NHS Funding Bill

Philippa Whitford Excerpts

2nd reading & 2nd reading: House of Commons
Monday 27th January 2020 Commons Chamber

[Matt Hancock]

Yes and yes; my hon. Friend anticipates my whole section on Mr PFI sitting over on the Opposition Front Bench. During his time in the Treasury, the hon. Member for Leicester South, managed to sign off some of the worst PFI deals. [Interruption.] The hon. Gentleman sighs, but I do not think he understands the damage he has done.

This Bill confirms that spending on the NHS will rise from £115 billion last year to £121 billion this year, to £127 billion, then £133 billion, £140 billion and £148 billion in 2023-24.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

To clarify the point, are the Government committed to buying out the PFIs that are currently a burden on health boards and trusts?

[Matt Hancock]

We absolutely will be looking at doing that where we can. Unfortunately, that is difficult to do, because, over time, and especially during the time that the hon. Member for Leicester South was in the Treasury, the legals on these PFI deals got tighter and tighter. There are 106 PFI deals in hospitals and we are going through them. We will work towards making them work better for patients, and if that means coming out of them completely, I will be thrilled.

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[Dr Whitford]

The right hon. Gentleman’s overall figure for health spend is correct, but the public health spend—as opposed to private patients—is only 7.5% of GDP, and that is the figure the public are interested in, not the figure including people who can afford to go private.

[Jeremy Hunt]

I suggest to the hon. Lady, whom I greatly respect, that the overall figure is actually what counts. I agree that public health spending matters, but it is absolutely the case that we are heading to being one of the higher spenders in our commitment to health. That is very significant and should not be dismissed.

Often, the debate about funding can distort some of the real debates that we need to have about the NHS. One of those is the debate on social care. If we do not have an equivalent five-year funding plan for social care, there will not be enough money for the NHS. That is because of the total interdependence of the health and social care systems. It is not about finding money to stop people having to sell their homes if they get dementia, important though that is; it is about the core money available to local authorities to spend on their responsibilities in adult social care. I tried to negotiate a five-year deal for social care at the same time as the NHS funding deal we are debating today. I failed, but I am delighted to have a successor who has enormously strong skills of persuasion and great contacts in the Treasury. I have no doubt that he will secure a fantastic deal for adult social care to sit alongside the deal on funding, and I wish him every success in that vital area.

The second distortion that often happens in a debate about funding is that while everyone on the NHS front line welcomes additional funding, their real concern is about capacity. The capacity of staff to deliver really matters. I remember year after year trying to avert a winter crisis by giving the NHS extra money, and most of the time I gave the money and we still had a winter crisis, because ultimately we can give the NHS £2 billion or £3 billion more, but if there are not doctors and nurses available to hire for that £2 billion or £3 billion, the result is simply to inflate the salaries of locum doctors and agency nurses and the money is wasted. Central to understanding capacity is the recognition that it takes three years to train a nurse, seven years to train a doctor and 13 years to train a consultant, so a long-term plan is needed. It is essential that alongside the funding plan, we have in the people plan that I know the NHS is to publish soon an independently verified 10-year workforce plan that specifies how many doctors, nurses, midwives, allied healthcare professionals and so on we will need.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Having spent 33 years as a surgeon at the very sharp end of the NHS, I welcome the multi-year funding because it should allow better planning, but it does come after a decade of drought. Between 2010 and 2015, the average annual uplift was 1.1%. Between 2015 and 2018, it was only 2%. That means that over that period of eight years—during a time of inflation, and particularly rising demand with an ageing population—the NHS in England faced a real-terms cut, which is why quoting the spend per head is actually more realistic and more accurate. Scotland spends £136 a head more on health, which is why the Secretary of State is forever claiming that Barnett consequentials are not passed on in Scotland. Every penny of resource consequentials are passed on, but here is a little explanation of percentages: if the starting amount is bigger, the same amount will be a smaller percentage. We have explained this before, but we keep hearing this nonsense. In actual fact, if the Scottish Government used the same per capita spend on health as the UK Government does for England, Scotland would be £740 million worse off.

[Patrick Grady]

I have raised with the Minister the concern about the cap that the Government have put on the spending figures through the use of the money resolution, but the whole Bill is going to be committed to the English Legislative Grand Committee, so Members from Scotland are not going to be able to table amendments to pursue exactly such points with the Government. We are not going to be able to inquire, as other Members from the rest of the UK will be able to do, table probing amendments or question the impact of the Government’s spending. Does my hon. Friend agree that that really undermines the point of this being a sovereign UK Parliament?

[Dr Whitford]

The whole issue of English votes for English laws applying to Bills that have direct Barnett consequentials for the three devolved Governments is obviously complete nonsense, and certainly makes all devolved MPs second class.

The Government are committed to £33.9 billion a year in cash terms by 2024. As has already been pointed out, that is actually just the same £20 billion that was promised in 2018. It is not extra, new money. It is not on top of the £20 billion. It is the same amount. It has been described as a 3.4% increase in real terms, but the Health Foundation has already suggested that, due to inflation, it is actually only 3.3%, and the Institute for Fiscal Studies predicts that it will be only 3.1%. The key problem of making a commitment in cash terms is that if inflation rises post Brexit—by which I mean at the end of 2020—as is likely, the commitment would simply wither on the vine. It should be front-loaded because the urgent need is now, and it should be in real terms; otherwise, talking about 2024 in cash terms is actually just pie in the sky. The three main health think-tanks and the British Medical Association think that 4% is required to restore the service to the performance that is expected. More than that would be required for service redesign, to match the shopping list we heard the Secretary of State recite.

I am glad that the Secretary of State has moved away from talking about apps. The idea that people are going to rub a mobile phone over their tummy to diagnose appendicitis is for the birds. People need doctors. Healthcare is delivered by people, and the idea that an app on our phones can replace that is just nonsense. However, I was glad to hear the Secretary of State talking about internal IT in the NHS in England because, frankly, it has fallen behind since the Care.data scandal. There is a lot that could be done IT-wise to utilise the existing workforce in a much better way. In Scotland, radiologists can view any X-ray anywhere in Scotland through the picture archiving and communications system. We have electronic prescribing, which is not only efficient, but a patient safety issue because doctors cannot prescribe a drug to which the patient is allergic. These are things that should be focused on, rather than gimmicky apps on mobile phones. Again, this is just money focused on the NHS revenue funding.

The NHS long-term plan, exactly like the 2015 five-year forward plan—we are seeing a bit of a theme here—was predicated on game-changing investment in both public health and social care. The public health grant for local authorities that is currently proposed is only expected to rise by 1%. That means a significant real-terms cut, on the back of £850 million of cuts that have already happened, resulting in a reduction in smoking cessation, sexual health and addiction services. That does not make sense, as even the Secretary of State admits that prevention is better than cure.

[Alison Thewliss (Glasgow Central) (SNP)]

My hon. Friend is making a very good point about cutting away at prevention services. One of the services in England that has seen huge cuts is breastfeeding support. If such services are properly invested in, they can be a huge investment for the future of health, as well as for the here and now.

[Dr Whitford]

My hon. Friend does a lot of work on this topic. There is no doubt that a lot of investment must go into children’s earliest year, because our risk of so many conditions in later life is actually laid down between conception and the age of two. Energy and funding should therefore be focused at that point.

We have been waiting for three years for the promised Green Paper on social care, and there was absolutely nada in the Queen’s Speech. But this is a discussion about how to come up with an innovative system of raising the funds for social care. It is not an argument about whether social care needs to be funded. The answer is quite simple: it does. The gap is currently more than £6 billion. As well as spending more on health in Scotland, we also spend £130 a head more on social care, but that allows us to provide free personal care, which allows people to stay in their own homes and live their later life with dignity, where they want to be—where we would all want to be if we needed support. Last April, this care was extended to people under the age of 65 who need it because they have degenerative conditions such as Alzheimer’s, multiple sclerosis or motor neurone disease. This would be a worthwhile investment for the UK Government to consider, because we simply cannot fix the NHS without fixing social care.

The Prime Minister enjoys trumpeting his 40 new hospitals, when we know that there will actually be six, but there is no mention of additional capital funding to cover the more than £6 billion backlog in maintenance and repairs that the shadow Secretary of State described so vividly; one could almost smell some of the problems he was describing. This backlog built up when NHS trusts slid into £2.5 billion of debt after the introduction of the Health and Social Care Act 2012, because the transactional costs—the bidding and contracting—were taking so much money away from the frontline. Year after year, we saw this repeated movement from capital to resource just to keep services afloat. That has to be stopped.

The biggest challenge in all four health services is workforce shortages, and that challenge is already being made worse both by Brexit—with a 90% drop in European nurses and European dentists coming to this country—and by the issues around pension tax reforms that are driving senior clinicians, particularly doctors, to cut their hours and their shifts. These factors are making workforce shortages an acute issue. In their manifesto, the Government committed to 50,000 extra nurses, and we saw the Secretary of State leaping up and down in delight, boasting about it. We are to expect the extra nurses over the next five years, but the problem is that we are still waiting for the 5,000 extra GPs that were promised for the last five years, and there are actually 1,000 fewer GPs in England than there were five years ago.

Everyone should welcome the expansion of the nursing workforce from 280,000 to 330,000, whether it is done through recruitment or training, or whether it is due to retention; I do not have an issue with that. But this expansion was costed in the manifesto at £879 million. Now, I am sure that everyone welcomes the return of the nursing bursary, even if it is only half of that which we provide in Scotland. Unlike in Scotland, nursing students in England will still have to pay tuition fees, which is likely to deter some mature students, who have a tendency to specialise in mental health and learning difficulties—areas of huge nursing shortage. It is not clear what the £879 million is actually for. Surely it cannot be for the salaries, because they would each cost only £17,500 a year, which is not even the real living wage. If it is for training and the bursary, have the Government forgotten to add the salaries into this Bill, because 50,000 extra nurses is a significant hike in the NHS salary bill? If it is the former and they are planning to recruit on a salary of £17,500 a year, then good luck with recruiting anybody.

This Government simply need to reverse the real-terms cuts they have made over the past decade. On a point of principle, they also need to go back to discussing funding of the Department of Health and Social Care in the round, not picking out the NHS in England to make it sound like a big number while cutting everything else. It is critical to invest in prevention and in social care, so a return to departmental spending and departmental investment would be very welcome. In all of this, they need to make sure that they are wrapping services around the patient. The patient is the person who should be at the centre of NHS and social care.

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[Andrew Bowie]

I am perfecting it. I am delighted to be called to speak at this time in this debate on a Bill that demonstrates our commitment to implementing our promise to the British people in the last election to invest in our NHS: to invest a record amount in our NHS. In fact, we are talking about the biggest cash increase in the history of the NHS, delivering new hospitals, more nurses, more doctors, more primary care professionals in general practice and millions more appointments in GP surgeries every year across England; we are demonstrating once and for all that the NHS is safe in the Conservatives’ hands and putting an end, I hope, to the disgraceful, lazy, scaremongering trotted out every election by the parties opposite, which is in place of—in fact, caused by—a dearth of realistic policy proposals that appeal to the British people.

This is a debate about NHS funding. It has been rightly certified as relating exclusively to England, as this matter is fully devolved, and it has focused on the areas— how and where—the extra money will be best spent south of the border. However, it would be remiss of this House to let this Bill pass on Second Reading today without at least mentioning the effect that this transformative amount of money being invested in the NHS, coupled with decisions on funding in education, local government and policing taken by this Conservative Government, will have north of the border in Scotland.

Thanks to this Conservative Government, the block grant to Scotland will increase by an unprecedented £1.1 billion this year, to £29.3 billion, with £635 million of that increase due to our commitment, cemented here today, to boost spending on health to record levels, as it could be transformational. Indeed, it needs to be, for despite the bluff and bluster of the Scottish National party—or, in fact, because of the bluff and bluster of a Scottish National party obsessed with stoking division and grievance, and foisting upon the Scottish people another referendum that they do not want—the health service in Scotland is suffering.

