Whistleblowing

Debate between Philippa Whitford and Norman Lamb

Wednesday 3rd July 2019 Commons Chamber

[Norman Lamb]

Shockingly, the BMA abandoned him, and that is a story in itself, which needs exploring further. Not just in the NHS but across the economy, people are often literally on their own, faced by expensive lawyers. I speak as a former employment lawyer and I know what happens in employment tribunals. They were intended as a layman’s court, but they are anything but that these days.

The third story I want to mention is that of my constituent Mark Wright, a successful financial planner at RBS. Things started to go wrong after he raised concerns about unacceptable practices in the bank—this was before the crash. On 17 September 2008, immediately after the collapse of Lehman Brothers, an intranet statement was put up in RBS saying that the group was “well capitalised”. That was clearly an attempt to reassure staff, including staff shareholders, customers and investors that the bank was secure. Of course when the bank crashed, those staff shareholders lost a fortune, and many, including my constituent, believe that they were badly misled by that intranet statement.

Mr Wright’s mental health was destroyed as a result of trying to challenge the bank, as was his career. He made a complaint to the Financial Conduct Authority, which reported his name back to the bank, for goodness’ sake. The FCA was later criticised by the Complaints Commissioner. I pursued his complaint with the FCA and it denied knowledge of the intranet statement repeatedly to me, yet an internal FCA email has emerged, after a subject access request to the Complaints Commissioner. It was dated 14 March 2014 and it said

“the intranet notice that Mr Wright refers to was online between 17 September 2008 and January 2009… as staff used it to take reassurance that all was well which would tend to support Mr Wright’s allegations”.

That was an email within the FCA, yet we were never informed of that email or of that finding in that explosive document.

Clearly, the FCA has a copy of that intranet statement, yet it will not or cannot disclose it to us. The FCA says that the law does not allow it to do so. RBS, which is part state-owned, will not disclose it, yet clearly it is in the public interest that it should be disclosed. I believe I was misled by Andrew Bailey, the chief executive of the FCA, who told me, in effect, that Mark Wright’s allegations offered nothing that was not already in the public domain and he referred to an intranet statement by Fred Goodwin, which he said had been

“in the public domain for nearly 10 years”.

Yet the intranet statement has not ever been in the public domain. The Treasury Committee, which had looked into this, had never received a copy of it. So I was misled, and we have a regulator that is too close to the banks; that failed to protect Mr Wright’s disclosure or his identity; that, crucially appeared to fail to take the allegations about the misconduct of that bank seriously; and that cannot or will not put a crucial statement into the public domain. Let us just think about the damage caused by bankers in the run-up to the crash. Had we empowered people like Mark Wright to do the right thing, rather than destroyed them and ignored them, we might just have prevented the disgusting behaviour and greed of bankers, and we might now have seen some of those responsible for destroying our economy behind bars. As it happens, they have got away with it.

The fourth and final story is of foster carers throughout the country who are frightened to raise concerns about any behaviour from the council that they deal with. Of course, the council refers children into their care, so if a foster carer is concerned about the behaviour of a social worker and expresses concerns, that council can just stop the flow of children to them, and so their income stream—their ability to earn a living—disappears. This has a chilling effect on the willingness of any foster carer to speak out about child protection concerns, because they fear losing their livelihood.

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

Does that not highlight how, whether in finance, the NHS or anywhere else, this happens in situations with a power differential and a hierarchy? Someone has power over someone else and can make them lose their job or lose what they love doing, so there is a constant threat.

[Norman Lamb]

The hon. Lady is absolutely right. We need effective legislation to redress that imbalance of power.

All the cases I have outlined highlight the value and importance of enabling people to expose wrongdoing. Effective protection for brave people who decide to speak out is first of all vital for that individual—they should be celebrated, not denigrated—but it also benefits us all if we give them protection. As the right hon. Member for Sutton Coldfield (Mr Mitchell) said earlier, this is actually an issue of good governance. It is about keeping organisations honest; protecting businesses from fraud, crime and other wrongdoing; and maintaining the highest possible standards. Good protection for those who speak out acts as a deterrent against bad behaviour; closed, secret cultures, which cover up wrongdoing and destroy those who try to speak up, deliver poor public services or cheat customers in the private sector, particularly in financial services, or lead to the toleration of bullying, sexual harassment and so on. So often, non-disclosure agreements are the final step that keeps the wrongdoing secret, slamming shut the door on proper scrutiny. Things need to change.

