Junior Doctors Contract

Philippa Whitford Excerpts

Monday 30th November 2015 Commons Chamber

[Mr Hunt]

I thank my right hon. and learned Friend for his robust support. I seem to remember that when he was Health Secretary posters were put up all over the country saying, “What do you call a man who ignores doctors’ advice”, with a picture of my right hon. and learned Friend. He knows exactly what this is all about. It is not just Conservative Health Secretaries: Nye Bevan and Alan Milburn went through this.

My right hon. and learned Friend is absolutely right: we will all be delighted if the strike is postponed. Incidentally, it begins at 8 o’clock tomorrow morning, not midnight—I must correct that. He is right: the Government’s focus is unremittingly on improving patient care. We have made it clear that any settlement has to be within the current pay envelope. The great sadness is that the vast majority of doctors are passionate about doing something about seven-day services. If only we had had the chance to negotiate from June, we could have avoided the situation we are in.

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

I, too, welcome the fact that the Secretary of State has been to ACAS and made the change to plain hours that would have resulted in hours between 7 o’clock to 10 o’clock on a Saturday being counted in the same way as the equivalent period during the week. That would particularly punish people who already work at weekends such as acute medical staff and doctors working in accident and emergency—the very people we need.

I welcome the fact that the Secretary of State has made that change. I should be grateful for clarification of whether the threat of imposition is there or not. The statement says that it has been removed, but in his reply to the shadow Secretary of State he implied that it has not been removed. It would be helpful if he clarified the position.

We keep talking about more people dying at the weekend. May I again stress that it is not excess deaths at weekends, implying that hospitals look like the Mary Celeste? It is excess deaths of people admitted at the weekend, who may die on any day of the week. Junior doctors already cover weekends. It is the additional services to diagnose and get people on their journey that we are discussing. We need to focus on that. Unfortunately, the Secretary of State, in previous statements, has moved from talking about excess deaths to talking about the consultant opt-out clause, which applies only to routine work—I am sorry, a toenail clinic on a Sunday will not save lives—but he needs to focus on strengthening the seven-day service for urgent cases, in which people are ill and where existing provision leads to excess deaths. Hopefully, we can make progress. I join the Secretary of State and everyone in the House in hoping that there is not a strike tomorrow.

[Mr Hunt]

The hon. Lady is right that this is about the excess mortality rates of people admitted at the weekend—not of people who are already in hospital at the weekend. I am afraid that she is mistaken in her characterisation of the rest of the Government position. Clinical standards are clear: people admitted at the weekend, or at any time, should be seen by a consultant within 14 hours, but that is true in only one in eight hospitals across seven days of the week, which is why sorting out the consultant contract for urgent and emergency care matters. Although the opt-out in the consultant contract applies only to elective work, half as many consultants are available in A&E on Sunday as are available during the week, although Sunday is one of the busiest days of the week, so it is not just about junior doctors. However, if we are going to make life better for junior doctors, we need to make sure that they have more senior cover and do not feel clinically exposed, which is what independent studies have said they feel.

Governments of any party must have the right to set the terms and conditions of an employment contract. That is a right that no part of the public sector has moved away from, and it is a vital right for all employers. I have simply said that I will not move towards any new contract while negotiations are happening during this time-limited period. That was what my statement clearly said, and the BMA for its part has said that if this agreement is honoured, it will remove the threat to strike during that period.

Sugary Drinks Tax

Philippa Whitford Excerpts

Monday 30th November 2015 Westminster Hall

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

Thank you, Mr McCabe. I am actually Dr Whitford; Eilidh Whiteford—my hon. Friend the Member for Banff and Buchan (Dr Whiteford)—is the other one, whom I always get mixed up with.

Like the hon. Member for St Austell and Newquay (Steve Double), I am clearly not skinny. I was not overweight as a child; it was the usual comfort eating later on, middle age, lack of exercise and all the rest of it. I know what it is like to move through a world where everything shouts “eat me” all the time. We live in a totally obesogenic environment. The idea that it is easy to resist things is simply not true. Everything is geared towards making people eat unhealthily. We spend a little more than £600 million on obesity prevention, but £256 billion is spent on advertising unhealthy foods. It is David and Goliath. It is difficult for people to make the right choices.

Obviously the debate is about the sugar tax, but as Members have said, the issue goes much wider than that. The hon. Member for Totnes (Dr Wollaston), who is the chair of the Health Committee, talked about the sheer scale of the problem. One third of children leaving school are obese or overweight and a quarter are obese—that is the reason for the differing figures mentioned earlier. It is predicted that 70% of the population will be overweight or obese by the mid-2030s. That is an astronomical number. Our health service will not cope with all the directly obesity-related problems such as type 2 diabetes, cancers and heart disease. We have heard figures about the cost of that from other members of the Health Committee, but it is estimated that the societal costs are £27 billion. We all know someone who was overweight or obese as a child, and we know about the bullying, exclusion and self-contempt that occurs and the impact that that has on schooling, and therefore on jobs, which leads to another generation of deprivation. People say that a tax might be regressive, but it would be no more so than duty on cigarettes or alcohol. It is important to see it in that light.

We have discussed evidence from Mexico, which we heard in the Committee, but other countries such as Norway, Hungary and Finland have taken the same approach. Although not all the evidence has been peer-reviewed, published and assessed, all the details of the national experiments point in the same direction. Cochrane reviews coming up in the next year to 18 months will be able to put that information in a solid position based on experiments and data. At that point it will not be possible to ignore the issue, but we need to be thinking now about our options and what we will do.

Although this is a debate about sugar tax, the Health Committee made nine recommendations. Sugar tax is the one that the media are interested in, because it catches the light, but it is part of a whole package and a sugar tax is not even in our top three recommendations. The first is about promotions, because 40% of food bought in our shops is on promotion, and that is heavily weighted towards unhealthy foods. We need to look to rebalance that. One Member who has scuttled off said that we would come up with other rules such as getting rid of discounting, or we would suggest portion control—darn tootin’ we will!

We need to realise what we are fighting, because we are talking about something deeply shocking and very dangerous. The argument is that people who are less well off save money if they can buy one for £1 or two for £1.50. However, the evidence we heard is that, if that means they buy two packets of biscuits, one will not be put in the cupboard for next week; both will get eaten this week, and the same mum or dad will be back the following week to shop for another packet of biscuits. Therefore they have not only eaten far more unhealthy food and sugar but spent more money. Promotions of unhealthy foods in multi-buys are not helping anyone.

We also see a change in portion sizes. Packets are getting bigger, and there is the bottomless cup at McDonald’s or wherever. There is the end of the aisle, the pester power and the stuff at the till. Every mum and dad out shopping at the supermarket with their wain—that is Scottish for child—will know what it is like: they can see the light at the end of the tunnel, then their child hangs out of the trolley and grabs something. They may put it in their mouth, which means the mum or dad is obliged to pay for it. Some supermarkets have been good at taking that opportunity away, but not all of them. My local supermarket still has sweets right at the till.

Promotions have a big impact and should be tackled. So should marketing, because of the sheer scale of the budgets for and against obesity. It is not just about asking for advertising to be put after 9 o’clock; it is particularly about what is emerging on the internet in social media and advergames, as the hon. Member for Totnes mentioned. Things keep wriggling around, so we need a strategy broad enough to cover that.

Reformulation is almost the holy grail. We have seen its success with salt, but it took a long time. We have taken about 40% of the salt out of the British diet, and by and large people have not noticed. However, we do not have 10 years to do that. Reformulation is also much harder to do with sugar, because it has an impact on the structure and texture of food, but we need to get on with it. The reason why we are spending so much time talking about sugary drinks is because, as the hon. Lady said, they are one product where reformulation is easy: we can replace sugar with sweeteners.