Before I go on, I wish to put on record my thanks to the amazing people who work in NHS Scotland, particularly those at NHS Grampian. They do incredible work, going above and beyond to serve the people of Scotland and north-east Scotland. Their service and sacrifice are something that everybody in this Chamber is grateful for, and I include the hon. Member for Central Ayrshire (Dr Whitford) in that, not just for her service in Scotland, but her service overseas. My admiration for what she has done in Palestine knows no bounds. However, I do think that health service workers are being let down by the Scottish Government, for whom everything—investment in our NHS, the education of our children and the delivery of policing—plays second fiddle to the obsession of separation from the rest of the United Kingdom.

The story of the SNP’s management of Scotland’s NHS is, sadly, one of underfunding. Spending on the NHS in England increased by 17.6% between 2012-13 and 2017-18, whereas it increased by only 13.1% in Scotland in the same period.

[Dr Whitford]

The hon. Gentleman was not in his place when I spoke earlier to point out the fact that if the global funding in Scotland is higher, the Barnett consequential makes a smaller percentage. Scotland spends £136 more per head on health and £130 more per head on social care. I think he should go and work out a little bit of mathematics, because percentages relate to what the starting point is.

[Andrew Bowie]

I thank the hon. Lady for her intervention, but my figures were from the Scottish Parliament Information Centre, and that is a Parliament oft quoted by SNP Members. Moving away from funding, the story of the SNP’s record on the NHS in Scotland is also one of failed waiting time targets. The 12-week treatment time guarantee unveiled by Nicola Sturgeon when she was Health Secretary in 2011 has never been met—not once. For the quarter ending September 2019, just shy of 30% of in-patient and day cases were not treated within 12 weeks. The situation is even worse for my constituents living under the NHS Grampian umbrella, where more than a quarter of patients—34.6%—were not seen within the mandated 18-week referral time in the month ending September 2019. That is not the fault of the amazing people at NHS Grampian; how can they hope to meet targets when they are being so chronically underfunded by the SNP? According to the Scottish Parliament Information Centre, the 2019-20 cash allocated to the NHS Grampian health board was £7.7 million short of the target set by the NHS Scotland Resource Allocation Committee. The total shortfall over the decade for NHS Grampian is estimated to be £239 million.

I am sorry to say that the cancer waiting times are little better, with a fifth of people with urgent cancer referrals waiting more than two months for treatment. The target is that 95% of patients with urgent referrals are seen within 62 days, but this was met for only 83.3% of patients in the quarter ending September 2019. We have a GP crisis in Scotland—a shortage. It is shameful that the Royal College of General Practitioners expects a shortfall of 856 doctors across Scotland by 2021. There are delays to the promised Inverness medical centre, and fears over the same happening at the Aberdeen cancer and maternity units. There is a completed children’s hospital in Edinburgh, but it is sitting empty due to “ongoing safety concerns”. We also face a shameful, tragic situation at Queen Elizabeth University Hospital in Glasgow, where children have died and it has emerged that Health Protection Scotland reports had identified contamination risks as far back as 2016, with dozens of individual cases.

[Andrew Bowie]

I thank the hon. Gentleman for his intervention, and I tend to agree with him, but I have deliberately avoided getting into, “England is better than Scotland.”

[Dr Whitford]

indicated dissent.

[Chris Bryant]

indicated dissent.

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[Simon Hoare]

I would not be seen dead in my hon. Friend’s patch. I have enough issues with my own.

There are two community hospitals in my constituency: Westminster Memorial in Shaftesbury and the excellent Blandford Community Hospital. I am a friend of both, and both friends’ organisations do a huge amount of vital fundraising work. The Minister is well apprised of the important role such hospitals play, particularly in rural settings after discharge from A&E, just before people can go home. Community hospitals need support and fresh attention.

Likewise—I am pleased that the Department prioritised this earlier in the year—community pharmacists play a huge and important role. I am told by our CCG that it is almost a cardinal sin to even consider this, but I would love to see a representative of the community pharmacies on the boards of each CCG, by mandate, because they have a vital role to play in our NHS family. As the previous chairman of the all-party parliamentary group on multiple sclerosis, may I also urge a greater rapidity with regard to the prescribing of medical cannabis?

NHS dentistry needs a fillip. I am often contacted by constituents about this—indeed, I was contacted by a lady from Stalbridge the other week who has now been trying to get on an NHS dentist waiting list for two years. That is simply not good enough when dental health is coming under pressure.

Speaking with another APPG hat on, I know that my right hon. Friend the Secretary of State is alert to the need for a speedy renewal of the health grant for those suffering as a result of thalidomide. That takes place in 2022-23. We all know the story of thalidomide; I am not going to rehearse it. We owe the victims of that scandal our support, and I hope that the grant will be renewed, either from new money from the Treasury in the comprehensive spending review or from the current NHS budget.

This is an opportunity to think about the future of the national health service, as my hon. Friend the Member for Watford (Dean Russell) said. We would all hold it in even greater esteem if all of us, as patients, were alert to the cost—the actual cost—of our medicines and our treatments. There would be far fewer medicines flushed down the loo and far fewer appointments missed if people knew the true cost to them, as taxpayers.

A number of hon. and right hon. Members have referenced the need to bolster preventive health still further. There is far more that we can do. Very often, the NHS is a national ill-health service; it merely picks up the problems that a more proactive preventive agenda could have solved. In that regard, I make a plea, in particular, for bowel cancer and prostate cancer—indeed, for the male cancers generally, which often get overlooked.

[Dr Whitford]

In a debate in August 2017, the Minister at the time agreed to reduce the starting age for bowel cancer screening in England from 60 to 50—as it has always been in Scotland—but here we are, two and a half years on, and there is no sign of that. Does the hon. Gentleman agree?

[Simon Hoare]

I do. The stasis of the past few years, as we have wrestled with and resolved the issue of Brexit, has almost pushed everything else out of public attention and political action. I rather hope that now, having got Brexit done, we can move on, with a comfortable majority, to deliver on exactly these things. Forgive me, Mr Deputy Speaker, but I should have declared an interest, although non-remunerative, as a trustee of a bowel cancer research charity.

Representing North Dorset, a heavily rural constituency, I know that we are all alert to—I do not think anybody has the solution to this in short term—how we are going to address the demographic time bomb of huge numbers of rural GPs retiring.

Health and Social Care

Philippa Whitford Excerpts

Thursday 16th January 2020 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

As the Secretary of State has said, health and social care is delivered by people, and I would like to pay tribute to all my former colleagues across the UK who, regardless of system, are working their best to help patients.

All four UK national health services face the same challenges of increasing demand, workforce shortages and tight finances, but the NHS in England has faced almost 10 years of unprecedented austerity, with annual uplifts of about 1% for quite a significant part of the past decade.

The NHS Funding Bill will enshrine in law the Government’s plan to give £33 billion extra per year by 2023-24. Although that is a bit of a stunt, as the Government do not have to force themselves to act by law, I am sure that it will be very welcome after such a long drought. Of course, in real terms it represents £20 billion, and is therefore not additional new money but the extra funding already promised by the former Chancellor in 2018. It is claimed that it represents the biggest uplift ever for the NHS, but it amounts to 3.4% per year, which is actually still less than the average annual uplift across the NHS’s history. It should allow stabilisation of the NHS in England, but it is unlikely to provide enough money for major transformation projects.

The extra funding is again to be funnelled largely into the NHS itself, to make it sound like a bigger number, but it ignores the other responsibilities of what is actually called the Department of Health and Social Care. Public health funding has been cut by £850 million, with the 10 most deprived areas in England losing over a third of their central public health funding, while the least deprived areas lost only 20%. Prevention services, such as smoking cessation, which was mentioned by the hon. Member for Broxbourne (Sir Charles Walker), have been cut. That does not make sense, as £1 spent on helping someone to quit smoking saves £10 in treatment for lung and heart diseases later.

Similarly, although the plan includes an extra £1 billion for social care, the funding gap is currently estimated to be £6 billion. With cuts of up to 60% to their central budgets, councils simply cannot make up the difference. There is little point in pouring extra money into the NHS without also tackling social care—it is like trying to fill a bath without putting in the plug.

Although it was Labour that introduced private healthcare companies into the NHS and saddled all four UK health services with financially crippling private finance initiatives, it was the coalition Government’s Health and Social Care Act 2012 that created the full-blown healthcare “market” in NHS England. The NHS long-term plan proposes to unpick some of that, with legislation to remove the barriers to integration, such as by repealing section 75, which forces commissioning groups to put contracts out to tender, and getting rid of tariffs, which can act as a perverse incentive and encourage hospital admissions.

It was the competitive market that drove NHS trusts in England into debts totalling £2.5 billion within two years. That led to the closure of beds and to the downgrading and closure of A&E departments, and it has caused a marked decline in emergency care services, which have been consistently lagging about 10% behind NHS Scotland’s A&E performance since March 2015. It is important to focus on the data from type 1 emergency departments, as that is the most relevant definition—hospital-based A&E units that are open 24 hours a day, seven days a week. Diluting that with data from minor injury units and walk-in centres just masks the real situation.

Performance has deteriorated in all four nations this winter, but while one in six patients in Scotland are waiting longer, a third of those in England and Wales are waiting more than four hours in A&E. Unlike the three devolved nations, NHS England does not publish the total time spent in A&E by a patient. It restarts the clock to measure trolley waits for those needing beds. As was mentioned by the shadow Secretary of State, in December, nearly 100,000 patients waited over four hours, and often up to 12, for a bed. That time is on top of the original wait in A&E.

The Government’s plan seems to be to change the measure rather than dealing with the issue, but the four-hour target is the canary in the coalmine, warning of stress on the whole system—not just A&E, not just the flow through hospitals, but the assessment of what is happening in the community. Poor disease prevention rates and struggling primary care services lead to more patients going to A&E, while a lack of social care provision means that they can get stuck in hospital, which causes a lack of beds for emergencies. The Government list social care reform in their legislative programme, but the previously promised Green Paper is still nowhere to be seen, and no solution has been proposed.

The Scottish Government choose to invest £276 more per head in health and social care, because in a comprehensive health system a pre-emptive approach is more cost-effective. That provides significantly more GPs, nurses and beds per head of population. Free prescriptions ensure that people take their medication and control chronic conditions, while the fact that joint replacements and cataract surgery are not rationed helps older people to remain active and independent rather than needing more and more social care. Free personal care allows the elderly to stay in their own homes, rather than ending up in care homes or even hospital.

The workforce is the biggest single challenge facing health and social care services. That problem has been aggravated by Brexit, with a 90% drop in the number of EU nurses coming to the UK and a one-third increase in the number leaving it. As was mentioned earlier, the shortage of doctors has been acutely exacerbated by the Government’s changes in the annual pension tax allowance; some doctors are receiving tax bills for tens of thousands of pounds after working overtime. Many senior clinicians have been refusing to do extra shifts, for which they are financially punished. That is likely to have been a major contributor to this winter’s poor performance, as we have not experienced either a flu epidemic or severe weather. I wish the Government and the medical bodies well in sorting out an acute problem that will only make life for our patients worse.

We have been promised 50,000 extra nurses, but as only 31,500 will be new staff, that will not cover the 44,000 nursing vacancies in England, and as recruitment is spread over five years, the gap is unlikely to close. I am sure that the profession welcomes the Government’s U-turn on the nursing bursary—yet another disastrous Tory policy is having to be unpicked—but the promise is for only £5,000 a year, compared with £10,000 in Scotland, and nursing students here will still face tuition fees. The removal of the bursary led to a one-third drop in the number of nursing applications, and a 5% drop in the number of students starting each year. In contrast, 21% more nursing students have been starting each year in Scotland since 2016.

We have been promised 6,000 extra GPs to deliver 5 million extra appointments over the next five years, but we are still waiting for the 5,000 extra who were promised in the 2015 general election. There are actually 1,000 fewer GPs in England, so I will not hold my breath.

I welcome reform of the Mental Health Act—which is quite different from the legislation in Scotland—and, in particular, the focus on compulsory detention, but we need investment in mental health support and early intervention. It is good that we are talking much more openly about mental health issues, including those of Members in this place, but we are still some way from achieving parity of esteem.