The question is: does the current law work? Palpably, from the examples I have given, it is clear that it does not. First, it leaves out key groups—not only foster carers—that simply are not covered by the legislation. It leaves out job applicants, volunteers and priests. Just think about the abuse of children by so many priests over the past few decades. Had priests been given the protection to speak out, perhaps we would have prevented some of that dreadful abuse. The legislation leaves out non-executive directors and trustees. It leaves out relatives and friends of the whistleblower when they are victimised because of what the whistleblower has done. It leaves out someone who is victimised by being presumed to be a whistleblower—if a company thinks that someone has spoken out, even if they have not, and does something like dismissing them, that person has no rights under the legislation because they are not actually the whistleblower. That is a ludicrous situation.

Local Government and Social Care Funding

Debate between Philippa Whitford and Norman Lamb

Wednesday 24th April 2019 Commons Chamber

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

I associate myself with the comments of the other two Front Benchers about the events over the weekend. I had the honour of being in Jerusalem for Easter and was shocked on Thursday and then on Sunday to hear of such horrific events. I was sitting in a site that is so precious to the three monotheistic faiths when I heard that, after the terrorist attack in New Zealand, we had had violence in Northern Ireland and then the horrific attacks in Sri Lanka.

Turning to this afternoon’s debate, I echo the comments of the hon. Member for Denton and Reddish (Andrew Gwynne). Here we are yet again. The Green Paper that we should be debating to consider sustainable funding for social care has been kicked into the long grass five times, and there is no sign of it coming forward. Is that just because the House, the Government and the civil servants are too busy with Brexit, or is there really a lack of ideas on how to solve the situation? The problem, however, is that we should urgently be thinking about a way forward.

The NHS five year forward view was based on game-changing public health changes and funding and increased social care funding and provision, because otherwise all we will see is increased demand at the front door of the NHS and then a blockage and leakage of funds at the back end. The four-hour target that we often talk about does not just measure A&E performance; it is about the flow of patients through the system. If patients cannot get home at the other end, the system simply breaks down.

Local government in England has seen an average 28% cut in funding, and I have been shocked by some of the figures that Members have mentioned, which range from 46% to 75% to 97% cuts in central funding. Obviously, everyone has faced cuts to their budgets, but there has been only a 5% reduction in local government funding in Scotland despite a 7% cut in the resource budget. The situation has been much more protected than has been the case in England. In Wales, there has been an 11% cut.

I welcome the long-term NHS plan because it unpicks some of the damage done by the Health and Social Care Act 2012, particularly by reforming section 75, and it tries to drive integration, which I think Members on both sides of the House would recognise is the only way forward. However, it was disappointing to discover yesterday on the Health and Social Care Committee that local government was not involved, almost at all, in putting together the long-term plan, yet it will be expected to deliver more and stronger social care to relieve pressure on the NHS.

[Norman Lamb (North Norfolk) (LD)]

Does the hon. Lady agree that it should have been a long-term health and social care plan if we actually believe in joined-up, integrated working and that the funding settlement for the NHS, very tight as it is, simply will not work without addressing the underfunding of social care?

Human Medicines (Amendment) Regulations

Debate between Philippa Whitford and Norman Lamb

Monday 18th March 2019 Commons Chamber

[Dr Whitford]

It is critical that the patient’s dose is not changed or put in danger. The management of any condition is dose sensitive. We cannot go down to homeopathic doses of antibiotics or blood pressure medication—that would be crazy.

Pharmacists can give a different form, such as liquid, solid or capsule. Again, for some patients that will not be a problem; for others, it will. The hon. Member for Newton Abbot (Anne Marie Morris) mentioned generic drugs. Generally, NHS prescribers use generic drugs as the default to save money. However, I have had patients who had appalling side effects from the generic form of tamoxifen, but not from the non-generic brand. There always has to be a right for GPs to say, “In this case, I will use the brand.”

The most important bit of this statutory instrument is that it allows a change to a completely different drug. It may be a drug that is approved by a panel sitting somewhere in London with the colleges, who say that it is a reasonable replacement for the other drug, but that does not take into account the fact that patients are all individuals. I can tell you that they are all individuals.

Pharmacists are very knowledgeable—in Scotland, we have had community pharmacists for over a decade and they contribute massively—but they work to their own protocol, they work within limits and they do not have access to the patient’s notes. Therefore, they cannot see that the patient has been on a drug in the past and had terrible side effects. They will replace with a protocol drug, but what about the responsibility? Why is this happening right now?