We also need to reformulate to drive down sweeteners. We need to reset our sweet tooth—we have all seen someone washing down a big slab of sticky cake with a diet soft drink—because the craving remains. Even those who choose diet soft drinks will find that their craving for sugar remains, so when they cook they will add more sugar and they will eat more cake and biscuits. Sweeteners can really help us to speed up the removal of sugar, but we still need them to be on a downward journey. That must be done with industry, which has done a lot. Many soft drink manufacturers provide a choice, so if a sugar tax is introduced, hopefully that should nudge people across to less sugary drinks, as the hon. Member for Totnes said. It would be ideal if there was no tax collected at all, because that would suggest that the policy was working. At the moment, however, the traditional product is still absolutely packed with sugar.

[John Glen]

The hon. Lady is speaking with her customary authority on the subject. Does she agree that the industry has the potential to go a lot further so that we can make more progress before a sugar tax, which has attracted all the attention, is instituted? It is a matter of providing choices, and a lot of consumer power could be harnessed to help us make that progress.

[Dr Whitford]

As the hon. Member for Totnes mentioned, the people who make such choices tend to be those who are more oriented towards a healthy diet anyway. It is about trying to teach people in the mire of deprivation, and often in the mire of despair, who smoke more, use more alcohol and take more sugar. They are the very people who are hit by all our measures to try to bring about health improvement.

All the industries are making efforts, but they are afraid of being out there on their own and seeing their competitors mopping up their business. That is why we need regulation. In our inquiry, that came out from the retailers in particular, who said they wanted a level playing field. Whether it is through a sugar tax or regulation, they want to feel that everyone has to move forward.

We also need leadership. The Food Standards Agency was important in leading on salt reformulation, so we need to work out who will be the leader on this, because we need a focused project to get not just sugar but fat and calorific intake out of our diet. As has been mentioned, there are also hidden sugars, particularly in tomato products such as baked beans, tomato sauces and bolognese sauces in which it is easy to hide sugar. When we start to look at that, we see that it is quite scary.

That is where labelling and education comes in. The traffic light system has been helpful for a broad range of foods. When we are looking for a sandwich in a rush, we can spot the green and amber on the label as opposed to the red and red. However, that will not help with sugary drinks, which get a red light and two green lights because they do not contain salt and fat. Therefore, someone who picks that up might think, “Two greens— that must be quite good.” That is why the labelling of teaspoons of sugar is important. The industry could be applauded as it took every single teaspoon of sugar out of a drink.

We have heard talk about the nanny state and people having the freedom to do what they like, but as a doctor for 33 years I heard that about seatbelts and crash helmets. People want to feel the wind in their hair, but they do not look so good if they have come off their bike. We talk about the challenge of cigarettes and alcohol, and sugar is the same. All Governments have a responsibility to look at the report and all the measures it suggests, and to bring them in as a full package, because we need to tackle this, and we need to start now.

--- Later in debate ---

[Barbara Keeley]

As I was saying, we should look at the whole range of options. I want to talk about health campaigns. The Public Health England campaign Change4Life is an excellent example of providing families with information about small changes they can make to improve their health, as well as with advice on healthy recipes, diet and exercise. However, I fear that the announcement of a 25% cut to the non-NHS part of the Department of Health’s budget will have a significant impact on Public Health England. I want public health bodies to be able to continue campaigns to tackle obesity, but I am worried that their ability to do so will be damaged by these significant cuts. I am concerned that we will not in future be able to fund campaigns such as Change4Life, and that they may just not happen.

We must also be careful that the huge cuts to the public health grant given to local authorities do not reduce the advice and support available to those wanting to lose weight. At many community events in Salford, I have seen health improvement staff working with community groups and running all kinds of sessions. I fear that we will not have that in future.

Although the debate is about a sugar tax, I want to mention the importance of increasing physical activity among adults and children. I was a member of the all-party commission on physical activity, which published its report “Tackling Physical Inactivity—A Coordinated Approach” in 2014. We have discussed various aspects of our children’s health, but inactivity is a key factor, which is why a number of Members have referred to it. It is important that we encourage children to maintain active lifestyles from an early age.

[Dr Whitford]

May I draw the hon. Lady’s attention to a novel approach that has come out of St Ninians primary school in Stirling, called the daily mile? A teacher got the children to go out and run round the field. That seems to have made a huge difference at the school. Obviously, it costs absolutely nothing, and it seems to help the kids to concentrate, because they have been outdoors in the fresh air and—in our neck of the woods—probably in the rain as well.

[Barbara Keeley]

That type of initiative is wonderful, but fewer and fewer children are walking to school, and an awful lot more are being taken there by bus or by their parents. The Health Committee report reminds us that the latest figures show a fall in physical activity. In 2012, only 21% of boys and 16% of girls did enough exercise to meet the Government’s physical activity guidelines. That is a fall from four years earlier, when the figures were 28% for boys and 19% for girls. We are therefore going in the wrong direction, and we are all becoming couch potatoes. We might worry about this for ourselves, but it is a great concern when children are involved.

I am a former member of the Health Committee, and it is a pity that little emerges from the report, which simply reiterates and endorses the findings of its predecessor Committee’s inquiry, in which I was involved.

--- Later in debate ---

[Jane Ellison]

I am going to come on to teaspoons, and I do not want to run out of time before I do so. I will make a bit more progress and then see how we are getting on for interventions.

The Government cannot tackle obesity alone. I welcome the fact that we have consensus across the House on that, and the Committee draws that point out in its report. Businesses, health professionals, schools, local authorities, families and individuals have a role to play, as my hon. Friend the Member for St Austell and Newquay (Steve Double) brought out.

I want to talk about some of the industry action that has been taken. There has been progress in recent years on reducing sugar consumption. The focus under the voluntary partnership arrangements, which have been discussed, has been on overall calorie reduction, of which sugar can form a part. Billions of calories and tonnes of sugar have been removed from products and portion sizes have been reduced in some areas. Some major confectionery manufacturers have committed to a cap on single-serving confectionery at 250 calories, which is an important step.

We have to be realistic about consumer relations, which are important. Before I was an MP, I worked for the John Lewis Partnership—John Lewis and Waitrose—and I know only too well the important role that retail relationships play in an average family’s life. We need to involve those partners. Some retailers have played a part, for example by removing sweets from checkouts. Interestingly, they did so after asking their customers in surveys what support they wanted, as family shoppers, from industry to help them to make healthier choices. Much of the action that retailers have taken was in response to that.

I was very interested in the point that my hon. Friend the Member for Salisbury (John Glen) made in an intervention about consumer power. There is much greater consumer power to be unleashed, but the challenge to the industry to make further substantial progress remains. Like the Chair of the Health Committee, I have had some encouraging conversations in that regard, but we need to make more progress.

Providing clear information to consumers to help them make healthier choices is important, as a number of hon. Members have set out. The voluntary front-of-pack nutrition labelling scheme, introduced in 2013, plays a vital part in our work to encourage healthier eating and to reduce levels of obesity and other conditions. The scheme enables consumers to make healthier and more balanced choices by helping them better to understand the nutrient content of foods and drinks.

