NHS Whistleblowers

Philippa Whitford Excerpts

Wednesday 18th July 2018 Westminster Hall

[Geraint Davies (in the Chair)]

I call Dr Philippa Whitford to move the motion. I know it is a bit early, but we are all here.

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

I beg to move,

That this House has considered NHS whistleblowers and the Public Interest Disclosure Act 1998.

It is an honour to serve under your chairmanship, Mr Davies. Gosport, Morecambe Bay, Mid Staffordshire and Bristol Royal Infirmary are NHS scandals that all have quite a few things in common: they went on for a long time and often whistleblowers who might have brought the issue to an end and saved lives were punished or ignored. They were certainly intimidated. The anaesthetist who raised the issue of baby cardiac surgery at Bristol Royal Infirmary ended up in Australia.

The term “whistleblower” suggests a pressure cooker—a build-up of pressure to the point where someone cannot resist it any longer and feels the need to come forward. We are trying to decompress some of that impression by having audit of patient safety through such systems as Datix, where staff get used to reporting every little aspect that does not go smoothly, which therefore creates the habit of coming forward. We still have issues. They often relate to the whole system, the trust or perhaps the behaviour of certain medical or clinical staff. There is no easy way to come forward, and the people seeing that behaviour take a long time to be listened to or to step up.

In the investigation into Mid Staffordshire, which was the worst NHS scandal, Sir Robert Francis’s report spoke about developing a “freedom to speak up” culture, to make doing so normal. Sir Robert suggested only minor changes to the Public Interest Disclosure Act 1998 but, as I will come on to later, I think it needs major change because it underwrites everything else.

[Mr Jim Cunningham (Coventry South) (Lab)]

I congratulate the hon. Lady on securing this timely debate. I had two cases in Coventry, going back 10 or 15 years, in which consultants were suspended for whistleblowing. On the one hand, the Government encourage whistleblowers, but on the other the national health service seems to have a different definition of whistleblowers. One of those cases ended up in court. I do not know the exact figure, but it cost between £3 million and £4 million, and went on for at least 10 years. Meanwhile, back at the ranch, the individual was losing their skills. What does she think about that?

[Dr Whitford]

Obviously, I am unaware of the individual case and the rights and wrongs of it. However, a review of the cost of whistleblowing as it stands shows that having an effective system and effective law would save us money overall.

Sir Robert Francis envisaged “freedom to speak up” guardians in each trust, to whom whistleblowers could go informally to seek advice and support. Such guardians are in all trusts across England. They include a wide range of people, and the appointment system is not altogether clear or transparent. We will have to look at what kinds of staff work best, whether appointments have been appropriate, and whether whistleblower guardians can recognise, if they are clinicians—which many of them are—that there might be a conflict of interest, because the issue might be in their department. The national guardian has been in place since 2016, but her position is non-statutory and sits inside the Care Quality Commission. Her role is described on the website as “leading cultural change” rather than deciding individual cases.

Through all the publicity, there has been quite a change in atmosphere and tone. The whole issue has had a significant airing. In Scotland, we have an alert and advice line run by Public Concern at Work. It is interesting to see the changes from the second half of 2016 to the first half of 2017. The number of concerns that the hospital, or the health board as it is in Scotland, admitted immediately were valid—instead of their having to be proved, or their being put off—went from 0% to 14%. The number of those that were ignored or denied dropped by 30%, and those reported to a manager or a senior manager went up by 30%. That suggests quite a difference in practice. The numbers are quite small, but they suggest a pattern. The data showed that, naturally, the most common group to report is nurses—they are the biggest employed group within the NHS—and the most common reason was still patient safety.

The problem is that that is all still legally underpinned by the Public Interest Disclosure Act, which was passed in 1998. It was a private Member’s Bill very similar to one that had been introduced a few months before. It therefore did not have a Second Reading, and it had only one day in Committee. At the time, it definitely was ahead of what was going on elsewhere, and was a recognition of the importance of whistleblowers, but that was 20 years ago. It really is time for change.

[Mike Hill (Hartlepool) (Lab)]

Does the hon. Lady agree that workers are still put off by responses to whistleblowing allegations and, under the legislation, the threat of disciplinary action if the complaint is perceived to be malicious?

[Dr Whitford]

I utterly agree. It is important to be clear that a disclosure in the NHS, which is what we are focusing on, regarding patient safety as opposed to employment issues, which are quite separate and dealt with differently, is in the public interest. The problem is that in cases where whistleblowers have been punished and have suffered detriment, what starts as reporting becomes a bullying and harassment issue that ends up in a normal employment tribunal setting, and the original concern is not dealt with.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Lady on bringing this matter to Westminster Hall for consideration. Some 7,000 staff raised concerns about bullying or patient safety in 2017-18. Over the same period, some 356 whistleblowers said that they had experienced repercussions, ranging from subtle persecution, such as career opportunities being closed off, to being fired unjustly. That is truly shocking. Does she agree that the Minister may have to look at a full investigation into just how far-ranging these matters are?

[Dr Whitford]

I thank the hon. Gentleman for his intervention. I hope that this is just the first little step towards putting the matter on the agenda. The tragedies at Gosport brought the whole issue back. A nurse had come forward years and years ago, and could have saved hundreds of lives had she been listened to. Not being listened to is almost the least that can happen to a whistleblower, in that often they suffer detriment or reprisals and even lose their jobs.

The one change that Sir Robert Francis suggested to PIDA that has been made in England and Scotland is redress for discrimination regarding new employment—that is, applying for a new post within the NHS. Work is under way to introduce that in Wales as well. However, the main Act remains as it was. The first key weakness of PIDA is that it does not ensure an investigation of the whistleblower’s concern. Given the risks they take when they come forward, the detriment they may face, and the months or years of tribunals or other stages, it is crucial that the concern that made them step forward is not either overshadowed or completely ignored. I think that is their biggest frustration.

The Act most certainly does not protect whistleblowers. It describes itself as protecting whistleblowers from detriment, intimidation and reprisals, but PIDA can be used only for litigation after the detriment. Once someone has lost their job they can take their employer to an employment tribunal and attempt to have redress. The problem at that point is that the whistleblower has to prove that it was their disclosure—their coming forward and speaking up—that drove the loss of their job. Of course, employers will find all sorts of other excuses, such as, “Oh, they didn’t get on with their colleagues,” or, “They were a trouble maker,” or, “They were late for work.”

The success rate of litigation under PIDA is 3%, which is appalling, and shows how utterly weak the law is. Whistleblowers suffer further detriment while going through litigation. They know that they may face being landed with the costs. They may face bankruptcy, and stress that could go on for extended periods. Furthermore, between 2013 and 2017, people had to pay for employment tribunals. That, of course, closed that avenue off to many whistleblowers.

I make the simple case that we need a new public interest disclosure law. It should not sit inside employment law. It should not be a tweak to what we have now. We should recognise that the Public Interest Disclosure Act covers all sectors. The NHS may be one of the most common sectors to have whistleblowers, but the Act covers finance, research and business. We need a specific law.

It must be utterly clear that such disclosures are in the public interest, and that is where I disagree with the hon. Member for Stirling (Stephen Kerr), who may speak later. I do not agree with paying bounties to those who would disclose. Whether or not it creates a conflict of interest, it certainly gives the impression of doing so. It is utterly important, in the defence and protection of whistleblowers, that they can show that the only reason they have come forward is to protect patients or whoever the consumer is in their service.

[Stephen Kerr (Stirling) (Con)]

Just for clarity, I am not advocating bounties. It is one of the options to be looked at, but there are reservations about it, which I know the hon. Lady shares.

--- Later in debate ---

[Dr Whitford]

I thank the hon. Gentleman, who has set up an all-party group on whistleblowing and on the Public Interest Disclosure Act 1998. I welcome that, but one of my concerns is the issue of bounties.

It is important that we have a new PIDA law and an independent, statutory body that is equal to other bodies and can take on the NHS, NHS Improvement and the CQC. It must not be a department in one of those regulators; it must be separate from the NHS to ensure real independence, and it must investigate and act on concerns. If a local investigation has failed or is failing, there should be a mechanism to report that to an independent body. If we get to the point where there is simply a slanging match within a trust, there will never be a satisfactory resolution, so arbitration needs to come in and look at the cold facts and the original facts of the disclosure. Often, what is looked at is the process, but not whether the whistleblower was actually right to raise an issue in the first place.

It is critical that whistleblowers are protected from detriment from the moment of speaking up. They should be protected during the investigation, and they must not be picked on either subtly, as the hon. Member for Strangford (Jim Shannon) said, or blatantly—they must not lose their jobs. It is important that legal penalties for reprisals against whistleblowers can actually be enforced.

There should be a system of redress for whistleblowers that does not involve litigation. Litigation is expensive for the NHS and the whistleblower, and is utterly confrontational. That means that, at the end of the process, even when a whistleblower has been proven to be right and genuine, there has often been such a breakdown in relationships that it is not possible for them to go back to their previous role.

[Mr Jim Cunningham]

I thank the hon. Lady for giving way once again. The case I outlined actually ended up in the courts, and the hospital was told to take the individual back. Well, it never took him back. There was a long, drawn-out process over a number of years, and it was eventually settled through litigation. That individual—Dr Mattu—was a well-known consultant.

Some of the older Members will remember the case, going back 10 or 15 years. We had debates and got the support of Mr Speaker. The hospital tried to use letters I sent to it, in which I raised issues that had been raised with me, in the courts, and the judge ruled it out of order. The hon. Lady is right that we need an independent body, but where it finds that the hospital is guilty, as it were, and that the whistleblower was doing their job, it should have the power to order reinstatement—that is the nub of the matter—to ensure they are not victimised.

[Dr Whitford]

I agree that there should be protection to ensure that whistleblowers are not victimised, but the problem is that if the relationships have been allowed to break down because the system is so confrontational, often even the whistleblower does not consider it possible to go back. That is a tragedy, because it often means losing someone talented, particularly at a time when we are so short of staff in all four NHS systems in the UK.

The body obviously needs to be statutory so it has enforcement powers, but it should also be responsible for developing standards and training to show hospital trusts, health boards and hospitals, regardless of the system, what good looks like. Setting up, speaking up for and reporting on a body structure for the NHS will be for all four nations, because health is devolved, but PIDA still sits above that. It needs to be the underpinning statutory law that gives the body force.

In Scotland, we are still working on our system. Obviously, the Francis report looked at the system in England. We have whistleblower champions in our health boards, but we are working on setting up the independent national whistleblowers office. The difference between that and the national guardian in England is that it will be statutory and independent of NHS Scotland. It will sit in the office of the Scottish public services ombudsman, so it is utterly outside the NHS and clearly sends a message of independence. It will be able to adjudicate in individual cases. Normally, that will be when all local processes have been exhausted, but provision is being considered to allow an earlier referral when the local system has simply broken down and the concern about patients has been lost in the conflict-driven system.

Standards are being developed for all health boards so there is a consistent approach. The standards that sit above everything else are that whistleblowers will be listened to, that their concerns will be acted on and that they will be supported. The former Secretary of State, who is now away to sunnier climes or travelling the world, used to keep saying in the Chamber that whistleblowers are central to patient safety. I have to say that I slightly disagree.

When someone is forced to blow the whistle, it is because the patient safety systems have failed. In Scotland, we have a national patient safety programme, which is the first in the world that is right across the system. People cannot pick and choose whether they do the huddle at the start of an operating list or whether they do the World Health Organisation checks before operating on somebody. It looks at the frontline to try to reduce errors, but we know that there will still be situations that are not ideal, so someone will need to come forward. That is the thing: whistleblowers are a backstop. The patient safety system, the Datix system or the auditing may need to be improved, but whistleblowers provide a backstop to prevent us from going over the cliff, to prevent more people from dying and to allow timely action.

The problem is that, although doctors have a duty of candour laid on us by the General Medical Council, we also see the landscape littered with people’s careers and jobs, as the hon. Member for Strangford said earlier. For an individual, that is really difficult. They think, “If I speak up and step forward, it may be the end of my career. I may be out of a job. I may be out of this hospital.” For patients’ sake, we need a change, we need to get it right, and we need a new public interest disclosure law. We should start work on that now.

--- Later in debate ---

[Justin Madders (Ellesmere Port and Neston) (Lab)]

It is, as always, a pleasure to serve under your chairmanship, Mr Davies.

I congratulate the hon. Member for Central Ayrshire (Dr Whitford) on securing the debate and on her powerful and knowledgeable contribution. As always, she drew on her many years of experience in the national health service. She listed a series of scandals in the NHS and raised themes common to them all. They lasted too long, and too often those who blew the whistle paid a high personal price for their actions. She raised the real risk of clinicians finding themselves with potential conflicts of interest, which requires further thought, and rightly highlighted the fact that the current legislation does not create an obligation to investigate the original complaint—it is primarily concerned with protection after the event.