Having been a member of the pre-legislative Committee a year and a half ago, I welcome the Health Service Safety Investigations Bill. The aim is to copy the principles of air accident investigation, with a focus on learning lessons to prevent reoccurrence rather than apportioning blame to one person, particularly as “system failure” is nearly always a contributor and the chance to “design in” safety is then missed. While that will hopefully improve the learning from major incidents, it would be good to see more being done to prevent them from happening in the first place.

I was working as a surgeon in 2008, when the Scottish patient safety programme was set up. The first step was the introduction of a team approach to “pre-flight checks” in operating theatres to prevent surgical errors. As was reported in the British Journal of Surgery, that resulted in a 37% drop in the number of post-surgical deaths over approximately two years—among the largest reductions in surgical deaths ever documented. I was therefore surprised to hear from one of our Committee witnesses that the World Health Organisation pre-operative checklist was not standard practice in all surgical services in England.

The internationally acclaimed Scottish programme now extends to every aspect of healthcare and, despite dealing with increasing numbers of older and more complex patients, it has dramatically reduced hospital mortality by a quarter over the last 10 years. Reducing complications saves money, as well as being better for patients. For example, a one-third drop in bed sores since 2012 is estimated to be saving between £2 million and £5 million a year in Scotland.

The Government must accept that they got it wrong in 2012 with the Health and Social Care Act, and again in 2016 with the removal of the nursing bursary. They need to get rid of tuition fees, restore the bursary, and genuinely work to repair the fragmentation and damage done to the NHS in England by their “market” approach. The Prime Minister likes to attack the Scottish NHS. I gently suggest that he take the plank out of his own eye, read some statistics, and focus on sorting out the mess that his party has made of the health and social care system for which he is actually responsible.

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[Jeremy Hunt]

I thank the hon. Lady for raising that. We have made huge progress in sepsis care, and the vast majority of people who go to A&E now are checked for sepsis, but mistakes still happen, and I am sure that it affected her as it affected the families of the people I have talked about.

We must not be complacent about the things that go wrong. In the NHS, we talk about “never events”—the things that should never happen. Even now, after all the progress on patient safety, we operate on the wrong part of someone’s body four times a day. It is called wrong site surgery. When I was Health Secretary, we amputated someone’s wrong toe, and a lady had her ovary removed instead of her appendix.

[Dr Whitford]

I know that the right hon. Gentleman visited the Scottish patient safety programme to see in action the WHO checklist, which is designed precisely to prevent such events, so can he explain why the checklist was never introduced during his time as Secretary of State?

[Jeremy Hunt]

Actually, we do have WHO checklists throughout the NHS in England—I think they were introduced under Lord Darzi in the last Labour Government—but the truth is that even with those checklists, which are an important innovation, mistakes are still made because sometimes people read through lists and automatically give the answer they think people want to hear. This is why we have to be continually vigilant.

What is the solution? It is to ask ourselves honestly, when a mistake happens and when there is a tragedy, whether we really learn from that mistake or whether we brush it under the carpet. To understand how difficult an issue that is, we have to put ourselves in the shoes of the doctor or nurse when something terrible happens, such as a baby dying. It is incredibly traumatic for them, just as it is for the family. They want to do nothing more than to be completely open and transparent about what happened and to learn the lessons, but we make that practically impossible. People are terrified about being struck off by the Nursing and Midwifery Council or the General Medical Council. They are worried about the Care Quality Commission and about their professional reputation. They are worried about being fired. In order for a family whose child is disabled at birth to get compensation, they have to prove that the doctor was negligent, but any doctor is going to fight that.

The truth is that many of the mistakes that are made are not negligence, but we make it so difficult to be open about the ordinary human errors that any of us make in all our jobs. As we are not doctors and nurses, people do not generally die when we make mistakes. That shows the courage of entering that profession, and if we make it difficult for people to be open, we will not learn from those mistakes. That is why we need to change from a blame culture to a learning culture. That is also why, as we reflect on the devastating news that the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Mid Bedfordshire (Ms Dorries), gave the House last night that the Shrewsbury and Telford Hospital NHS Trust is now examining 900 cases dating back 40 years, we realise that the journey that the NHS has started on patient safety must continue. We should take pride in the fact that we are the only healthcare system in the world that is talking about this issue as much as we are, and if we get this right, we can be a beacon for safe healthcare across the world and really turn the NHS into the safest and highest-quality healthcare system anywhere.

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[Anne Marie Morris]

My hon. Friend makes a very good point, and I was very pleased to hear the Secretary of State say that community hospitals were valuable. We must have a fundamental rethink of the infrastructure and look at what we really need. In rural areas, where we cannot get to the best stroke centre, say, we must think seriously about how we use or reuse such facilities.

[Dr Whitford]

Talking about assets, do we not also need to sweat the assets that are in the community? In Scotland, we have had community pharmacies with minor ailment services since 2005, and we now have the same for optometrists, to the point that only a tiny percentage of people ever need to go to A&E if they have an eye injury, a red eye or another problem.

[Anne Marie Morris]

The hon. Lady—I almost said my hon. Friend because we share some common issues, and she is a great spokesman from the SNP Benches—is absolutely right. I think we would actually all agree that we need to look at the people who deliver these services and at the breadth we have, and involve them all appropriately.

We must also look at the new professions with the new associate levels. Physician associates take a huge part of the burden, and have a great career across the whole of primary and secondary care. Let us be innovative and creative, and provide the training, the financial support and the respect that I think many people working in our health system feel they do not necessarily receive from this place, although clearly they feel they have it from their patients. IT has always been the call of the Secretary of State, but again, let us be more imaginative. It is not just about communication; it is also about diagnosis and the delivery of care. There is much that can be done.

The Queen’s Speech refers to a medicines and medical devices Bill, which it is absolutely critical to get right. I am very keen to look at the speed of getting medicines to patients, but we need to do more than deal with clinical trials. There is much that has to be done with regard to the Medicines and Healthcare Products Regulatory Agency and NICE and their systems. I would like to see the approach to access to medicines be more ambitious.

Finally—I am getting the evil eye, I think, Madam Deputy Speaker—I am very pleased that in the NHS Funding Bill we are now committing to enshrine increased spending in law. My concern is: do we have the right level of spending, how will we be measuring need and is that spending matching the increase in demand? That is a good promise, but it needs considerably more work.

This Government have done a good job in setting out some of the key issues and priorities that we as a House need to address, but we must look at the detail, we must implement this and we must deliver.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 29th October 2019 Commons Chamber

[Jo Churchill]

I totally agree with the hon. Gentleman, and my constituency neighbour, the Secretary of State, is totally on this programme.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

In January, the Secretary of State announced that genomic testing would be provided in NHS England to healthy subjects for a few hundred pounds. This ill-advised plan, which would have widened health inequalities, seems to have gone quiet, so can the Minister confirm that the Government no longer plan to sell genetic testing and genomic testing in NHS England?

[Jo Churchill]

As the hon. Lady knows, because we have worked together on this agenda, it is never about selling the product; it is about better patient care and ensuring that we get technology to the patient as speedily as we can for better and appropriate diagnosis.

--- Later in debate ---

[Matt Hancock]

We will see shovels in the ground, I very much hope, from next year. I pay tribute to my hon. Friend, who has campaigned endlessly for these improvements to the hospital in Redditch. There is no better supporter of Redditch than her. She has badgered me endlessly, met me formally and bumped into me on the campaign. Every time I see her, she says, “Can we have the improvement to the hospital?” and the answer is yes.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The Secretary of State says that the NHS is not on the table, but President Trump and his trade officials have been very clear that they will seek to more than double drug prices, driving up the bill from £18 billion to £45 billion a year. What discussions is the Secretary of State having, and does he accept that this is why devolved Governments must have input in trade deals?

[Matt Hancock]

The NHS is not on the table in any trade deal. Medicine pricing and drugs pricing is not on the table in a trade deal. Let me bring the hon. Lady’s attention to this quotation from the former US trade general counsel, Stephen Vaughn, who said that if the UK really is determined to make no changes at all on pharmaceuticals, we can absolutely hold that position and that that has nothing to do with them. Quite right —we do hold that position; they are off the table.

The National Health Service

Philippa Whitford Excerpts

Wednesday 23rd October 2019 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Before I start my speech, I would like factually to correct the Secretary of State, who claimed that Barnett consequentials in Scotland are not passed on. I reassure him they are all passed on. He talks about the figures as a percentage. Scotland spends £185 a head more on healthcare and £157 a head more on social care. Of course it is a smaller percentage but, in actual cash, Barnett consequentials are all passed on. I would be grateful if he would either improve his maths or stop repeating this narrative.

I really welcome some elements of the Queen’s Speech, particularly the Health Service Safety Investigations Bill. I was asked to serve on the Joint Committee, which I felt did an incredible job, but we completed that job last July; approaching a year and a half on, sadly, the Bill has still not come forward. I hope it will not be too tardy from this point.

[Matt Hancock]

It is in the other place at the moment.

[Dr Whitford]

Okay; I welcome that. However, I would suggest that the Healthcare Safety Investigations Bill is about looking at mistakes after they have happened. I invite the Secretary of State again to look at the Scottish patient safety programme, which is more than 10 years old and has reduced hospital deaths, including post-surgical deaths, by over a third because the aim is to prevent harm in the first place.

I welcome the Secretary of State’s reference to whistleblowers, but it is not just about having guardians in hospitals. It is critical that the Public Interest Disclosure Act 1998 is reformed. Only 3% of employment tribunals are successful. All Members who have dealt with any cases on this issue will know that the wreckage of whistleblowers’ careers acts as an absolute brake on people coming forward. You can say what you like, but they are faced with the question, “Do I speak up and risk my career, my family income and my home?” It is not just a matter of paying lip service to this issue; we actually need change.

I welcome the ending of the private finance initiative, which was originally brought under a Conservative Government, but was really accelerated, I am afraid, under Gordon Brown. We are now facing the fact that £13 billion-worth of hospitals in England will have cost £80 billion by the time they are paid off. I call on the Secretary of State not just to end the PFI going forward, but to look at whether these contracts could be ended and renationalised to avoid another £55 billion having to be paid over the next 30 years. This problem is UK-wide, so we were saddled with these contracts in Scotland as well. There are health boards across England that are spending up to 16% of their income on their PFI contracts, and that obviously undermines patient care.

[Sir Mike Penning]

The hon. Lady is making a perfect point. I had the honour of being the roads Minister, and I desperately asked my officials to look at the PFI contracts on motorways around the country, including the M25. They found that the cost of coming out of these contracts is so formidable—simply because these companies’ lawyers were frankly a lot better than Gordon Brown’s lawyers when the contracts were written—that no Government would do it, so we are trapped. Some trusts—not least the trust in Romford, which also has a polyclinic—are trapped in debt from the private sector, which makes them completely inefficient.

[Dr Whitford]

I thank the right hon. Gentleman for that point. Of course, Governments can borrow at a much lower interest rate than any private business. Money is being sucked out of the NHS through the PFI across the UK, but there are also other ways in which money is being sucked out of the NHS, particularly NHS England—for example, through outsourcing under the Health and Social Care Act 2012. Private companies have to make a profit. Their chief executive is bound to make profit for the shareholders. They are not bound to deliver quality of care. We have seen clinical commissioning groups get trapped in this way. Six commissioning groups in Surrey tried to bring community care back into the NHS—they were not breaking a contract—but Virgin did what Virgin always does if it does not get a franchise renewed. It sued the CCGs. It is all hidden behind a commercial veil, but we know that at least one of those commissioning groups paid over £300,000 to settle out of court, and six groups together means that the figure was likely to be well over £2 million.

[Mr Sheerman]

I agree with almost everything the hon. Lady says about PFI contracts. We got a terrible PFI contract in Halifax and Calderdale. It is still a millstone around our necks. When I chaired the Education and Skills Committee, we looked at PFI contracts. The fact is that they are financial agreements, and some were better than others. But a lot of very clever City types came to places like Halifax and ran rings around the trust, so it got a bad deal. That is the truth of the matter.

[Dr Whitford]

That is true, and this obviously applies to the process of bidding and tendering for delivering services. An NHS orthopaedic department will not be able to compete with a major multinational with regards to its bid team, its tendering team and its ability to put in loss leaders. The problem is that all this money is being lost in a circular reorganisation that has been going on in NHS England literally for the last 25-plus years, with people being made redundant and given a big package, but then someone quite similar being re-employed or the same person being re-employed somewhere else with a different title—health authorities to primary care trusts to clinical commissioning groups. It is a huge waste of money, which is being sucked away from patient care, and that is where we want the money actually to go.

