NHS (Contracts and Conditions)

Philippa Whitford Excerpts

Monday 14th September 2015 Westminster Hall

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

I declare an interest: I am a doctor and member of the British Medical Association, and I still work in the hospital.

We are talking about data showing that people admitted at the weekend are more likely to die within 30 days than those admitted on weekdays. It is important to listen to what Bruce Keogh said, which is that it would be misleading to assume that all of those deaths could be prevented. We use terms as if the deaths were avoidable or talk about people “dying unnecessarily”, but we do not know. We must understand what the data show. There is nothing wrong with the data and nothing that can ever be bigger, because the NHS is the biggest single health service in the world. Professor Freemantle has done the work twice and the pattern is there, but it is not people dying at the weekend; it is important to realise that his data show the reverse. They show fewer people dying on a Saturday or Sunday then dying on a Wednesday. What is higher is the number of people who are admitted, and we need to understand that. As the hon. Member for Totnes (Dr Wollaston) said, they are sicker people. On a Saturday, there are 25% more people in the most ill category and on a Sunday there are 35% more people in that category.

[Mrs Cheryl Gillan in the Chair]

It was said that there was an increased number of deaths among elective patients admitted on a Sunday, and people wondered why that was. As a surgeon with a Monday list, I can say that the norm now is that patients come in on the morning of surgery. So, for me to get permission for someone to come in on a Sunday, let alone a Saturday, means that that person has complex co-morbidity. If we are simply looking at additional populations, we cannot simply use a broad sweep and assume that all of this can be changed, because it cannot be; these people are inherently more ill, whether they are elective patients or emergency patients. Those data are absolutely there and they remain when we re-analyse them or try to balance them, so this issue needs to be tackled.

There are a few myths going around, including the idea that the opt-out clause is a major barrier. The opt-out clause that was cited was for routine work. Consultants do not get to opt out of emergency work at night or at weekends if they work in an acute service. If a consultant works in a service where acute provision is at all relevant, that acute provision is part of what they do and they do not get to opt out of it. Nine out of 10 consultants work out of hours and the other 10% are engaged in specialties for which there is not an acute service.

There has been talk about getting people to work for only 40 hours. My colleagues who are still up the road holding it together work for 48 hours and they simply cannot work more than that because it is illegal under the European working time directive to do so. Most consultants within the acute system work 48 hours a week, and I am sure that those of us who are married to them or simply aware of them will be well aware of that fact; indeed, we will have been told that in no uncertain terms in the last few months.

It is important that we focus what we do on trying to save the lives of those among those 11,000 people who can be saved. When I was a junior doctor, I was aware that getting scans out of hours or at weekends was very difficult, and so patients hit “pause” for a few days. I do not think there is that much difference in services; I find it hard to believe that there is. In Scotland, the situation has been changing for five or 10 years, not by threatening or cajoling people but simply by evolving. Our consultant radiologists cover the entire weekend; our stroke patients get CTs; and our heart attack patients go straight to get angiography, will get an angioplasty there and then, and will go home after breakfast the next morning. So this idea that we have big tracts of those in medicine sitting home watching “Coronation Street” is not true.

The NHS will be cash-strapped; it has to save £22 billion per year in the next five years, which is a big challenge. So now is not the time to say, “We can provide GP services eight to eight, seven days a week.” The pilots have not been successful. The uptake was 50% for Saturday and 12% for Sunday, and some of those pilots reported that there was great difficulty in covering the out-of-hours GP service, which people who feel unwell should be going to, because what was being talked about was totally routine.

Both in hospital and in primary care, we need to focus our attention on improving the access for people who feel unwell, which includes people being able to access a GP and not having to go to A&E with something that means they do not need to be there. That is recognised within the profession, but it is important for people to work together towards that aim rather than pulling out the pin and throwing a grenade at somebody, which is obviously how the profession regards what has happened during the summer. Like many people in Westminster Hall today, I was inundated by messages from colleagues, including from doctors south of the border who I do not know at all. They were very angry at the statement on 16 July that senior doctors do not work outside 9 to 5, which is patently not true.

We need to look at what we should do about these figures. One of the groups that shows the effect of this situation very strikingly is stroke patients. However, research by Bray looked at 103 stroke units, including units where there was seven-day consultant review through the day, and compared them. There was absolutely no difference between that seven-day service and units where there was a routine ward round and no ward rounds at the weekend. What made a significant difference was the ratio of fully trained registered nurses to patients. When that ratio was halved, so that there were twice as many nurses, the mortality was reduced by a third. So, before we go rushing into policy, even if we are working cross-party it is important to understand the data sufficiently to answer the question, “Do we need more doctors or do we actually need more nurses?” That is a pretty important question to answer before any moves are made.

It is also important to focus on the emergency side. People say, “Well, Tesco is open 24/7”. Actually, it is not open 24/7 totally. People will not find the fishmonger 24/7; the baker will not be making fresh bread; and there will not a butcher producing fresh cuts of meat. It will be the basic system that is open 24/7, so let us not confuse matters. And frankly, we can generate a person to work in Tesco, stacking shelves or operating the till, an awful lot quicker than we can create a GP, which will take 10 years because there are five years of medical school and then five years of training, or a consultant, which requires five years of medical school and—in my time—about 15 or 16 years of training.

There is no quick fix for this situation and we cannot afford to take on extra staff, but actually the money would be the easiest bit because we do not have the extra staff. The Government talk about 5,000 extra GPs and yet the British Medical Association shows that we will lose 10,000 GPs in the next five years. That means that we would need 15,000 GPs, and we simply cannot produce that number. So we need to ensure that we hang on to all the doctors we have, including the junior doctors, because that partly comes down to what those junior doctors see, including how they see their seniors working and what they think of that as a career. I say that because junior doctors have always gone to places such as Australia but they used to come back; now they are not coming back.

This whole matter could have been handled better, but the issue is working with people. The Scottish Government are also working towards seven-day cover, but they have been very clear that what they are talking about—the priority within that system—is seven-day cover for people who are ill. That means expanding the out-of-hours service for GPs and expanding what is available to us as senior doctors inside hospitals. That is the route that must be followed, and not the use of a grenade.

After the Francis report and the increase in the number of nurses being taken on to try to get the figures that are sought, what we had at the beginning of the summer was trusts that are struggling being told, “Cut back. Don’t use agencies. Don’t replace people unless they’re absolutely crucial.” We need to give serious thought about whether it is actually more nurses that we need before we rush in to bring in a whole lot—

[Maria Caulfield]

I welcome the hon. Lady’s thoughts and agree with a lot of what she has said. On the issue of nurses, does she agree that it is not just the number of nurses that matters but the skills mix? Because of budget constraints, what has happened over the past two decades is that the skill of senior nurses has been cut back, and those senior nurses are now often not on duty at nights and weekends, which has made a crucial difference.