I turn to the issue of teaspoons of sugar, which has come up a lot in the debate. It is more complicated than something so simple should be; “teaspoons” sounds straightforward, but labelling is an EU competence, so member states cannot mandate additional forms of expression, such as spoonfuls of sugar, for pre-packed food. Under EU legislation, it would be possible for companies to represent sugar content in the form of spoons of sugar or sugar cubes on a voluntary basis, as long that met a number of EU criteria—I will outline what some of them are. It would sit alongside front-of-pack nutrition information, which I remind the House is voluntary, not mandated, in order to meet the same criteria.

[Dr Philippa Whitford]

For the public nowadays, “teaspoons of sugar” is more helpful than “sugar cubes”, because very few people use sugar cubes.

[Jane Ellison]

I am aware of that; the point has been made to me a number of times.

Let me mention a few of the criteria that would apply if we were to move in that direction. There would be a requirement to consult, and we would have to ensure that any measure was supported by scientific evidence and did not constitute a barrier to trade. Any such form of labelling would need to be agreed with the Commission before it was implemented, to avoid future infraction proceedings.

I have heard the strength of feeling in the House and I understand the point being made, but references to sugar cubes are quite powerful; last year’s Sugar Swaps campaign proved that they can be made meaningful. However, I will ask my officials to look carefully at the issue, because I have heard a great deal of interest in it being expressed today, and I know that the Health Committee took evidence on it. I wanted to underline the point that it is not as straightforward as it might seem, but we will look closely at it again in the light of the interest in it.

[Dr Whitford]

Did the same apply to cigarettes? Were we not allowed independently to add the warnings and so on that we put on cigarettes in this country? Did that have to be EU-wide?

[Jane Ellison]

As we approach the transposition of the new EU tobacco directive, the hon. Lady will see that the measures being taken are EU-wide, but those are two slightly different things. I am happy to come back to her in more detail after the debate, but generally speaking, packaging and labelling are EU competences.

I was delighted to hear so many hon. Members say that front-of-pack labelling was important. The scheme is popular with consumers. It provides information on calories and levels of specific nutrients in an easy-to-read, intuitive format. Businesses that have adopted the scheme account for two thirds of the market for pre-packed foods and drinks. Within the Change4Life programme, front-of-pack colour-coded nutrition labelling will continue to be included as a key message whenever there is a campaign focused on healthy eating. We use that in all the Change4Life materials, across a wide range of formats.

I want to reassure the hon. Member for Worsley and Eccles South (Barbara Keeley), who spoke from the Opposition Front Bench, that there will indeed be a physical activity strand in our childhood obesity strategy. I agree with the balance that the Health Committee struck on tackling childhood obesity, which is an important strand of the work. The great news about physical activity, as the Committee’s report underlined, is that it is good for everyone, whatever their weight. There is no downside to being more physically active, so of course we will want to reflect that.

This has not been touched on much this afternoon, but there is also a significant role for the family of health professionals in giving advice and supporting families to make changes to their lives. That relates particularly to families in more deprived communities. Only this morning I was talking about the role of health visitors, for example, in family education and family support. Again, a strand of our strategy will develop that.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 17th November 2015 Commons Chamber

[Mr Hunt]

I absolutely give my hon. Friend that reassurance. There are no preconditions, and this morning I wrote again to the BMA to reiterate that point. Of course, if we fail to make progress we have to implement our manifesto commitments, but we are willing to talk about absolutely everything. I agree strongly with my hon. Friend that it will be difficult to avoid harm to patients during those three days of industrial action. Delaying a cancer clinic might mean that someone gets a later diagnosis than they should get, and a hip operation might be delayed when someone is in a great deal of pain. It will be hard to avoid such things impacting on patients, and I urge the BMA to listen to the royal colleges—and many others—and call off the strike.

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

It is 40 years since the last junior doctor strike—before I even started medical school. Given the ballot tomorrow, does the Secretary of State regret the antagonistic approach that he took before the summer towards senior and junior doctors? Should he instead have worked with them and not threatened to impose a contract so as to reach a stronger emergency seven-day service?

[Mr Hunt]

I do not know what the hon. Lady thinks is antagonistic about holding reasonable discussions with doctors for three years to try to solve the problem of seven-day care. Those discussions ended with the BMA, after two and a half years, walking away from negotiations last October. We made a manifesto commitment to have a seven-day NHS and to do the right thing for patients, and we simply asked the BMA to sit round the table and talk to us about it. I am confident that we can find a solution.

[Dr Whitford]

Claiming in July that senior doctors do not work outside 9 to 5 was perhaps felt to be antagonistic. Contrary to the figures quoted by the hon. Member for Dudley North (Ian Austin) last Monday, A&E figures for NHS England are 5% below those in Scotland. With such disappointing figures before we even get into winter or face a work-to-rule, and in the presence of eye-watering deficits, how does the Secretary of State plan to support hospital trusts through the winter?

Off-patent Drugs Bill

Philippa Whitford Excerpts

Friday 6th November 2015 Commons Chamber

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

I was interested to hear the hon. Member for Torfaen (Nick Thomas-Symonds) mention the research into zoledronic acid. I took part in the AZURE study, which indeed means that this bisphosphonate, which strengthens bone, will help bone to avoid getting invaded in the first place. We already use it in breast cancer for patients who have bone metastasis, but it provides a perfect example of where a second use can be found.

The hon. Member for Newton Abbot (Anne Marie Morris) expressed concern about prices going back up, but that simply does not apply. These drugs have been through the whole process, so we know about their safety and their side-effects; they are now cheap and generic. They are made by lots of different companies, and the reason they do not get licences is that it is simply not worth while because the companies cannot put the price back up. If a formulation is changed—if it was a tablet and is now an injection, or if it was an injection and is now a tablet—it is possible to apply for a new patent. If it is exactly the same drug, even with a new use, the company cannot get a new patent. It is not willing to spend the money on sponsoring it.

I have heard people say, “It is in the guidelines”—and believe me, many of these drugs are in NICE guidelines. NICE guidelines say exactly what was said at the beginning of the debate, which is that tamoxifen should be made available to patients who are at high risk of breast cancer. However, it is not licensed for them.

I am a breast cancer surgeon, and in my practice we carry out an operation called sentinel node biopsy. Instead of taking all the lymph nodes out of a woman’s axilla and giving her lymphedema—which some Members will have seen, either in their families or in their constituents—we try to remove only one or two, and we use dyes to target them. One is a blue dye called patent blue dye. It is so old that it is not even made in this country any more, and it literally costs pennies, but it is unlicensed. One of its possible side-effects is anaphylactic shock. That is very rare, thank goodness, but there it is. According to all the UK guidelines, that is the approach that must be taken to breast cancer patients.

I used to have to sign a form before every case that I handled, stating that I accepted personal financial liability if the patient suffered. Eventually I said, “Wait a minute: I am not putting my house on a piece of paper for every case when I would be in trouble if I did not handle that case.” Thankfully, my health board was eventually willing to underwrite it.

The idea that guidelines give us protection is unfortunately not true. When guidelines were introduced, the medical profession was reassured that they did not handcuff a clinician, and if a patient was treated off-guidelines, because patients do not fit in cubbyholes, there would not be an issue. Similarly, following guidelines slavishly does not give any protection. Doctors carry legal responsibility for any drug that they prescribe. So the specialists will prescribe off-patent drugs, and we will be using them.

[Kit Malthouse]

I am slightly confused. Doctors are absolutely responsible for what they prescribe, but only if they do so negligently. The hon. Lady would not expose herself to litigation if she had, for instance, used the dye on a patient who then suffered from anaphylactic shock if that had been an appropriate and responsible thing to do given the patient’s condition at the time.

[Joanna Cherry (Edinburgh South West) (SNP)]

There is a risk.