In his analysis, the hon. Member for Stirling (Stephen Kerr) suggested that PIDA was intended to be a deterrent but that, given the way it has operated, it is not that at all because whistleblowers are still being punished. Both he and the hon. Lady pointed out the woeful success rates in employment tribunals, which should give us all pause for thought about whether the legislation is fit for purpose. The hon. Member for Stirling talked about how litigation can sometimes be a war of attrition and employers can be very defensive at times, and how at the bottom of all this is an individual—sometimes a highly skilled individual—whose talent has been wasted and lost because they have blown the whistle.

My hon. Friend the Member for Hartlepool (Mike Hill) spoke with great passion and no little knowledge of some of the experiences of those who have blown the whistle. He was right that some employers have not embraced the spirit of the legislation; in fact, they contrive policies to run contrary to what we are trying to achieve here. Having met many of the staff in the NHS, I know they care deeply about the work they do and they want to do the best by their patients. That is why it is so important that we provide an environment where they are able to raise their concerns about things they may be worried are going wrong, without fear of repercussion or unfavourable treatment. They must also be confident, once they have raised those concerns, that action will be taken.

However, despite some notable advances in the protections available in recent years, it remains the case that even the best run organisations, with the most comprehensive policies in place, can still feel very daunting for individuals who want or need to blow the whistle. I know from my many years working as an employment lawyer—although not one who lined his pockets in this particular area—that it is extremely difficult for an employee to raise those issues. As we have heard already, the consequences of doing that can be hugely damaging. They can face anything from being shunned by their colleagues to summary dismissal on spurious charges, and the impacts of the kinds of things they deal with can last much longer than the period of employment to which we are referring.

In that respect, it was deeply concerning to read in the Francis report about staff who were on the brink of suicide because of the treatment they had received after speaking out. One of the few criticisms on the record of the NHS is the fact that many promising careers have lain in tatters as a result of ineffective protections under this legislation, while other people have spent years languishing in the legal system, with the taxpayer racking up tens of thousands in legal fees in the process.

Of course, while protecting whistleblowers is vital across all professions, it should be pointed out that NHS staff also have a professional duty to raise concerns. The NHS England and NHS Improvement policy states:

“If in doubt, please raise it. Don’t wait for proof… It doesn’t matter if you turn out to be mistaken as long as you are genuinely troubled.”

We cannot say that enough; I just wish it was easier to see that delivered in practice.

The Minister recently brought forward regulations to provide some additional protections for the present and future employment prospects of whistleblowers, which we welcomed. I raised a number of concerns during that debate and the Minister was good enough to write to me afterwards setting out some of the responses. However, one issue that I do not think we have got to the bottom of was protections for other workers who support whistleblowers. There is a worrying gap in the existing legislation. It is easy to envisage circumstances, particularly in the health service, where two or more employees might have an issue of concern that they jointly notice, but only one of them, in law, can make that protected disclosure.

When I raised that point to the Minister, her response made clear that the only remedy available to such associated parties would be to register a grievance under their employer’s grievance policy. That is a very worrying omission from existing legislation and I ask the Minister to consider whether she will look at that again, as well as at the many points that have been raised about the deficiencies of the existing legislation.

Another lacuna in the existing law was exposed much more prominently by Dr Chris Day. On 10 January 2014, Dr Day made a protected disclosure about critically low staffing ratios during a night shift on an intensive care unit at the Queen Elizabeth hospital in Woolwich. Unfortunately, the trust and Health Education England decided not to act on his concerns and terminated his contract, based on what Dr Day believes were false allegations, thereby stalling his progress to consultant.

Sadly—like many whistleblowers, as we have heard today—rather than having his rights protected by his employer, Dr Day was instead forced to defend them via legal redress at an employment tribunal. This is because Health Education England contended that

“even if the facts alleged by Dr Day were true, HEE could not be liable in law for any acts causing him detriment.”

That was significant because, while not acting directly as the employer, HEE recruits doctors in training, supplies them to various trusts and appraises them. The result was a wholly unnecessary and extremely lengthy legal battle, whereby Health Education England, which is a body of the Minister’s Department, effectively sought to move around 54,000 doctors out of whistleblowing protection. Despite the clear principles at stake, the Government consistently refused to become involved in the case to prevent the costly and embarrassing outcome that we have now arrived at.

In September 2017, in a written parliamentary question, I asked about the cost to the NHS of defending the legal action brought by Dr Day. I was told that the total legal fees incurred by Health Education England stood at over £100,000, while Lewisham and Greenwich NHS Trust had incurred costs of £30,000. In May this year, Health Education England was ordered to pay Dr Day’s solicitors’ legal costs of £55,000 after it backed down and accepted that it should be considered an employer after all.

After four years and more than £200,000 of taxpayers’ money spent, Health Education England has accepted its responsibility and made a statement that I consider frankly astonishing:

“Having never wished to do anything other than facilitate whistleblowing for doctors in training, HEE is happy to be considered as a second employer for these purposes if it removes a potential barrier for junior doctors raising concerns.”

I ask the Minister to explain why this situation was allowed to go on for so long, when the case was refuted not on the basis of the facts, but on a technicality that flies in the face of everything we have tried to achieve today.

[Dr Whitford]

As in the case of Dr Day, the issue of poor staffing levels or rota gaps is a common incidence for people blowing the whistle because they feel it is unsafe. Scotland has just passed a safe staffing law, and I wonder whether, as with Datix and other systems, we need staffing level reporting to be seen not as whistleblowing but as something that should be done routinely. Whistleblowing would then start to become a smaller and smaller part of what staff might feel they had to do.

[Justin Madders]

That is an important point; we should see reporting issues such as staffing levels as something that would not be such a big deal. As is happening in Scotland, the safe levels should be ingrained not only into law, but into the culture of the workplace.

In conclusion, I repeat the same point that I made when the recent statutory instrument was discussed: that we now have a two-tier whistleblowing system, which provides some NHS employees with a greater level of protection than others working in the health and social care sector—social care workers, construction workers or anyone else who does not happen to work within those particular areas. Social care in particular is an issue. Public Concern at Work found that more than half of whistleblowers also reported some kind of victimisation, with 23% saying they had been dismissed after raising concerns. I ask the Minister, who is of course also responsible for social care, whether she considers that a satisfactory state of affairs.

Whistleblowers should be not just protected, but celebrated for the role that they play in defending the safety of others. Nobody making such a disclosure should do so in fear, wherever they work, nor should they face the risk of having their livelihood taken away. We owe it them to ensure that those protections are as effective as they can be.

[The Minister for Care (Caroline Dinenage)]

It is a great pleasure to serve under your chairmanship, Mr Davies.

I start by thanking the hon. Member for Central Ayrshire (Dr Whitford) for bringing forward this important debate on a vital issue and for the keen interest she has shown in patient safety across the board. I always listen carefully to what she says, not only because her contributions come from her perspective as a clinician—something that should be incredibly valued—but because, as a Member, I respect the practical, constructive and calm way she presents information to the House. It always makes an enormous difference as a Minister when information is given in that way. I also thank her for the role she has played in the pre-legislative scrutiny of the health service safety investigations Bill—another piece of legislation we are introducing to ensure that our health systems are continually learning and making a difference when things go wrong.

I also put on the record my thanks to my hon. Friend the Member for Stirling (Stephen Kerr) for setting up the all-party parliamentary group on whistleblowers. I am delighted he has taken that step. There are all-party parliamentary groups on a range of different issues, and one often wonders where they are coming from. However, I welcome his wholeheartedly, and I am keen to hear its considered recommendations. I am also delighted that the new Secretary of State for Health and Social Care has already stated his commitment to the health and social care workforce. The work of my hon. Friend’s APPG will go to the heart of that.

The Government are committed to building a culture of openness and transparency in the NHS, which is part of achieving our goal of making it the safest healthcare system in the world. We need to make sure that people who work in the NHS feel safe to speak up. We want that to become routine, and it is a key part of our commitment to ensuring patient safety and improving the quality of services. The NHS should support and welcome all staff—be they permanent employees, agency workers, volunteers or other contracted staff—raising concerns, wherever they have them.

The importance of people in healthcare speaking up has been demonstrated by many brave champions of patient safety, such as Helene Donnelly at the Mid Staffordshire NHS Foundation Trust. It is through the bravery of Helene and those like her that we can fully recognise the changes that have to happen in our health and care services. As the hon. Member for Central Ayrshire has said today and in the past, people blowing the whistle is a sign that the system has failed somewhere earlier on—that something has gone wrong and has not been put right. We want a culture in which we do not need whistleblowers like Helene because stronger preventions and better patient safety measures are in place, because people feel confident to admit when something has gone wrong, and because people feel protected and supported and are willing to raise concerns in the workplace as a norm.

Hon. Members will know that I am the Member for Gosport. I have recused myself from speaking as a Minister on the situation there so that I can continue to represent my constituents in that case, which I have been involved in for the last eight years. However, the case amply demonstrated the risks of not listening to those who raise concerns. It is clear that much of the pain and suffering experienced by families could have been avoided had those whistleblowers been listened to earlier.

Speaking up and raising concerns should be routine in the NHS. As the hon. Lady said, whistleblowing legislation has been in place for 20 years, and all hon. Members have been vocal about its limitations. I am not averse to reviewing the legislation, and I am keen to hear any proposals that the new APPG and other Members feel would be appropriate. Evidence on the legislation’s effectiveness—or ineffectiveness—would be helpful. Hon. Members know that reviewing that legislation does not fall within the gift of either myself or the Department; the Department for Business, Energy and Industrial Strategy holds the control there. However, I am more than happy to speak to Ministers in that Department about this.

We are aware that improvements to our health and care system are needed to ensure that workers feel safe to speak up about problems. Responses to our call for evidence in 2013 highlighted that whistleblowers did not feel that way, which is why we legislated in the Small Business, Enterprise and Employment Act 2015 to require prescribed persons to produce an annual report on whistleblowing disclosures made to them by workers. The regulations to implement that reporting duty are now in place, and the prescribed persons’ first annual reports, covering 2017-18, are due to be published in the next few months. That is aimed at increasing public confidence that prescribed persons take whistleblowing disclosures seriously, through greater transparency about how they handle disclosures, and particularly that they investigate and take action where necessary.

[Dr Whitford]

The Minister mentions prescribed persons. The fact that Members are also prescribed persons shows how difficult and confusing it can be for whistleblowers to know where they should go. I suggest it would be difficult and confusing for an MP to know what to do with such information and where to go. I recognise that the NHS, as one of the major generators of these cases, perhaps needs its own structure. However, if we had an independent body that covered all other sectors, everyone who wants to blow the whistle would at least know where to go, because a lot do not at the moment. As my hon. Friend the Member for North Ayrshire and Arran (Patricia Gibson) said, they may blow the whistle in the wrong way and to the wrong person, and they will suddenly not be covered by PIDA at all.

[Caroline Dinenage]

The hon. Lady makes a valid point, which we will take into consideration.

As the hon. Lady knows, the National Guardian’s Office was established in 2016, and the independent national guardian, Dr Henrietta Hughes, was appointed to support NHS whistleblowers and to improve the NHS reporting culture. The National Guardian’s Office also provides leadership, training and advice for a network of more than 750 “freedom to speak up” guardians based in all NHS trusts and foundation trusts. There have been more than 6,700 cases of speaking up in the last financial year. The National Guardian’s Office is looking to extend a network into primary care later this year.

The ability of the National Guardian’s Office to effectively engage the system is already helping it to make recommendations to trusts, arm’s length bodies, the Government and providers of services to the NHS to help drive this cultural change. Its role in the system is as an influencer of change, rather than an imposer of requirements. Organisations should rightly remain responsible for tackling their own cultural issues.

The NHS is one of the largest employers in the world and makes a large investment in its workers. We do not want to lose great people from the NHS because they face discrimination for doing the right thing. That is why we introduced protections from discrimination for people seeking NHS employment who are perceived to have previously blown the whistle. That regulation came into force in May and will support NHS Employers in being an exemplar to others in fostering a culture of openness and a willingness to report problems with care. Separately, we also extended the definition of “worker” within the whistleblowing statutory framework in the Employment Rights Act 1996 to include student nurses and student midwives, meaning that those people are now protected under the Act.

Aside from statutory protections, on 1 April 2016 NHS England and NHS Improvement published a single national integrated “speaking up” policy to provide clarity and consistency across the system. In March 2017, NHS England also launched the whistleblowing support scheme—a nationwide pilot to help workers in primary care who have spoken up. A similar pilot was launched in September 2017 by NHS Improvement for people who have made a disclosure in secondary care. The schemes offer a range of services to support people back into employment. It is too soon to say how the pilots are progressing and how effective they have been. The aim is to ensure that any future scheme is fit for purpose and meets the needs of people who require support after making a disclosure.

We have also made changes at the regulatory level of the health and care system to better protect whistleblowers. The CQC has a legal duty to report on whistleblowing disclosures, and it has revised the “well-led” domain of its inspection assessment framework to include how organisations are progressing with implementing the recommendations from “Freedom to Speak Up”. It is important to mention the link between an organisation’s CQC rating and how seriously it takes speaking up, with 100% of organisations rated as outstanding by the CQC having guardians who reported that speaking up is taken seriously in their organisation, in contrast with only 36% of trusts rated as inadequate.