[Dr Whitford]

I made the point that Bray’s paper talked about registered nurses—so, degree nurses—and that reflects the skill mix.

We need to know what the actual problem is rather than just running in and throwing ideas and policies around. Attacking staff who work very hard and for really long hours is not very fruitful. We need NHS staff to believe in the political decisions, the guidance and the direction being taken in the future, so I simply suggest that everyone in this House look at the way forward.

[Mrs Cheryl Gillan (in the Chair)]

When time permits, it is our practice in Westminster Hall that when a Member has been here for the opening speeches and then had to step out temporarily, we give them the opportunity to speak. So I call Andrea Jenkyns to speak.

--- Later in debate ---

[Ben Gummer]

Those are very reasonable questions. If the hon. Lady will allow me to continue with what I was setting out, I will certainly answer them.

That assortment of academic research, together with the wide anecdotal evidence from people who have experienced poor care in good hospitals, either for themselves or for their relatives, led NHS England to conduct the Seven Days a Week forum in 2013, which gathered together clinicians to look at the challenge. It produced a clear strategy for dealing with differences in care quality at weekends, compared with the week, and set out 10 clinical standards that it believes hospitals must meet to eradicate the difference between weekday and weekend working. Many hospitals are implementing the 10 clinical standards on a variable basis during weekdays, so the work done for weekends was helpful in determining a standard clinical approach for maximising the ability to reduce avoidable deaths for weekend and weekday admittances. The product of that forum was taken forward by NHS England and incorporated into its five-year forward view, in which the NHS, separately from the Government, made a commitment to seven-day services. It did so not because of the benefits to patients—as my hon. Friend the Member for Sutton and Cheam (Paul Scully) said, that is a secondary reason for pursuing the agenda—but purely because of the need to reduce excess mortality where possible.

This is a challenge on the scale of infections in hospitals. It is our duty not only to find out precisely why excess deaths are happening—as the hon. Member for Central Ayrshire correctly said, further work is needed and the data must be understood—but to do what we can as quickly as possible to reduce them where we think they are preventable. That is why NHS England incorporated the seven-day service into its five-year forward view. NHS England asked for an additional £30 billion of spending between 2015 and 2020, of which it said £22 billion can be achieved through efficiencies within the service. It is important to point out to the hon. Member for Warrington North, who made that point, that they are not cuts but genuine efficiencies within the organisation. On top of the £22 billion of internal efficiencies though a better use of IT, to which she alluded, and better job rostering—I will turn to that in a minute—there will need to be an injection of £8 billion to make up the rest of the £30 billion. That package will implement the five-year forward view, which includes seven-day services and many other things of great importance and about which all parties agree, such as shifting resources from providers to primary care, social care and the community sector.

This programme was not invented by the Secretary of State in a speech given to annoy doctors and consultants, much as that might be the impression given by some people on Twitter. It is the policy response of a Government taking seriously the clinical evidence and advice of NHS England, led by Professor Sir Bruce Keogh. We are responding to give NHS England and the providers tools with which they can deliver a seven-day NHS service in hospitals and GP practices.

I turn to the changes in the contracts, which are at the heart of the petition and the speech of the hon. Member for Warrington North. The contract terms are based on a review by the doctors and dentists pay review body, which identified a number of areas where contract reform is needed, including the systems of opt-out and on call. It asked a completely reasonable question: why should it be that some members of the workforce, who are expected to work at weekends as part of their normal shift patterns, do not have the option of an opt-out from their contract, while others—who tend, as it happens, to be far more highly paid than those who do not have the option of an opt-out—do? It proposed a series of changes, which in our view make up a far better contract for both junior doctors and consultants. On balance, we feel that it presents a real opportunity for consultants and doctors to improve not only their working conditions but, in some cases, their pay.

To take some salient examples from the consultants’ contract, we want a far more equitable and reasonable distribution of clinical excellence awards—many consultants are privately critical of how they are awarded—within not a cut to the total consultant budget, but exactly the same existing pay framework.

[Dr Philippa Whitford]

To point out a slight difference, we do not have those awards in Scotland. We have local discretionary points, but the national clinical awards have been done away with for quite some time. Much as we also struggle with staff, we have not been haemorrhaging them south on that basis.

[Ben Gummer]

The hon. Lady points out that contractual differences already exist between NHS Scotland and NHS England. Officials have looked with interest at the experience of NHS Scotland—one of the pleasures of the devolved NHS system is that we can all learn things from one another. I hope that the new replacement of the clinical excellence award will be perceived as far fairer by clinicians and will reward those surgeons who are giving their utmost in academic research and the professional development of others. That is a tangible improvement to consultants’ terms.

It is important to point out, as several of my hon. Friends have done, that we are talking about ensuring that, at most, consultants work no more than one weekend in every four. That is the basis on which they will be contracted to work in a seven-day NHS. We are not talking about seven days at a time, but about shift rotas and patterns, as many people in professional life already recognise, not least some of those who have spoken in this Chamber. We need to get to a situation in which NHS professionals at the top, as well as those at the bottom, are trusted to organise their life and work patterns according to the professionalism they hold so dear. Many consultants in the NHS want to move to contract reform so that they may express their professionalism in that way, and we need to ensure that it happens so as to bring them with us, rather than its being forced on them.

For that reason, I am delighted that the consultants committee of the BMA has agreed to rejoin negotiations. It has seen that there is a basis for reaching an agreement, which suggests—contrary to some of what has been said by Opposition Members—that things are being done with a sense of collaboration. We have wanted to enter the negotiations for some time. The BMA, for reasons no doubt connected with the election—probably understandably—decided to withdraw from negotiations, but it has now come back. We and the consultants committee can reach a good position on the proposed contract.

The junior doctors’ contract is a proposal of great strength, not least because we include a significant increase in basic pay rates, which should be welcomed across the board. The contract addresses one of the points made by the hon. Member for Warrington North and does something important for the way in which junior doctors are perceived by their management. Instead of offering, in effect, danger money for excess hours, which is surely not the way to manage a workforce, it gives junior doctors a right to a review of their hours, so that they may properly manage their work rotas and patterns. For the first time, that will be enshrined in their contract. They will have far more predictable work patterns; providers—employers—will be forced to think seriously about work-life balance when constructing the roster; and, on pay and on the offer to juniors for their working life, the proposed contract will produce a far happier outcome.