It suggests to me that the Department of Health and Social Care is expecting massive shortages, to the point where the simple act of picking up the phone and saying to the GP, “I don’t have drug A. Would drug B be reasonable for Mrs Smith?”, is somehow impractical. I find that very worrying. It may be that Mrs Smith has had six drugs to control her blood pressure. Drug 2 and drug 5 caused her to faint or have blackouts, but the pharmacist does not know that.

Epileptics have been mentioned. The issue with epileptics is that any change can destabilise their epilepsy. They are therefore never prescribed by generic, but are prescribed by brand to avoid precisely that.

[Norman Lamb]

The hon. Lady makes a very good point. Does she agree that there is often an interaction between epilepsy drugs and other drugs that the patient may be on and that any interruption of that relationship may cause problems?

[Dr Whitford]

The right hon. Gentleman makes a very good point, and one that applies to many drugs. When we prescribe, we sit and look at the interactions. I would expect a pharmacist to look at that. They will have the patient’s full prescription and should, therefore, be able to look at interactions.

[Norman Lamb]

They do not have the patient’s records.

[Dr Whitford]

That is the key thing: they do not have the patient’s records and they do not know what problems a drug may have caused in the past.

This change could have a real impact on epileptics. It brings the danger of a fit, and the fit itself may be a threat to them. Obviously epileptics are exposed to sudden unexpected death in epilepsy and can suffer from trauma, depending on where they are when they take the fit. They can even lose their driving licence for a year because they have one fit. The social impact of that on epileptics is enormous.

It says in the explanatory notes that, because of that, epilepsy drugs and biological drugs would not be considered suitable for the protocol. However, it does not say that in the SI—they are not excluded. It is important that such people are protected.

Social Care

Debate between Philippa Whitford and Norman Lamb

Wednesday 25th April 2018 Commons Chamber

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

It seems no time since we were discussing this topic in the autumn. There are three groups of people who require social care. The first and the one commonly thought about are the frail elderly. There is expected to be a rise of 25% in those aged 85 and above between 2015 and 2025. By 2030, that proportion will have gone up 63%. Therefore, this requires us to make urgent preparations. Elderly people requiring social care need support and comfort.

The next group comprises those who are facing the end of life. They want dignity and, if possible, to be at home. If their family is looking after them, they want their family to have respite. The third group, as has already been mentioned in the debate, are younger people with disability. For them, it is the quality of their whole life, their mobility and their ability to participate in society. This last group is expected to rise by 9.2% between 2010 and 2020.

The five year forward view for the NHS and the amount of money requested were based on a game-changing approach to public health and a strong increase in social care funding. In actual fact, the opposite has happened and social care has lost almost £5 billion. Age UK says that 1.2 million elderly people have a social care need that is not being met—up 48% since 2010. In England, there has been a 26% drop in local authority-funded patients getting social care—that is 400,000 people —despite an increase in the ageing population.

One third of the elderly population are looked after by their family. Those carers have been paid tributes here, but they need a bit more than tributes; they need support and, in particular, they need respite, because many of them are literally working all the hours of the week. There will be 2 million carers who are themselves over 65. At the moment, carers’ allowance is only £60 a week; it is not even the same as the jobseeker’s allowance. In Scotland, this is one of the benefits that we now have control over, and it is rising to meet the level of the jobseeker’s allowance. That is little enough tribute to these people who, frankly, are saving the state millions.

Some 700,000 people were identified by Age UK as getting no help whatsoever. The Green Paper is looking at options in the long term, but the problem is that social care needs funding now, and it is estimated that the gap will be £2 billion by 2020. The social care precept has been identified, allowing local authorities to raise council tax by 2% to 3% over the next few years. That will bring in £1.8 billion, but it will be the richer areas that will be able to raise more money.

The better care fund has been put forward for the integration of health and social care, which we should all welcome. It is estimated to raise £1.5 billion by 2019-20. The problem is that some of it—£800 million—has been raided from the new homes bonus, and when we are not here talking about social care, people are at the Dispatch Box talking about the lack of housing and the lack of affordable housing. The problem is that if we do not get away from silo thinking, we will never reach a point of health in all policies.

At the same time, the local authority funding grant will be cut by £6.1 billion by 2019-20, so we are talking about giving with one hand and taking away with the other. As has been touched on, the cuts to local authority funding of social care are causing providers to close. In the first half of 2016, one third of local authorities had at least one home care provider—and half had a care home or nursing home—that closed due to becoming bankrupt. Anyone who has had a relative supported by these services will know how traumatic it is, particularly if it is a residential care home, for someone who may have lived somewhere for years suddenly to be moved to a strange place.