NHS staff who are prepared to speak up are an important asset. We want NHS staff to feel confident that, when they speak up in the public interest, it will not have a negative impact on their career. Supporting those who speak up in the NHS is utterly crucial to achieving those aims.

[Dr Whitford]

I appreciate how consensual the debate has been, and I hope the Minister recognises the points raised. As was mentioned, NHS structures will be different in each of the four nations, but PIDA sits above that. Perhaps, in trying to work together to tackle those differences, we can also share good practice from each country that sits within the NHS. We simply cannot go on as we are, because people die, and then people lose their careers. We are running without looking. I hope that the Minister takes this forward, both with the APPG and other Members.

Question put and agreed to.

Resolved,

That this House has considered NHS whistleblowers and the Public Interest Disclosure Act 1998.

Department of Health and Social Care and Ministry of Housing, Communities and Local Government

Philippa Whitford Excerpts

Monday 2nd July 2018 Commons Chamber

[Dr Wollaston]

I absolutely agree. This is about not just funding for public health, but the policy levers. We do not need lots of talk about the “nanny state” that denigrates important national public policy drivers, because although we need funding for local services, as the hon. Lady says, this is also about the policy environment that is necessary to make important changes. Investing in public health makes a huge difference for people.

One of the problems here is that when the public are asked where they would like the priorities to fall, we often hear, understandably, about the importance of cancer outcomes, mental health and emergency waiting times. Public health is often bottom of the list because nobody necessarily knows when their life has been saved by a public health policy. The reality is that the major changes and achievements relating to life expectancy have arisen largely thanks to public health policy, but we rarely turn on the television and see a programme called “24 Hours in Public Health”, which is a shame.

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

In the air quality debate last Thursday, I touched on the need for health in all policies. From active transport to quality of housing, is that not where we need to drive public health?

[Dr Wollaston]

The hon. Lady is absolutely right. Health in all policies means using every opportunity to maximise public health. When Departments work together, such as on the childhood obesity strategy, we need maximum engagement across the whole of Government to make that effective. The way it was put to us when the Committee visited Amsterdam was that it should be viewed as a sandbag wall, and if any part of it is missing, we are not going to achieve what we want. That applies to all of public health.

--- Later in debate ---

[Nigel Huddleston (Mid Worcestershire) (Con)]

It is a pleasure to follow the hon. Member for Bristol South (Karin Smyth). In fact, all the speakers so far this evening command the respect of both sides of the Chamber for obvious reasons given what they have said. I, too, agree with a large amount of what has been said. It is also a pleasure to speak in this very week of the 70th anniversary of the NHS.

We are talking this evening—it is in the Order Paper—about NHS expenditure summing to greater than £120 billion. That is a staggering sum and it just shows how important the NHS is not only to the Treasury and the Government, but, perhaps most importantly, to the public. Certainly, this is the top topic of interaction for my constituents. It is very, very important to them. The NHS is right up there with the royal family and the armed forces in making the Brits proud to be British, and for understandable reasons. I therefore very much welcome the £20.5 billion increase in real terms spending on the NHS. It is not only obviously needed because the population is ageing and the cost of healthcare is growing, but also desired by the British public. Some 86% of the British public say that they feel the NHS needs more spending. They are also willing to pay for it. It is very important that we listen to the public very carefully when they say that they need more spending on the NHS and that they are willing to pay for it. We will come in a moment to how they should pay for it. The British public are not stupid. They are fully and well aware that Government expenditure all comes from taxation, either now, immediately, or in the future in terms of debt. That is important, as they recognise that we cannot magic money out of thin air. We must also be very responsible and careful as politicians that we respect the fact that, whenever we decide that we wish to increase Government expenditure, what we are effectively doing is reaching into the pockets of hard-working people in this country and saying, “We’ll take some of that out, thank you very much.” We have to be really respectful of that and explain why we are doing it and what we are doing it for. The laziest thing to do in politics is pretend that other people are going to pay for all this and to promise the world to everybody. It is a dangerous route to go down and the British public will eventually see through that approach.

If we are going to be straight with the British public, how will we achieve this increased expenditure? I am sceptical, but not as sceptical as my hon. Friend the Member for Totnes (Dr Wollaston), about the Brexit dividend. I do, however, like to talk about a deficit dividend; as we reduce the massive amounts of interest that we are paying over time, there will be a benefit to the UK population. We have to be honest about where the money could come from, and hon. Members have mentioned other ideas about how it could be generated, including by looking at council tax, tax-free allowances and the pension age.

We do need to look at the pension age very carefully again. We have already increased the pension age to 67 and 68, but as the population ages and we all live longer, it is not unreasonable to expect us all to work longer. As we work longer, we generate more taxes during our lifetime, and that is pretty important. We have to consider whether it is reasonable that we should all be living 15 or more years after we have retired without paying more tax.

[Dr Whitford]

Is the hon. Gentleman aware that the increase in life expectancy is actually stalling and not continuing to soar? Unfortunately, it is another inequality between richer areas and poorer areas, and the danger is that people in deprived areas will get no retirement at all.

[Nigel Huddleston]

The hon. Lady makes a perfectly valid point. The differentials in life expectancy concern me greatly, but we have come such a long way. Pensions were first introduced in 1908 for people aged 70, when the average life expectancy was 48 for men and 52 for women. Life expectancy increased slowly as the century went on, but I believe that it is now—quite staggeringly—78 for men and 82 for women. This is well beyond the average age at which we retire, so we have to look at the situation carefully.

Rather than directly tax people more, I would like to see economic growth, which was mentioned earlier. Every 1% increase in economic growth adds £7 billion to the economy, whereas every 1p increase in income tax raises just £5 billion. We have to look at having a good mix. The more that we can grow the economy the better. Owing to the growth in the economy, HMRC receipts actually increased from £414 billion in 2010-11 to £594 billion last year, so the more that we can do for economic growth, the better for us all.

Alternatively, we could shift Government expenditure from one Department to another, but that is very difficult to do in the age of austerity and perceived austerity. As a Conservative, I believe in Government spending that is as small as it can be, but as large as it needs to be. The message that I heard from my constituents at the last election is that they believe that it probably needs to be just that little bit bigger, particularly for health, social care and education.

The British public are now respecting and accepting the fact that Conservatives are very careful with their money and are respectful of taking tax and money out of their pockets. They know that we are not going to spend money willy-nilly. More than 60% of the British population—across all demographics, including party political persuasions, age groups and income groups—support a taxation increase to spend more money on the NHS, and we need to listen to that.

But we need to move the conversation away from being all about inputs. Everyone in this House needs to commit to avoiding this kind of arms war, whereby there is always a debate and a fight about who can spend most. Instead, we need to put much more focus on the outputs, such as improving diagnoses, treatments, survival rates and other matters in the NHS. That is part of the debate. I was glad that the Health Secretary focused on that while introducing the additional spending. It is an important factor to consider; productivity very much needs to be part of the deal.

We need to continue focusing on an NHS that is free at the point of need, but we need to be clear with people that it is not free. The NHS never has been free and never will be free. It comes at a cost and we all have to pay for it. We need to ensure that we keep focusing on cost, look at other areas of savings and educate the public that there is a cost when they miss an appointment, when an ambulance goes out unnecessarily and when people go to A&E but do not really need to do so. We should all play our part in ensuring that NHS money is spent as wisely and carefully as possible.

There is still a lot of work to do on social care and public health, as my hon. Friend the Member for Totnes said. We should try to put together a cross-party royal commission, as other have said, and investigate moving the NHS out of party politics as much as possible, but that is a debate for another day.

--- Later in debate ---

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

As many Members have mentioned, we are approaching the 70th birthday of both the NHS and the social care system. I was shocked to work out that I graduated in the first half of that period, when the NHS was a youngster of only 34. That was a bit depressing; how did I get so old?

Most patients in all four UK health systems will have a very good experience, because they interact with dedicated and caring staff. But all four systems face three big challenges that we have talked about before: tight finances, workforce shortages and increasing demand. As others do, I welcome the £20 billion extra funding that will be there by 2023. Over the next five years, that equates to a 3.4% uplift each year. That is double the 1.2% that the NHS has been experiencing over the past eight years, but it is below the 3.7% that has been the average since 1948. So it is welcome, but to call it a windfall can make people complacent that the challenges within the NHS and social care have simply gone away.

I agree with the hon. Member for Totnes (Dr Wollaston) that it is very disappointing that this is again only NHS resources, with no money for public health, for training or for capital or maintenance and, most importantly, no funding for social care. Trying to fund a health system without supporting social care is like trying to fill a bath with the plug out.

The other question is of course: where is the money coming from? I am afraid that I am also in agreement with the hon. Lady that I do not see much chance of a Brexit dividend; I know that I am Irish, but I do not really believe that there is a pot of gold at the end of the rainbow.

The Secretary of State for Health and the Secretary of State for Scotland have both mentioned that Scotland will get a £2 billion windfall through the Barnett consequential, and that would of course be hugely welcome, but in fact no detail has been sent back in response to the letter from our Finance Minister, and we will simply have to wait for the autumn statement, because the Barnett consequentials are not always as they appear. When NHS England got £337 million to prepare for winter pressures, naturally NHS Scotland was hoping for £32 million; in fact, by the time all the other cuts were applied to it, £8.4 million made it over the border.

The Scottish Government have increased health funding by 45% since coming to power in 2007, and despite an 8% cut in the Scottish budget since 2010, we still invest £163 a head more than is invested in people in England. We focus on things like quality improvement, and we have the first national patient safety programme. That has reduced costs, and it has a massively reduced mortality. It also helps to avoid litigation, which is at a much lower level in NHS Scotland than here in England.

The next issue is the workforce. There is no extra funding for Health Education England, although it is expected to educate 1,500 more medical students and train 5,000 more GPs. Despite 36,000 nursing vacancies, the nursing bursary has been removed, and this House voted to remove the postgraduate nursing bursary just last month, so it is difficult to see how we will tackle those challenges. Even before Brexit, we are losing EU staff. In the NHS in England, 19% of its EU doctors are in the process of leaving. Unfortunately, Scotland is also seeing 14% of its EU doctors going. We have registered a drop of 90% in the number of EU nurses willing to come to work in the UK system, and we have had the issue involving more than 2,000 non-EU doctors being turned away and refused tier 2 visas in the first five months of this year. I welcome the fact that that situation has now changed, but this is about the message that that sent out. It is about the need to have an immigration policy that will deliver the people we require. Social care workers will be a particular issue, because they will not qualify for tier 2 visas. They will not be classed as highly skilled enough, and they will not earn enough.

A further challenge is increased demand. Public health has received no extra money, and it has already faced cuts. That has resulted in cuts to services such as smoking cessation and tackling addiction, inactivity and obesity. I called earlier for health in all policies, and tackling issues such as poverty and adverse childhood experiences is really important. They drive a huge amount of mental and physical ill health. We often blame increased demand on the ageing population, but I would point out, having graduated in 1982, that I worked in Victorian hospitals, on Nightingale wards, and I remember the first CT and MRI scans. Since then, we have modernised not all but many of our hospitals and increased the availability of technology and expensive new treatments. We are now entering the age of gene therapies, which will be incredibly expensive. The chief medical officer in Scotland has formulated a policy called realistic medicine. It advises that, as doctors, we should not presume that every patient always wants the latest brand new treatment or to be put through an operation. We should not presume; we should just ask them what is important to them.

One of the things that is important for everyone is keeping their independence. I do not just believe in independence for Scotland; I believe in independence for older citizens. That involves not rationing hip, knee and eye operations, as is still happening here in England, but investing in them. If we delay people’s hip or, particularly, knee replacements, their muscles waste, the end result is poorer, and they will have become more dependent in the meantime. Rationing cataract operations, as is happening in two thirds of units in England, increases the risk of falls. That will simply cost more in the long term. We are trying to get people operated on at an earlier stage, so that they can stay more independent. If people can see and walk, and if we give them a bus pass and get them out and about, they will cost us less in the long term.

The most important missing item in the statement on NHS funding was, as has been said, funding for social care. The hon. Member for Hertford and Stortford (Mr Prisk)—I used to live there when I was a teenager—talked about providing free personal care. That is something that we do in Scotland. Someone in a care home there will pay accommodation costs, which are means-tested, but regardless of whether someone is in a care home or at home, we provide free personal care. That might seem more expensive, and indeed it is—we spend £113 a head more in Scotland than is spent here—but by comparison to being in hospital, it is incredibly cost-effective. Over the past five years, Scotland has seen just one third of the rise in A&E attendances and emergency admissions that has been seen in NHS England, and that is a cost that is worth getting back.