I had hoped that the juniors committee would already have agreed to come back to the table, and I remain hopeful. The committee is meeting imminently—in six minutes’ time, in fact—and I hope that it is listening to the words in this Chamber, because hon. Members and others listening have heard nothing from both Government and Opposition Members but unalloyed praise for NHS staff and a real desire to work cross-party to secure the kinds of advances in quality that everyone wishes to see. With the juniors at the table, we could reach a constructive and reasonable resolution to the need to change their contract. That need was impressed on Ministers not only by the DDRB—the review body on doctors and dentists remuneration, but by the NHS’s own independent pay review body. Many in the service, perhaps more quietly than those who have been most exercised on Twitter, know that it is necessary.

Dementia Care Services

Philippa Whitford Excerpts

Wednesday 9th September 2015 Westminster Hall

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

I commend the hon. Member for Charnwood (Edward Argar) for securing this debate on what is probably one of the biggest challenges we will face over the coming decades. There is no easy answer, north or south of the border or on either side of the House. I think we all fear it. Previous generations have feared other illnesses and avoided them. They talked about consumption instead of TB, or about “the big C” instead of cancer. Most of our generation are less afraid of cancer than of Alzheimer’s. We are afraid of disappearing, or of being married to someone who simply is not who they used to be. That is a fear we all live with.

The Scottish National party welcomed the then Government’s introduction of a national dementia strategy in 2009. The Scottish strategy came in 2010. We set out clinical standards the following year and updated our strategy in 2013. We reached the 64% diagnosis target in 2013, when England was diagnosing 48% of those with dementia. I commend the fact that that has now risen to 59%, although there is obviously more work to do. Northern Ireland was diagnosing 63% of sufferers. What happens to someone when they are diagnosed? Think of the fear that we all have, and then imagine the bombshell that diagnosis is.

There is no easy answer, but we have done a few things in Scotland that we feel have worked. All our health boards now have a linked member of staff, like the cancer nurse specialists we have for breast cancer, which was my specialty. Since 2012, we have had the older persons’ acute care plan, which looks at secondary care and modern hospitals. I welcome the talk about dementia-friendly towns and villages—I will go home and throw down that challenge to my area, because that is not something I have come across.

In the past 18 months, our hospital has been completely redesigned, with colour zones and images of what everything is, instead of just words. Toilets, beds, kitchens—how to find one’s way around is all visual. We also have champions in every single ward. All that has really changed things. We have reduced length of stay from 22 days to eight days; we have reduced falls by half, and we have reduced returns to A&E from 26% to 8%. These relatively cheap, simple changes actually save a lot of money.

We obviously need more research and development, because at the end of the day families want a treatment to make early diagnosis worth while. Otherwise, what is the point? We have to be able to intervene. We can slow things down, but we want a drug that will stop dementia and reverse it. At some point further down the line, we will face the challenge of drug companies coming to us with an expensive drug that will do that. It will be important for the National Institute for Health and Care Excellence and other agencies to weigh up the sheer scale of dementia that we face and the money that could be saved by using even quite an expensive drug.

[Kit Malthouse]

One of the interesting developments over the past couple of years, which was looked at by Dennis Gillings, the international dementia envoy appointed by the G8, has been the question of whether the financial equation around the development of a drug could be changed by negotiating an international exception for its patent life, extending it by, for instance, five or 10 years. That might propel investment into research to find a cure and also make it cheaper when it does emerge, because the time for commercially exploiting it would be extended. Would the hon. Lady support such a proposal?

[Dr Whitford]

I absolutely would. In my previous life as a breast cancer surgeon, when I was also doing breast cancer immunology research, I watched what became Herceptin go from its development on the bench-top into common use. That took 21 years. This is something we often do not recognise when we moan about big pharmaceutical companies: they are investing in something that may turn out to be a mirage. The more that we can look at supported or shared R and D, the cheaper the drug will be when it finally comes to market. I would commend something like that.

The current problem is that most patients face living with dementia, and we must think about how we help them and their families to do that. We should be challenging ourselves to make dementia-friendly our surroundings and all the agencies that sufferers may interact with, whether through visual aids, through other people recognising them or, as the hon. Member for Stockport (Ann Coffey) said, through technology. The eHealth programme in Scotland is working on that, including devices in patients’ homes that it can interact with and establish whether the person is okay. Much of the care that people receive is the 15 minutes that the hon. Lady mentioned. How can we improve that? How can we ensure that the faces are not different every day? Some patients and families report 100 carers in a year. We should look at how we organise the care and remember who the real carers are: the family.

It is predicted that one in three of us will be carers for someone with dementia. We have a vested interest in ensuring that we look after them. The carer’s allowance is currently £60 a week, which does not even match jobseeker’s allowance, for a job that could be 164 hours a week, so we need to think of how we support carers and the work that they do. In Scotland, things are slightly different as we have free personal care, so the family does not pay for the carer who comes into the home. If that person has to go into a care home or nursing home, they do not pay for the personal care. The system has been expanded and deepened and actually allows us to keep more people at home for longer.

One problem is that care jobs attract lower earners. How can we motivate people and attract high-quality candidates if they are being paid the lowest possible amount?

[Ann Coffey]

On free personal care, the budget in Scotland is capped. Free personal care is probably welcome, but the problem is that sufferers do not necessarily get the required level of care because demand is managed by stopping the supply. That is the problem with a capped budget. Free personal care is not really a panacea for families seeking the care that their relatives need.

[Philip Davies (in the Chair)]

Order. Before I call Dr Whitford, may I ask that she bring her remarks to a close?

[Dr Whitford]

Okay. Free personal care is obviously not a panacea, but some families have someone coming in four times a day to offer support and people of different levels are coming in. The request for such care is made through the general practitioner, so a health assessment is made. As I said when I first stood up, Scotland does not have a magic answer, but we are coming at the issue from a different angle. Some of what is being done in Scotland can be shared and clearly the same goes for some of the things being done elsewhere.

Remembering who these people are and helping them to remember is important. The volunteer projects involving music and football to help people find themselves are really important. We must remember that they are still in there. They are still a person, and they require our sympathy and to be able to keep their dignity.

Contaminated Blood

Philippa Whitford Excerpts

Monday 20th July 2015 Commons Chamber

[Ben Gummer]

My hon. Friend is entirely right to say there are some exciting medicinal prospects on the horizon. The demands, especially on those for hepatitis C, have to be seen in the round of all sufferers of hepatitis C, but this is an additional factor to be played in. We hope the particular group affected by hepatitis C will be considered by NHS England as part of its discussions on how to take forward future cures.

Penrose reported just before the election. There is an enormous amount of work going on in the Department at the moment, and this is a priority for the Department. We know we need to move quickly. I want to reassure my hon. Friend ‘s constituents that we want to have this matter settled before the end of the year.