Perhaps some consideration should be given in the Green Paper to combining health and social care, and to looking at some of the different approaches in order to consider whether it is actually safer to provide social care publicly. In Scotland, we have been increasing the funding into the community in primary care, which will rise to 11% of the health budget, and in mental health, community care and social care. The aim is to rebalance the budget over the coming years to 2021 until half the health budget is going to the community. We have been funding integration joint boards since 2014, and the care, design and planning is by health and social care partnerships. This is already joining up health and social care, so that we do not have the situation that I experienced when I worked in a hospital, with the social care side and the health side bickering over where Mrs Jones would be best served. With integration, we should just be able to work out what is best for Mrs Jones.

[Norman Lamb]

From what the hon. Lady is saying, I get the impression that she rather agrees with me that the Government will never come up with a solution by focusing in their Green Paper on one part of one part of the problem—in other words, older adult social care. We need to look at the whole system across the NHS and social care.

Valproate and Foetal Anticonvulsant Syndrome

Debate between Philippa Whitford and Norman Lamb

Thursday 19th October 2017 Commons Chamber

[Norman Lamb]

I thank the right hon. Gentleman for that, and he is right in what he says; I, too, feel that there is a sense of inertia. For goodness’ sake, for as long as women are not getting told about this, more such babies are being born. That is the awful horror of this.

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

Many of us in the House have been approached by constituents or groups about several of these drug scandals, which represent a paternalistic time, when the patient was not part of a team in an open discussion with the doctor. I am sure there are many of these, so should they be looked at together, as the principles of them all are the same?

--- Later in debate ---

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

I, too, pay tribute to the right hon. Member for North Norfolk (Norman Lamb) for securing this debate and trying to air this issue again. Epilepsy affects 1% of the population—600,000 people—and it is not a trivial condition. It is dangerous. As we have heard, 1,200 people a year die due to epilepsy, and we must not diminish that fact. At the lowest level, someone who has a fit after being well controlled suddenly cannot drive again, which can have quite a big impact, but at the other end of it there is death. We therefore must be careful not to send out a message that anti-epileptic drugs are bad, or even that Epilim is. It works really well, and it is one of the drugs that often can control the most dangerous seizure—the tonic-clonic or grand mal, as it used to be called—without the use of other drugs.

Almost all anti-epileptic drugs carry risk. Sodium valproate is the worst by far, but all the ones we have heard of in the past—phenytoin, phenobarbital, primidone and carbamazepine—carry some risk. We therefore have to recognise that it is not just as though the doctors prescribed the wrong drug. This condition is really hard to deal with, and we need people to have specialist input. We are really asking that from when girls reach puberty until they reach menopause or get into their 50s—when there is no risk of them having children—decisions are made with them by specialists.

As we have heard, there was obviously a recognition right back in the ’70s that sodium valproate could bring about congenital abnormalities, but what appears to have changed is the scale. If we look back, we see that people used to discuss a 2% risk of malformation and “some possibility” of developmental delay. We are now talking about 10% of children having a birth defect, which might be something like a minor cleft palate that can be dealt with, right through to spina bifida, meaning the child faces major physical disability. On a much worse scale, some 40%—almost half—of children face some form of developmental delay, which might mean an autistic spectrum disorder, learning difficulty or ADHD. That is a big change.

We heard earlier about the 1995 paper that started to bring these cases together. Before that, there were predominantly case reports—someone saying, “Oh, this is odd; I’ll write it up”—but we needed someone to bring things together. When we hear that 400 affected babies have been born in the year since the recent attempt to deal with this issue, we realise that had the yellow-card reporting system been working when we had perhaps 500, 600 or 700 cases a year, the situation would have been spotted much more quickly.

The system utterly failed to recognise a pattern and has to be reformed. If a woman gives birth to a child with a birth defect, or there is in the very early years recognition of some kind of major developmental delay, and she is on a drug, that should be reported, and I do not care what the drug is. Her GP may never have seen such a thing before and might not recognise that there could be an association, but someone sitting in the MHRA who is receiving 400 or 500 reports certainly ought to.

The obvious question is how to tackle this issue. The toolkit was put out in February 2016, because we have recently recognised the huge scale of the problem—the change is the recognition of the scale. It is therefore shocking and incredibly disappointing to hear that more than two thirds of women have not received any part of it. It is great that there is now some marking on packaging, but perhaps more of that needs to be combined, because we then do not have to depend on people remembering to hand something out or to pick something up. We would be empowering women to say, “Oh, what’s that? You’ve never talked to me about that,” and both sides would have the chance to have a discussion.