Members have talked about funding the service and the need to look at interesting ways to do so, and I agree that national insurance needs to be reconsidered. It used to be called national health insurance, but it of course covers many other things, such as benefits, pensions and so on. However, it is something to consider, because the threshold actually starts quite low when people are earning poorly and then starts to thin out when people are earning well. That does not seem fair. It is the same for retired people who have a generous pension and do not really go on paying national insurance. That cannot be right when they are entering the most important years.

In Scotland, we believe in integration, not competition. It is estimated that the healthcare market in England wastes £5 billion to £10 billion just in administration. The NHS in England faces reorganisation anyway as it moves through sustainability and transformation plans into accountable care organisations or systems or whatever they are to be called. Perhaps the Government should consider getting rid of section 75 of the Health and Social Care Act 2012 that forces services to be put out to tender, resulting in outsourcing and fragmentation. England needs integration and co-operation, not financial competition. Tariffs that reward a hospital only for admitting someone instead of trying to keep them home are counterintuitive.

I agree that place-based planning is the best approach for reorganisation, but it must be centred on patients, not budgets. It must start with designing what is required for the long term, not at the bottom line and then working back. In this next reorganisation, the Government should be radical and get rid of the healthcare market and, as the NHS turns 70, think of moving to a unified, public national health service.

Adult Social Care: Long-term Funding

Philippa Whitford Excerpts

Thursday 28th June 2018 Commons Chamber

[Mr Betts]

I completely agree. If we are still talking about this in two or three years’ time we will have failed. We have to get some decisions and get on with it. As politicians, we are often very good at coming up with ways to spend money. In this report we have actually come up with ways to raise money, which is the difficult part. We have done the heavy lifting for both the Government and the Opposition Front Benches. We now say, “We’ve handed the pass over to you. Get on and run with it and make it work.”

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

I, too, welcome this cross-Committee report and note that it aspires to provide free personal care, as we have in Scotland, and to extend it to those in need under 65, which we will start next April. While that has significant costs, does the hon. Gentleman agree with the assessment of the Scottish experience by the King’s Fund and the Health Foundation, which suggested that overall it saves money, because people can remain in their own homes rather than care homes and rather than being admitted to hospital?

[Mr Betts]

I saw the King’s Fund report and I have seen the analysis. That was an aspiration eventually. However, the Select Committees’ felt that the immediate pressures of the funding gap, which will grow if we do not do anything about it—because of the demographics over the next few years, the fact that we are not meeting the needs of those with moderate care needs, the fact that we are not paying our workforce properly and that many care providers are in financial difficulties—mean that those issues have to be addressed and then, eventually, we can move on to the free care aspiration set out in the report over the longer period.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 19th June 2018 Commons Chamber

[Stephen Barclay]

The two do go together because the mental health workforce is a key component of the NHS workforce. I am sure that the hon. Gentleman will welcome the extra £1 billion by 2020 that the Prime Minister announced yesterday, as well as the Government’s prioritisation of mental health, which for too long has been seen as a Cinderella service within the NHS.

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

In 2015, the Secretary of State suggested that junior doctor rotas contributed to avoidable hospital deaths, but research shows that the most important factor is the number of patients under the care of each registered nurse. A 7% increase in mortality for every patient means that 36,000 nursing vacancies in England pose a real threat to patient safety. So with no announcement, and a 33% drop in applications since the removal of the nursing bursary, will the Government follow the Scottish Government’s policy and reintroduce the bursary?

[Stephen Barclay]

The hon. Lady will be well aware that there are 14,000 more nurses in the NHS than five years ago, but she is right to point to the wider issue of long-term workforce planning. That is why she will be aware that Audit Scotland criticised NHS Scotland for its lack of long-term workforce planning.

[Dr Whitford]

rose—

[Mr Speaker]

The hon. Lady’s second question will be a lot shorter, I am sure.

[Dr Whitford]

As the Minister heard, the Scottish Government have just passed a law on staffing. With an ageing population, social care is critical to the function of the NHS, but the charity Independent Age says that we will be short of 700,000 care workers by 2037. With no extra funding for social care announced yesterday, how will the Secretary of State make caring a real profession? Would not it be good to start with a decent wage?

[Stephen Barclay]

The hon. Lady’s supplementary question really reinforces the answer that I gave a moment ago: the essence of why we need a long-term plan is so that we anticipate these issues. We are addressing that through the Green Paper on social care, and that is part of the investment that the Prime Minister announced yesterday.

NHS Long-Term Plan

Philippa Whitford Excerpts

Monday 18th June 2018 Commons Chamber

[Mr Hunt]

My hon. Friend asks two important questions. As she knows, we have committed to phase out capital-to-revenue funding, because if we are to make the NHS sustainable in the long run, we urgently need to make capital investment in estates, technology and a whole range of new machinery, including cancer-diagnostic machinery and so on, and we will not be able to do that if we continually have to raid capital funds for day-to-day running costs. That was one of the main reasons why we decided that we had to put revenue funding on a more sustainable footing. My hon. Friend is absolutely right about that.

Transformation funding is also important, because when the five year forward view was published, pressures in secondary care and the acute sector meant that a lot of transformation funding was sucked into the hospital sector and we were not able to focus on the really important prevention work that can transform services in the long run. I am very sympathetic to the idea that we need, if not a formal ring fence, a pretty strong ring fence for transformation funding, so that the really exciting progress that we see in some parts of the country can start to spread everywhere.

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

I echo the comments made about the approach of the NHS’s 70-year anniversary across the four countries of the UK, having myself spent a fair chunk of those 70 years—perhaps slightly longer than I care to admit—working in the NHS.

Like most people present, I imagine, I absolutely welcome the additional funding, which has been described as bringing the UK to the same level of spending as France by 2023. In that description is, though, the admission that we do not spend the equivalent of what France spends right now. Indeed, we saw a deficit of almost £1 billion in 2017-18, despite transformation funding being sucked in to try to clear that deficit.

I echo what the hon. Member for Totnes (Dr Wollaston) said: is transformation funding on top of this funding? If it is just revenue funding, will there be a separate announcement about transformation funding? The Secretary of State also mentioned the need for prevention, yet we do not see any mention of money for public health. That is where we need to be doing prevention.

It is said that we need a 3.9% increase in social care spending, but that is not identified in the statement. If the Green Paper is to come only in the autumn, social care may not get real funding until next year. With the demographic challenge that the Secretary of State mentioned, that is just too far away. The NHS has faced, on average, an uplift of 1.2% over the past eight years, according to the King’s Fund. Taking it up to 3.4% brings it more in line with the traditional uplifts that we have seen, and yet, in actual fact, with an ageing population, the pressure is even higher. Hopefully, this will stop the slide of the NHS, but the NHS Confederation says that it is not possible to transform on this kind of money. It is, therefore, important that these other projects are looked at separately and are funded separately.

As for where that money is to come from, I do not know how the Prime Minister kept a straight face when she talked about the Brexit dividend. The Institute for Fiscal Studies says that there will not be a dividend. The Office for Budget Responsibility talks about a £15 billion drop in public service and finances. I want to know how the rise will be funded. Will it all be just borrowing and tax rises? The Government should be honest about how they will fund this rise.

[Mr Hunt]

First, may I thank the hon. Lady for doing something that the shadow Health Secretary did not do, which is to welcome this £20 billion annual rise in the NHS budget? I completely agree with her about the importance of prevention, the importance of social care and the importance of making sure that we sustainably invest in transformation funding. The think tanks do disagree on what level of rise is necessary. Lord Darzi and the Institute for Public Policy Research said 3.5%; we are on 3.4%, which is not far off that. The IPPR went a little higher, but, like the hon. Lady, Paul Johnson said that this will stop the NHS going backwards.

With respect to overall funding levels for the NHS, the United Kingdom currently funds the NHS at the western European average as a percentage of GDP. That is not as high as France or Germany and it is true that, by the end of this five-year period, our funding will end up at broadly similar levels to those of France today, although of course it may change them over the five-year period.

I gently say to the hon. Lady that if that is a worry for her, she needs to explain to NHS users in Scotland why, when NHS spending has increased by 20% in England over the past five years, it has increased by only 14% in Scotland because of choices made by the Scottish National party. For every additional pound per head invested in the NHS in England only 85p has been invested in the NHS in Scotland. I hope that she makes a pledge, as I hope Labour does with its responsibility for Wales, that every extra penny that she gets through the Barnett formula will go to the NHS, because that is what the voters in Scotland want.

Hepatitis C

Philippa Whitford Excerpts

Tuesday 12th June 2018 Westminster Hall

[Sir David Amess]

That is excellent news. I thank my hon. Friend for that positive response to looking at this issue.

The testing and treatments initiatives in place will lead to a decline in the prevalence of the disease. However, prevention will come from identifying and educating at-risk groups. To do that, we need the help of substance misuse services, sexual health clinics and peer programmes that can educate those most vulnerable sections of society on the transmission of the virus. I am advised that these services are at risk of closure without sufficient increases in their funding. Perhaps the Minister will have some news on that when he replies.

Harm reduction is another paramount mode of prevention. If we can reduce the harm to at-risk groups, we can combat one way in which the disease is transmitted. That can be achieved by providing clean and sterilised injecting equipment. Our report also emphasises the treatment-as-prevention approach towards tackling newer infections. That approach has been successful in treating drug users and other users engaging in riskier behaviours to prevent the spread of hepatitis C.

As I said earlier, between 40% and 50% of people living with hepatitis C in England are undiagnosed, which is shocking. It is therefore vital that we continue to increase testing and diagnosis levels. It is generally believed that the vast majority of those who have been diagnosed and put in touch with support services have now been treated, which I welcome. The challenge is therefore to locate those people who remain undiagnosed. That is a tricky one; it will be a real challenge.

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

The hon. Gentleman talks about all of those people who have hepatitis C who have been diagnosed being treated, but my understanding is that these new antivirals are given to those with the most severe disease and have cirrhosis, rather than to everyone who is diagnosed with hepatitis C on a preventive basis. Can he clarify that?

[Sir David Amess]

I am concerned by what the hon. Lady says. No doubt the Minister will eventually be passed a note from his officials and will advise us on the situation. That does not seem right if it is what is happening, and I hope that the Minister will correct me if that information is wrong. It is also vital to re-engage those who have been diagnosed and have slipped through the net to the point where they are no longer in touch with those services.

The APPG thinks that the way to combat these issues is to change how we test for the virus. We recommend routine testing in substance misuse services, sexual health clinics and prisons. We also advocate increasing testing in primary care and in settings such as hostels, day centres and police custody. I know that that will not be cheap, but if it could be done it would be wonderful. Another solution is to test for hepatitis C on occasions when people are already having blood tests, which seems like common sense to me. For example, should we not consider testing people for hepatitis C while they are being tested for HIV, or when taking blood in accident and emergency centres?

Diagnosis is one thing, but accessing care is another. It is therefore essential that people who are diagnosed are referred for treatment as soon as possible, without delay. There should be a direct link between diagnosis and care. The time between diagnosis and the commencement of treatment should be minimised, to prevent patients from dropping out of the care pathway altogether. One way to achieve that would be to make treatment available immediately following diagnosis. That may be ambitious, but it is, ideally, what our APPG wants. Another way would be to streamline the referrals process. As it stands, some secondary care services will only accept referrals for treatments from general practitioners. Allowing referrals from any service at which someone might be tested and diagnosed, as the APPG recommends, would go some way to solving the problem.

[Sir David Amess]

Oh dear! I say to my hon. Friend—I and, indeed, you, Mr Streeter, were in this place when we were dealing with all these issues—that the fragmentation is very worrying. My hon. Friend is right to point out that more work needs to be done on the issue.

[Dr Whitford]

I am not sure whether the hon. Gentleman is aware that there is a cap on the number of patients who are allowed to receive drugs such as sofosbuvir; certainly, hepatologists I have met in recent years report having to ration it to the most severe cases. The limit was set at about 10,000 patients a year. This year, it has been increased to 15,000, but that is not a target; it is a cap. It means that despite it having been stated that 160,000 patients in England suffer from hepatitis C, it would literally take 10 to 16 years to treat them all, so this is a matter not of referral but of access to the drugs.

[Sir David Amess]

I said at the start that I was totally the wrong person to lead this debate. I put my hands up: I was not aware of the cap. It, too, is a little worrying, but perhaps the Minister will have an answer. I am the first to admit that money is not always available for these things, but it is worrying that we are talking about another 16 years. That is not what our all-party group wants.

If services share data more effectively, the number of patients lost to follow-up will certainly be reduced. That will minimise cases such as prisoners who have been diagnosed being released before being referred to a service that provides the treatment that they so desperately need. Another example is where general practitioners have records of people who have been diagnosed but never received treatment.

On the subject of treatment, pioneering treatments have been in place since 2014. I am advised that they are shorter in duration and have higher cure rates and fewer side effects. They have thus been instrumental in making progress in the way we treat hepatitis C, and many people have been cured thanks to the drugs available since 2014. Notwithstanding that, we should continue to maintain targets for the number of people treated and to maintain universal access to treatment for those who have been reinfected. Those targets should be local, regional and national.