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

The problem of contaminated blood products was an international one, but Penrose was a Scotland-only inquiry. It could not compel witnesses from elsewhere in the UK and that needs to be borne in mind. The victims and their families are key. Many families were infected because patients were not warned, and families have been bereaved. What consultation has there been with the Scottish Government, who held the inquiry and apologised on the same day, about this apparent delay? How much of the £25 million will be spent? We must ensure access to treatment, whether that is the new antivirals or transplants. We hurt these people; we must not let them down.

[Ben Gummer]

I thank the hon. Lady. It is a good example of the new mode of working between our Governments that officials in the Department of Health have been working very closely with their counterparts in the Scottish Government. Of course, most of the events that the Penrose report refers to were pre-devolution. It is therefore entirely right that the recommendation is adopted across the United Kingdom, not just in Scotland. I expect that cross and close working will continue through the course of the settlement process.

NHS Reform

Philippa Whitford Excerpts

Thursday 16th July 2015 Commons Chamber

[Mr Hunt]

I thank my hon. Friend for her important comments, and for sitting through a very long speech I gave this morning. We are trying to achieve many things. At their heart, as she rightly says, is a recognition that culture change does not happen overnight. She is right that the profiling of the extra money that the Government are investing in the NHS is important, because we need to spend money soon on some things, such as additional capacity in primary care, as in two to three years’ time that will significantly reduce the need for expensive hospital care. We are going through those numbers carefully. She is also right that local leadership really matters. I know that she will agree, especially as she comes from Devon, that leadership needs to be good at a CCG level as well as a trust level, because CCGs have a really important role in commissioning healthcare in local communities. That is an area where we need to make a lot of improvements.

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

I have to declare an interest: like most doctors, I am a member of the British Medical Association.

I commend the Secretary of State for his announcement about a national officer for whistleblowers. Shona Robertson, Scotland’s Cabinet Secretary for Health, announced this in June, and we are taking action on the Francis report in the same direction. It is vital that members of staff feel they have someone to speak to if things are not going well, and that if they are not being responded to locally there is an independent voice that they can go to.

With regard to seven-day services, the excess deaths of people who are admitted at weekends is recognised and abhorred by the vast majority of doctors. I do not know anybody who gets up and works the hours we do and does not care that someone did not do well. However, I think we are blurring the lines between the elective and emergency systems. The sickest people the Secretary of State mentions—those who run the risk of dying if admitted on a Friday or a Sunday—are not part of the elective system but of the out-of-hours emergency system. It is suggested that hospitals are like the Mary Celeste and there are no doctors. In fact, any service with an emergency component runs 24/7, but there is a multi-disciplinary team. Sometimes patients will be stuck on a ward because they cannot get access to a scan or there is no physiotherapist to help them recover from their stroke.

We are already working towards solving this in Scotland. We are doing so in a more collaborative way, and that is important. There is no resistance to that, because it is recognised that we need all parts of the service. This is different from people coming in for a routine check-up on a Sunday when that does not result in a detriment to them if it is not available. The biggest shortage we have is in human resources—doctors, nurses, physios, occupational therapists and radiographers. I recommend that the Secretary of State separate these two aspects. The first is that hospital consultants did not get the option to opt out of 24/7 care for emergency patients in the contract, whereas GPs did. It is a matter of providing, funding and setting up a full service with all that is behind it to deal with ill patients seven days a week, no matter when they come in.

The other aspect is trying to get value for money. If we have invested in expensive machines and theatres, we want them to work as many days a week as possible so that we get value for money, but that must be secondary to the first priority, which is looking after sick people. I suggest that the Secretary of State starts talking about the two aspects on separate tracks and not crossing backwards and forwards, and that this should be collaborative. I echo the hon. Member for Totnes (Dr Wollaston) in saying that we require the money to be front-loaded so that we get it to start changing the service now.

[Mr Speaker]

Order. May I gently say that from now on we are going to have to enforce the time limits on Opposition responses to ministerial statements much more strictly? Otherwise they eat into the time available for other colleagues. The shadow Secretary of State has five minutes in response to a 10-minute statement and the third party spokesperson has two minutes. That really does have to be adhered to as a matter of course from now on.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 7th July 2015 Commons Chamber

[Mr Hunt]

I am very happy to do that. My hon. Friend is right to point out that the solution to the problem is not just about expanding the number of appointments offered by GPs, although we are doing that; it is also about looking at the very important role that pharmacists and other allied health professionals have to play in out-of-hospital care.

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

The Secretary of State mentions recruiting 5,000 extra GPs, but I note in a recent speech that that was downgraded from a guarantee to a maximum. With 10% of trainee posts unfilled and the BMA’s recent survey suggesting that a third of GPs will leave in the next five years, is that not going to be difficult? Has the Secretary of State had any consultation with the BMA and the royal college to ask why they are leaving?

[Mr Hunt]

It will be difficult. The commitment has never been downgraded: we always said that we needed about 10,000 more primary care staff, about half of whom we expected to be GPs. We have had extensive discussions about the issues surrounding general practice, such as burn-out, the contractual conditions and bureaucracy. We are looking at all of those things. The commitment is to increase the number of GPs by about 5,000 during the course of the Parliament, and that is a very important part of our plan to renew NHS care arrangements.

[Dr Whitford]

I assume the Secretary of State is aware that two of the pilot sites for the seven-day, 8 till 8 working—one in north Yorkshire and the other in County Durham—have abandoned the project owing to poor uptake by patients, with only 50% of appointments used on a Saturday and only 12% on a Sunday. Given that they found that it had a detrimental effect on recruiting cover for out-of-hours GP urgent services, does not he feel that this needs a rethink and that consultation with the profession and looking at cover would be of most benefit?

[Mr Hunt]

The hon. Lady is presenting only a partial picture. In Slough there are about 900 more appointments every week as a result of the initiative for evening and weekend appointments. Birmingham has dramatically reduced the number of no-shows and Watford has reduced A&E attendance measurably. Some really exciting things have happened, but of course we will continue to consult the profession to make sure that the programme works.

A&E Services

Philippa Whitford Excerpts

Wednesday 24th June 2015 Commons Chamber

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

It is obviously a lively debate on both sides of the House. As someone who is not long from being on the front line, as a surgeon in the NHS, I find it a bit sad to listen to how angry this debate is. The four-hour target should be a tool and not an end in itself. It is used to take the temperature and to understand what is happening underneath. We would not shove a patient in a bath of ice water if they had a temperature; we would look for the infection, try to understand it and try to treat it. Unfortunately, the four-hour target has simply become a stick, and today that stick just seemed to be being thrown backwards and forwards.