[Dr Whitford]

There is indeed a risk, as my QC expert has muttered. Part of the case would be that the doctor had prescribed an off-licence drug.

Experts in the field will prescribe many drugs that are off-patent for the treatment of secondary cancers. We are aware of the evidence, and we will use such drugs when we have the experience, but general practitioners will not. If a drug is not in the British National Formulary, they cannot check the dose, which might be different from the dose for the other usage.

We are seeing more and more non-doctor prescribers. We are seeing nurse prescribers and physio prescribers. We do not want to limit the use of future drugs that may be discovered by not sorting out the present position. It should not be beyond the wit of man. The NHS is surrounded by organisations, such as quangos, that could surely be used to deal with it.

[The Minister for Community and Social Care (Alistair Burt)]

Given the hon. Lady’s experience in this area, her presence in the House provides me with an opportunity that is too good to miss. Let me ask a question that goes to the heart of the reason for the Government’s concern about the Bill.

If I understand the hon. Lady correctly, it is not impossible to prescribe off-label if there is an indication that, say, the prevention of breast cancer may be aided by the use of tamoxifen. There is nothing to preclude that, although it may be difficult in the circumstances that she has described because of possible considerations of liability. Is she arguing that there should be no off-label prescribing because everything should be licensed, or not? I do not know whether it should be one or the other—[Interruption.] It is not a stupid question. We believe that if it is possible to prescribe off-label, the Bill is not necessary, but if it is not possible because of the difficulties that the hon. Lady has identified, perhaps that should not happen. Her experience is vital in this regard.

[Dr Whitford]

As I was trying to suggest, someone who is an absolute expert in a field will be comfortable prescribing off-label, because they are using the drug every day, and they know exactly what it does and how to use it. But our patients spend the majority of their time in primary care, and a GP, who is unable to look up and check the dose or indication, will be a little more uncomfortable. People who are non-consultants—those at staff grades, who are at other grades—will be less comfortable. We see that exactly in the prevention of breast cancer; this drug has not come on stream at the speed that would have been expected, because people are uncomfortable. There is certainly not enough protection to mean that nurses are going to prescribe a drug that is not licensed, and the vast majority of drugs do not have guidelines, so what the Minister describes is not a protection.

[Alistair Burt]

I just want to be sure about this. If I understand the hon. Lady correctly, that hesitation could apply to any off-label prescribing now, but off-label prescribing goes on—doctors and GPs do find the information and do it. I would not want to take the implication from her that off-label prescribing is wrong. It just needs the appropriate amount of information to make sure that it is right—otherwise, we do have to license everything.

[Dr Whitford]

When a drug is proven and is going to be in common usage, it should be licensed—otherwise, we are suggesting, “Why bother with licensing any drug?” We are talking about drugs that could make a big impact, but they will do that only if they are in common usage. Expecting doctors to face any potential that they are signing away their mortgage on their house by prescribing something is simply bizarre. Of course there is off-label prescribing as a drug develops, but once we have something with rock-solid evidence behind it, which we expect everybody of every grade and every profession within the NHS to use, we should give them the reassurance of licensing.

[Joanna Cherry]

My hon. Friend speaks knowledgeably about the treatment of breast cancer, but a number of my constituents who are living with multiple sclerosis have also written to me about this Bill. Scotland has one of the highest incidences of multiple sclerosis in the world. Can she confirm that the Bill will be of particular benefit to patients with multiple sclerosis in Scotland?

[Dr Whitford]

Yes, absolutely; a drug called simvastatin is simply used for lowering cholesterol but it has been shown significantly to reduce brain atrophy in patients with a certain type of MS.

We do not know what is in the future. Other drugs will be found to have a second use, so why would we not take this very practical Bill through and allow ourselves to deal with a bizarre anomaly? As I say, this is not beyond the wit of man. Let us pick one of the quangos around the NHS and get this job done.

--- Later in debate ---

[Alistair Burt]

Because if the message that goes out from this debate is that there is only one way to get these drugs, and if people feel that they cannot get them because of what has been said here, that would be darkness indeed. That is not the truth. That is not the position.

[Dr Whitford]

I find it bizarre that the right hon. Gentleman says that we must not bring in this change because it would undermine access to other drugs, because that tends to suggest that we should not have any licensing at all. Why is he happy to have drugs licensed but also feels that we should have unlicensed drugs?

[Alistair Burt]

Because current medical practice appears to be that drugs are available on licence for indications that are already there, but it may then become clear that some drugs are also useful for things that were not previously indicated. If the patent position is as we have discussed, then no licence process is put forward and people can prescribe off-label, as they do in many cases. Accordingly, the system works with both. The Government’s worry about this Bill is that, because of the attention paid to what is being said, it will be suggested that there is some sort of prevention mechanism that does not enable people to get the treatment they need. I am very anxious to state that that is not the case, as I think the hon. Member for Central Ayrshire also said. These drugs can indeed be prescribed. That has to be the message.

[Dr Whitford]

rose—

[Alistair Burt]

I will give way, but then I want to set out what the position is rather than what it is believed to be.

[Dr Whitford]

As I said, there is still an implied risk to people, and those who are distant from the research will not do this. The only reason these drugs are not licensed is that it is not worth the company’s while. Surely letting the Bill go into Committee would allow us to iron out all the issues to the satisfaction of the Government.

[Alistair Burt]

The issue about licensing could apply to any off-label prescribing. What we are talking about for some would, in theory, have to apply to all, because there is a risk to everything. That suggests a provision of licensing for all, which is not where we are going. This matter is not closed—let us be quite clear about that. If this measure does not go through today, the matter is not closed.

--- Later in debate ---

[Alistair Burt]

In that case, I am more than happy to again let the message go out from the Chamber today that these drugs are available and can be prescribed. Where it is clinically appropriate, they should be prescribed. Seeking this legislation will not change that availability.

Members of the House are doing a highly effective job of bringing their constituents’ concerns to the attention of Ministers and asking our help to resolve this issue. We are not aware of colleagues bringing examples of people who have been refused treatment. It is vital to know if there is evidence of people being refused treatment. As I said, the clinician’s letter that the hon. Member for Torfaen read out was wrong. Unless there is a clinical reason for not supplying the drug, there is nothing to prevent the doctor from doing so.

[Dr Philippa Whitford]

I simply make the point that we are now not just talking about doctors prescribing. It is unrealistic to expect physiotherapists and nurses to prescribe drugs off licence. It just will not happen.

Access to Medical Treatments (Innovation) Bill (Money)

Philippa Whitford Excerpts

Tuesday 3rd November 2015 Commons Chamber

[George Freeman]

My hon. Friend makes a good point. That is the premise on which the Bill introduced by Lord Saatchi in the other place earlier in the year in the previous Parliament was predicated. My hon. Friend is right that it is a controversial proposition that fear of litigation for medical negligence is putting clinicians off innovating. The evidence that the Government received through the consultation was that some clinicians do feel that that is a problem, but very few saw it as the principal problem or the principal obstacle. A number of clinicians made the point that several factors have acted in recent decades to slow down the rate of innovative prescribing and other procedures in surgery and elsewhere, not least increasing central control of procurement from NHS England, which puts in place very tight procurement guidelines, as well as a general sense of an increasingly litigious society, which is just one of a number of factors cited in an extensive range of barriers to innovation.