[Mike Gapes]

The right hon. Member for Hemel Hempstead (Sir Mike Penning) mentioned the Barking, Havering and Redbridge University Hospitals NHS Trust in Romford. Queen’s Hospital in Romford is part of that trust, as is King George Hospital in my constituency. There is an independent treatment centre on the site of King George Hospital, and several years ago it was proposed that the centre be brought back in-house. But the company involved went to court and the NHS had to concede that it would remain as an independent treatment centre. These things are very damaging to the finances and integrity of our NHS.

[Dr Whitford]

Well, I am afraid that it was the Labour party that set up independent treatment centres. I am a surgeon, and one of the issues was that such centres were sucking away the routine elective work that contributes to training future surgeons, and leaving the NHS to deal with the complex, chronic, expensive cases. Before the Health and Social Care Act, the NHS usually managed to find enough money down the back of the sofa that, at the end of each year, it would have about £500 million left. After the changes, it was £100 million in debt, £800 million in debt, and then £2.5 billion in debt. That is because money is sucked out in all these different ways, leaving a lack of funding that leads to rationing, which is pushing people to have to pay for more of their own care. We are hearing about that with co-payments—paying for a second cataract operation or for a second hearing aid. My Choice, which the Health and Social Care Act also brought in, raised the cap from 2% to 49% of income that an NHS hospital could earn through private patients. The highest amount at the moment is over 27%.

The idea that that does not impact on NHS patients is nonsense, because surgeons have limited capacity in terms of who they can operate on during the day, so if someone is able to jump the queue within the NHS, they are taking someone else’s place. As we saw with Warrington and Halton Hospitals NHS Foundation Trust, price lists have been pinned up in clinics suggesting to people that they might want to pay £7,000 or £8,000 for a hip or knee replacement, and there were also a lot of cosmetic and minor operations. I would gently suggest, as a surgeon, that surgery is not a sport. Either the patient needs an operation clinically, in which case it should be provided by the NHS, or they do not, in which case they should not be able to buy it from the NHS. Under the principle of My Choice, hugely high thresholds are being set. In the case of some CCGs, a person has to have had two falls before they can have a cataract operation, or they have to be in pain, even in bed, to get their hip done. That is driving families to club together to address that. That is not right. If someone needs it, the NHS is meant to provide it free at the point of need, and if they do not, every single operation is a risk and should never be done to attract income for an NHS trust.

[Bill Grant (Ayr, Carrick and Cumnock) (Con)]

I value the hon. Lady’s comments about how money is being sucked out of the NHS. In Scotland, we have a particular issue with a large showpiece hospital in Edinburgh that should have been opened in 2012, seven years ago, that is sucking money from the NHS—millions of pounds annually over the past six or seven years. She may wish to comment on that.

[Dr Whitford]

Well, it has not been sucking money for the past six or seven years because it was only declared open in February. I totally agree that it is a huge setback that, due to a failure within the health board’s tendering process for the build, it did not recognise the need for the level of ventilation in an intensive care unit. I would gently suggest to the hon. Gentleman that I do not think he would have wanted our Cabinet Secretary to simply go ahead putting babies and children in an intensive care unit where the ventilation was not considered safe.

In Scotland, so far our funding for the NHS has doubled in the past 10 years and will actually increase further next year. But it is not just about funding; it is about structure. What is happening in NHS England is fragmentation. It is not just that NHS hospitals are competing with private companies; they are competing with each other, and that undermines collaboration. We need to have collaboration, with the patient at the centre. Anything that fragments or undermines that collaboration is weakening the quality and safety of care.

[Tom Tugendhat]

Will the hon. Lady give way?

[Dr Whitford]

Okay, for the last time.

[Tom Tugendhat]

The hon. Lady is speaking very powerfully on many issues, as usual. I would be interested in her point of view on other health providers, because as she knows, having worked around the world, many of them do things differently, particularly around Europe, for example, where many of the hospitals are not owned by the state. Many of those hospitals compete and services are provided by different bodies—private companies, charities or community groups. Will she comment on how that works, because the French and Germans seem extremely happy with their healthcare?

[Dr Whitford]

As people in the Chamber may know, my husband is German and therefore I know that system in Germany relatively well. I would point out that the hospitals do not collaborate there either. As it is about income for the hospital, surgeons and clinicians will not always refer a patient on even though they know there is an expert down the road. I would not particularly defend that. I lost my sister-in-law two years ago, and the bills were still coming in for almost a year. That is quite a stressful and upsetting system. Not everything is covered. Patients still, as in many insurance systems, have to cover a gap, which can be significant and quite painful for them. These systems could not generate the epidemiological data, or anything like the treatment and outcome data, that is generatable in all four of the UK health services, because they do not have a nationwide system.

When I was back on the Health Committee for a short time this spring, we heard talk about the changes to the Health and Social Care Act. It is critically important that those go ahead, because there are perverse incentives within that legislation. At the moment, the tariff is paid to a trust only if patients are admitted. That is a perverse incentive against managing people in the community, or even prevention. It is important that section 75 is done away with completely so that there is not pressure on commissioning groups to put things out to tender, because that is a wasteful process. I remember reading about £500 million wasted in Nottingham, where there were preparations for a tender, then the private company did not go ahead and then it did go ahead.

All this is taking money away from patient care. That is the basis of the argument about publicly provided services. I am sorry, but the quips about drugs and so on by the Secretary of State were childish. Was he suggesting that nurses and doctors go into the North sea to drill for oil, or that that is the suggestion from the Opposition Benches? It is not the suggestion from anyone on the Opposition Benches that drugs would not be purchased. It was just a childish response. Having private companies pulling NHS England apart undermines it, fragments it and makes it not patient-centred, and being patient-centred should be the goal of every single health service across the UK.

[Several hon. Members rose—]

--- Later in debate ---

[Andrew Selous (South West Bedfordshire) (Con)]

Thank you very much indeed, Madam Deputy Speaker. Although I wish the House were completing the necessary Brexit legislation today, it is always a particular pleasure and, indeed, a responsibility to speak on the important subject of the NHS.

I, too, start by thanking every member of NHS staff —including two members of my own family—for what they do. The pressures on them are unrelenting, day in, day out, as all of us in this House must acknowledge. I, too, have a personal reason to be grateful to the NHS: when I was 24, I had a haemopneumothorax in the middle of the night, and the NHS saved my life with an emergency operation carried out in the hospital just over the river. Had it not been for the brilliant care I got some 30 years ago, I would not be here today making this speech.

When I met a number of presidents of royal colleges last month, they told me that they thought we needed to double the number of medical students in training. It is brilliant news that we recently increased their number by a quarter, but the ongoing NHS people review shows that demand is such that a doubling is needed. Another area we need to consider is highlighted by evidence that one to three hours a day of a doctor’s work could be done by non-clinical healthcare staff. Are we using our staff as effectively and appropriately as possible? I am worried by how many medical students we lose: having trained in this country at public expense, too many then go off to Australia, Dubai or elsewhere. Are there perverse incentives in the system? Where is the value for money for the taxpayer?

I hear from staff that sometimes they work with computers that take half an hour to warm up. Yes, we want to get rid of the fax machines and to use the latest technology, but computers that are just turned on and then work are vital for NHS staff under pressure. We need to put more nurses into care homes to curb inappropriate calls on accident and emergency services for residents. We need to make sure there are enough practice nurse courses in rural areas, where there are gaps that lead to poaching. Perhaps we could use the apprenticeship route.

I understand that 27% of medical school students who graduate go into general practice, yet the Royal College of General Practitioners says the percentage needs to be nearer 50% to meet the acute need for doctors in GP practices up and down the country. There is also great variation in the proportion of medical school students who go into general practice. We need to learn how to increase the proportion going into general practice, so acute is the need. I am also concerned that we do not have a proper career path for associate specialists, particularly in surgery, in our hospitals. They are valuable members of staff, but they can drift around the system a bit, and I understand that about 20% of them are leaving. We need to look after them better and plan for them more appropriately.

We need to link our health visitors more closely with the new primary care networks. Health visitors do invaluable work, but their national child measurement data is not transferred to GPs. That leads to problems and to childhood obesity not being tackled. As co-chair of the all-party group on obesity, it is great that we have chapter three of the childhood obesity plan, but I would just remind the Minister that the actions from chapter two, on watershed promotions and point of sale, have not yet been implemented. We need them to be implemented.

We also have a very bizarre issue in that the equality and outcomes framework does not cover children’s weight. In fact, it specifically excludes it—it covers only adults. Come on! We need to vary the contract to make sure it measures children’s weight.

We must do better on foetal alcohol syndrome disorder. It needs to be included in personal, social, health and economic education, and we need a massive public campaign. I am awaiting a letter back from the Secretary of State on that. It is a huge and growing issue that we do not talk about enough in this House.

We live in an obesogenic polluted environment, with unacceptably low levels of active travel. We need to design the healthy environments of the future if we are to relieve the NHS of the pressures that are otherwise going to overwhelm it.

We also need to be aware of the opportunities that NHS staff have to spot incidents of modern slavery. I would like to commend a very alert healthcare worker who last week, on the eve of Anti-Slavery Day, spotted the first victim of modern slavery in her hospital. She was alert to the symptoms and had done the training. NHS staff have a unique opportunity to bear down on modern slavery, and that is so important.

I was staggered to hear from the Scottish National party’s spokesman that the taxpayer is paying out £80 billion for £30 billion-worth of hospitals.

[Dr Whitford]

The figure is £13 billion.

[Andrew Selous]

It is even worse, then. Some trusts are paying up to 16% of their income on PFI payments. We really must learn from that and do much better.

--- Later in debate ---

[Chris Stephens]

That may very well be the case, but if the hon. Gentleman thinks that the concerns around TTIP were scaremongering, I disagree with him most strongly. Many of us thought that TTIP would have been Thatcherism’s ultimate triumph. I am glad that it did not proceed.

I will vote for the Opposition amendment because there are those of us in the House who do not trust the Government and who have real concerns about future trade deals and what they would mean for the NHS. Everyone in the House has a responsibility to support that amendment.

[Dr Whitford]

rose—

[Bim Afolami]

rose—

[Chris Stephens]

I give way to my hon. Friend first.

[Dr Whitford]

It is the case that Trump cannot change the NHS into an insurance system, but there are at least 19 Conservative Members who have expressed that view at some time in their career. What Trump has promised is to drive up the drugs bill by at least two and a half times.

[Chris Stephens]

As usual, my hon. Friend makes her case excellently. There are few people in the House who could match her knowledge of healthcare.

--- Later in debate ---

[Mr Deputy Speaker]

Yes.

[Dr Whitford]

On a point of order, Mr Deputy Speaker. In response to my question this morning about compensation for the victims of the contaminated blood scandal, the Minister for the Cabinet Office and Paymaster General suggested that the Government were waiting for

“the determination of legal liability, to which the inquiry’s deliberations relate”,

but surely he must recognise that under the Inquiries Act 2005 a public inquiry cannot determine liability, so how can I call for the Minister for the Cabinet Office to correct the answer that he gave?

[Mr Deputy Speaker]

You have done it for me. Those on the Treasury Bench have heard you.

NHS Pensions

Philippa Whitford Excerpts

Wednesday 26th June 2019 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I declare an interest: I spent more than 30 years as a consultant in the NHS and am married to a GP, so naturally the issue affects us. However, it also affects many of our colleagues.

The first thing to hit was the lifetime tax allowance changes. In my husband’s practice, I saw GPs being driven out at the age of about 57 or 58. They had had no intention of retiring early, but they had been warned in their annual meeting with their accountant that, because of the taper, they would suddenly reach a high marginal tax rate of well over 50%, which naturally is not very attractive. The result, exactly as other hon. Members have laid out, is that we are losing the people with the most expertise—the people who train the new people.