There is even an argument for making the targets more aspirational. Currently, there is a target to treat 12,500 people in England per year, and the all-party group would like that to increase to 20,000 new treatment initiations. If the target is not raised, there is little chance of achieving NHS England’s target of eradicating hepatitis C by 2025. It might be more pragmatic to have initially an even greater target, which would progressively be lowered in the future. That approach would reflect the assumption that, as overall prevalence falls and approaches minimal levels, those still living with the virus will be harder to locate within the population.

Treatment should be focused in the community. That will ensure that access is not hindered for those who have difficulty accessing secondary care services. The all-party group recommends making treatment more readily available in GP clinics and pharmacies, homeless shelters, substance misuse centres, sexual health clinics and prisons.

Funding is where the crunch comes, and we have quite a bit to say on it in our report. Although new curative treatments have considerably decreased in cost, pioneering new treatments for hepatitis C are not immune to concerns. The way in which the new treatments were initially rolled out by NHS England drew criticism at the time. For example, restrictions were placed on the number of patients able to access them each year in England. Of course, the hon. Member for Central Ayrshire (Dr Whitford) has reminded the House of that. I am sure that the Minister is aware of recent negotiations between NHS England and the industry to develop a new funding model in this area and one that does not restrict access for patients. Without such dialogue, elimination in England would be severely compromised.

The all-party group has gone further, however. We recommend that any future deal should prioritise equitable availability throughout the country—I suppose we are thinking here of the postcode lottery—that does not discriminate against patient populations. On the subject of the all-party group’s recommendations, we believe that we should continue to monitor elimination progress with reference to progressive targets. The report calls for more diverse data on the virus to be collected and shared. It is the group’s belief that that would additionally allow for improved allocation of testing and treatment resources.

As the all-party group’s report makes clear, we believe that the eradication of hepatitis C in the foreseeable future is an extremely achievable goal—we really think we can do this. It is a goal to which our international partners are committed, which is very good. Some of them are making greater progress towards achieving it than we are, for whatever reason. For the target to be met, we must change our approach to hepatitis. It is my belief that the recommendations that I have summarised today must be implemented, and as soon as possible. Failure to do so will only prolong the existence of hepatitis C in this country. We have at our disposal the means to eliminate it. Let us do that.

--- Later in debate ---

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

It is a pleasure to serve under your chairmanship, Mr Streeter. Hepatitis C was identified about 25 years ago. When I was a young doctor, it was simply known as non-A, non-B hepatitis, because no one had any idea what it was. As the hon. Member for Southend West (Sir David Amess) said, we are talking about something that many people simply do not know they have. That is a key, underlying problem. Patients may only be aware that they have hepatitis C when they start to have liver symptoms, which is the start of cirrhosis or malignancy.

With any condition, we first want to prevent it. As was mentioned, at needle exchanges we already have blood screening to ensure that it is not coming from transfusion. We have to remember those in this country who previously suffered from contaminated blood that was iatrogenic—caused by doctors and the health service.

I agree with the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) that we need a more medical approach to the issue of drugs. If we drive problems underground, there is no possibility of detecting and treating people, to achieve the elimination that the World Health Organisation is aspiring to.

In Scotland we are recognised as world leaders, in the sense that we had a strategy in 2005, 2008, 2011 and then our elimination strategy, which was introduced in 2015. The 2011 strategy fed into what became the World Health Organisation strategy, as one of our senior leaders was seconded to it. The big change is sofosbuvir and ledipasvir—the new antivirals that are well tolerated and able to clear the viral load in 90% of all patients. Of course we would prefer a vaccine, as the hon. Member for Strangford (Jim Shannon) mentioned; that is how we eliminated smallpox and how we are trying to eliminate polio. However, the problem with hepatitis C is that, as he said, there are six genotypes, but 50 subtypes, and it mutates regularly. It is one of those viruses with a coating that is very hard to get a handle on with the immune system and therefore to develop a vaccine for, so we need to use the drugs until a vaccine is available.

The Scottish Medicines Consortium passed sofosbuvir in 2014 and NICE passed it in 2015. Unfortunately, NHS England took the approach of trying to slow things down because the drugs are very expensive. However, dealing with liver failure and having to consider liver transplantation is even more expensive. A cap of 10,000 patients with cirrhosis and the most severe conditions from hepatitis C was set.

In Scotland in 2015, we took the opposite approach—a public health approach—to try to reduce the virus in the community and prevent it from occurring.

[Dr Poulter]

The hon. Lady is making very good points. I am sure she will correct me if I am wrong, but the other point to make is that in Scotland there has been a much more joined-up approach in tackling heroin addiction. Scotland is much further forward than England in addressing such issues, in having a co-ordinated strategy and in recognising how addiction leads to prisons and the criminal justice system. Indeed, there is not the fragmented commissioning of services that we see in this country. Does she agree with me that that is something that England can learn from in addressing the lack of joined-up working and commissioning?

[Dr Whitford]

I thank the hon. Gentleman for his comments. As NHS Scotland is still a single public body, we do not have the issue around commissioning. We are also trying to take a much more health-based approach to addiction. As happens in England as well, we have multiple needle exchange programmes. This place has held us back from trying to introduce safe injection in Glasgow, which has one of our highest drug-addicted populations and highest incidence of drug-related deaths. However, that initiative comes under the Home Office and we have not been granted permission to try to take it forward. Always taking a criminal justice approach gets in the way of achieving the medical outcomes that we want.

It is really important to recognise the breakthrough of the drugs. With an eight or 12-week course, expensive as it is, more than 90% of patients will achieve a sustained virological response. That means they remain with undetectable levels of virus 12 to 24 weeks after the end of their treatment. The problem with rationing treatment to those who are actually ill is that it is the people who are not ill with hepatitis who spread it to other people, because they are out and active. If they are drug users, they are still using drugs. Someone who is so ill that they are confined to bed is not spreading it. That is why we took a public health approach to eliminating hepatitis C over the coming years. We certainly aim to achieve that before the World Health Organisation target date.

As the hon. Member for Southend West said, one of the key issues is people not knowing that they have the virus, so, in Scotland, part of our approach has been to create opt-out screening at various points of blood being taken. That will be from general practice in areas of high prevalence. It already includes bloods taken in accident and emergency. It includes screening at other times such as when we screen for HIV. Obviously, we screen for HIV when a woman has her booking appointment at the time of her pregnancy. We need to use all the opportunities that we can. Of course a patient always has a right to opt out, but when we make something the norm it becomes easier for people to agree.

The prison population obviously has a big problem with drugs, including IV drugs—either in the present or the past, before the prisoners were incarcerated. It is important that we get the tests taken up by such populations.

We also offer testing in more social settings, where there have been education events around hepatitis and HIV and where peer-to-peer work has been done. It is important that we raise awareness and try to reduce the stigma. There is a problem with always talking about HIV drug users, as opposed to recognising that someone might have been contaminated by blood in this country, while undergoing maternity care or surgery overseas, or, as was mentioned, in a tattoo parlour: it means that people do not care. We end up with, “Well, it’s their own fault”, which maintains the risk to everyone else and hampers elimination. As well as raising awareness, we absolutely have to reduce the stigma.

It is important to take a public health approach, as we have done in Scotland. I commend that to NHS England, which should remove the cap and do as we are doing: try to set a minimum target for new people to be found and treated as soon as possible. We have seen the new cases reduce from 1,500 in 2007 to 700 in 2013, but it is the chronic cases that have been out there for years that we have to find because they still carry the virus and can spread it to other people.

Of course, NHS England should try to get the price down. There is no right for drug companies to profiteer as opposed to having a fair return, but the issue must be taken in the round. We must recognise that eliminating the virus by using drug treatments while we wait for a vaccine will overall be an huge benefit to society.

--- Later in debate ---

[Steve Brine]

Point taken; feet will be held to said fire. I do not think that NHS England is found wanting in this area, and I will go on to say why, but I take my hon. Friend’s point and will follow it through, because I want this to work.

The new industry deal may allow for longer contract terms that cover a number of years, but whether a long-term deal can be reached and what its duration is will be contingent on the quality and value of the bids submitted by industry. I expect the outcome of that in the autumn.

On local delivery networks, NHS England has established 22 operational delivery networks across our country to ensure national access to the antiviral therapy. I will touch on the issue of the cap in a minute. Those clinically led operational networks are given a share of the national annual treatment run rates based on estimated local need.

That local operational delivery network model ensures better equity of access. Many patients with chronic hepatitis C infections come from marginalised groups that do not engage well with healthcare, as has already been said. Through the development of networks, it has been possible to deliver outreach and engagement with patients outside traditional healthcare settings, such as offering testing through drug and alcohol services and community pharmacies.

As hon. Members know, I have a great soft spot for community pharmacies, and I think that they can and do play an important role in this space. In April, I hopped along to Portmans Pharmacy, which is just up the road in Pimlico, to see the pharmacy testing pilot of the London joint working group on substance use and hepatitis C that is going on there. I saw the testing and the referral to treatment that takes place in pharmacies that offer needle and syringe programmes across six boroughs in London.

Portmans Pharmacy has provided a needle and syringe programme and the supervised consumption of methadone for a number of years. Those points of contact with people who inject, or previously injected—a key distinction—drugs provide an ideal opportunity for us to make every contact count and to test for hepatitis C, as we think that about half of people who inject drugs in London have the virus.

The approach of Portmans Pharmacy and the London joint working group is innovative. It aims to provide quick and easy access to testing and a clear pathway into assessment and treatment in specialist care, which is obviously critical. I pay great tribute to the work that the group has done. It has rightly received a lot of coverage and a lot of plaudits. I am anxious and impatient—as my officials know, I am impatient about everything—to see the peer-reviewed results of that work and where we can scale it out more.

The hon. Member for Central Ayrshire mentioned treatment in respect of the cap. It is different north of the border, but NHS England offers treatment as per the NICE recommendations. The drugs that she mentioned are expensive, which limits the number of people who can be treated each year, but treatment has been prioritised for those most severely affected. The NHS then provides treatment to others who are less severely affected. So far, 25,000 people in England have been treated with the new drugs and a further 13,000 will be treated this year. The NHS procurement exercise should allow for even larger numbers to be treated each year. Of course, nothing is perfect in life. Resources in a publicly funded health system are finite, which is why we have to target them at the most challenged group. That is one of the reasons why making every contact count through primary care and pre-primary care, as I call community pharmacies, is so important.

[Dr Whitford]

Does the Minister accept, though, that the people who are likely to continue to spread the condition are those who are less ill? The old concoctions tend not to be so effective or well tolerated. That is a big difference from the new antivirals, which are very effective and very well tolerated. It strikes me that in England, we may be letting more people become more ill before they qualify for the better drug.

[Steve Brine]

Of course, the hon. Lady states a fact not an opinion, and I accept that, which is why I speak of the importance of primary care and of making every contact count. The people who Portmans Pharmacy interacts with are not all sick. People who have a hepatitis C infection or a drug-use issue have other issues—they get flu too—so they interact with that pharmacy, and the pharmacy makes every contact count by grabbing people earlier. That is one reason why I am so passionate about the way that that underused network can help us to reach the ambitious targets that we have set.

Everyone has rightly talked about prevention—in many ways, I am the Minister with responsibility for prevention and it is the thing that I am most passionate about in our health service. As well as testing and treating those already infected, an essential part of tackling hepatitis C must be the prevention of infection in the first place, or the prevention of reinfection of those successfully treated, which would not be a smart use of public resources.

NHS England and Public Health England, which I have direct ministerial responsibility for, are actively engaged in programmes at a local level to prevent the spread of infection. As people who inject drugs or share needles are at the greatest risk of acquiring hepatitis C, prevention services, particularly those provided by drug treatment centres, are key components of hepatitis C control strategies. Clearly, the key to breaking the cycle of hepatitis C is to prevent infection happening in the first place.

--- Later in debate ---

[Steve Brine]

I will not prolong this discussion, Mr Streeter, but I take my hon. Friend’s point and I think it is a subject that will receive further airing, to put it mildly.

[Dr Whitford]

Will the Minister give way one last time?

[Steve Brine]

One last time and then I must conclude, because I want to touch on prisons.

[Dr Whitford]

Obviously, this debate has emphasised the importance of diagnosing people and getting people to undergo testing. However, does the Minister see that it is much easier to encourage people to undergo a test when they can be promised that they will get effective, tolerable treatment that will be successful, as opposed to their perhaps being left languishing on what is now relatively old-fashioned treatment that is full of side effects?

[Steve Brine]

Yes, of course, and that is why I have talked about the local networks, and about early detection and prevention. What the hon. Lady says is self-evident.

The Hepatitis C Trust, which has rightly received many plaudits today, has played an important role for us in recent years in piloting pretty innovative ways of increasing testing rates, through mobile testing vans—for example, in the constituency of my hon. Friend the Member for Southend West—and the pharmacy-based testing work that I mentioned, as well as the introduction of peer educators in prisons, which a number of people have mentioned today. My hon. Friend mentioned his visit to Wandsworth Prison, which he was right to say is a very good example of peer educators working.

