleague came up with a slightly incorrect figure. I will not go through every area, but I applaud the presence of Devon MPs in particular, given the manner in which they have massed themselves with colleagues from across the House. Devon will get a £30.3 million increase in its social care budget over the next three years and will receive half of that in the year that is about to start. My hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) referred to an £18 million increase for North Yorkshire. I can give him a bit of good news: it will actually be £19.6 million over the next three years. I am grateful to the Chair of the Public Accounts Committee, the hon. Member for Hackney South and Shoreditch (Meg Hillier), for her support for the Budget measures. Hackney will receive £12.8 million, as she acknowledged. Like many colleagues, she sought a long-term funding settlement.

[Norman Lamb]

rose—

[Mr Dunne]

I am afraid I cannot take interventions, as we have very little time.

The spending review provided a settlement for the NHS. The Chancellor indicated that there will be a social care Green Paper this summer. Several colleagues called for a cross-party consensus. The Green Paper will provide an opportunity for debate and consultation, and such discussions should focus on that.

The second Budget measure was a £100 million increase in funding for A&E services, so that people who present at A&E who do not need intense or urgent care can be diverted to GPs or clinics run by nurse practitioners. That best practice has been proven to work in A&Es that have such a streaming service, so we are looking to provide facilities for basic capital spend to ensure that every A&E hospital across the country has streaming in place by next winter. I am pleased that that has been welcomed by hon. Members from across the House.

The third measure—this was touched on in the debate, albeit not in such detail—is the £325 million capital investment in the first set of sustainability and transformation plans. Those who make the strongest case for investment and can deliver better, more joined-up services, which can bring real improvements to patient care, will benefit from the funding. We look to that to be an exemplar for other areas whose plans are less well developed, to encourage them to develop a better, more integrated approach to patient care for the future, including closer working with local authorities for the provision of social care. That should encourage areas to bring forward more comprehensive plans for the next wave of STPs, which will be supported. As hon. Members have said, we look forward to explaining more about that at the time of the next Budget.

[Mrs Flick Drummond (Portsmouth South) (Con)]

Will the Minister give way?

[Mr Dunne]

I am afraid I had better—

[Mrs Drummond]

It will be very quick.

[Mr Dunne]

Okay, a very quick question.

[Mrs Drummond]

Something that has been missing from the debate is the 6.5 million carers in the UK— 17,000 of them are in Portsmouth—who save costs of £132 billion a year. Will the Minister recognise that in the Green Paper and, in particular, respite care for them?

[Mr Dunne]

In the sustainability and transformation plans there is the opportunity for commissioners of care and health services to look holistically at the demands of the residents in their area, which to a degree includes palliative care and respite care. As we move towards an STP, there is a greater opportunity for those things to be considered as well.

[Barbara Keeley]

I agree with the hon. Member for Portsmouth South (Mrs Drummond). There is a real dearth now and respite care for carers has got lost. With £120 million, 40,000 carers could be helped with a respite care break. The Minister should look at that.

[Mr Dunne]

As I just said, the STPs provide an opportunity for areas to place greater focus on respite care if they consider that to be required.

I would like to touch on the adequacy of the social care funding package. The announcement means that in the next three years councils will have access to some £9.25 billion of more dedicated funding. That includes extra money going to local authorities through the combination of the improved better care fund and the social care precept, which, for those councils introducing it with effect from next month, will raise some £1 billion extra. The £1 billion provided in the Budget and the £1 billion from the precept amount to the £2 billion called for by external sources for the coming year. That funding will allow councils to expand the numbers of people they are able to support and, in turn, address issues at the interface with the NHS such as delayed discharges from hospital, which as we know cause problems with patient flow through the system.

Questions were raised about how the social care funding is to be allocated. I inform colleagues that 90% will be allocated using the improved better care fund formula to local authorities that have responsibility for adult social care. That distribution takes account of the ability to raise money through the council tax precept for social care and means that it is well targeted at areas of greater need and market fragility. However, in recognition of the social care pressures faced by all councils, 10% of the funding will be allocated using the relative needs formula.

The response to the measures from external audiences reflects comments made by hon. Members today: they have been broadly welcomed. Of course, several hon. Members said that it is not enough, but that is a traditional response to any increase in money—it is always easier to say that it is not enough. Hon. Members have generally recognised that the Government have listened to concerns about social funding. Those of us with responsibility for the health service recognise that there has been a particular problem in dealing with delayed discharges from hospital. Through closer working in the sustainability and transformation plans as they are rolled out across the country, with local authorities working more closely with health service providers, we think that the money will provide a lifeline to help to remove some of those pressures and to improve patient flow through our hospitals.

I would like to touch on the medium-term challenge and how in the coming months we can try to use the development of a social care Green Paper to address the longer-term concerns. The Government are committed to establishing a fair and more sustainable basis for funding adult social care in the light of the future demographic challenges that the country faces. We will therefore bring forward proposals to put the state-funded system on a more secure and sustainable long-term footing, setting out plans in a Green Paper. Some hon. Members asked when the Green Paper will be published. If I was in charge of Government timetabling, I would be in a better position to answer. They will not be surprised to hear that I cannot give a definitive answer, but, to use traditional parliamentary language, it would be fair to say that it is expected to be published in the summer.

[Mr Bradshaw]

Will the Minister clarify the Government’s position on the idea of a posthumous levy on estates? The Chancellor ruled that out, yet we read in the newspapers that the Prime Minister slapped him down over that. Are the Government ruling it out or not?

[Mr Dunne]

I will not pre-empt anything in the Green Paper, and it is not for me to give the right hon. Gentleman any comfort on discussions that might or might not have happened around the Budget.

We recognise that the NHS and social care face huge pressures and that there is more for us as a Government to do. However, we can be confident that we have plans in place both to cope with the pressures that we currently face—winter, A&E pressures and delayed discharges—and to sustain the system for the future. We have a long-term plan in place through the “Five Year Forward View” and the efficiency work being undertaken and rolled out progressively this year. We have given extra funding to both the NHS and social care to support those plans, and we have plans to bring forward a Green Paper on social care. I am pleased that that was broadly welcomed and recognised by hon. Members and distinguished parliamentarians in the debate, and I am grateful for that support.