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

Does the Minister not recognise the concern of the Association of Medical Research Charities and many within the profession about what the Bill opens up? The position when I started 30-odd years ago was that doctors could do what they liked. We have spent decades protecting people, slimming down the ethics paperwork to run trials, and I do not see that the Bill is necessary. I think it is dangerous. The problem is that people think it is about access to new drugs. It is not. Any drug that is licensed we can prescribe. This says that doctors can try what they like. That is quite scary.

[George Freeman]

The hon. Lady makes a series of interesting points. Her criticisms would perhaps apply more to the Bill introduced by Lord Saatchi in the other House. Let me confirm that this Bill has nothing at all to do with clinical research. It is to do with clarifying the freedoms that she is right to say that clinicians enjoy today. Clinicians are free to prescribe any treatment for their patients that they feel is appropriate on the basis of the clinical evidence.

The specific problem that the Government recognise, whether or not this Bill is the appropriate mechanism to deal with it, is that in order for clinicians to feel confident in making an innovative prescription or adopting an innovative procedure, the biggest barrier is the lack of information on what innovative procedures are out there already and being used by other clinicians. It was with that in mind that the registry was originally proposed in the Bill introduced by Lord Saatchi. It was originally intended as a registry of innovative practices that clinicians adopted under the procedures in the Bill, which merely clarify the existing protections already afforded by medical negligence law. It was felt that that registry would be a helpful innovation in itself.

The Government’s view is that, as we build an infrastructure for the provision of information to clinicians to support off-label use of medicines and access to the latest information on innovative treatments, that registry could provide a much more interesting function of providing to clinicians, at the click of a mouse, an up-to-date registry of innovative medicines that are available and off-label and other treatments that other clinicians are already using. I want to stress that this Bill, which has a very different structure from the original Bill introduced by Lord Saatchi, has nothing to do with research at all. It is purely to do with supporting innovative prescribing by clinicians by providing them with information on innovations that they might consider.

[Dr Whitford]

Does not this undermine our existing structures of clinical research? Those protect the patient through ethics and research being reviewed, whereas this allows a couple of doctors to say, “We’re going to give you liquorice for your cancer”, and that can get put on to a database. Many in the profession are anxious about this.

[George Freeman]

I want to make two things absolutely clear. First, this Bill, in law, would have no impact at all on clinical research. We in the Department have been very clear about that. If it in any way changed the basis on which clinical research is regulated, it would be a very serious matter, because we lead the world in terms of our ethical and regulatory controls on research, and it is vital that we do not affect that.

Secondly, it would be a matter of very serious concern if this Bill were to undermine patient or public trust and confidence in our NHS, our research medicine and our clinical trials infrastructure. I flagged up on Second Reading the fact that I do have some concerns. Some of those relate to the way in which this debate is conducted, although I am not making any comment about the hon. Lady’s intervention. It is very important that we explain to people what this Bill does and does not do. If we mislead them, it is not surprising that we will get a lot of unnecessary fear. It is very important that we clarify that this has nothing to do with clinical research.

--- Later in debate ---

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

There are many ways for a surgeon to share their experience if they have carried out an operation in the heat of the moment to save someone’s life. The BMJ publishes things on a weekly basis and can share interesting cases. The danger of the Bill is that the database is being used as a fig leaf to make it sound like access to innovative treatments. The hon. Member for Daventry (Chris Heaton-Harris) said that a doctor would have to prove that something was safe, but the first person prescribing liquorice for cancer has no method of proving that it is safe. That is the basis of research.

Phase 1 trials involve a small group of patients who fully consent to undergo treatment and know what they are taking on, based on pre-clinical research. Phase 2 is larger, and phase 3 involves multiple hospitals. We have that process to avoid a couple of doctors in a canteen saying, “That’s not a bad idea. I’ll back you if you back me”, and patients being given something dangerous. The Bill would not, of itself, undermine research in some way, but if patients and the public feel that they are guinea pigs for any old treatment that someone wants to have a bash at, that will undermine research.

It has taken decades to get to our current level of safety, checks and balances. That has been streamlined, and single ethical permissions are carried out once for the whole country, and then recognised in all health boards and areas. That has made things a lot easier, but it is crucial that patients who sign up to a treatment know that there has been a degree of rigour before they are given that drug.

If someone is bleeding to death in the middle of the night, of course a surgeon can innovate because every operation is slightly different, but we are talking about access to medical treatment that will predominantly involve drugs that have not had sufficient pre-clinical work. That is of concern to research charities and the royal colleges—I am a member of the Royal College of Surgeons—because of patient safety. The absolute concern is not even the secondary impact on research; it is the impact on patient safety and people finding that they are being given something totally unproven.

[Andy Slaughter (Hammersmith) (Lab)]

The hon. Lady is making a good point, and I agree with everything she says. As a lawyer rather than a doctor, I think the problem with the Bill is that—unintentionally, I am sure—it also undermines carefully constructed jurisprudence on clinical negligence, and it is dangerous for that reason.

[Dr Whitford]

Of course the Bill is well intentioned, and its title will attract support from people who think that it means getting access to drugs to which we do not currently have access. It is not that any doctor can prescribe anything—we cannot. We can prescribe drugs that are licensed and recognised, and have a basic safety profile. In Westminster Hall we often debate access to expensive, innovative, brand-new treatments, but that is not about our right as a doctor to prescribe them; it is about who will pay for them because some of those drugs are expensive. As the Minister has said, that would still be an issue. In what sense would a commissioning group have evidence to allow a doctor to prescribe a drug that has absolutely no basis, but that would have to be funded?

The Bill is basically a bit of a mess. What problem is it trying to answer? People think it means that they will get earlier access to new drugs, but drugs should be taken forward on the correct path to protect patients and doctors. Doctors need to know that what we are doing is right, and not some random thing that has been on a database after somebody tried something once and it seemed to work. We know that there are placebo and random effects.

[Maria Caulfield (Lewes) (Con)]

I support everything the hon. Lady has just said. I was a research nurse in cancer care for more than 10 years. We observed good clinical practice standards, and the standards of the Medicines and Healthcare Products Regulatory Agency and the FDA, because mistakes happened. Those safeguards are in place for a reason. The No. 1 reason is to protect the patient.

[Dr Whitford]

I did my MD thesis in the late ’80s on the use of monoclonals in breast cancer, which was then totally blue-sky thinking. What became Herceptin was found at that time. I remember speaking at a conference in America where people presented their research. At that time, they thought they had to put a toxin on the back of an antibody to make it work. They were using ricin, which was used in the Bulgarian umbrella murder, and—surprise, surprise—almost all their patients died. They got around that in America by going to Mexico and to prisons. It is not the case that everything a doctor thinks might work will be good for patients. We have developed a safe system over decades and we give it away at our peril.

Junior Doctors’ Contracts

Philippa Whitford Excerpts

Wednesday 28th October 2015 Commons Chamber

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

The hon. Member for Lewisham East (Heidi Alexander) described what a junior doctor is, and that is really important. Many people think that being a junior doctor is just for the first couple of years, and isn’t it character-forming to work a bit hard and not have a lot of money? However, in the NHS, which is quite a hierarchical beast, a junior doctor is a junior doctor all the way until they are not a junior doctor and they become a senior doctor: either a consultant, as I was for the past 19 years, or a GP. That means we are talking about people who might be in their 30s, with children, families and mortgages. They are not youngsters who are able to move around flexibly and have very few financial commitments. It is important that we remember that.