People working in A&E face great difficulty, which is why we are not recruiting trainees to A&E and why we are losing senior doctors at an incredible rate from A&E. Instead of being one of the most rewarding places to work, people see it as the most miserable.

[Dawn Butler]

Although the target is used as a measure, or to take the temperature, does the hon. Lady not feel that the fact that it has gone up 401% since 2009-10 is something to be worried about?

[Dr Whitford]

Did the hon. Lady say that the target has gone up 401%?

[Dawn Butler]

The time that people have had to wait for four hours has gone up—

[Madam Deputy Speaker (Natascha Engel)]

Order. Interventions should be kept to a minimum. The hon. Member for Central Ayrshire (Dr Whitford) is not on a time limit, but please be aware that many Members are coming in to speak. Thank you.

[Dr Whitford]

Absolutely, we have seen the performance drop across the UK. The Minister quoted a report showing that England was performing better than Scotland. I would be interested in seeing that one—where it is comparing like for like with core A&E services—because those are not the figures I have seen. However, we all face the same challenge. We are dealing with older patients, who are more complex. The figures from Scotland last winter showed that we did not have a huge increase in numbers, but far more of those patients had to be admitted. Nothing else could be done, and we will face that situation more and more in future. The problem is that we are losing the staff to deal with that, and we are talking about A&E, but in the vast majority of cases, they key issue does not lie with A&E. There are two simple things: the number of patients coming in, which relates to out-of-hours GP access, and patients getting back out, which is described by the Royal College of Emergency Medicine as exit block.

It is important to remember that the four hours does not involve someone sitting on a chair, waiting for four hours. People are often given that impression—that they turn up in A&E and sit there, and no one will touch them for four hours. However, they will be triaged, see a clinician, have a history taken and have investigations. They may well get sewn up or be given something, and they will go home. Those patients are moving through. Our problem is the patients who have to come in, and it results in a whole cascade of issues, such as people stuck on trolleys getting the start of a bedsore, or families made miserable, or staff very depressed at trying to look after people in a corridor. It also results in people ending up boarded to any ward—any port in a storm—so that people are not in the correct ward and not getting the correct treatment from the correct team. We know that that, bizarrely, results in longer patient stays, which exacerbates the problem.

What we need to do—as we have done in Scotland, where we set up the unscheduled care action plan—is to work with all stakeholders. That involves looking at how patients flow through. It is not about people being obsessed with measuring the target and counting it, but about people opening the gates in front of the patient. The data on how long patients wait should be automatically available to staff from their system; it should not require an extra body to generate that data.

If we have the data weekly, which means we are getting them timeously, we can see one week from the other and ought to be able to see the patterns. The problem with monthly data for something that is identified as a currently acute issue is that, by the time they are collated, verified and out, staff may not remember quite what made that a bad week, whereas with weekly data, they can see whether they are getting a response to their actions.

I support keeping weekly measurements, but I do not support them being used as a tool—and certainly not for beating one another across the Benches here. I can tell hon. Members that staff in the NHS feel that they are beaten over the head with these targets, so it is not about having a target, but about how it is used. In the paper released by the Royal College of Emergency Medicine here yesterday, one of its myths was that the four-hour target is a distraction. It pointed out that it allowed a focus.

To try and tackle the problem in Scotland, we have ensured that the majority of our A&Es have a co-located out-of-hours service. I mentioned before that achieving 8 till 8 in every GP practice is so far in the future that it cannot be reckoned on as a solution to this problem. We are unable to fill the GP vacancies we have now. Telling them that they will be working from 8 till 8 on Saturday and Sunday is not overwhelmingly attractive.

The pilots that have been done have started to report in the last fortnight, and they have reported a very poor uptake. When people want to deal with an out-of-hours problem, they come to A&E. Rather than trying to change the whole population, we could have a system in which people are easily diverted once they get there: “If you have this, please step next door to our primary care service.” We need to look at those solutions, and some are working quite well.

The other issue is health and social care. To get patients out at the end of their journey, they need to be able to get into care. We need to remember that, although extra money may be given to health and social care through the health side, if we are cutting local authority budgets at the same time, we end up cutting the legs from under the NHS.

[Dr Murrison]

The hon. Lady is making thoughtful comments and I am following them carefully. I agree with her that co-location can work in some places, but clearly it is not going to work everywhere. Does she not agree that most people who attend accident and emergency departments are neither accidents nor emergencies, and they would be much better cared for by general practitioners? To do that, however, GPs need to be trained for that case mix and incentivised for it, and most importantly, the public needs to be trained, too, about accessing the proper professional.

[Dr Whitford]

Before the movement of out-of-hours GP services under the banner of NHS 24, most local areas had a doctors-on-call service. In my county, we had Ayrshire doctors on call, which was provided by local doctors at rooms in the A&E departments in our two hospitals. Patients quickly learned where they could go to be seen quickly. We also had a car service that allowed us to make home visits. That functioned very well until NHS 24 came and pulled it away.

We have to get back to local GPs working like that as part of a co-operative in a focal position. Each practice cannot generate enough GPs or work to have someone sitting there all day Saturday and all day Sunday. When the Secretary of State talks about 8 till 8, it is not clear whether he means that that will happen in each individual practice or on a regional basis. Most of the pilots that have started to publish their experiences have quickly made it into a doctors-on-call service. There is more common sense behind that approach and it is more sustainable.

We have to look at the flow within hospitals. We should not have trackers running around bean counting when patients had what done, but people going in front of patients, opening the gates, looking at bed management and ensuring that patients are in the right place.

All these matters cascade back on to staff. We are struggling to maintain and recruit staff. There was only a 50% take-up of trainees for accident and emergency, and we are haemorrhaging senior people, which exacerbates the problem. We need the co-location of GPs and we need to look at the exit block, not only out of A&E and into the hospital, but out of the hospital.

[Marie Rimmer (St Helens South and Whiston) (Lab)]

A 25% reduction in the number of GPs and practice nurses has been forecast over the next five years. I have the statistics to prove that. People talk about the cost of agency staff and locums in hospitals, which is out of all proportion. There are also massive increases in costs—

[Madam Deputy Speaker (Natascha Engel)]

Order. It is essential that we keep interventions to the absolute minimum.

[Dr Whitford]

The problem with moving patients into hospitals is being exacerbated by the reduction in in-patient facilities. Every new hospital seems to have fewer beds than the old hospital it replaces. The Scottish Government finally accepted the view of clinical staff that that could not go on. We now treat people in a different way. People used to get a hernia done and lie there for a week. My breast cancer patients used to come in and stay for 10 days. That has changed, which is great for those patients, but there is an inexorable rise in the number of older patients who have complex needs. The problem is not that we are living longer. I get quite upset at the phrase, “the catastrophe of living longer”. I suggest that Members think about what the alternative is. At medical school, I was definitely given the impression that people living longer was the point.