The subject of prisons is one the House knows is of great interest to me. Given the number of people who, sadly, actively inject drugs across the criminal justice system and the custodial system today, it is obviously likely that a significant proportion of those in the infected but undiagnosed population will have spent some period at Her Majesty’s pleasure.

As part of the health services commissioned for those in detained settings, an opt-out testing programme for blood-borne viruses, including hepatitis C, in adult prisoners was fully implemented across the English secure estate last year, 2017-18. Because of the expected higher rates of prevalence, opt-out testing for blood-borne viruses is offered in 100% of the prison estate in England, as part of the healthcare reception process, although, it has to be said, with differential success and outcomes. We are currently addressing that through a range of initiatives that have been put in place to improve the delivery of testing and the provision of successful treatment in prisons. So, in some areas the whole-system changes are being piloted.

My shadow, the hon. Member for Washington and Sunderland West (Mrs Hodgson), made the very good point that we’ve started, so we must finish. Absolutely; as I said earlier, it would be a very inefficient use of public resources to start treatment inside the secure estate. That is why, when we talk about through-the-gate treatment, that treatment must include health treatment. That is something—I cannot believe that my hon. Friend the Member for Bracknell (Dr Lee) is getting a second mention in this debate; I see that he is on his feet in the main Chamber—that I look forward to talking to the new Minister with responsibility for prison healthcare about, whenever he or she takes up that lucky role in future hours or days.

Let me take the opportunity once again to congratulate the all-party parliamentary group on liver health. It is not the first time that I have said this and it will not be the last: so much good work in this place goes on in all-party parliamentary groups, including so much informed debate. As a Minister—I am sure that others in the Chamber who have been Ministers would concur—I think that those groups are incredibly valuable to us and to the work that we do.

That is why I spend so much time listening to all-party parliamentary groups, helping them, including helping them to launch their reports, and then writing back with line-by-line responses to their reports, because their work is so vital to us. It is critical on a public health issue such as this, which, as I said at the start, is often overlooked and sometimes brushed under the carpet as being a little bit, “We don’t want to discuss this.” That is because, exactly as the hon. Member for Central Ayrshire said, there may even—God forbid—be an unspoken feeling that, “Well, with their behaviour they had it coming.” She is very brave to say it and I have no qualms in repeating it, but I think that feeling does exist.

The measures that I have spoken about today are not a panacea; the target is an incredibly challenging one for us. However, the Government, Lord O’Shaughnessy—who speaks for us in the other place on this subject and shares an office with me—and I are all passionate about this issue. We passionately believe that it is something that we can and will beat. We are taking it seriously, and we are in a good position to push forward and significantly reduce the burden of hepatitis C, in line with our commitment on it.

This debate shows us that improvement in hepatitis C testing and delivery of treatment are best delivered where there have been whole-system improvements. The Government, together with the wider health and social care system, have got to take all the opportunities available to us to address this key, but sometimes overlooked, public health challenge.

Infection Prevention and Control

Philippa Whitford Excerpts

Tuesday 15th May 2018 Westminster Hall

[Nigel Mills (Amber Valley) (Con)]

I congratulate the hon. Member for Strangford (Jim Shannon) on securing this debate. It reminds me of a debate on much the same topic that we had a few months ago. Its aim was to find out from the then Minister when the Government might enforce the strategy they had announced. It is a pity that we are repeating that debate a few months later and we still do not have the answers. The case has been set out very clearly by the previous speakers. There is not much advantage in repeating it, but, just to reinforce the point, we are talking about 5,000 deaths annually. The World Health Organisation estimates that half of those are preventable through effective hand hygiene. I do not know of other situations in UK life where we could have 2,500 people die each year unnecessarily and that would not be a national scandal. We would do anything we possibly could to fix it. There are things we can do to save a large proportion of those lives that are not very difficult or expensive. Our strong message today is: let us get on and do them.

I accept it will not be easy. We are not talking about finding the number of people who do not practise any hand hygiene and making them practise it; we are talking about making sure that as many health staff as possible get up to the very high levels of compliance with hand hygiene rules, rather than being in the middle. I suspect that no health service staff are deliberately not cleaning their hands as often as they ought to. We know they work in high-pressure situations. They do their very best for patients, and occasionally some behaviours creep in that perhaps should not. The important thing is to have processes in place that can identify when performance is perhaps slipping and then remind people, gently and constructively, how important hand hygiene is. That is why we need accurate and sensible monitoring.

We all know what happens when a colleague in a team says, “We have got to do one of these audits today. I’ll go round and watch to make sure you are all practising the right hand hygiene.” We all know what will happen. We have all been in those situations. We are all very careful to make sure we wash our hands as best as we possibly can. We all think we know the same rules, so we all comply with the same things. The person observing probably does not know the rules any better than those being observed. It is no surprise, therefore, that we end up with near 100% compliance. In fact, it is a surprise that we do not end up with 100% compliance in that situation. It is like the driving test. I have never looked in my mirror as much in my life as on my driving test, because I knew I was being checked on that.

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

Is there not a simpler approach? Should not the audit be unannounced and carried out by people like secret shoppers, which is a technique that we use in Scotland?

[Nigel Mills]

Yes, that would be clear progress. However, I sense that we would notice an unknown person walking round the ward with a clipboard, which might make someone behave more carefully. I am not sure how easy it is to stop the word going round the hospital that such work is being done, but I accept that that is better than one member of the existing team doing it. The question is: can we find a better way of monitoring compliance and getting the data we need, so that we can work out what is happening, see what the trends are, and see whether they are reflected in infection rates? As hon. Members have pointed out, there are various techniques on the market to do that electronically.

Simply counting how many times the ward dispensers are squeezed will not work because we need to know the type of ward, how many patients there are and how sensitive the work is to know how many times people need to squeeze the dispensers. We need a system that says, “On a ward carrying out this sort of activity with this number of patients, we would have expected this level of hand hygiene-compliant moments, and we actually got this many squeezes on the dispenser. That is only a quarter of what it ought to have been. That tells us there is a big problem on this ward.” Or it might tell us that we got 80%, which is probably a sensible level to get.

In my constituency is the Deb Group, a large employer that produces hand hygiene gel and monitoring techniques. I accept there are many rivals on the market and many different ways of monitoring. Some people prefer to have each member of staff wear a badge with a sensor that can tell how often that member of staff approaches a hand hygiene gel dispenser, so that we can monitor at an individual level rather than a ward level.

All those ideas are out there. We need the Government, and presumably the Care Quality Commission or NHS Improvement, to say to hospitals, “We want you to collect real data. We don’t want you to do stupid observations that give you 99% compliance, which we know is meaningless, just so that you can tick a box to say that you’re compliant. We want you to collect real data. We don’t mind how you do it, and we’re not going to punish you, take money off you, or put you in special measures if that data shows that you’re at 25% or 35% compliance, and all your rivals are at 97% because they’re doing it wrongly. We want you to do it properly, get the data, use the data, and improve your performance where you can see that it is linked to infections being too high.”

When the CQC reviews hospitals and other health environments, it should check that hospitals are collecting that data sensibly and using it to improve performance. The CQC should be very serious about that when it assesses a hospital. Can we see that hospitals know what their performance is, have a plan in place to improve it, and are improving it, and that infection rates are falling? It would be a serious matter if hospitals were not doing that work properly—if they were just having a quick half-hour assessment now and again, and producing data that they must know is complete rubbish.

We have the right plan; we know what we want hospitals to start doing. Let us get it in force, and task the CQC to ensure that hospitals are doing it. Let us set out clearly what we want hospitals to do and ensure that they are not too scared to go down that line, thinking that their data will suddenly get worse and they will be punished for it. Let us do what we know we need to do, and hope that we do not have to come back in another couple of years to talk about the fact that 2,500 people have died because we have not managed to put something in place that is easy and relatively cheap, and that we know works.

--- Later in debate ---

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

I pay tribute to the hon. Member for Strangford (Jim Shannon) for securing this important debate. As he said, it is only a few weeks since the World Health Organisation’s “Save Lives: Clean Your Hands” campaign and we are talking about how to reduce healthcare-associated infections. Most hon. Members have rightly focused on hand-washing and hand hygiene, because it is crucial, but that alone will not tackle hospital infection. It is not just about hand-washing; it is about the cleaning of wards.

We started to see the rise in MRSA, MSSA and so on after we started to outsource cleaning. I remember watching a young man cleaning with a machine in the Royal in Glasgow. He looked about 20, and if anyone who has a 20-year-old son can tell me that he knows that there is such a thing as corners, I would be delighted to admit defeat. We need people who are committed to the space. I was very glad that my hospital in Ayrshire never outsourced. We kept ward maids who had their own patch, in which they took pride, and there were supervisors who came along—a bit like someone’s mum-in-law with a white cloth—checking under the beds and the trolleys and on top of the curtain rails. It is really important that the environment is clean.

Bed occupancy is another issue. We know that the NHS in England has been under pressure for quite a long time, because the number of beds has halved over the past 30 years. England has one of the lowest bed ratios in Europe, at 2.4 per 1,000. Bed occupancy has been more than 95% and the recommendation for a safe level is 85%. The average in Scotland in 83%. That will vary between rural and urban areas, but if there is no time to clean the bed between patients, the risk increases. If the hospital is under pressure with a queue down in A&E, people are going to cut corners.

As the hon. Member for Moray (Douglas Ross) mentioned, the fabric of the building is crucial. If something is cracked or broken or old or wooden, it is not possible to clean it properly. That is why we have the Healthcare Environment Inspectorate in Scotland, which—believe me—turns up unannounced, poking around in every nook and cranny, looking under trolleys and wheelchairs, in the toilets and the shower rooms. That also includes external unannounced observation of people washing their hands.

I will turn to staffing levels. Across the UK we face nursing workforce challenges. Although we are struggling with a 4.1% nursing vacancy rate in Scotland, in England at the moment it is more than 10%. That creates pressure on everyone else on the ward. As the hon. Member for Amber Valley (Nigel Mills) said, there is a temptation, if not to do no hand hygiene, perhaps not to spend long enough with the gel on the hands and not to take quite the same quantity.

It is important to remember that clostridium difficile is caused by the overuse of antibiotics. It may spread from patient to patient due to poor hand-washing, but the initial problem was overuse and prolonged use of broad-spectrum antibiotics. It is very important that that is controlled. We need to think about sources, such as pressure sores and intravenous access, whether it is a peripheral drip or a central line. An important one at the moment is the management of urinary catheters. How long is it left in place? Is it too long? If it needs to be in longer, is it being changed regularly?

We also need to monitor surgical site infections. In Scotland, two wounds are monitored so that we are aware of whether things are improving or worsening. Although the hon. Member for Moray complains about a 1.37% wound infection rate after C-section, that has actually decreased over many years, and for hip replacements the rate is 0.63%. Some of that is not due to hand-washing. I have been a surgeon for more than 30 years and have seen the change from big interrupted black silk sutures that allowed penetration points for infection, to subcuticular invisible mending that means that the wound seals very quickly, using better dressings and glue to seal the wound so that there is less risk of external ingress. There is also a plan to add bowel surgery and vascular surgery—a dirty operation and a clean operation—because that is how we can monitor if something more general is going wrong.

Like the rest of the UK, in Scotland since about 2000 we have been trying to tackle infections. We lost our white coats and had to wear short sleeves—I still do. We were not allowed watches—I still do not wear one—and hand-washing and hand gel were promoted. Nevertheless, in 2007-08 an appalling outbreak of clostridium difficile in the Vale of Leven Hospital affected more than 150 people and caused 34 deaths. That wake-up call made us realise that tackling healthcare-acquired infections cannot be done in isolation; it must be part of a quality improvement and safety drive.

We created Healthcare Improvement Scotland, and in 2008 we established the Scottish patient safety programme, which was based on principles from Boston but was the first national patient safety programme. It is a structure on which we can hang evidence-based practice about many of the challenges that put patients at risk. It involves not the great and the good sitting in an office, but frontline champions from all health boards and all areas. It is driven by outcome data, which is shared, published, peer reviewed and actioned. We have to make hand-washing, like patient safety, part of daily practice; it must not sit on a shelf in a folder.

The Scottish patient safety programme was started to tackle all risks. I came across it as a surgeon, because it was used to tackle surgical errors such as wrong-site surgery and drug errors—patients being given the wrong drug—but it also addressed healthcare-acquired infections and hand hygiene. We had ward champions and unannounced audits carried out by people from other wards. I agree that, unfortunately, the worst performers in every audit were the doctors. That is why we had to publish the results, put them on the doors of the ward and literally name and shame. We also did a lot of education with relatives, because they come in from outside. In recent years we have made our hospital grounds smoke-free to try to tackle the issue of staff and patients forming a mug of smoke that people have to walk through to get to the door.

All infection-control measures are brought together in one manual, the “National Infection Prevention and Control Manual”, which means that everything is in one place. If there are five or six different initiatives and guidelines, they can sometimes be slightly different and can end up causing confusion.