It is important that we do not get carried away into thinking that the NHS is about machinery, buildings or gizmos and gadgets. Every one of those gizmos and gadgets is used by a person. It is people in the NHS who care for, treat and diagnose people. If we do not have the workforce, all the waiting times that we like to stand up and talk about will be completely shot. The workforce issues that all four UK nations face are being made worse by these problems.

Many people may think, “A £1 million pension pot allowance? What a great problem to have!” It is a great problem, but the difficulty is that in general practice, GPs reach a high salary quite early, unlike in a hospital where becoming a consultant takes 15 or 16 years, so people have taken out added years and bought extra service. Because we graduate late, it ends up being very difficult to work for 40 years and have a half-salary pension. We thought about buying added years—we looked at it twice, but we could never afford it.

It is the same issue that arose with the Women Against State Pension Inequality Campaign and with Hewlett Packard, Magnox and all the others: people are expected to commit to a pension in their early 20s, but when they get to the other end, the goalposts have moved. It hits them when they can do nothing about it but bail out—and that is what they are doing.

The lifetime tax allowance limit has already driven out consultants and GPs before the age of 60, but what makes the problem much more acute is the tapering annual tax allowance. As we have heard, it was introduced in 2010 at more than £250,000 to avert tax avoidance and gaming of the system. Senior medics in the NHS are probably the highest-paid people who do not run a business. They are on pay-as-you-earn, so they cannot play the game of writing off this, that and the other or paying themselves in weird ways; they just get their payslip, and the tax is taken. They are not in the tax avoidance game that was perhaps thought of when the taper was introduced. The commercial sector is defined contribution, not defined benefit; it is how the limits interact with the NHS, and probably other public service schemes, that causes the problem.

The annual allowance was reduced to £50,000 in 2011 and then to £40,000 in 2014. For those caught by the taper, the allowance can go right down to £10,000. The threshold is £110,000—not £150,000, which was the impression that the Chancellor gave at Treasury questions on 21 May. People hit a cliff edge, as hon. Members have highlighted: all of a sudden, they are caught in a system where they are taxed over and over on the same income. It particularly affects consultants, who are paid about £110,000 or more, and full-time GPs.

Those who have been caught out and hit by these bills are now talking to their colleagues. The result is that people are refusing promotion and refusing to take on the extra duties that are required in the NHS, such as becoming an education director, a manager of junior doctors or a clinical lead, because anything that could bring in extra income for extra work could suddenly push them over the threshold. Doctors cannot see in advance whether they will be hit, so they cannot manage things over the year.

Some of the bills that arrive have been absolutely horrendous. The average bill is £18,500, but many are getting towards £100,000. No one has that kind of amount lying around in their bank account, however much they are paid. Even trying to pay the bill has caused terrible problems. People are paying it either from already taxed income or by taking a loan on which they will have to pay interest—or they are using scheme pays, borrowing from their pension pot to pay off their bill and then having to pay the money back at non-commercial rates. That still reduces their final pension pot, because the money has technically not been in it for the same length of time.

[Sir Robert Syms]

A BMA consultant told me that an actuary has done some modelling and found that the penalties are so severe that somebody who works 48 hours a week and has to borrow money from their pot at the end will have a lower pension than someone who works 24 hours a week.

[Dr Whitford]

I thank the hon. Gentleman for securing the debate and for making that point. I have not seen that actuarial working, but it highlights how completely bonkers the scheme is. People are trying not to do anything extra; they are doing everything to stay below the threshold, because once they are over it, they get sucked into a Kafkaesque spiral that pulls them down to ridiculous levels.

Another problem for GPs in England is that they are not getting their pension statements because of issues with the system; I think Capita runs it at the moment, and we know how well it runs some of the other services that it has been asked to manage. Non-pensionable income is counted, which seems very weird for pension tax allowances. The notional growth in someone’s pension pot is also being counted as income. I am sorry, but income is income; it is what someone earns or receives, not what might be sitting in their pension pot for them to gain in 10 years. All these problems are catching doctors out, because they cannot see them. As they have begun to suffer, all they can do is ensure that they stay below the threshold.

The former junior Health Minister—the hon. Member for Winchester (Steve Brine), with whom I have spent many hours in this Chamber—highlighted the fact that 80% of people affected will change practice. That is leading people to refuse anything that will lift up their income—not only promotion and extra duties, but extra sessions. Many of those who are in their early to mid-50s are talking about retiring, which would be cataclysmic. The survey that he mentioned shows that some 30% are already considering doing so.

Between six and seven years ago, we were suddenly hit with a doubling of our pension contributions—from about 6% to about 14%—which meant that my take-home pay went down. Here we are, six or seven years later, being punished because our pension pots are too big. It is completely bizarre.

The problem is that we cannot afford for those who are affected to retire. Every time we discuss workforce, we talk about recruitment and retention. These people are the ones who will train the new recruits, and we need to hold on to them. As has been mentioned, the measure is not devolved but its impact is devolved in health. Only this place can sort out the pensions mess.

I am really disappointed that we do not have a Treasury Minister listening to this debate, and I hope that at some point we will have a debate to which a Treasury Minister responds. The Minister for Health, who is here today, will have to gather our comments and take them to the Treasury, and we would rather communicate directly with the Treasury. This issue has to be sorted, or there will be an absolute workforce meltdown within the next two years.

--- Later in debate ---

[Anneliese Dodds]

I certainly will, Mr Gray. Thank you.

As I was saying, this debate is broadly around the contours of the taxation system and how they affect high-paid workers in particular. I am sure that the hon. Member for Winchester is aware that Labour has a different approach from that of the current Government around progressive taxation. We set out our proposals at the last general education: we indicated how, by increasing the tax paid by the very best-paid workers, we would free up the resources that are necessary. I am sure that he has seen what Labour produced in that regard—in particular, we would not pay for the boost in spending that the NHS needs only through a short-term windfall, which in practice is what the Chancellor did, because all the commitments that the Government made to the NHS were as a result of lower than projected spending and higher than projected taxation receipts.

That is not a sustainable way to fund our NHS in the long run. Instead, we should look at the longer-term measures that are necessary, which is exactly what we have been doing.

We need to ensure that NHS workers on lower incomes can save properly for retirement, but we also need to look at the situation that has been the focus of today’s debate. We need to focus on the changes that were made in the 2015 pension scheme, and how they interact with the variety of alterations that have been made to tax release. It is especially important to do so in the context of staff retention, and I understand the comments that Members have made about that topic. We have a particular problem with NHS staff leaving their jobs early, which in my experience is not merely because of these issues, although of course they are important. When I talk to senior staff in the NHS, they also mention stress, a general lack of resource, having to deal with short-term changes such as operating theatres being closed because of a lack of staff, and so on. A whole variety of features is driving those retention problems.

[Dr Whitford]

I accept that there are many other issues, and obviously all four UK health systems are stretched because workforce is their No. 1 issue, but this problem comes on top of that. People who feel stretched—people who feel they have a terrible work-life balance, who are working late and so on—suddenly find that the extra sessions they do are costing them money. That is a final slap in the face.

[Anneliese Dodds]

I am aware of that; for many, this issue can be the straw that breaks the camel’s back, especially when it is not anticipated.

I hope that the Government will look carefully at the impact of threshold effects, particularly cliff edges that lead to radical changes in the amount of tax paid, which is a significant problem with the UK tax system generally. The situation for incurring VAT is analogous to this one: small businesses are deliberately staying below the threshold because as soon as they go over it, they have to start paying VAT—not necessarily at a very high rate, but with all the bureaucracy and so on that comes with it. This situation is very similar: there is that cliff edge, where tax treatment suddenly becomes very different from what it was before.

In the long run, Government should aspire to learn from the best of what happens in other countries that have a more granular approach; where income is more tightly tied— and sometimes entirely tied—to tax treatment, so that as one’s income goes up, tax liability goes up stepwise. That seems a very sensible approach, but of course, getting there is a long-term aspiration. In the short term, I hope that the Minister—who I know is an open-minded person—will ask his Treasury colleagues to sit down with the experts and representative organisations, and talk to them about how these problems arise because of the interaction of the complex pension system with the complex treatment of tax release, so that there can be some kind of short-term fix with a view to, in the long term, having a much more rational approach to tax release on pension contributions.

--- Later in debate ---

[Stephen Hammond]

Let me make it clear that not only are the changes having an impact, they are likely to continue to have an impact. I recognise that; the hon. Gentleman will hear later in my remarks that we recognise that point.

My hon. Friend the Member for Poole was right to talk about the long-term plan and the cash settlement that goes with it. He was also right, though, to mention that any plan will work only if it works: if we make sure the people delivering it can do so with the numbers and experience required. The hon. Member for Newport West (Ruth Jones), although she said she was not expecting to speak this morning, made a thoughtful speech and raised a number of issues from her direct experience that informed the debate.

My hon. Friend the Member for Winchester (Steve Brine) represents the place where I was born and spent my childhood, so for that and other reasons, I always listen carefully to what he says. He was right to stress at the start of his speech that this is not about tax breaks for particular people, although that is the headline; the reality is that perverse disincentives are being created against providing the care that we need. I listened carefully to the hon. Member for Glasgow North East (Mr Sweeney), who has just intervened on me to reiterate the point he made in his speech about the experiences of some consultants, and I recognise that those experiences are not unique to Glasgow North East.

The hon. Member for Central Ayrshire (Dr Whitford) always makes many informed remarks, given her experience. She made a point that perhaps has not been picked up, but is important in informing the debate: this is not just about losing a number of potential outpatient appointments and clinicians to service them, but about the impact on training. In many of the places that I have had the honour to visit as Health Minister, it is clear that the mentoring and support provided by senior staff to more junior staff is an important contribution, not only to the wellbeing of those junior staff, but to their education and, therefore, to the benefit of patients. That is undoubtedly one of the consequences of what we are talking about today.

[Dr Whitford]

Obviously, senior clinicians are critical to clinical teaching, which is part of the work. However, as other Members have highlighted, consultants are refusing to take on the extra sessions involved in organising that teaching and running rotas for either junior doctors or medical students. Without that, it will just be chaos.

[Stephen Hammond]

The hon. Lady is right to make that point; as I said in my remarks about her speech, I recognise the impact on training. There is clearly concern that unless we address this matter, it will have a number of impacts, of which that is one.

The hon. Member for Oxford East (Anneliese Dodds), speaking for the Opposition, rightly opened her remarks by pointing out the scale of the cost of tax release for pensions to the Treasury. She made valid points about doctors’ knowledge about that liability, and about the interaction of core tax principles with particular schemes. I was rather hoping that she would also welcome the long-term plan and the cash settlement, but I suspect that element of unity was probably a step too far.

As my hon. Friend the Member for Poole may have mentioned at the beginning of his speech, we have fewer Members here and a lower number of contributions. However, those contributions, combined with some of the interventions, have meant that we have had a debate of high quality.

Needless to say, I have heard the representations from everyone in the Chamber. It will not surprise anyone that I have received, as has the Department, representations from NHS employers reporting exactly what we have been discussing—that consultants are increasingly no longer willing to work additional sessions. The lost capacity is clearly difficult to replace, especially in some clinical areas where there are already shortages, and it can be expensive, as employers can pay a premium for locums to fill the gap. It is obvious and right that where there is evidence of an impact on the delivery of services, the Government should be prepared to take action.

At the outset, I reiterate that the Secretary of State and I take seriously the concerns of doctors. That is why we have been involved in a number of discussions with the Treasury, which has resulted in the 50:50 flexibility and the consultation. I will come to that in a moment, but, as Members will hear as I develop my remarks, that will not be the end of our conversation with other Departments.

Looking at the case for pension flexibility, it is true that outside public service, employers in some cases have flexibility to adjust benefit packages to allow high-earning employees to target a lower level of pension saving and so reduce the potential for large regular annual allowance tax charges. That flexibility is not currently present in the NHS. The NHS pension scheme does not allow any flexibility over the level of pension growth. Staff who participate in the scheme must pension all regular earnings from their employment. The Government are right to take the view that it is important to ensure that staff have a good level of pension savings, but senior clinicians, particularly consultants and GPs, have a unique degree of flexibility over their workloads and obviously can reduce their commitments. Consultants can reduce the number of additional sessions undertaken, and many GPs are self-employed. That can create incentives for clinicians to seek to control their income and pension growth by limiting or reducing their NHS work to avoid breaching their annual allowance. As a number of Members have discussed, that clearly has an impact on the delivery of patient care.