People are surviving their first major illness and, actually, their second major illness. They may present with breast cancer in their mid-70s to someone like me and have four co-morbidities. Such patients do not get in and out quickly for elective surgery, and they do not get out quickly when something major goes wrong, such as pneumonia or a chest infection. We therefore need to stop the downward trajectory in the number of beds, because we will not get the flow of patients if we go on cutting beds.

For me, the key things that we need are the co-location of GPs; an out-of-hours service for out-of-hours issues that are better dealt with in primary care; and enough beds in the right places. Finally, we need to smooth the way of our patients to get back to their homes. In Scotland, we have free personal care that allows us to keep more people at home and stop them going into hospital and to get more people back out of hospital.

I commend the “Five Year Forward View”. Much of it is taken from something that was written in Scotland several years ago called “2020 Vision”, which was about integrating health and social care.

[Karin Smyth (Bristol South) (Lab)]

I am not aware of the position on co-location in Scotland, but one barrier to the successful implementation of co-location in England is that the tariff and the funding mechanism mean that is it not efficient. Will the hon. Lady say what the position is in Scotland, because perhaps we can learn from that in England?

[Dr Whitford]

As I am sure the hon. Lady is aware, we have a totally separate system, for which I am grateful. We do not have a system of tariffs. We have a single NHS, so we can sit around a table and try to work out a solution. That is one of my concerns about the situation that the NHS in England faces and it is where I would veer away from the “Five Year Forward View”.

The principle of working together and integrating health and social care is commendable. The integration boards in Scotland started work in April because “2020 Vision” is a few years older than the “Five Year Forward View”, but we face the same challenge: local authorities are struggling with their budgets, which can end up eating away at the health side.

The four-hour target is still useful as a weekly target to provide a quick response to what is going on in our hospitals. However, it should not be used as a stick to beat staff or to beat ourselves in this House and make public capital. The NHS is too precious for that.

--- Later in debate ---

[Maria Caulfield]

I will not take any interventions owing to the restriction on time.

I shall give the House an example. When I worked as a nurse in A&E—under the Labour Government—an elderly gentleman was brought in during a busy night shift. He had fallen at home and broken his hip, and he was put in a corridor to wait. After three hours and 30 minutes, he called me over, saying, “Nurse, I desperately need to go to the toilet.” I had nowhere to put him. The best thing I could do was to wheel a curtain around his trolley, and there, in the middle of a busy hospital corridor, that elderly gentleman with war medals on his chest went to the toilet. He was seen within four hours. That box was ticked and he was deemed to have had good healthcare, but I was not particularly impressed with that care. Let us not kid ourselves that meeting that target always means that the patient experience is good or that the outcome is any better.

My second point, which relates to my worry that this debate is being used as a political football, is that the four-hour target is not being seen in the context of the bigger picture. Other targets show that, even with the increased numbers attending A&E, more and more patients are getting their treatment within four hours. Similarly, the clinical outcomes—surely the most important factor—relating to diseases such as heart attacks show that morbidity and mortality rates have improved. There have also been better outcomes for people who have had strokes and for trauma victims. So outcomes for patients are improving despite the four-hour target not having been met during the past 100 weeks. We should welcome that and congratulate our NHS staff on achieving it.

Thirdly, if this is a serious debate about A&E services throughout the whole of the United Kingdom, which we are surely all here to represent, why are we not looking at the rate in Scotland of only 87%, in Labour-run Wales of 83% and in Northern Ireland of 79%? This debate is a political one, and as a healthcare worker, I find that distressing. It is interesting that those Members who have worked in the NHS believe that the four-hour target is a useful tool but that it should not be used as a political stick.

[Dr Philippa Whitford]

I would like to know where the hon. Lady got her figure of 87% from. Our figure is 92.6%, and we measure it every week.

[Maria Caulfield]

I was given the figure by the Nuffield Trust.

[Dr Whitford]

Not by the NHS?

[Maria Caulfield]

It is an NHS figure.

I shall attempt to move the debate forward with my fourth point. If we are serious about tackling the issues resulting from the number of patients using A&E services, we need to acknowledge that 15% of patients who go to A&E could receive treatment elsewhere, in local community facilities. We need to look seriously at the Government’s proposals for seven-day-a-week health service, and if Opposition Members are serious about working with healthcare professionals to improve the experience of patients, they should surely welcome the introduction of out-of-hours services to take the pressure off A&E.

The thing I find most distressing about the motion is that it is full of criticism and complaints but offers no solutions. My plea to Opposition Members is that we should work together for the benefit of patients. We cannot continue to have patients whose care is being compromised even though they have ticked the four-hour box. We have only to look at the example of Mid Staffs, where the four-hour target was met time and again while terrible incidents were happening behind the scenes. Let us stop using the NHS as a political football; let us start working together. I would welcome the efforts of all Members to work together with the Government to deliver out-of-hours services and take the pressure off A&E units and the staff who work in them.

Drugs: Ultra-rare Diseases

Philippa Whitford Excerpts

Tuesday 16th June 2015 Westminster Hall

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

I was a breast cancer surgeon for more than 30 years, and I often experienced the situation that has been described in the debate with my patients and new cancer drugs. We were turned down for Kadcyla earlier this year. With cancer, it is often end-of-life research that later translates to early treatment research. People read things in the paper and say, “Oh, £90,000 for six months of life—that doesn’t make sense.” Inevitably, however, those drugs move forward. We have a different system in Scotland, and while listening to the debate I have been struck by how what is required is a system that is open and can be approached, and which looks from all angles.

In Scotland, the Scottish Medicines Consortium considers drugs as NICE does, and it considers worldwide evidence. It will work up a drug in detail. The balance for us seems to be slightly more on effectiveness than cost, although obviously cost is part of it. Our impression is that, for NICE, cost would sometimes be a bigger component. They are both looking at cost-effectiveness, and we all know there is not an infinite pot of money.

What has changed in our system over the last year is that we have combined our cancer drugs fund with our rare diseases drug fund and simply called it the new drugs fund. The amount in the fund has been quadrupled from £20 million to £80 million, which means that in any year it is a little more flexible in responding to demand, whether that is for drugs for rare diseases or for a new cancer drug. NICE only assesses three drugs a year, so rare drugs are never going to get that work-up. They need a separate system. In Scotland, we have pathways to follow for rare diseases and ultra-diseases.