The hon. Member for Filton and Bradley Stoke (Jack Lopresti), who is no longer in his place, mentioned the important issue of antimicrobial resistance, which will make it harder to tackle infection. Our behaviour in healthcare is helping to drive it. We are threatened by a post-antibiotic era. Alexander Fleming came from Ayrshire, and it would be horrific to think that the antibiotic era might last less than 100 years. Antibiotic stewardship is critical, and it is part of our patient safety programme. The Scottish Government are now also working with vets, because part of the issue is the use of antibiotics in animal husbandry. It therefore comes under the title of the “one health” programme.

The purpose of the Scottish patient safety programme was to reduce deaths, and within just three years there was a 9.3% drop in hospital standardised mortality rates and a 24% drop in deaths in intensive care. The hon. Member for Moray said that there is an infection rate of 2.7% in intensive care, but we have to remember that those are the sickest, most complex patients, and they are therefore most at risk of having or bringing in an infection. There was a 90% drop in ward clostridium difficile rates within three years. Deaths from C. diff dropped by 79% between 2007 and 2015, and those from MRSA dropped by 87%.

Many hon. Members mentioned sepsis. We have all seen the horrific cases in the media, and 40,000 deaths is more than many cancers, which get a lot more attention. In Scotland we established the Sepsis Collaborative, which ran from 2012 to 2014. It focused on just one measure: the national early warning system, which was about delivering antibiotics intravenously to the patient within an hour. Every hour’s delay increases the death rate by more than 7.5%. In 2010 an audit showed that fewer than 25% of patients were getting an IV antibiotic within an hour, but by 2014 it was more than 80%. The aim was to reduce deaths by 10%, but during the time of the programme there was an almost 20% reduction.

All parts of the UK have seen a dramatic fall in C. diff and MRSA, but all have seen a rise in E. coli, which is a bug that lives in the bowel. It is largely driven by catheter infections and it concerns older patients. It is one of the challenges we face, because many of these bugs will be resistant. There is actually a higher mortality rate from E. coli than from MRSA.

One of the differences in approach is to look at healthcare-acquired infections not by themselves, but as part of patient safety. In Scotland there are no financial incentives to meet standards, either for the hospital or for the staff; it is just pure clinical competitiveness. Nurses and doctors go to work to do a good job, and if we give them the tools, the education and the training, they will do that. We also have to give them time and support. Having a more complex quality improvement structure makes it easier to share good practice. That is what we are talking about today. We want to see a change in approach, not in a protocol folder on a shelf, but in the DNA of staff.

--- Later in debate ---

[The Minister for Health (Stephen Barclay)]

As always, Mr Howarth, it is a pleasure to serve under your chairmanship.

I join the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), in congratulating the hon. Member for Strangford (Jim Shannon) on securing the debate, which provides an opportunity for the House to emphasise the importance of raising standards of infection prevention and control in the NHS. He was kind to pay tribute to the Secretary of State for his work on patient safety, and on putting that front and centre in his priorities. As the hon. Members for Ellesmere Port and Neston and for Central Ayrshire (Dr Whitford) acknowledged, that is a point on which the House is united in a common cause. How we reduce infections is of real importance to our constituents, as my hon. Friend the Member for North East Derbyshire (Lee Rowley) said, and that is reflected in our surgeries, because it impacts on the lives of those we represent. There is therefore a great deal of common cause.

The debate is timely because it was World Hand Hygiene Day on 5 May, which is an initiative that the World Health Organisation started in 2010 to remind us all, including patients and family members, to practise good hand hygiene, to help reduce the spread of infections. The hon. Member for Strangford was right to challenge the Government to reinvigorate our approach to hand hygiene. A number of initiatives are under way in Government to address exactly the points that he raised. Public Health England has been raising awareness, and NHS Improvement has begun a number of initiatives, such as its NHS provider bulletin and a hand hygiene theme in its executive masterclass. Other ways of raising awareness include the Royal College of Nursing’s glove awareness week. As the hon. Member for Central Ayrshire said, that it is all about taking practice from guidance or files and embedding that into the DNA, the culture and the way people operate, who include visiting relatives and staff at all levels, including doctors as well as nursing staff.

A number of hon. Members, including my hon. Friend the Member for Amber Valley (Nigel Mills), raised technology and what more we can do. One theme of the debate was whether the Government are doing enough to drive forward the use of technology. I recognise the limits of direct observation and how behavioural change may respond to those. That is why the Government are actively looking at the extent to which technology can facilitate this area.

We have carried out an initial assessment; indeed, the NHS Improvement director of infection prevention and control, Dr Ruth May, and her team recently visited the Royal Wolverhampton NHS Trust, which has been trialling an electronic monitoring system to make an initial assessment of that. Their feedback is that the system is reliant on existing technology, and that many IT systems would not be able to support that. A number of practical issues need to be addressed before one would have a roll-out of technology. I reassure the House that Dr May and her team are actively looking at that issue. We all recognise the impact, not just on patient safety, but on the cost of infections and unnecessary deaths. We are actively looking at the issue of technology.

The hon. Member for Strangford also asked if we could publish more. To pick up on the remarks of the hon. Member for Central Ayrshire on the way information is published in NHS Scotland, dialogues are already taking place. I am happy to ask officials to ensure that, as part of the collaboration that is already under way in NHS Improvement with colleagues in the Scotland and England NHS, we look at best practice to ensure that we are working with and maximising the learning from both sets of NHS.

Public Health England has carried out some initial analysis of the available data to determine the suitability of the data available for publishing. Currently, the data is incomplete and will not truly reflect the usage of hand gel. We are exploring how to improve that data. The hon. Member for Central Ayrshire commented that transparency on what is being done and on variance in performance around infection rates is a key driver of prevention.

[Dr Whitford]

The Minister may know that as a breast cancer surgeon, I was involved in developing the breast cancer standards for Scotland. The only action was peer review—putting everyone’s performance up at an annual conference. No one wants to be at the back of the class; in actual fact, seeing genuine performance drives up quality.

[Stephen Barclay]

The hon. Lady is right that peer review is always a powerful motivator. That sort of transparency drives behaviour, so we need to ensure that we do that in an effective way that does not alarm patient families, because of the publication of data that could be misrepresented by those who have different objectives. The need to get more publication of data is an important point, which the hon. Member for Strangford and others raised, on which we need to do further work.

The hon. Member for Upper Bann (David Simpson) asked in his intervention about the specific issue of patients going outside to smoke, and whether there was an associated infection risk, for example through drips. I am advised that there is no additional risk of infection, as long as the drip is well managed. If colleagues have specific issues about the infection risk associated with that, that is the nature of the debate and helpful to know.

My hon. Friend the Member for Moray (Douglas Ross) spoke of the pain and distress to patients caused by infections, and the important link to buildings. Although that is relevant in Scotland, to which he referred, I accept that the point would also apply to the England NHS. The state of the buildings and the maintenance programme have a part to play, not just in the Scottish NHS, but in the England NHS as well.

The hon. Member for Strangford asked whether hand hygiene could be a national marker of care quality. The Department is considering how we could do that effectively. The points he raised were heard and I will ensure that they are addressed. As and when we have any update, I will be very happy to share that with him.

Overall, a great deal of progress has been made. We are committed to reducing the number of infections. Since 2010 we have made excellent progress on MRSA and C. difficile. In the 12 months ending March 2018, MRSA cases were down 54% on the 12 months ending May 2010, and C.diff infections were down 47%. Considerable progress has been made, but as the hon. Member for Central Ayrshire mentioned, although we have made progress in slowing the rate of increase of E. coli infections, there is more to be done to bring that rate down. NHS England has the challenging objective to bring that down by 20% as part of its mandate. As a result of slowing that down, there were 2,400 fewer cases of infections than there would have been with the previous trend.

Clearly, there is more to be done on E. coli and it is an area of considerable focus in the team. Those cases also have a fiscal cost of between £3,000 and £7,000 per infection, but the much more material cost is the patient safety issue and the harm that accrues as a result. NHS Improvement is leading this programme, aimed at a 20% reduction in E. coli bloodstream infections in 2018-19. It is an ambitious but important target. NHS Improvement has begun working with the medical director of NHS England, Steve Powis, on setting up pilots with local health economies across England to engage and assist in the reduction. That may be an issue that my hon. Friend the Member for Morley and Outwood (Andrea Jenkyns) wishes to pick up with me after the debate—how we can work together, given her powerful but extremely sad experience of the events that befell her father.

Colleagues recognised the considerable amount of work on antimicrobial resistance, which is an important factor in treating infections. Our latest estimate is that over five years, there could be an extra 6,000 deaths attributable to pan-antibiotic resistance. Lord O’Neill’s review on AMR said that drug-resistant infections will cost the world 10 million extra deaths a year and $100 trillion by 2050. Those are pretty scary figures, but they underline the importance of preventing infections occurring in the first place.

That brings me on to patient safety. Following the tragic events at Mid Staffordshire and the subsequent public inquiry led by Sir Robert Francis, the NHS embarked on a journey of improvement based upon three strands: better regulation, greater transparency and a culture of learning. Assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated, is addressed by the fundamental standards of care, enshrined in regulations, that all Care Quality Commission registered providers are expected to meet. A number of colleagues mentioned the role of the CQC as part of the checks and balances that need to be in place.

In November 2016, the Secretary of State launched new plans to reduce infections in the NHS, including the sepsis commissioning for quality and innovation. Through that, we have incentivised hospitals to improve their sepsis care. Independent CQC inspections have focused on E. coli rates in hospitals and in the community. In addition, we have appointed a national infection prevention lead to ensure a sustained focus at national level, improved training and information sharing, so that NHS staff can cut infection rates and, through the National Institute for Health and Care Excellence’s 2017 guidelines, highlight standard principles and advice on good hygiene.

Considerable progress is being made. Data published in 2017 suggests that four in 10 of all E. coli blood infections cannot be treated with commonly used antibiotics. Infection prevention and control is a key element of tackling antimicrobial resistance, and hand hygiene plays an important part in that. We are working extensively with stakeholders, including the royal colleges, academia and the research community, industry and our expert advisory groups, to inform our next steps.

Several colleagues, including the hon. Member for Ellesmere Port and Neston, mentioned sepsis. We have made significant progress since our focus to improve sepsis practices increased in January 2015. There is new NICE guidance and a new national CQUIN measure to incentivise providers to improve the identification and timely treatment of sepsis. The hon. Member for Central Ayrshire was absolutely right about the time-critical nature of that treatment. That work is already delivering change. The most recent data, which is for the third quarter of 2017-18, shows that emergency department assessment for sepsis has increased from 52% to 92%, and in-patient assessment has increased from 62% to 84% since April 2016.

Considerable progress has been made, which reflects the renewed focus across the NHS, in England and Scotland, on the time-critical nature of sepsis treatment, but we know there is more to do, which is why a new cross-system action plan was launched in September 2017. That plan outlines a range of activities to ensure that the NHS is on the highest possible alert to tackle that devastating condition. Indeed, just recently, on 25 April, NHS Improvement issued a national early warning score 2 patient safety alert to support providers to adopt the revised NEWS2 to detect deterioration in adult patients, including better identification of patients likely to have sepsis.

My colleague the Minister for Care, my hon. Friend the Member for Gosport (Caroline Dinenage), hosted and gave a speech at the launch of Health Education England’s paediatric sepsis e-learning package, which, again, is about raising awareness at an early stage. That training package was informed by clinicians and by parents whose children sadly passed away from sepsis, so we can learn from those tragic events and ensure that warning signs are better picked up at an earlier stage.

As several Members recognised, hand hygiene plays a key role in infection prevention and control, in supporting patient safety and in our efforts to address antimicrobial resistance. Considerable progress has been made—MRSA has more than halved and C. difficile has reduced by just under half since 2010—but, as the hon. Member for Central Ayrshire rightly said, E. coli remains a key area for renewed focus. We have successfully slowed its growth, but we now need to reduce it significantly. Part of the challenge is that a lot of it occurs outside the hospital setting, in the community.

I look forward to working with colleagues from across the House on this shared objective in an area where shared practice, from both England and Scotland, can help. We can learn from each other and from Members’ experiences in their constituencies. We will continue to embed hand hygiene practice and promote awareness of it in the NHS, not just through World Hand Hygiene Day but through debates such as this one.

Education (Student Support)

Philippa Whitford Excerpts

Wednesday 9th May 2018 Commons Chamber

[Stephen Barclay]

I am happy to confirm that. We now have 13,100 more nurses on wards since 2010 and we have a commitment to expand the numbers—[Interruption.] It is a new programme and we are expanding the number of apprenticeships. We have committed to 5,000 this year, expanding to 7,500.

It is interesting, is it not? Having routes that give people opportunities to progress—having different choices for people and empowering individuals, not all of whom want to go to university—so that people from different backgrounds can go into the profession is the very essence of what our party stands for. It is shame—

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

Does the Minister therefore challenge the figure of only 30 apprentices and does he recognise that with a four-year course they will not be ready until 2022, and there is a need for nurses now?