It is obviously quite some time since I started as a junior doctor. More than 30 years ago, in 1982, we had absolutely no limits on hours. My light week was 57 hours; my heavy week was 132 hours. You just had no idea what your name was by the end of a weekend. It took more than 10 years of my career before the first new deal started to come in, in the early 1990s, and trusts or hospitals had to pay an additional premium to junior staff if they worked excessive hours. The definition of excessive hours at that time was still pretty lax, but it was the first step. It was tightened up in 2003, when the European working time directive came in. The Secretary of State talks about taking away those safeguards, but that he will replace them with something else. But with what? They have served us well. When trusts are in financial difficulties, the pressure on them to save money is likely to outweigh completely any little safeguard. The 48-hour working time directive does not come with punitive safeguards, and the financial one was important.

It is important to remember that the basic pay is already for 7 o’clock in the morning to 7 o’clock at night, Monday to Friday. That is a pretty long day for most people. It is proposed that the time covered by basic pay should be extended to 7 o’clock in the morning to 10 o’clock at night and include Saturday. What many people do not know is that a junior doctor starts at under £23,000 a year—below the benefit cap we have been arguing about. The salary is made up largely of out-of-hours.

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

Does the hon. Lady not agree that in any other walk of life that would be intolerable, yet we put up with this situation in the national health service? Secondly, does she agree we still have not seen the £8 billion the Government promised, during the general election, to put into the NHS?

[Dr Whitford]

I totally agree with that.

As mentioned on both sides of the House, people do not work in an NHS hospital to make a lot of money. It is not high up the list of ways for the smartest people in our country to make money; it is a vocation, which means we have a responsibility not to exploit them. The Secretary of State says that no one will lose money, but what will happen to the people who start next August? After the first hours change, when I started my surgical career in Belfast, the “two in three” rota—every third evening off and no weekends off for a year—was no longer legal, and the hospital henceforth considered extra hours to be voluntary service. The NHS is a hierarchical organisation, bullying exists within it, and the junior doctor is in a weak position. These safeguards have worked well for a long time, and I would be reluctant to see them go.

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

Does the hon. Lady agree that across the piece—nurses, doctors, everybody—there is a huge loss of morale in the NHS? It is down to us to stand up for the workforce and put them at the heart of our thoughts, rather than concerns about how it might look politically.

[Dr Whitford]

I totally agree. I also agree with the Secretary of State about patient safety. There is no one in the profession who does not want a seven-day emergency service that is strong and responsive to the needs of unwell patients, but we keep moving from people who are ill to routine services. He has said we must not call them avoidable, yet he just referred to 200 avoidable deaths a week, which is exactly what Bruce Keogh described as “rash and misleading”, and people object to that. There are no excess deaths at the weekend; the issue is with people admitted at the weekend, usually for radiology or investigation. Scotland has been moving on this for the last decade, by working with the profession, not pulling out the pin and throwing a grenade.

[Mr Jeremy Hunt]

For the sake of clarity, the 200 avoidable deaths are not about the weekend effect specifically, but come from the Hogan and Black analysis, which found that 3.6% of hospital deaths in England had at least a 50% greater chance of having been avoidable, which is separate from the weekend effect—the higher mortality rate among people admitted at weekends. None the less, where there are avoidable deaths—where death rates look higher than they should be—we have an obligation to do something.

[Dr Whitford]

I agree that it is important to investigate, but it is also important to understand the cause of the problem. A lot of the problem at Mid Staffs was the ratio of registered nurses to patients. That was echoed by Bray in his review of 103 stroke units, which showed that additional consultant ward rounds at weekends had no impact on death rates, while a better ratio of registered nurses reduced them by a third. We need to know the problem before spending billions trying to solve the wrong thing.

[Andy Slaughter]

I am grateful to the hon. Lady for busting this myth about weekend death rates—these might be sick people admitted at weekends who die within the 30 days. In fact, fewer people die in hospitals on Saturdays and Sundays than on other days. The Secretary of State is not giving the right impression of the figures.

[Dr Whitford]

I agree.

Since coming here, I have heard stories of people unable to access diagnostic imaging or to work up patients, but there is no argument about that from the profession. That is what we need to focus on, yet a lot of this seems to be about routine. There are fewer doctors at weekends because we do not do routine work. We have teams of people doing toenail and blood pressure clinics in the week. Professor Jane Dacre estimates that doing those at weekends would require 40% more doctors. We cannot do that. We need to make sure that hospitals at weekends have enough people and the right people to be secure, but junior doctors are already there—it is not they who are missing—and emergency services already have a consultant on call. We might need more discussion about their being physically in, but that is a discussion to have with the profession, whereas what we heard on 16 July, which gave the public the impression that senior doctors only worked 9 to 5, Monday to Friday, was very hurtful to the entire profession.

[Grahame M. Morris (Easington) (Lab)]

The hon. Lady is making some extremely powerful and relevant arguments. I wish to make a point about the importance of junior doctors in my region, having spoken to some of them at the demonstration on Saturday. They are essential to the functioning of the service. They have the option of going not only to the Antipodes but to Scotland, where these contracts do not apply. If we lose these valued staff, it could hurt my region more.

[Dr Whitford]

We will roll out a red carpet somewhere on the M74 and welcome them with open arms. The progression and migration in Scotland towards robust seven-day emergency care has been happening through a dialogue, not through a threat to impose a contract.

There are other things in this, such as the plan to change pay progression, which is currently on an annual basis, to recognise experience. That will be replaced with just six pay grades. Such a move will affect women in particular, because they tend to take a career break and they tend to work part-time, so they will get stuck at a frozen level for much longer. It may also be a disincentive to people to go into research, because they will be stuck on the same rung of the ladder for longer. We do not want that disincentive. We need to make sure that we are valuing how people develop and the experience they accrue along the way.

[Mark Spencer]

The hon. Lady is making a powerful case for dialogue. Will she join the Secretary of State in calling for the BMA to come back to the negotiating table or join the shadow Secretary of State in refusing to call for it to do so? Which will she do?

--- Later in debate ---

[Dr Whitford]

There is no doubt that we require dialogue, but it must involve sitting down at a table without preconditions. What we had in July and through the summer was a threat of imposing a contract, instead of proper negotiation. That is where we should be trying to get to: both sides negotiating in good faith across a blank sheet of paper. The threat of imposition is what has hurt the junior doctors.

There has also been talk of taking away the guaranteed income protection of GP trainees, there to try to keep them at the same level as they were, and replacing it with a discretionary payment. Such a payment can be taken away at any time—it can be cut and it can be changed. The Secretary of State aspires to have 5,000 extra GPs by 2020. We know from the BMA that one third of GPs—10,000 out of just over 30,000—are planning to leave, which means we need to find 15,000 extra GPs. Anything that is a disincentive for people to go into that profession is not serving the NHS.

[Dawn Butler (Brent Central) (Lab)]

Does the hon. Lady think the Secretary of State is an incentive or a disincentive to junior doctors?

[Dr Whitford]

Sorry, I did not hear that. [Interruption.]

[Dawn Butler]

Conservative Members do not want me to repeat the question. Does the hon. Lady think the Secretary of State is an incentive or a disincentive to doctors?

[Dr Whitford]

I think that how this has been handled is a total disincentive, but that could change. We could simply take the decision to move to negotiations without preconditions—without the threat of imposition. We are talking about a threat to impose changes to the terms and conditions of people who, in the past, routinely worked more than 100 hours a week, as I did. That is a ghost that haunts the NHS and it really frightens junior doctors.

[Rehman Chishti]

rose—

[Dr Whitford]

I will give way one last time, but I need to make progress; otherwise nobody else will get to speak.

[Rehman Chishti]

I have a huge amount of respect for the hon. Lady. She talks about her experience of working long hours. Does she think that what the Secretary of State has just said about introducing new limits on junior doctors’ working hours is the right way forward?