We have predominantly focused on the results of using sodium valproate during pregnancy but, as the hon. Member for—

[Norman Lamb]

Strangford.

[Dr Whitford]

Sorry. I am not doing very well today. Six hundred and fifty names is hard enough; adding another 650 constituencies just does my head in!

As the hon. Member for Strangford (Jim Shannon) mentioned, by the time a women is pregnant—crucially, by the time she knows she is pregnant—it is too late, because these abnormalities happen in the first trimester: those first two months when the brain and spinal cord are forming and the arches of the face are combining. That is why we particularly see neural tube defects, brain function abnormalities and cleft palate. Many women who lead hectic lives may already be two months pregnant by the time they finally know, and that means it is too late. That is why the annual review is important.

Epilim is perfectly fine for a girl to use if it gives good control for grand mal seizures, but we need to flag up the fact that when she is expected to be approaching puberty, discussions need to start with her and her family. Family planning is important for all women, but for women on these kinds of drugs, which must be stopped in pregnancy, it is crucial. We need to have that discussion so that the alternatives can be considered. I echo the comment that if a woman is pregnant and did not plan for that, she should not stop the drug on her own. She should have emergency access to a specialist who is able to look at her type of epilepsy and discuss the options with her, such as whether it would be safe to take nothing or if it would be better to change to something else. It should be recognised that uncontrolled seizures in pregnancy can cause the loss of the mother and the baby. We must not have any kind of irresponsibility by not flagging that up.

We had a debate in this Chamber last week on baby loss. It was a very powerful cross-party debate on the anguish that people face, whether it is due to early miscarriage, stillbirth or neonatal loss. We talked about that loss and bereavement, but any of us—male and female—who have had children know of the expectation and joy that comes from waiting for a child. There is still exactly that bereavement when we know that our child will face a life of physical and mental difficulties, and of learning disabilities. We know that a child with a marked learning disability has only a 7% chance of working. For the parents, there is the stress of knowing that there will come a point when they are not there, and of wondering how their child—perhaps now a young adult—will actually survive facing a harsh world.

Financial support is absolutely crucial to give families peace of mind. We need an inquiry, but rather than holding multiple inquiries, we should recognise that bringing some of these common themes together into one would be a much more powerful way to get people to understand that we are talking about relentlessly repeating patterns. Let us try to reform the things that allowed this to happen and to ensure that we support the families and the children to whom, sadly, it has happened.

NHS Pay

Debate between Philippa Whitford and Norman Lamb

Wednesday 13th September 2017 Commons Chamber

[Dr Whitford]

It is very important that people recognise the role that everyone plays, but for nurses in particular this is not just a matter of pay. Last year, we spent a lot of time debating changes to working tax credits, which can leave a lone parent nurse very much worse off. We also spent a lot of time debating the imposition of tuition fees and the removal of the nursing bursary. The nursing bursary still exists in Scotland. It is a non-means tested bursary of £6,500, potentially with a caring supplement of £3,500. We know that the average age to take up nursing study is at the end of the 20s, which means that people often have family commitments. Such people will receive approximately £10,000 a year so that, at the end, they will not face what future nurses in England will face, which is a debt of more than £50,000. The repayment on that kicks in immediately, because graduate nurses start at around £22,000, which is over the limit. At the lower end of band 5, that is another £400 a year off. By the time a nurse gets to the top of band 5, it is another £1,000 a year off. They will never manage to pay off that £50,000 to £60,000, which means that their salary will be reduced by that amount throughout their careers.

[Norman Lamb]

Does the hon. Lady agree that what appears to be happening is that many of the mature students who previously went into nursing often do not want to take on that debt? That means that we are losing people who seek to transfer from other professions, which is really damaging.

[Dr Whitford]

I totally thank the right hon. Gentleman for his intervention. That is absolutely the case. It has never been a negative—in fact it has always been a benefit—that we have attracted people who were a bit older to the role of student nurse. Perhaps they had another degree or a student loan to pay off, but they always had a bit more life experience under their belt.

As a very junior doctor in my first year, I remember what it was like when my hours alternated between 132 and 175, and I had no life that did not involve people who were dying or ill or who had been hit by a car. That is very difficult for a person who has just come out of uni, and who is used to going out for a pint and having parties. There is real advantage in training people who may have had a family and who have lived a bit of life. As the right hon. Member for North Norfolk (Norman Lamb) said, there are people who are attracted to nursing but who will not take it up because they will not put their family through it. We have seen that already with a 23% drop in applications.