The biggest change in Scotland in the last year is patient and clinician evaluation. If the evidence for a drug is so strong that it will go through on the nod and there is not an issue, that is fine and PACE is not engendered; but if things look more finely balanced or the drug will not go through, patient groups or drug companies can request a PACE assessment. That will involve expert clinicians, patients and patient groups, and allows people to get slightly outside the numbers and talk about life change, quality of life and money saved in respect of other aspects of the NHS—things that perhaps do not appear in a research paper. That is what is required: a system.

At the end of the day, the system will not produce a favourable result for every single person and every single new drug in the world, but it has to be fair. We cannot have things not being looked at properly, or individual requests being used as the main way of accessing a drug. The system I am talking about is meant to be a transition—supporting young people, for example, who have been on a trial, by giving them access on a compassionate basis, while we get through the paperwork prior to a drug being accepted. It cannot be left as the main method.

[Jonathan Edwards (Carmarthen East and Dinefwr) (PC)]

That system sounds excellent. I commend the Scottish Government on their work. That could be a great help to my constituent, Mr Trystan James, who suffers from tuberous sclerosis complex and is reliant on a clinical trial drug to deal with a life-threatening tumour. Of course, his drug prescription is therefore completely at the discretion of the drugs company and his family are going from one prescription to the next. That relates to what the hon. Member for Strangford (Jim Shannon) said about emotional pressure on families. I commend the Scottish Government on their work.

[Dr Whitford]

The important thing to remember is that if this is all done by individual requests, the NHS does not go to the companies. We need to realise that companies have often made investment over decades and that nine out of 10 drugs they research will go nowhere, but it is important to have a wider debate with companies to get the best price. Hon. Members mentioned that some companies are willing and able to reduce the price to get a drug in.

Drugs are licensed. We must not mix up licensing with funding. Licensing is about asking, “Is this drug safe and proven at a basic level?”, not anyone coming in and saying, “Rare plant juice will cure everything.” These are licensed drugs that we could prescribe—a doctor has the right to prescribe them—but the NHS has to make the decision about whether to fund them; those are funding decisions, not licensing decisions.

It is important that families know what the pathway is and how they move on when their clinician takes a case forward. It is important that they know they can respect decisions and how to lobby at the next step, and that they feel their voice is being listened to. We feel that PACE has, over more than a year, allowed us to do that. Clinicians in Scotland got frustrated about decisions going through without us informing that decision.

There could be a system that sits on the side of NICE, or a sub-group. One of NICE’s three assessments will never be given over to a drug intended for 88 patients when it is also assessing drugs that might be taken by 500,000 people. Rare diseases would always fall behind, and that is why those must have their own system and why the patient voice must be heard in these ways. Obviously, things have changed with the Health and Social Care Act 2012, but I commend such a structure to the Minister.

[Mark Durkan (Foyle) (SDLP)]

The hon. Lady is making a thoughtful contribution. Does she agree that it would be worth all Administrations in these islands, who together form the British-Irish Council, collaborating on these issues, particularly borrowing from the good example being developed in Scotland, and seeing whether there can be common achievement and common advances, and perhaps even creating some common funding stream, as well as the discrete funds that she has talked about?

[Dr Whitford]

Obviously, devolution gave us the power to do things differently, but I do not think that we should re-invent the wheel. Often, we will accept work done by NICE or re-evaluate it quickly, to see whether things should be applied differently, but we do not just go back to the beginning. However, I am sure that ideas can be shared in both directions.

It seems that certain drugs were left as orphans when the system changed. We know that patients with the brain tumour form of tuberous sclerosis, which the hon. Member for Carmarthen East and Dinefwr (Jonathan Edwards) mentioned, can access the drug through the cancer drugs fund, but if they have a kidney tumour and are treated by urologists they are not part of that system and simply will not be aware of it. Such random unfairness exists.

[Jim Shannon]

There is a forum and association, driven by the Health Minister, that discusses matters together with the three regions. A UK-wide strategy is already in place. The process is allowing that to happen already. However, it is delayed and has not happened yet; that is why we are concerned.

[Dr Whitford]

I think it is a matter of what ideas go on the table and what is being discussed in the meetings. Good ideas are going ahead. I commend the idea of including patients and clinicians in evaluations, because the numerical data from trials will often be small due to the nature of the diseases in question, and we will have to look wider. The problem for children is that if these drugs are to prevent deformity, they have to be got in early. People with Morquio already have the changes. We do not know yet how much change could be prevented, or how much saving there could be on a person’s disability in the long term if metastatic breast cancer treatments, which eventually become adjuvant treatments, are given earlier.

I commend the system I have talked about. I know it is difficult and challenging, but it is clearly fair, with an interim period for compassionate reasons, and people know where their voice should be heard.

NHS Success Regime

Philippa Whitford Excerpts

Thursday 4th June 2015 Commons Chamber

[Ben Gummer]

My right hon. Friend will be aware of the hospitals in Essex that have been placed in special measures. He will also be aware that focusing on one or several particular institutions is not sufficient to sort out the problems in the wider local health economy. That is why the success regime is being brought in—to try and deal with those systemic issues. Once the success regime has been concluded, I hope that his constituents will rapidly see an improvement in the service that they receive and that they deserve, wherever they are in the county.

On his second point about funding per head, he will know that NHS England has already started to look at that and, in some instances, address it. I have the same problem in my constituency in Suffolk, and it needs sorting out in the medium term across the country.

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

The Minister talks about consulting commissioning groups locally, but why is he not willing to listen to groups of doctors across the country who talk about the point I made on Tuesday—fragmentation? We need integration. Local authorities are having their budget taken away, which means cuts to social care. Social care companies are one thread away from bankruptcy. We need to fund both sides of that, yet we are running round looking at structure. We need to move and look at outcomes. I have heard the Minister talk about “Five Year Forward View”. In Scotland we are already doing that as part of 2020 Vision: look at the patients, as the Minister says.

[Ben Gummer]

I take this opportunity to congratulate the hon. Lady on her entry into the House and on her maiden speech, which I enjoyed listening to in the Queen’s Speech debate. In England we are addressing the issues surrounding social care and its integration with the health service. That is why we have introduced the £5 billion better care fund. Under the success regime, far from looking at structure, we are trying to see how we can better link up services. That is why local councils will be a key partner at the table in the discussions.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 2nd June 2015 Commons Chamber

[Mr Hunt]

My hon. Friend is absolutely right to draw attention to that issue. We have plans to train another 5,000 GPs across the country. In the last Parliament, we increased GPs by about 5%. We need to go much further, as part of a real transformation of out-of-hospital care.