[Stephen Barclay]

I absolutely recognise that the apprenticeship route will take four years, but the Government have given a clear commitment to that and that is backed up by significant—[Interruption.] The UCAS figures are embargoed, so I do not have the latest figure. The point is that it is a four-year programme and it will take time to roll out, but it is backed by significant funding: the NHS is contributing £200 million to the apprenticeship levy. That is a signal of this Government’s commitment. The Minister for Apprenticeships and Skills is here, championing the apprenticeship route, as are other Members through the Select Committees. It is a shame that some Opposition Members are not reflecting on the benefits offered by apprenticeships as an alternative route into the nursing profession that will deliver more nurses. That should be welcomed.

--- Later in debate ---

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

As the Minister says, we are here to discuss removing the bursary from postgraduate nursing students, but it would be crazy not to learn from the experience of the past two years following the removal of the undergraduate bursary in 2016. Scotland maintained that bursary, as indeed did Northern Ireland and Wales. We provide £6,500 as a bursary and up to £2,500 carers allowance for those with caring commitments, and obviously there are no tuition fees, so that saves another £9,000 a year. Our students are therefore £18,000 a year better off. Only in England has the undergraduate bursary been removed and tuition fees introduced. So nurses in England will face coming out with debts of £50,000 to £60,000.

As has already been said, there has been a 33% fall in applications. Several Government Members have said that there are still plenty of applications, but what talent has been lost in that third? Exactly who are the people who are not applying for nursing because there is no longer a bursary? There has been an even bigger fall—42%—in the number of mature students applying, yet we know that mature nursing students have a much greater tendency to stay in the place where they start and to stay in nursing. We are discussing postgraduate students tonight, and the biggest advantage of postgraduate students is that they will be trained more quickly. The Minister mentioned the fact—although he did not expand on it—that postgraduates already have student loans. The idea of asking them to take on second student loan is likely to result not in a 33% or 42% drop but in an even bigger drop.

The Minister talks about the extra money that the NHS is investing, but why not invest it in attracting people to study nursing as a degree? It is fine to talk about nursing apprenticeships, but we hear that only 30 people have taken those up, and they will not be ready until 2022, so they are not a quick answer. I have nothing against the idea of nurse apprentices, but nurses are now leaders in the health service; we have advanced nurse practitioners and nurses who are managing and leading services. That requires them to be educated to degree level and to have the experience to act as leaders.

What we hear from the Royal College of Nursing is not that there are now 700 fewer nurses in total, but that 700 fewer nurses have started training through the degree course, yet all this change was meant to be about expanding that number. It has not expanded; it reduced last year. The danger is that that pattern will continue and be even more marked for postgraduate students.

In Scotland, obviously, we have maintained the bursary. Instead of a 3% fall in the number of people starting studying, we have seen an 8% rise. Indeed, we have already seen a 10% increase in the number of people signing up for nursing places this year. We all need nurses, because all four national health services are struggling with the workforce, but NHS Improvement reports that there are 36,000 vacancies in NHS England. That is catastrophic. Literally, one in 10 nursing jobs in England is empty. That is more than twice the vacancy rate we face in Scotland. This is safety issue. The Secretary of State talked about safety. This is part of what led to the junior doctors’ strike, because we are talking about avoidable deaths. Research shows that the only measure that reduces avoidable deaths in hospital is the ratio of registered nurses to patients—not healthcare assistants, auxiliaries, doctors or anyone else. This is about registered nurses actually looking after patients.

The extra places that we were told would be funded by removing the undergraduate bursary will start only this autumn, so they will not be ready until 2021. The apprentices will not be ready until 2022. Postgraduate students starting this autumn will at least be ready in 2020. This is urgent. The NHS in England is struggling for want of nurses. They are the people who make the difference to safety. The Government should be investing in whatever will produce high-quality nurse leaders as quickly as possible, and that is postgraduates.

--- Later in debate ---

[Vernon Coaker]

Let us see where this goes. The hon. Lady’s point is that it does not matter that there has been a 33% fall in applications, because other things will happen, but that is not the view of the Royal College of Nursing. Applications from mature students have been disproportionately affected by the funding reform; the number of applicants aged over 25 has fallen by 42%. I do not know whether the Minister intends to respond—it would be a shame if he did not—but perhaps he can explain why that figure does not matter. That point needs to be addressed in debate. The hon. Lady disagrees, but I say that it does matter, and that it will cause problems for future nursing recruitment.

[Dr Whitford]

The hon. Member for Lewes (Maria Caulfield) asks why not enough nurses were coming through. Is that not simply because there was a cap on places? The Government keep linking the bursary with the cap. The issue was not the bursary; it was the cap. If the Government want to invest in nurses, they should lift the cap but not remove the bursary, because that will shrink the number of applications.

[Vernon Coaker]

I thank the hon. Lady for her intervention. I say to the Minister that there is hard evidence from the Government’s own equality analysis that the reforms will

“increase the amount of student loan borrowing for postgraduate students and could lead to a fall in student numbers. The government has acknowledged that, due to the student intake, the impact will fall largely on women, older students and, to a lesser extent, students from ethnic minorities.”

Where is the Government’s defence of that, and what are they doing to mitigate it? I have no doubt that the Government would say, “We have done x, y and z.” Indeed, that is what the hon. Member for Lewes has said, but where is the Minister’s explanation?

It is not just the Government equality analysis that says we should be concerned about the changes. A House of Lords Secondary Legislation Scrutiny Committee report, published just a few days ago, also raised concerns. First it criticised the process and then it said:

“Our second, no less strongly felt concern is with the wider impact on recruitment to post-graduate nursing courses which may result from the switch from bursary to loan support”.

That is why this debate is so important. There is evidence from a highly respected Select Committees of this House, and from the Government’s own equality analysis, and were it not for the actions of my Front-Bench colleagues, we would not even be debating the issue and the House of Commons would not even be reflecting on a major change to the way in which we fund the postgraduate training of our nurses.

We all agree that the nurses of this country deserve our respect, and that they do a wonderful job, but the point of this debate is to ask whether we are going to address the shortage of nurses following the removal of nursing bursaries. As my hon. Friend the Member for Ashton-under-Lyne (Angela Rayner) said, we have serious concerns and doubts about that, and it is quite right that those are debated.

Let us see whether the hon. Member for Lewes is right, or whether the Royal College of Nursing is right that the huge fall in applications we have seen at undergraduate level will be reflected at postgraduate level, and that down the track the Government will regret ignoring the professional bodies and their own equality analysis. The Government need to reflect on that and see what more can be done. Rhetoric about our nurses being brilliant is fine, and we all share that admiration, but at the end of the day, what this country needs is hard-nosed policy that works.

--- Later in debate ---

[Rachel Maclean]

Thank you, Madam Deputy Speaker.

Martin Lewis’s comments were, it is true, aimed at politicians on both sides of the House, but we have all heard the Labour party’s recent claims about student debt. The idea that that is the same thing as a debt has, in reality, put people from different backgrounds off studying at university. Student debt is not the same thing as a credit card debt. It is a graduate tax that people pay only when their income reaches a certain level, and that is the same for nursing students. We have to go forward with a sustainable solution.

[Dr Whitford]

Will the hon. Lady give way?

[Rachel Maclean]

I will not, because time is short.

Conservative Members will work to fight against the weaponisation for political ends of students and people who want to be students. We will open up more opportunities for everyone in this country to make a career in the NHS, if that is what they choose to do, and we will run the economy in a balanced way to support our precious NHS during this Parliament and in the years to come. I will not be voting for Labour’s motion tonight.

Question put.

The House proceeded to a Division.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 8th May 2018 Commons Chamber

[Stephen Barclay]

I am very happy to do so. We are removing the cap on the number of places covered by the bursaries and increasing the number of student places by 25%, which means that there will be 5,000 more nurses in training as a result of these changes.

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

The Secretary of State’s removal of the nursing bursary and introduction of tuition fees have resulted in a 33% drop in applications in England. In Scotland, we have kept the bursary, a carer’s allowance and free tuition, which means that student nurses are up to £18,000 a year better off, and indeed they also earn more once they graduate. Does the Minister recognise that that is why applications in Scotland have remained stable while in England they have dropped by a third?

[Stephen Barclay]

The hon. Lady speaks with great authority on health matters, but, again, she misses the distinction between the number of applicants and the number of nurses in training. It is about how many places are available, and we are increasing by 25% the number of nurses in training. That is what will address the supply and address some of the vacancies in the profession.

[Dr Whitford]

Workforce is a challenge for all four national health services across the UK, but, according to NHS Improvement, there are 36,000 nursing vacancies in England, more than twice the rate in Scotland. The Minister claims that more nurse students are training, but in fact there were 700 fewer in training in England last year, compared with an 8% increase in Scotland. The key difference is that in Scotland we are supporting the finances of student nurses, so will the Government accept that removing the nursing bursary was a mistake and reintroduce it?

[Stephen Barclay]

The distinction the hon. Lady fails to make is that in England we are increasing the number of nurses in training by 25%; we are ensuring that nurses who have left the profession can return through the return-to-work programme; and we are introducing significant additional pay through “Agenda for Change”. As my right hon. Friend the Member for Harlow (Robert Halfon) said, we are also creating new routes so that those who come into the NHS through other routes, such as by joining as a healthcare assistant, are not trapped in those roles but are able to progress, because the Conservative party backs people who want to progress in their careers. Healthcare assistants who want to progress into nursing should have that opportunity.

Breast Cancer Screening

Philippa Whitford Excerpts

Wednesday 2nd May 2018 Commons Chamber

[Mr Hunt]

Yes, and I can reassure my hon. Friend that GPs will be briefed and that people will be referred for additional support to clinically trained staff at Macmillan Cancer Support and Breast Cancer Care. We have to be transparent with patients, however, about the absence of a clear clinical consensus on the efficacy of scanning for women in their 70s. The fairest thing is to explain that different people have different views and allow them to come to an individual choice, and that is what we are doing. It will of course cause considerable distress to those given that dilemma, but if anyone wants a scan, we will do that scan.

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

I thank the Secretary of State for my advance briefing, but, as a breast surgeon and co-chair of the all-party group on breast cancer, I gently take issue with his comment that we do not need to diagnose breast cancer early because of the changes in treatment. I would not like that message to stand: diagnosing early is still crucial.

Obviously this is horrendous for the women involved, but it will also create anxiety for women who are not aware whether they are involved and who might not have been part of the trial. Reassuring them will be a challenge. I welcome the independent review into how it happened and how it went so long without being picked up, and I am interested to know what will happen with the trial now—the loss of almost 500,000 women from it might have a major impact.

Given the normal pick-up rate of breast screening, approximately 2,500 cancers would have been picked up across England in the last round. As the Secretary of State says, this issue did not apply in Scotland, but some of the women affected might have moved and settled in Scotland, so when did he inform the Scottish Government?





The Secretary of State said that the Department knew in January. As far as I can establish, officers in Scotland were informed of a minor issue in March, were told only last week that it was actually more major, and were not told that it might affect women who now live in Scotland. There has clearly been preparation and talk about funding in England, but how many women who live in Scotland have been identified, and what efforts have been made to track them down? What preparations for funding or the expansion of services have been made for Scotland and, indeed, for the other devolved nations?

As was mentioned by the hon. Member for Leicester South (Jonathan Ashworth), radiology, and particularly breast radiology, is a huge shortage specialty. What funds will be provided to ensure that it can be delivered without messing up the normal system?

Will women who do not receive a letter in the next few weeks be able to telephone, or can the Secretary of State really guarantee that if they have not heard by the end of the month, they are clear? As a doctor, I find that a bit scary.

[Mr Hunt]

The hon. Lady has asked some important questions. I am sorry if what I said was not clear, but I do not think I said that there was no need to diagnose early. It is obviously incredibly important for cancer to be diagnosed as early as possible. What I said was that I had been advised that in many cases, because of advances in breast cancer treatment, it would not make a difference to the particular women affected in this case. I fully accept that in some cases it will, and of course it is very important to diagnose all cancers as early as possible.

I will find out from Oxford University the dates on which it expects to report the full outcome of the AgeX trial. Obviously we all want to hear the results as soon as possible. I will also inform the hon. Lady of the exact date on which Scottish Government officials were informed. Let me reassure her that if there are any additional costs to the Scottish health system, it will of course be recompensed.

We do not think that major pressures will be created in the Scottish screening programme, and we are confident that we will be able to contact everyone in the UK who is registered with a GP—whether in Scotland, Wales, Northern Ireland or England—by the end of May. We have had very productive discussions with Scottish officials about the IT exchange that will be necessary to ensure that women living in Scotland also receive their letters by the end of May. We cannot guarantee that every single one of them will have been contacted by then—some will have moved abroad, and some will not be registered with a GP for whatever reason—but we think that we can contact the vast majority, and the helpline will be open for anyone to call if they think they may have been affected.