State Pension Age for Women

Debate between Philippa Whitford and Norman Lamb

Wednesday 5th July 2017 Westminster Hall

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

Let me correct the hon. Member for Gloucester (Richard Graham). If he reads section 28 of the Scotland Act 2016, he will see that the Scottish Government are prohibited from doing anything about pensions or relating to age.

The key issue is communication. The Work and Pensions Committee said that people should have 15 years. The Government said, “Well, you did. It changed in 1995”. But they wasted 14 of those years by not informing women. They only started to write to women in 2009, one year before the first batch of women found that their pension age had changed. Many only discovered in 2011, when they were informed of the second change, that they were being hit by a double whammy.

The problem, as I mentioned earlier, is one of communication—an article in the Financial Times is not an acceptable way to inform women such as me, born in the 1950s, that our pension age is changing. HMRC and the DWP can certainly find us when they want to, so I would have thought they could send a personal letter. The idea that we should have to ask for our pension age is ridiculous when we have known what it was for our whole lives. The Government owe those women a duty of care; those women who have suffered the gender pay gap, raised children and cared for the sick—

[Norman Lamb (North Norfolk) (LD)]

Will the hon. Lady give way?

[Dr Whitford]

I will give way.

[Norman Lamb]

I thank the hon. Lady for giving way—

Health Service Medical Supplies (Costs) Bill

Debate between Philippa Whitford and Norman Lamb

2nd reading: House of Commons & Programme motion: House of Commons
Monday 24th October 2016 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

This is an uncontroversial set of measures and I confirm my support for the Bill as it stands. The great strides in medical science over the past decade and beyond are obviously to be celebrated, with cutting-edge new treatments for life-threatening and life-shortening conditions, including a number of rare diseases and cancers, offering many people the hope of improved health, longer life and a quality of life that in the past would not have been possible. As well as the enormous benefits it brings to patients, the life sciences industry makes an incredibly valuable contribution to the UK, and it is only right that we acknowledge that today. However, there is an inevitable cost attached to the triumph of modern medicine, and the challenge is to ensure patient access to new treatments as quickly as possible, while ensuring value for money for the NHS.

The Bill seeks to address some of the shortcomings. It addresses clear abuses of the current system and I think that it will bring greater consistency to the existing arrangements for controlling the cost of medicines new and old. As I have said, I find myself in agreement with the proposals.

It is good that so many companies recognise their responsibility for keeping the branded medicines bill in check by signing up to the pharmaceutical price regulation scheme. Under the scheme, manufacturers pay a rebate to the Department of Health to cover expenditure on branded medicines above agreed limits. It is a responsible approach, helping to ensure that patients can benefit from access to novel drugs in a way that is sustainable for the taxpayer. However, I agree with the Secretary of State on the need to address the current disparity whereby the statutory medicines pricing scheme delivers lower savings than the voluntary scheme. Those differences are expected to widen, which is clearly not in keeping with the spirit of either arrangement, so it makes sense that they should be more closely aligned. As he said, we have to remove the incentive to shift from one scheme to another.

I particularly welcome the proposals to strengthen the authority of the Secretary of State to intervene where unbranded medicines are priced excessively. The NHS and patients benefit immensely from medicines, which were once available only at great public expense, becoming available far more cheaply after the patent expires and generic products come on to the market. We should recognise the great value that the competitive market brings, saving the NHS more than £13 billion every year, according to the British Generic Manufacturers Association, but we also know that the overall cost of generic items is increasing at a faster rate than branded items, and that there have been some outrageous increases, to which other hon. Members have referred, in the price of some individual generic drugs in recent years when there is only a single company producing that drug. It looks like a clear case of profiteering, where the NHS is being ripped off.

Let us be clear what the implications are when a particular company makes an excessive profit from increasing the price of a drug in that way. It means that other NHS patients, particularly those in more marginal areas that do not get the attention that they deserve, lose out. There is less money to spend on, for example, teenagers with mental health problems or learning disabilities. There is a price to be paid for that excessive profiteering. It is utterly unethical behaviour. I hope that the Competition and Markets Authority can find a way to take action against these companies, which appear to have constructed a business model to exploit the loophole.

As hon. Members have said, a number of generic medicines increased in price by more than 2,000% in the last decade. The most horrific example I have come across is a medicine that increased in price from £13.98 in 2005 to £632.96 in 2015, a rise of more than £600 per item dispensed. It is utterly despicable for any private company to think that it can do that. The Government are right to take action to end that outrageous practice.