It is clear that retaining and maximising the contribution of our highly-skilled clinical workforce is crucial to the NHS and the long-term plan for the NHS. While any pension tax regime should seek to achieve the fiscal ambition of distributing pension saving incentives fairly, it has to be recognised that, in combination with the fixed structure of the NHS pension scheme, that could produce—listening to the evidence today and the evidence I have directly received—unintended consequences for service capacity and the delivery of patient care. The Government are prepared to change the rules to give clinicians more flexibility.

Alongside the publication of the “Interim NHS People Plan” earlier this month, my right hon. Friend the Secretary of State announced our intention to consult on new flexibility for clinicians. The consultation will be published in the coming days—I hope very shortly—and will set out proposals for a 50:50-style option, offering 50% pension accrual and halved contributions. Earlier this year, as part of the new five-year GP contract, the BMA and NHS England asked the Government to consider introducing that option. While I recognise that the BMA has not been unequivocal in its support, it has welcomed the proposal as a step in the right direction.

The Government believe that a 50:50 option balances the benefit of flexibility with the fiscal impact to the Exchequer. The 50:50 option will allow clinicians to build up their pensions more slowly and at a lower cost. Clinicians will still need to make their own personal assessment as to whether their financial interests are best served by taking advantage of the 50:50 model or continuing with full-rate accrual, but I have heard—not necessarily in the debate today, but directly from a number of consultants—that the 50:50 option is not flexible enough and that other measures should be considered.

The new pension flexibility should be viewed as a positive development for clinicians. My hon. Friend the Member for Winchester mentioned that he has asked me about the consultation period on the Floor of the House and that he has spoken to consultants about it. The consultation will be an opportunity to listen to a range of views before any final proposition is agreed. I encourage all Members here today to encourage their local clinicians to take part in that consultation. Equally, I encourage anyone from the health system in its widest context to take note of the debate and take part in the consultation. We want not only to hear any suggestion that there is a generic case for tax changes, but to listen carefully to what clinicians say using their own personal examples to provide evidence for any change they seek.

[Stephen Hammond]

The consultation is both. I recognise, as I said a few moments ago, that the 50:50 option has not received unequivocal support from the BMA, but to its great credit, it has asked us to consider that. We have come forward with this proposal. The BMA has welcomed it, but has said that it would want to discuss further options for flexibility and other pension matters. We have said that the consultation will look at the merits of the 50:50 option—or question it—but we will rightly open up that consultation to other suggestions. My hon. Friend will have just heard me say that I hope Members will encourage their local clinicians to use the consultation as a way of expressing their concerns about the 50:50, if they have any, and to express their views on other measures they would like to see introduced in terms of pension contributions. I stress that point again in response to his intervention. He will probably be interested in my next set of remarks, which are on flexibility.

Although the 50:50 option provides a new flexibility, we recognise that it does not provide unlimited flexibility for clinicians to target their own personalised level of pension growth and contributions. The financing model for the scheme means that any flexibility that reduces contribution income has an immediate fiscal impact on the Exchequer. The 50:50 option does not set aside the annual and lifetime allowance tax policies, but will give clinicians a new flexibility to manage their pension growth.

Where 50% accrual reduces pension growth by more than they wish, clinicians can use the contribution savings from the 50:50 model to buy additional pension to customise their own pension growth incrementally. Additional pension can be purchased in units of £250. That clearly adds some flexibility to their ability to manage their own contributions. However, some clinicians may continue to experience annual allowance tax changes, even with accrual rates reduced to 50%. For that group, while 50:50 reduces the charge, it does not eliminate it. We recognise that a number of individuals may wish to target a lower level of pensions growth. We will listen carefully to that suggestion through the consultation.

[Dr Whitford]

Is the Minister suggesting that senior consultants in three pension schemes sit and manage whether they are going to use the 50:50 or add in top-ups? That creates a whole job for people who work often 50 to 60 hours a week doing the thing that they are actually meant to do; it would give them almost a side job to try to manage their pension. Could we not go back to something simpler, whereby they get their payslip with a fair amount of pension tax taken off, but not what is happening at the moment?

[Stephen Hammond]

I have listened carefully to what the hon. Lady has just said, and she will want to listen to my next remarks, but I think she will reflect on the fact that a system of annual and lifetime allowances has been in place for some time. They were first introduced by the previous Government, although there have been some changes. Whether or not she thinks it would be better to have an even simpler system, some people will have recognised over time that it is important to look at their own pension contributions. Although tax relief on pensions is one of the most expensive reliefs, and the NHS pension scheme is rightly one of the better schemes available, I absolutely recognise that annual allowances and negative tax rates have a huge impact on some clinicians and consequently on the services for patients.

Consultants have raised with me the issue of the tapered annual allowance that Members have spoken about. I have been asked why the taper threshold is currently set at £110,000, which cuts across, as many people have pointed out, the typical earnings of an NHS consultant, although some people might perceive £100,000 as a high level of income. Unsurprisingly, tax policy is not something that I can speak to, but I have asked the Treasury and it advises that the threshold income test is designed to ensure that only those on the highest incomes can be affected by the annual taper. In the Treasury’s opinion, the £110,000 threshold balances the desire to restrict the annual allowance taper to those on the highest incomes, while trying to minimise the reduction in the value of the individual’s annual allowance.

I have also been asked why the annual allowance taper calculation takes into account both pensionable and non-pensionable earnings. Again, with the obvious proviso that I cannot design tax policy, the Treasury advises that if non-pensionable pay is excluded from the annual allowance taper calculation, there is the possibility that an unscrupulous employer could reclassify some pay as non-pensionable. To ensure fairness, the Treasury includes all sources of income in the taper calculation. However, hon. Members will not be surprised to hear that I think the concern about unscrupulous employers is not one that applies to the NHS. I recognise the issues raised by hon. Members on behalf of their consultants with regard to the taper threshold, and I am grateful to the Treasury for the discussions we have had, which have resulted in the 50:50 flexibility, but I can assure hon. Members that that discussion has not concluded. We rightly recognise that other pension issues need to be resolved.

I am grateful that the Treasury continues to engage with concerns about the taper threshold and how it impacts upon the workforce. I am happy to assure hon. Members that the Department intends to continue having discussions so that the matter can have a resolution that we hope will sort the matter out in an equitable and fair way, and not only for tax principles. We want to ensure that the dedicated staff working in the NHS feel valued and understand that they will not be penalised through the creation of perverse incentives so that they do not do what we want them to do, which is to provide excellent patient care.

In closing, I again thank my hon. Friend the Member for Poole for raising this important issue. I hope that I have been able to do three things: first, show hon. Members that the Department and I as the Minister responsible for people in the health system recognise the concerns raised by hon. Members on behalf of their consultants. The issues have also been raised with me directly. Secondly, I hope people will recognise that the 50:50 option is an important first step in looking at issues associated with lifetime contributions. I urge hon. Members to encourage their consultants to use the consultation. Thirdly, I recognise there are still issues around the taper threshold and the annual allowance, and I give the Chamber a commitment that the Department will continue to discuss with the Treasury ways in which we might be able to resolve those matters. I conclude by reiterating how important the debate has been this morning.

Living with Dementia

Philippa Whitford Excerpts

Tuesday 25th June 2019 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, pay tribute to the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) for securing this crucial debate.

As has been said, the number of people suffering dementia in the UK is 850,000—I apologise, because I have already said “suffering” instead of “living with”, but many people are suffering. We talk about what is being done in pockets and what is being done well, but that is not happening for all those 850,000 people. Some of them are stuck in their houses, some are tutted at by people behind them in supermarkets and some are made to feel unwelcome in certain places. Until we can say that all 850,000 of those people are living well with dementia, we have not done our jobs.

There are 90,000 people living with dementia in Scotland, and more than 3,000 of them are under 65. The impact on those people has been touched on. It is estimated that only two thirds of people with dementia have been diagnosed, and that means that we do not actually have a handle on the scale of the problem.

Alzheimer’s—a term that many people use interchangeably with dementia—is the commonest form of dementia, but there is also vascular dementia; in many patients, it is mixed. A rarer form of dementia, Lewy body dementia, causes a particular type of dementia, with less memory loss but big impacts on movement. In particular, it causes hallucinations, and our police and firefighters should know about that. If they have had 50 calls from the same patient, it may be not because there is a burglar, but because that person is having hallucinations of a burglar. That is why we need to integrate all our public services, so that they learn from each other. Other conditions, such as HIV and Parkinson’s, can also lead to dementia. Many people know about memory loss, but there is not so much awareness of the difficulties that dementia creates with making decisions, concentrating and spatial awareness. People with advanced dementia have real difficulty moving around in our environment, and the situation is even worse if certain parts of the brain are impacted.

Unfortunately, at the moment treatment is very limited; there have been no new drugs for dementia since 2002. The most commonly used drugs are those that stop the breakdown of acetylcholine, a neurotransmitter that sends messages from one brain cell to the next. Those drugs can improve concentration, but they do not work against the underlying causes of dementia, partly because we still do not understand all the underlying causes. We see the breakdown of proteins, we see bits of proteins appearing in the brain and we see brain cells getting tangled up, but what exactly is causing all that? We need to upscale research to a totally game-changing level to understand the cause so that we can try to prevent and treat dementia. In Scotland in 2013, the Scottish Dementia Research Consortium was set up as an umbrella organisation to try to bring all such projects together. As well as laboratory research into the cause and treatment of dementia, research into a human rights approach to those living with dementia is critical in improving support and care.

We are also looking at adapting our health and care systems. As my hon. Friend the Member for North Ayrshire and Arran (Patricia Gibson) mentioned, two years ago Scotland published a national strategy for dementia, which is the country’s third such strategy; the first was in 2010. This one will focus on the whole pathway, from providing post-diagnostic support right through to end of life, and including community co-ordinators.

Dementia is the disease that our generation fears. My grandmother feared tuberculosis—people did not even name it; they called it “consumption”—and the people I looked after as a surgeon feared cancer. What many of us now fear is losing ourself, as we have heard described so graphically this morning, or losing the person we have loved all our adult life.

Providing social care is critical for those living with dementia and for their families. In Scotland, we have spent more on social care, which allows us to provide free personal care. That means that if someone can be supported at home to live with independence and dignity, it will not cost them or their family. Since Frank’s law came into effect in Scotland just two months ago, that has also applied to those under the age of 65. The care they receive is thus related to their illness and particular needs, without a bizarre cut-off at 65 that prevents a 64-year-old from receiving the care that they require.

The problem is that we are struggling to recruit people as carers, whether in care homes or in home care. Most people want to be cared for in their own home, but it is very labour-intensive. Some aspects of the situation are being made worse by Brexit. In parts of Scotland, such as the highlands, 30% of carers are from Europe, so there will be an existential problem for care services. We also need to turn caring into a proper professional career, with training, career development and a decent salary that rewards carers for the very difficult job that they do.

It is critical that we support a person with dementia along their entire journey. All we have to do is to sit in this Chamber and imagine ourselves in that clinic, getting that diagnosis, and then going home and finding that there is nothing—no information, no support and no one to answer questions. The integration agenda, which is further down the line in Scotland, is linking things up. We have linked our NHS back into integration since devolution, but integrating healthcare and social care is a lot harder; social care is much more fragmented, because it is provided by multiple private companies.

We have multiple projects going on in Scotland that are often recognised through Scotland’s dementia awards. My local health board has won one such award for its “Bridging the gap” project, which provides a dementia support adviser to liaise between hospital, community and family along the patient’s journey. In Wishaw, there is a theatre buddy scheme, so that if someone with dementia requires surgery, their buddy—they could be a worker or a relative—is there at the last moment before the operation and when the patient wakes up. One project that I particularly like is the provision of assistance dogs that have been trained by prisoners in Castle Huntly, which involves a double win: the prisoners are proud that they are helping someone in the community, and those living with dementia have assistance dogs.