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

How does the Minister intend to find the 5,000 extra GPs when many surgeries throughout the United Kingdom cannot fill the spaces that they have, and how does he plan to fund it? The proposals appear to only fund the setting up of seven-day-a-week, 8 till 8 GP services and not running costs—and these are big running costs.

[Mr Hunt]

I welcome the hon. Lady to her place. We do need to find these extra GPs and we will do that by looking at GPs’ terms and conditions. We need to deal with the issue of burnout because many GPs are working very hard. We also need to raise standards in general practice. In the previous Parliament, an Ofsted-style regime was introduced, which is designed to ensure that we encourage the highest standards in general practice. That is good for patients but also, in the long run, good for GPs as well.

[Dr Whitford]

Just so that the Secretary of State is aware, it takes 10 years to produce a GP, so that will not be an immediate response. The £8 billion that the Conservatives have suggested they will add by 2020 was just to stand still, not to fund a huge expansion, and as change, which the NHS requires, costs money, can the Secretary of State perhaps give us an indication of what extra we may expect in the next two years?

[Mr Hunt]

Well, I can, but may I gently say that under this Government and under the coalition we increased the proportion of money going into the health budget, whereas the Scottish National party decreased the proportion of money going into the NHS in Scotland? The £8 billion is what the NHS asked for to transform services, and that will have an impact, meaning that more money is available for the NHS in Scotland. I hope the SNP will actually spend it on the NHS and not elsewhere.

Health and Social Care

Philippa Whitford Excerpts

Tuesday 2nd June 2015 Commons Chamber

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

I am grateful for the opportunity to take part in this debate as the Front-Bench spokesperson on health for the Scottish National party.

I pay tribute to Charles Kennedy. Obviously, I did not know him in this place but I am a graduate of Glasgow University and was a contemporary of Charles, who spoke eloquently and entertainingly at our first medical year reunion.

I am honoured to have been elected by the people of Central Ayrshire to be their Member in this Parliament for the next five years. My predecessor, Brian Donohoe, was their MP for 23 years, initially for Cunninghame South and then lately for Central Ayrshire. He served on the Select Committee on Transport and even took on an additional duty as a special constable for the British Transport police, something of which he was intensely proud. Now that he is freed from the trammels and duties of being an MP, I know that he plans to develop his hobby of flying remote-controlled helicopters, which will at least keep him out from under the feet of his lovely wife Christine. Unfortunately, he does not golf, which is the other alternative. I wish them both well in his retirement.

Central Ayrshire is a coastal constituency, with beautiful sandy beaches all along its coast. In the south is Prestwick airport, Scotland’s oldest passenger airport and where Elvis stopped off on his way back from national service in Germany in 1960.

[Pete Wishart (Perth and North Perthshire) (SNP)]

His only British tour.

[Dr Whitford]

We now hear that he was once out drinking with Tommy Steele, so we will not go down that road.

The airport is the site of an aerospace park and, as many Members will know, is on the shortlist for consideration as a future spaceport. Unfortunately, the passenger numbers have dropped but a recent report shows the benefit we would accrue from a drop in air passenger duty. It would bring back European visitors to our lovely county and help rejuvenate our tourism industry.

Prestwick golf club was also the site of the first ever Open golf championship in 1860, but that competition is now more closely associated with its neighbour in Royal Troon, where I live. Royal Troon will host the British Open next year, and I invite all hon. Members to it, although they cannot have the spare bed in my house, I am afraid. Book early. Despite the obvious beauty and wealth in Troon, it, too, now hosts a food bank.

In the north of my constituency, Irvine is both an old town and a new town in that it was a royal burgh from 1372 that was suddenly surrounded by modern blocks in the ’60s. Regeneration of the town centre and, in particular, Harbourside is ongoing, but it contains two of the most deprived wards in my constituency. Inland, in the rolling Ayrshire countryside, there is a chain of villages, from the ancient settlement of Dreghorn, childhood home of our First Minister, through Dundonald with its fine castle and Symington with its beautiful church to the mining villages in the south of Annbank and Mossblown. Sadly, they lost their mines decades ago and are left stranded, bereft of work and poorly connected by both transport and digital services.

Tarbolton is the site where Robert Burns, our national bard, founded the Bachelors’ Club. As we might imagine from the name, this debating club was for men only, and the first toast to the Immortal Memory given at a Burns supper by a woman was just this year. We take a bit of time in Ayrshire. Now that the county of his birth is completely represented by Members on the SNP Benches, I would hope, Mr Speaker, that we might host a fine Burns supper next January, and I am sure that we will extend an invitation to you. I am sure that it has been observed by the House that there are nae wee, sleekit, cow’rin’, tim’rous beasties on these Benches.

As a doctor for well over 30 years, of course my interest is in health and the future of the NHS, which I consider to be one of Britain’s greatest achievements of the 20th century. The biggest healthcare challenge we face is developing integrated services to look after our older citizens with complex needs. Breaking up the NHS and franchising it out to rival private companies destroys collaboration and makes achieving that even harder. If the Secretary of State was still in the Chamber, I would point out to him that the report by the Commonwealth Fund to which he referred is based on data from before April 2013, when the Health and Social Care Act 2012 came into effect.

In Scotland after devolution, we went back to our roots, got rid of trusts and again became a single unified public NHS. That has allowed us to work right across our country in developing quality standards and improving safety. We have our challenges; the NHS in Scotland is not remotely perfect; we face the same challenges as the rest of the United Kingdom. But despite the quips that were made by the Secretary of State, it does come down to co-operation and not competition.

Nevertheless, it is important to remember that the NHS does not give you health. Health comes from having a decent start in life. Health comes from strong public health measures to tackle things like the prevention of diabetes, before we are swamped by a deluge of chronic illnesses in the future. But its most important foundation is what happens in childhood and, as we now sadly know, even what happens in pregnancy.

In my constituency, despite unemployment falling from 6% to 4%, child poverty has climbed from 20% to 25% since 2010. That is one in four of our children growing up in poverty. These are not the children of shirkers and slackers, as is often implied: 64.5% of them have a working parent. The causes are short hours, low wages and benefit cuts. I have heard the welfare state spoken about through gritted teeth in this House, but allowing young lives to fail will cost society more money in the long term—in prisons, in police, in addiction services and in long-term benefits. We need to invest in our children—but not just in them; in their families—to change their future. There is no point in talking about focusing on schools if they are sitting shivering and hungry at home at night. The first duty of any Government is the security of their citizens—not with regard to replacing weapons of mass destruction, but the real security that comes from knowing you can keep a roof over your head and food on the table.

I have served the people of Ayrshire for the last 19 years as a breast cancer surgeon. I hope I will be able to serve them further, despite missing that post, in my work here. I intend to work for them in the constituency and speak up for them in this House.