Generics account for three quarters of prescription items dispensed in the community. In those cases where competition fails to deliver value for money, it is important that there are measures at our disposal to control prices and to tackle abuses that could place intolerable pressure on NHS budgets. It makes little sense that generic medicines can be controlled through the statutory scheme, but that the Government are currently prevented from stepping in when a company’s branded products are regulated through the PPRS. It seems clear that we should remove that anomaly. I should add that, in using these powers to introduce price controls, the Government should of course exercise caution and guard against any unintended consequences that may impact on the viability of smaller companies. I am sure that the Government will be alert to that.

The aims and provisions of the Bill are admirable, but it is only part of a much wider debate about how we can sustain access to groundbreaking new treatments when the NHS is in the middle of the longest financial squeeze in its history. One intervention from a Government Member on the Secretary of State drew attention to the fact that the total bill for drugs is rising at an unsustainable rate. The right hon. Member for Chelmsford (Sir Simon Burns) also raised this question, and we have to address that because the NHS will not be sustainable at the current rate of increase in cost.

It is no secret that the NHS has struggled to adapt to modern medicines, particularly those that carry a large budgetary impact. Both NICE and NHS England have had great difficulty in figuring out which medicines to approve and how those medicines are to be afforded and brought to patients. Recently, NHS England has delayed funding for the new hepatitis C treatment, so I was interested in the points made by the SNP representative, the hon. Member for Central Ayrshire (Dr Whitford).

We also have the ongoing and deeply unsavoury case of the PrEP, or pre-exposure prophylaxis treatment. Not only is NHS England taking its legal challenge to the bitter end to avoid having to pay for the drug, but there have been reports of it pitting patient groups against each other by saying that patients could miss out on vital treatments for cancer or rare diseases for children should PrEP be funded. We do not want to get into comparing the rights and interests of one group of patients against those of another in that way.

Earlier this month, NHS England and NICE launched a consultation on proposals to change the way some drugs are funded when there is a high cost involved. NHS England and clinical commissioning groups are legally required to fund drugs recommended by NICE as being clinically and cost-effective, normally within three months of the guidance being issued, barring unique circumstances. Under the new proposals, if NICE recommends a drug that will bring an estimated cost to the NHS above a certain amount—£20 million is the suggested figure—NHS England can go back to NICE and ask it for longer to roll out the medicine if it is unable to agree a lower price with the manufacturer. Surely that is precisely the opposite of what we ought to be trying to achieve as regards speedier access to new drugs that are coming on stream. Ignoring questions about how that somewhat arbitrary cost threshold was arrived at, there is a concern that this is a creeping step towards the rationing of approved treatments in the NHS. It seems to me to be an admission that the NHS cannot afford to pay even for the drugs that are found to be cost-effective by NICE; similar concerns have been raised by Nicholas Timmins, that highly respected observer who is a senior fellow at the King’s Fund.

The great worry is that opening up the debate on how quickly or slowly approved treatments can be adopted will put us on a slippery slope to a new discussion about whether approved treatments should be adopted at all, and at the very least UK patients will be further disadvantaged—the SNP spokesperson has already made the point that we compare very badly with other countries —and there will be more delays in getting access to new cost-effective treatments.

[Dr Philippa Whitford]

Does the right hon. Gentleman recognise that we are one of a tiny handful of OECD countries that allow that opening price to be set completely by the pharmaceutical industry and to be set as high as it likes?

[Norman Lamb]

I note that point. I suppose my overall point is that given the unsustainable increase in the total drugs bill and given the actions that NHS England and NICE appear now to be taking, it seems that we will be in a more difficult position in getting speedy access to new drugs that can be life-saving. The Government need to reflect on that. The hon. Member for Central Ayrshire made the point in her speech that this Bill tidies up things that have to be tidied up, but there is a much bigger debate about how on earth the NHS can afford vital treatments that in other countries patients are getting access to much sooner.

If we are approaching a situation in which we are unable to cope with new treatments that have been judged by an arm’s length expert body, NICE, to be clinically effective for patients and cost-effective for the NHS, it is yet more evidence that the NHS needs more resources, and I repeat again to the Minister—he will be sick of hearing me say it—that at some point the Government must recognise that they are simply drifting towards a crash with the NHS. We face an existential challenge that this evening’s debate has highlighted and that has to be confronted at some point. I urge the Government again to consider a cross-party approach so that we can ultimately achieve, in discussion with the public, a long-term and sustainable settlement for the NHS and care that recognises both this dramatic increase in the cost of drugs and that all our loved ones want to have access to those drugs in their hour of need.