[Dr Whitford]

What the Secretary of State has not explained is how, within the same pay envelope, there will be more people at weekends, but not working extra hours—and not having fewer during the week. At the moment, we have a circle that cannot be squared. We need to see the detail of how that can be done. If the vision is to have more routine work at the weekend, that would result in a massive uplift in the number of doctors, which we simply cannot afford. We are already haemorrhaging doctors. Acute physicians describe 48% of junior places as unfilled, with the figure for obstetrics being 25%. They can go anywhere. We heard that over 1,500 of them registered for certification for overseas work just last week. We need to be careful that we are attracting them to stay. They are the brightest and best in our society; they have chosen a vocation. We need to bring them to the table, but by offering to start with a blank sheet of paper—not threatening them. As has been said, they are not radicals, but people who want to do the best for their patients.

I suggest that the Secretary of State and those working with him look at how they have spoken to both senior and junior doctors over this summer. Frankly, being new to this House, I found that to be quite shocking and quite disgraceful. We should draw a line under that and try to change the tone. We need to go forward and find a solution that is fair to junior doctors, fair to patients and safe—one that is not exploiting people and not threatening people.

Secondary Breast Cancer

Philippa Whitford Excerpts

Wednesday 21st October 2015 Westminster Hall

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

I commend the hon. Member for North Warwickshire (Craig Tracey) for securing this debate, which marks breast cancer awareness month. Most Members know my interest. I was a breast cancer surgeon for 33 years. The hon. Gentleman said that secondary breast cancer does not gain from the focus that we put on primary breast cancer. I have to disagree with that. In Scotland, we collect the stage at diagnosis and one in five patients still have metastases at the time of diagnosis. That means that we still have a huge job to do to get earlier diagnosis through screening and raising awareness, which is what October is all about. We are limited for time and I will do my best to respond to as many points as possible.

Regarding audit, I chaired the discussions on quality improvement standards for breast cancer in 2001, at which time we discovered that about a quarter of units did not gather any data at all. By 2003, we had managed to change that and we were getting data on the primary treatment of patients. That was against the breast cancer standards that we had set for the entire journey that a patient would go through. In 2007, I was chair for the update of those standards and, at that point, it became a standard that all patients with recurrence or metastases must come back to the multidisciplinary team for discussion. At that point, those data are also gathered. As yet, we do not have a Scottish-wide, absolutely rock-solid way of providing the data. They are being collected through our cancer registry, from SMR01 data and from what we do in-house.

In my unit in Ayrshire, we had a follow-up page for the patient at the end of the data system. Every year when the patient came for the follow-up, a chitty was ticked, sent up to the office and on it went, showing that the patient was alive and well on whatever date they had come. For patients moving to mammographic follow-up, if the mammogram is clear and there are no issues, the procedure is the same. The data on patients with recurrence or metastases must be collected at the multidisciplinary team. That is something that we were doing. We have to look at the systems to make it easy and not burdensome, but that requires that hospitals and trusts have an audit team. Our auditor sits in the multidisciplinary team, where she captures all the treatment of the primary and secondary patients. That is really important.

The hon. Member for North Warwickshire mentioned CNSs. There are different approaches. In our unit, we treat approximately 400 new breast cancers every year, which means that a significant number of patients have recurrent and secondary breast cancer. We talked about whether we should split our teams and have one for secondary breast cancer. We decided against that because we have a breast cancer team, which the patient will have met at the beginning. I felt that meeting the same team—a friendly face or someone the patient knew from three or four years ago—is a benefit.

Many units have surgical cancer nurse specialists, who do not move into chemotherapy or oncology. Obviously, that would not work that way. Our cancer nurse specialists travel the whole journey with the patient, looking after the patient in the surgical part of the journey and in the oncology clinic during chemotherapy. They are also there if the patient is unlucky enough to face recurrence or metastases. I believe that this linear approach—as long as enough nurses are provided for that support—gives the advantage of continuity.

My hon. Friend the Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) mentioned looking at the wellbeing of patients. In Scotland, we use something called the distress thermometer, which is used for patients undergoing treatment for primary and secondary breast cancers. It is quite a quick, easy tool that, at least, allows us to pick out a patient who is not doing so well and therefore identify them for additional support. Our cancer nurse specialists have all had additional training. We have a specialist oncology psychologist on our health board, who provides additional training to the nurses. Therefore, for someone who needs it, that extra help and counselling is available. For someone with more complex needs, or where the diagnosis of breast cancer or metastatic breast cancer comes on top of mental health issues, the oncology psychologist would give us that back-up by taking on the patient.

The hon. Member for North Warwickshire mentioned palliative care. In Ayrshire, we are lucky enough to have a hospice. It is routine for us to refer patients at the point at which they are metastatic and symptomatic. We do not refer them as soon as they are metastatic because if a patient is hormone-sensitive, they have a 50% five-year survival with metastatic disease. That is because we have so many treatment options and breast cancer appears to behave quite differently from other cancers in that we can get it into a balance. The patient can be very well and active, yet the disease is sitting there. As soon as the patient starts to have symptoms, we have liaison nurses in our hospitals and we make a referral. Part of our GPs’ quality outcome framework is that patients who are defined as palliative must be discussed regularly in primary care and be on a palliative care register.

We had the debate on assisted dying just last month. The clear decision of the House was that we would not go down that route. That throws back on to the Government, and us all, the responsibility to ensure that high-quality palliative care services are there. We cannot vote that way as convincingly as we did and then not step up to the mark. That is really important.

I do not have a lot of time to speak, but I should say that we are doing good things in Scotland. Because we are smaller, we have been able to create a single day when all the teams in Scotland come together—actually, they come together for two days: a trial and research day and an audit day. Our whole audit—all the dirty washing—is put up in a PowerPoint presentation and we have a completely open learning discussion about it. A one-year project is starting now, so hopefully the data, including detail on secondary, recurrence and survival, will be available in autumn next year.

--- Later in debate ---

[Jane Ellison]

I am sure we would all agree with that important point.

I will finish by discussing the new guideline that the clinical reference group is developing. The guideline will state that all patients with primary breast cancer should have a consultation with a clinician at the end of treatment that will include advice on spotting signs and symptoms that might indicate secondary breast cancer. That information will be delivered together with an assessment of the patient’s physical, psychological and social needs—I am interested in the distress thermometer that the hon. Member for Central Ayrshire mentioned, as well as in the contribution of the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron). The overall recovery package is being developed in partnership with Macmillan Cancer Support. The evidence is that that work is very effective where it has been done well. The advice that has been given will be recorded in the records of every breast cancer patient so that we know it has happened and so that we can track it.

NHS England hopes to publish the new guidance as a cancer resource on its website in the next few weeks. We will promote that guidance through the usual channels, but we would appreciate it if hon. Members with a particular interest, and particularly my hon. Friend the Member for North Warwickshire—I congratulate him on his appointment as co-chair of the all-party group—could draw this important document to people’s attention.

The clinical reference group will also consider how the care and support of patients diagnosed with secondary breast cancer can be improved, including through the provision of clinical nurse specialists. Of course, we agree that clinical nurse specialists play an important role. The number of patients reporting that they have been given the name of a CNS rose from 84% in 2010 to 89% in 2014, including 93% of breast cancer patients. We are doing a lot better, but hon. Members are right to highlight that, in the case of secondary breast cancer, we have some distance to go.