However, for those who are living with dementia now, the most important thing is to make them feel welcome and included in the communities that we live in. In 2016, I was lucky enough to be invited to speak at the launch of Dementia Friendly Prestwick, which is led by a very impressive team, particularly Julie and Lorna, who are leading lights within it. I had not done any of the work required to set it up; I was just asked to give a speech at the launch. However, I was inspired by that launch to set up Dementia Friendly Troon and Villages, Troon being the community that I live in.

In Prestwick, a relaxed cinema has been running for three years. There are subtitles, the cinema is free, it is not as dark as most cinemas, they serve home-baked food and they have even had a local potter make double-handed cups. The baking is all done by Berelands House, one of our local nursing homes. The cinema was a finalist in the Scottish Dementia Awards, and the sound and screen are of really high quality; I went to watch one of the movies myself. That service is provided by Friends of the Broadway, the Broadway being an old cinema in Prestwick.

In Troon, we have relaxed golf and an allotment, which is supported by other gardeners. We started by asking, “Why do we love living in Ayrshire, and how do we help people to hang on to that for as long as possible?”

[Jim Shannon (Strangford) (DUP)]

First, I apologise for not being here at the start of the debate; I had a meeting with the Turkish ambassador, so I just could not be here earlier. Does the hon. Lady agree that greater support should be provided for those living with dementia to enable family members and other close relatives to take care of their loved ones—that is really important—for as long as possible before putting them into care facilities?

[Dr Whitford]

I absolutely agree; care should be provided in the home, if at all possible. That is where we would all want to be. The hon. Member for Ayr, Carrick and Cumnock (Bill Grant) mentioned the hotel room that uses colour as well as technology to make it easier for a person with dementia to stay in it, as well as making it easier for their carer to be there.

Guided walks are provided in Troon. Troon promenade is being redesigned to make it easier to move around on, and Troon is part of Cycling Without Age, which provides cycle rides along the promenade on trishaws every Sunday afternoon. Staff at our local airport, Prestwick, have received the training to make it a dementia-friendly airport. That all depends on Alzheimer Scotland, which provides training to staff at the airport and at other, smaller businesses, such as hairdressers and cafés.

We are the ones who have to make the change. All we are asked to do is be patient, rather than tutting behind someone in a supermarket. In our area, we have managed to get two supermarkets to provide relaxed lanes where people will not be rushed, but will be invited and chatted to as they come through. Let us all be less hectic, and let us make everyone feel welcome in our communities.

--- Later in debate ---

[Caroline Dinenage]

Respite care was one of the themes of the carers action plan that we published last year. SCIE is putting together guidance for local authorities on how they can best provide that crucial respite moment for those brilliant carers. [Interruption.]

A diagnosis is very much for an individual, but also for their families and loved ones and for their communities and workplaces. When those come together, it is possible to live well with dementia, as my hon. Friend the Member for Witney (Robert Courts) said. Such personal experiences make me passionate about my responsibilities as a Minister. The hon. Member for Halifax (Holly Lynch) challenged me to continue to push the Government to keep dementia as a priority, and I always will. I am proud of the Government’s commitment to deliver on the dementia challenge 2020 in full to make this the best country in the world to live for anyone with a dementia diagnosis.

The challenge aims to transform the lives of people with dementia, as well as their carers and their families, through better awareness, care and research. We have made significant progress as part of the challenge, but we know, as we have heard today, that there is still much more to do. We have already started our work on our strategy for the period beyond 2020. This is not something that finishes in 2020. It is simply the start of the next phase and we will publish our thoughts on it early next year.

One of the key successes of the challenge has been improved diagnosis. We are meeting our ambition, and today two thirds of people living with dementia receive a diagnosis, but we clearly still have some way to go. Of course, not everybody wants a diagnosis, but we know that a timely diagnosis enables a person with dementia to access the advice, information, care and support that can help them to live well with the condition and remain independent for as long as possible.

We are focusing on reducing the variation in local dementia diagnosis rates. There is a real geographical variation, and targeted support to identify and engage the areas most in need of assistance will really help. Reducing the gap in diagnosis rates will ensure that people with dementia have consistent access to a diagnosis wherever they are in the country. We also know that receiving good quality care improves the lives of people with dementia. Equipping our health and social care workforce with the skills that they need is therefore crucial to the quality of care for those living with dementia.

Since 2012—the hon. Member for Bradford South (Judith Cummins) mentioned this—1 million episodes of the tier 1 dementia awareness training have been completed by NHS staff, and more than 1 million care workers completed the care certificate, or common induction standards. We continue to work to meet our commitment that staff have the training appropriate to their role. We want to see more people doing the tier 2 training, which is much more robust, so we are exploring options to see how we can increase take-up for anyone who needs it.

[Dr Whitford]

Is there an audit of hospital environments? Just before I left to come here, my hospital was redesigned using coloured zones and imagery to help people with early dementia move around the hospital independently. Are there similar projects elsewhere?

[Caroline Dinenage]

That is an interesting question. I do not know the answer, but I would be keen to look into it to find out. We are looking to explore ways to encourage the take-up of tier 2 dementia training. I recently co-signed a letter to health and care organisations with the chief executives of Skills for Care and Health Education England to highlight the importance of dementia training and education, which is a really important part of our discussions.

We are also meeting our commitment on Government funding for dementia research of £60 million or more each year, to reach at least £300 million invested over the five years up to 2020. The figure is actually more than £60 million this year—it is £83.5 million. In addition, we have the UK Dementia Research Institute, which is funded to the tune of £290 million: £190 million from Government and £50 million each from the Alzheimer’s Society and Alzheimer’s Research UK.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 18th June 2019 Commons Chamber

[Matt Hancock]

My hon. Friend makes an important point, one that we have frequently discussed. As he knows, I am married to an osteopath, so I do recognise the value that osteopaths bring to all of us.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Research shows that the ratio of registered nurses to patients is one of the most important factors in patient safety, so members of the Royal College of Nursing are calling on the Secretary of State to follow Wales and Scotland and to bring in safe staffing legislation. What is his answer to them?

[Matt Hancock]

Of course we need to have the right number of nurses. We need to make sure that we also put in the funding. If the SNP Government in Scotland had put the same funding increases into the NHS in Scotland, there would have been half a billion pounds more there over the last five years. So let us start with getting the money in that we are putting in in England, but is not fully being reflected by the SNP Government in Scotland.

[Dr Whitford]

The SNP in Scotland spends £185 a head more than England, so the Secretary of State should check his figures. At over 11%, the nurse vacancy rate in England is more than double that in Scotland. Whereas student nursing numbers have increased every year in Scotland, there are 570 fewer nursing students this year in England. Is it not time to follow Scotland’s approach, reintroduce the nursing bursary and end tuition fees?

[Matt Hancock]

I am not going to let the SNP spokesman get away with this. Normally, she brings a thoughtful contribution to health debates, but she said that there is more spending in Scotland per head. The truth is this: the increase in spending in England over the last five years is 17.6%, but in Scotland the increase is only 13.1%. That represents half a billion pounds less: the increase in spending that we have seen in England that they have not seen in Scotland. She should recognise that fact.

Listeria: Contaminated Sandwiches

Philippa Whitford Excerpts

Monday 17th June 2019 Commons Chamber

[Mr Speaker]

I hope the hon. Member for Stone (Sir William Cash) will not be saddened by the fact that he is not yet a member of the Privy Council. After all, he is a Staffordshire knight, he has served his constituency without interruption in this House for 35 years, and I remind the House that the hon. Gentleman has a whole chapter named after him in the late Hugo Young’s estimable tome on Britain’s relationship with Europe. There is a chapter in the name of Mr Bill Cash.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, would like to express our sympathies with the families of the five patients who lost their lives, but also the four who remain critically ill. Obviously, we do not know what outcome they face.

As the shadow health spokesperson highlighted, these sandwiches were sold to 43 trusts, and while there have been no cases since 25 May, the incubation period of listeriosis is 70 days, so will surveillance of those 43 trusts continue alongside the Health Secretary’s investigation?

The Food Standards Agency published a report in 2014 about the dangers of hospital food. It cited 32 failures, including sandwiches spending hours outside fridges, and fridges often not being cold enough. Indeed, it has been highlighted that hospital sandwiches have been the commonest source of listeria outbreaks over the past two decades.

As the Health Secretary says, simple cases are often a matter of people being unwell for a few days, but listeria poses a major threat to pregnant women, who may lose their child, and is life-threatening for people who are already ill. Will the Health Secretary therefore pay particular attention in his review to why on earth people who were seriously ill or frail were being fed sandwiches? Someone who has no appetite and is recovering from illness is simply not going to be tempted by a pack of sandwiches. That really makes the case for bringing food preparation in-hospital and producing tempting meals, because nutrition is critical to recovery.

[Matt Hancock]

I entirely agree with and endorse what the hon. Lady has said. She is quite right to point out that a meal has to be appetising as well as nutritious. The best hospitals deliver that, and I would like that practice to be much more widespread.

I reassure the hon. Lady that the 2014 report by the Food Standards Agency was, as I understand it, looked into in great detail and assurances have been made that what it raised has, correctly, been followed through. Obviously, that was before my time as Health Secretary but I have taken advice on precisely the point she raises and I have been assured that what was necessary happened. I am open-minded, however, on what may have happened and what more needs to be done, and the review will absolutely look into that question.

Finally, the hon. Lady is absolutely right about the incubation period. We remain vigilant. Because listeria is a notifiable disease, Public Health England is told of every case and is able to analyse the links from every new case to existing cases. Notification of most cases takes place after the fact, given the nature of the disease, but we are then able to find genetic links, where they exist, and find out whether different cases have the same source.

Vaccination and Public Health

Philippa Whitford Excerpts

Wednesday 12th June 2019 Westminster Hall

[Chris Green]

I wholeheartedly agree with my hon. Friend. When I was young, I had both chickenpox and measles. At that time, it was part of growing up, and many people who have had those diseases think, “It’s not a big thing; it’s not a big problem.” However, serious health outcomes or problems can develop from diseases that people may dismiss as not being terribly important. In that sense, solidarity is vital; we must all take responsibility not only for ourselves and our own families, but for the wider community.

Media and social media concerns are just one factor. There are a number of other barriers to achieving comprehensive vaccination. The World Health Organisation highlights vaccine hesitancy, and identifies three Cs: confidence, complacency and convenience. Is it convenient to have the vaccination? Are people confident or complacent about take-up, with a sense of, “I’ll be one of the 5%,” or, “It’s not really a problem in our society; the treatment isn’t actually dealing with a significant problem”? Or do people think that the disease has gone the way of smallpox and been effectively eradicated? That is not the case, especially given the ease with which people can travel across the world.

The UK is a leader in what we do here, but our support for countries around the world is also incredibly important. Support for funding the Department for International Development is often challenging, but I think there will be pretty much universal support for the announcement earlier this year of the £10 million to develop vaccines against global infectious diseases. That came on the back of the Ebola crisis in west Africa, where 11,000 people were killed, and it goes into a wider fund of £120 million committed to infectious diseases. The UK is the single largest contributor to Gavi, contributing a quarter of its funding and saving hundreds of thousands of lives around the world.

The UK also has an important role to play in co-ordinating and helping other countries. If another country does not have the health infrastructure that we have, they will need that support—that was the case in the Ebola example in west Africa—and we can lend our expertise. I reiterate that with flights from west Africa to the UK, Europe and the rest of the world, the transition of easily communicable diseases is a significant risk.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is great that the hon. Gentleman has secured the debate.

[Geraint Davies (in the Chair)]

Order. According to the rules, Front-Bench spokespeople are not supposed to intervene in half-hour debates, but if Chris Green is happy to take that intervention, I will allow it. I just thought that I needed to put that on the record.

[Chris Green]

I am happy to take the intervention.

[Dr Whitford]

As chair of the all-party parliamentary group on vaccinations for all, I was very disappointed that our debate in the Chamber sadly clashed with the local government elections and was therefore poorly supported. I welcome the hon. Gentleman’s comment on health systems. A huge amount of work has been done on eradication, but less than 10% of children have had their full World Health Organisation vaccinations. Thankfully, the big global players are beginning to see that it is about universal health coverage and routine vaccination.

[Chris Green]

Absolutely; those comments are so important. I recognise the hon. Lady’s chairmanship of the all-party parliamentary group on vaccinations for all, which is a really important group.