Members have said that we need to step up on palliative care, particularly in the light of last month’s debate—the hon. Member for Central Ayrshire made an important speech in that debate. We are committed to ensuring that everyone has access to high-quality, personalised palliative care. Breast Cancer Care’s new report, “Too little, too late”, is an important contribution to the debate about what we need to do. The Government have introduced five new priorities for end-of-life care—those are five important new principles—and my ministerial colleagues will be taking that forward. Nevertheless, I welcome Parliament’s new focus on palliative care and quality end-of-life care, which is important.

In the few seconds that I have remaining, I want to give people confidence that a lot of research is going on in this area. There is more research into cancer than any other disease in terms of National Institute for Health Research funding. In particular, the NIHR’s clinical research network is currently recruiting patients for nearly 100 trials and studies in breast cancer. One is a global trial that aims better to control secondary breast cancer using a drug called a dual mTOR inhibitor. I am delighted to say that the network recruited the first patient in the world to this trial, which I hope is an indication of the importance of our research infrastructure.

[Dr Whitford]

Will the Minister give way?

[Jane Ellison]

I am afraid that I do not have time to give way. We can speak after the debate; I apologise.

A lot of other things are going on in that area, but I will leave just a few seconds to my hon. Friend the Member for North Warwickshire. However, I reassure Members that this subject is of huge importance to the Government.

Mental Health (Armed Forces Veterans)

Philippa Whitford Excerpts

Wednesday 14th October 2015 Commons Chamber

[Johnny Mercer]

Thank you, Madam Deputy Speaker. I apologise—I spoke to Mr Speaker before you took the Chair.

I thank the hon. Member for East Kilbride, Strathaven and Lesmahagow for giving me a few minutes of her allocated time, and offer my sincere thanks to her for bringing what the Prime Minister rightly described today as “this very important issue” before the House. He correctly identified the strategic defence and security review as an opportunity to get our approach right in the future, and I fully support him in that intention.

The subject before us this evening refers to that great stain on this nation of ours, which I mentioned when I first spoke in this House. I regret to say that, aside from some excellent individual practice and charitable work, the way we look after our veterans’ mental health in this country remains poor. Many of our young men and women, who by good training and fortune walked away from battle without any physical scars, have been stricken in later years by an underlying sickness that can tear at the very core of the strongest and most enduring individual. I speak as a Conservative Member of Parliament. I work hard to support all the efforts of Government to produce and implement the exciting and progressive agenda so clearly laid out by the Prime Minister a week ago, but on this issue, while it remains in its current state, I am afraid I will not be silenced.

I have no personal agenda to drive here. I have never had the misfortune to need to use one of our tremendous military charities. I will forever be the soldiers’ voice in this debate, crafted from much time spent on operations with our young men and women, and now in my privileged position as a Member of this House and attracting a great deal of correspondence on this issue it is incumbent upon me to speak out and I will do so. I feel embarrassed at my fellow man sometimes as we stand here again tonight in 2015 in the seat of the world’s most advanced democracy and talk yet again about the stigma of mental health.

The stigma results from a basic lack of education and understanding about a human condition that affects one in four of us—a condition as medically valid as a broken leg or a fractured arm, but because it occurs in our heads, its treatment has historically been subjected to unacceptable social, political and financial disadvantage. That stigma ends in this Parliament, and I will not rest until it has.

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

I had the honour of chairing a disability employment session at the TUC today and a young man with autism came out with what I thought was a fantastic phrase about mental health issues in the workplace: “There is no normal.” We all have mental health; sometimes it is good and sometimes it is not. Maybe instead of us thinking about a certain percentage having a problem, we should acknowledge that we all have different problems at different times. That might make it easier for people to come forward.

[Johnny Mercer]

Absolutely, and when we have more time, we might discuss specific projects looking at what normal is and that process. That is an important part of this.

I could inevitably speak all night on this issue, but I will not. In preparation for tonight, I stayed up most of last night and read as much as I could of a couple of books I have on my desk in my office here in Westminster. One is called “Aftershock” by Matthew Green and another is called “The Battle against Stigma” by Mark Neville. We have got better in this area as a nation over the last few years. I would ask however that before any of us enter into an exercise of back-slapping on how far we have come on mental health, we all read those two books and reflect on both what we ask of our servicemen and women and how we look after them when they come back.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 13th October 2015 Commons Chamber

[Mr Hunt]

Once again, I thank my hon. Friend for his persistent campaigning on behalf of Kettering general hospital. It is a very busy hospital under a great deal of pressure, and I know that people work very hard there. The Under-Secretary of State for Health, my hon. Friend the Member for Ipswich (Ben Gummer), who has responsibility for hospitals, met campaigners from Kettering recently to discuss this issue, and I will bring the matter up with Monitor as well.

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

The Department of Health’s own figures show a dramatic change, from a £500 million surplus to a £100 million deficit in 2013, following the introduction of the Health and Social Care Act 2012. That deficit moved to £800 million last year and we have heard in the past week that it stood at more than £900 million from the first quarter of this year. Does the Secretary of State recognise that this situation has been exacerbated by the outsourcing and fragmentation of the NHS, which involves spending money on shareholder profits and tendering bureaucracy, rather than on patients?

[Mr Hunt]

I do not. That Act meant that we reduced the number of managers and administrators in the NHS in England by 19,000, saving the NHS £1.5 billion a year. The reason for the deficits that the hon. Lady talks about is that, around the same time, we had the Francis report on Mid Staffs, and hospitals in England were absolutely determined to end the scandal of short-staffing. However, agency staffing is not a sustainable way of doing that, which is why we are taking measures today to change that.

[Dr Whitford]

The Francis report recognised the problems of nursing levels. As hospitals will not be able to use agency staff or immigrant staff, how does the Secretary of State suggest they tackle the nursing ratios in hospitals?

[Mr Hunt]

If the hon. Lady looks at what has happened with permanent full-time nursing staff, she will see that the numbers have gone up in our hospitals by 8,000 over the past two years, so there are alternatives. We need to do more to help the NHS in this respect, and I will be announcing something about that shortly.

NHS: Financial Performance

Philippa Whitford Excerpts

Monday 12th October 2015 Commons Chamber

[Ben Gummer]

When my right hon. Friend the Chancellor made his commitment in the autumn statement on this year’s spending, he said it was a down payment on the five-year forward view and expressed his determination to ensure that the NHS is protected and promoted in all areas of Government.

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

The Minister mentioned successful trusts, but fewer than one in five predict reaching the end of this financial year in balance. That does not leave an awful lot of successful trusts. I echo the call for the funding to be front-loaded. Where are trusts meant to find staff if they are not allowed to use agency staff or nurses from overseas? Given that the deficit started to appear only in 2013—after the Health and Social Care Act 2012—does the Minister not feel that the Conservative party should review the direction of travel? The NHS was in balance from 2009 to 2013 and it has been on a downward slope ever since.

[Ben Gummer]

I will address the hon. Lady’s final point first, if I may. The previous coalition Government’s 2012 Act has saved considerable numbers—billions of pounds—which we would now have to make up if we had not made difficult decisions.

That allows me to address the hon. Lady’s first point. We have a choice: we can take the traditional view of politicians, which is to try to paper over the cracks and pour money into an unreformed system, or we can take the difficult decisions that will mean that we deliver patient care in the long term. That is what the Conservative party is willing to do: we are not only providing the commitment to funding, but taking the necessary, difficult decisions.

On the specific issue of agency nurses—one such example of difficult decisions—it is not so much the number of nurses available as the scandalous rates at which they were hired out to NHS trusts. We have taken action on that to ensure that NHS providers can procure agency staff when and how they need them at a reasonable rate.