There has been a slight decline in the UK in the take-up of vaccinations. Is the Minister concerned that recent healthcare reforms have inadvertently contributed to the decline in vaccination rates, as highlighted by the British Medical Association? The loss of care roles—such as primary care trust immunisation co-ordinators, who provide training as well as co-ordination—occurred as responsibility was moved away from primary care trusts.

Turning around the gradual decline in vaccination coverage is likely to involve the provision of more accessible services and more active outreach by health professionals into individual under-vaccinated communities; the wider provision of vaccination services, through things such as school visits by community nurses and mobile vaccination services; better training of health professionals on what vaccines are, what they do, how they work and what is in them, so that those professionals are ably equipped to answer parents’ questions; increasing public awareness of the benefits that vaccines confer and the danger that the return of vaccine-preventable diseases poses; provision of the right public health funding to enable vaccination services to function effectively, including by reaching under-vaccinated groups, which costs more than standard provision; and communicating with parents to improve their access to evidence-based information. By implementing some, if not all, of those ideas, we will help to address the difficulties that are leading to a fall in vaccination rates, and make a positive case for why immunisation is good for public health.

This debate is timely, given that NHS England is currently undertaking a review of GP-led vaccinations and immunisations. The review was first announced in January as part of the NHS long-term plan, but it began properly only in the last six weeks. The purpose of the review is to consider how screening and vaccination programmes could be designed to support the narrowing of health inequalities, as well as to reduce complexity, improve value and increase the impact of the current vaccination programmes delivered by general practices. That includes reducing the administrative burden on GPs by simplifying the system, addressing the anomalies in the system that directly incentivise some vaccines but not others, and looking at how we deal with outbreaks and catch-up programmes.

The review is a perfect opportunity to assess how each vaccine programme is performing and to address and improve underperforming programmes. There are also opportunities to streamline the system and introduce a consistent approach. For example, some programmes, such as flu and pneumococcal programmes, include call and recall measures to boost uptake, but that is not the case for other programmes, such as shingles.

Community pharmacies have a really important role, and they could make an important contribution to vaccination. They are a convenient way for people to address their healthcare and receive vaccination services, perhaps without the need for an appointment. Many community pharmacies in England already deliver the NHS flu vaccination service, which has proved popular among patients. Following that success, would it not be possible to provide a wider range of vaccines in that way? That would help people to remain healthy, and it would reduce GP’s workload and the wider pressure on the health service.

Community pharmacies are uniquely positioned to help the NHS to meet its immunisation targets in England, and to help to ensure that people in more deprived communities receive the vaccinations they need. In contrast to other healthcare settings, there is a greater density of pharmacies in the most deprived areas per head of the population, making pharmacies ideal for bridging the gap in areas where people face greater health inequalities.

I reiterate that the UK has a strong history of vaccinations, from being the country that invented the first ever vaccine to becoming a truly global player in creating a healthier world for everyone to live in. However, we must take stock of vaccination levels here at home, and we must not allow complacency or misinformation to reduce the level of immunisation. We must continue to strive for the highest levels of immunisation, so that our children continue to enjoy living in a healthy society free from disease. I thank the British Society for Immunology, Save the Children and the Pharmaceutical Services Negotiating Committee for their help. I am glad that we are having this important debate, and I look forward to hearing from the Minister.

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

It is a great pleasure to serve under your chairmanship, Mr Davies. I am pleased to stand before the House in recognition of one of our greatest achievements in health. I thank my hon. Friend the Member for Bolton West (Chris Green), my Lancashire neighbour, for tabling the debate. He is a great champion for his constituents and for raising science and health issues on to the parliamentary agenda.

Immunisation offers every child the chance of a healthy life, from their earliest beginnings and into old age. It saves millions of lives every year, and after clean water is the world’s most successful and cost-effective public health intervention. Our vaccination programmes are a cornerstone of the UK’s public health offer, and I know that all hon. Members here will join me in commending those involved in the delivery of our world-class vaccination programmes, which protect both individuals and all our communities. Our routine vaccination programme protects against 16 different diseases that, even today in developed countries, can cause serious long-term ill health, and even death, if not prevented.

The Government are committed to keeping vaccination uptake rates as high as possible. We constantly review ways to do that, and we are committed to ensuring that everyone eligible for vaccination takes up the offer. We should be proud that our routine vaccinations in England continue to have a high uptake, with more than 90% coverage for almost all childhood vaccines. That reflects the high levels of confidence that the vast majority of parents rightly have in our vaccination programmes.

[Dr Whitford]

The levels are above 90% for the majority, but does the Minister accept that the WHO advice is that the figure should be 95%, for community safety? We have to tackle this drop of even a few per cent.

[Seema Kennedy]

I wholeheartedly agree with the hon. Lady, who brings to this place her great expertise from a career as a doctor. The Government have a commitment to reach the WHO target of 95%.

My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) is no longer in his place, but he made an intervention. He referred to mothers, but I think that all parents—mothers and fathers—have a responsibility to ensure that their children are immunised. I urge parents who are thinking of getting the last rounds of MMR vaccines for their children to do so. In every classroom, there will be children who are immunosuppressed and unable to have those vaccinations, so it falls to all the rest of us, as parents, to ensure that our children have their vaccinations.

Evidence from Public Health England’s annual attitudinal surveys, which have been run since the early 1990s, shows that more than 90% of parents trust our vaccination programmes and most people automatically get their children vaccinated. Regrettably, there has been a small, steady decline in coverage since 2013. That is of concern. There are likely to be many factors contributing to it, not just a single one. We are not complacent and we know that we need to take action now to halt the decline. That is why I am so glad that my hon. Friend the Member for Bolton West sought this debate: it enables me to outline some of the measures that my Department is taking.

The Department of Health and Social Care leads on policy for immunisation in England, and officials are working very closely with Public Health England and NHS England to take steps to improve vaccination coverage and reverse the downward trend. That includes better national co-ordination of our vaccination programmes; making it easier for people to access vaccinations; making information readily available to parents and those needing vaccines; and better training for staff to enable them to answer questions that parents may have.

In addition, we have data systems to ensure accurate information on the immunisation status of children and young people, so that health professionals can provide a “catch-up” on any missed vaccinations. We will continue to improve those systems. For example, the Digital Child Health programme, which includes the development of a digital personal child health record, will create a system that allows parents and healthcare practitioners to access a child’s immunisation history, improving the ability to give immunisations at every opportunity.

NHS England is reviewing vaccinations in the context of the GP contract, to ensure that GPs are properly reimbursed for vaccinating their populations and that the right incentives for increased uptake rates are in place. That is set out in “The NHS Long Term Plan”, published in January of this year.

My hon. Friend the Member for Bolton West asked about community pharmacies and the very important role that they have to play in our primary care. I thank him for his suggestion. The Government recognise the value and importance of the services that community pharmacies provide. We want to see them working with primary care networks to encourage more people to use their local pharmacy to keep them healthy.

With regard to vaccinations, I am aware of the success, which my hon. Friend highlighted, of seasonal flu vaccines. Indeed, the number of seasonal flu vaccinations provided by pharmacies between September 2018 and March 2019 was more than 1.4 million. I had my seasonal flu vaccine in my local pharmacy in Penwortham. I am sure that my hon. Friend, as a very responsible parliamentarian, had one as well. His facial expression suggests otherwise; perhaps he will have one this September. I will write to him regarding his suggestion. NHS England is currently leading a review of GP vaccinations, and I would not want to pre-empt its findings.

It is very important that our vaccination programmes continue to evolve. They are constantly reviewed and updated to reflect the changing nature of infectious diseases, based on expert advice. The Government receive expert advice on vaccination programmes based on decisions from the independent Joint Committee on Vaccination and Immunisation. That includes advice on new and existing programmes and on which vaccines should be used. Recent examples of JCVI advice leading to improvements to our vaccination programmes include the extension of the seasonal flu immunisation programme to children and the extension of human papillomavirus vaccination to adolescent boys.

It is important to remember—the House will be aware of this—that if we do not continue to vaccinate, diseases that we rarely see in the UK at the moment will return. Examples of such diseases are diphtheria, measles, tetanus and polio. Vaccines are responsible for a substantial reduction in the number of those infections.

Let us cast our minds back to the early 1950s, when there were epidemics of polio infections, with symptoms ranging in severity from fever, to meningitis, to paralysis. At the time, there were as many as 8,000 annual notifications of infantile paralysis caused by polio in this country. Following the introduction of polio immunisation, the numbers of cases fell rapidly to very low levels. The last outbreak that started in the UK was in the late 1970s. Today, protection against that disease is included in our 6-in-1 vaccine, and owing to the success of the vaccination programmes, that disease and its effects are now rarely seen in the UK.

We should be very proud of our successes in the UK and of the public health benefits afforded by our immunisation programmes. However, as I hope I have made clear to hon. Members today, we are not complacent. We will continually seek to improve those services, seeking advice from experts and taking proactive action, to ensure that we have the best vaccination offer in order to protect the health of our nation.

Question put and agreed to.

Interim NHS People Plan

Philippa Whitford Excerpts

Wednesday 5th June 2019 Commons Chamber

[Stephen Hammond]

My right hon. and learned Friend the Father of the House is completely correct. We want to make sure it is clear that the EU nationals who work in the national health service—there are more than 63,000 of them—are valued and make a huge contribution to our NHS. He will probably be aware that my right hon. Friends the Secretary of State and the Home Secretary are in continuing negotiations, to ensure that there is no change to that position. I guarantee that we want to see EU nationals continue to work in and contribute to our great health service.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I welcome the interim NHS people plan. Workforce is the greatest challenge across all four health services, but the 41,000 nursing vacancies in NHS England are simply a patient safety issue and cannot be parked on some shelf or kicked into the long grass. The plan identifies the removal of the nursing bursary and the imposition of student fees leading to a drop of over 30% in new student nurses. Will the Minister commit to re-establishing the bursary? Scotland preserved the bursary and free tuition, and our nursing vacancy rate is less than half that. The plan also calls for 5,000 new GPs. I remember the former Secretary of State promising 5,000 new GPs by next year, and rather than being close to delivering that, there are 1,000 fewer. How will the Minister deliver 5,000 extra GPs? Will he increase funding to Health Education England to deliver it?

There is no question but that the NHS across the UK will need non-UK staff. How will the Minister attract both EU and non-EU staff when there has been a 90% drop in European nurses coming here, and non-EU doctors are leaving because of visa charges and the £400 a year they pay per member of their family to access NHS services? What is he going to do about the pension tax allowance rules that are driving young consultants out of the NHS?

[Stephen Hammond]

I thank the hon. Lady for welcoming the plan. I think she will accept that this is a good interim plan; it is a stepping stone. She asks what we are doing to fill nursing places. I point out yet again that we are increasing applications and ensuring that there are 5,000 extra clinical placements available, which is a 25% increase on last year. Far from being complacent about the number of nursing applicants, we are looking to ensure that more nurses can be trained in this country, beyond the 35,000 who are being trained at the moment.

The hon. Lady asked about doctors. The Royal College of Physicians has made it clear that we need more medical school students. We are committed to increasing the number of undergraduate medical school places for domestic students by 1,500, with the first 630 being taken up last year. By 2020, there will be five new medical schools across England, helping to deliver—[Interruption.] Of course it takes time, but if we do not take that step now, we will never make the end of that journey. That has been a consistent problem for many years. There are still more doctors coming through now, but we need to do more, which is why this plan is being put in place.

The hon. Lady will have heard me say to my right hon. and learned Friend the Father of the House that there are more than 63,000 EU nationals working in the health service. That is more than there were in December 2017, and over 5,000 more than there were in June 2016. She is right to point out that we want those skills in the right clinical areas. I reiterate what I said a moment ago: we wish to make it absolutely clear that the contribution of EU nationals working in the health service is extraordinary and valued and will continue to be so.

The hon. Lady briefly mentioned pensions. She will have noted that we launched a consultation yesterday, setting out some ideas. I am pleased to say that the British Medical Association has welcomed them but asked us to look at other flexibility within the pension rules. I encourage the hon. Lady and all consultants to take part in that consultation.