We should also be mindful of the potential impact of Brexit on the life sciences industry and the additional challenges we face in keeping the NHS medicines bill under control. If trade between the UK and other EU countries becomes subject to customs duties, import VAT and border controls, thereby increasing costs to the life sciences industry, that might in turn drive up the costs of new medicines to the NHS, and impact on access for UK patients to the most innovative new treatments.

Finally, we also need to make sure that evaluation processes and methodologies are fit for purpose. Traditional appraisal methods and notions of cost-effectiveness are unsuitable for many modern medicines, especially for drugs of immense scientific innovation that target just a small number of patients, but the NHS has been slow to respond to that. The Cancer Drugs Fund is a case in point—established as a sticking plaster after a cluster of promising drugs were judged not to be cost-effective. While it is almost certainly the case that many of those treatments came with too high a price to be routinely funded, few would deny that they were being evaluated under outdated processes that could not fully capture their value. Many rare disease treatments suffer from the same problem.

Companies have a duty to ensure that their medicines are fairly priced, but NHS England and NICE also have a duty to make sure that their evaluation processes and decision-making criteria are fit for purpose, so that new medicines are given a fair hearing without some of the excessive delays we have seen in the recent past. We owe it to patients to make sure that happens.

I support this tidying-up measure and, in particular, the ending of the outrageous practice of a number of companies profiteering at the expense of NHS patients, but this debate has also raised a much bigger issue about how we in this country afford groundbreaking treatments that keep our loved ones alive.

NHS Sustainability and Transformation Plans

Debate between Philippa Whitford and Norman Lamb

Wednesday 14th September 2016 Commons Chamber

[Dr Whitford]

I totally agree with the hon. Gentleman. I was about to come on to that. However, it is not just the funding, but the entire model. The tariff model that we have at the moment rewards hospitals for doing more minor things, and punishes them for doing more acute things. Taking on more A&E cases and more complex cases, working harder and doing more make their deficits grow. Our problem is that we have all sorts of perverse incentives in the system that mean that organisations will still be looking out for their budgets and their survival instead of working together.

In Scotland, we got rid of hospital trusts and primary care trusts, and, since 2014, we have had integrated joint boards. Those boards were handed joint funding that came from health and the local authority, which meant that the whole business of “your purse or my purse” disappeared. They were then able to start to look at the patient’s journey and the best way to make the pathway smooth. That is what we want to see.

Having a shared vision of where we are trying to go to is crucial. That means that stakeholders—both the people who work in the NHS and the people who use it—need to believe in where we are trying to get to. Public conversations and public involvement are the way forward. We should not be consulting on something that has already been signed off, but involving people in what they would like the plans to be, as that would make those plans much stronger.

We need to make deep-seated changes to the system, as opposed to only talking about the money for the deficits. This is something that the Health Committee has been talking about for ages. The phrase “sustainability” has become shorthand for paying off the deficit. Of the £2.1 billion earmarked for sustainability and transformation, £1.8 billion is for deficits, which leaves only £300 million to change an entire system. I know that we talk about money a lot in here, and of course it is important, but we have far bigger sustainability issues than the £2.5 billion deficit in the NHS. We have an ageing population, and those people are carrying more and more chronic illnesses, which means that we have more demand, more complexity and more complications. That is one of the things that is pushing the NHS to fall over. On the other side of that, we have a shortage in our workforce; we do not have enough nurses or doctors, and that includes specialists, consultants, A&E and particularly general practitioners. Although the advice has been very much that finances were third, and prevention and quality of care were meant to come first and second in delivering the five year forward view, finances seem to be trumping everything else.

It is absolutely correct that health is no longer buildings; there are lots of methods of health that are bringing care closer to patients, and also some things that are taking patients further away from their homes. We have hyper-acute stroke units, and we have urgent cardiac units, where they will get an angiogram and an angioplasty that will prevent heart failure in the future. However, we cannot start this process there; we cannot shut hospitals and units to free up money to do better things. We have to actually go for the transformation and do the better things first. We have to design the service around the pathways we need—that wrap-around care for patients—and then work backwards. If more health and treatment is coming closer to the patient, at some point they will say, “Actually, I don’t go to the hospital very often. I want the hospital to have everything it needs when I need it.” Then we can look at the estate to see whether we have the right size of units and the right type of units in the right place. What concerns me is that the process we have seems to be the other way around—we are starting with hospitals, which is often a very expensive thing to do, and hoping it will deliver everything else.

[Norman Lamb]

rose—

[Dr Whitford]

I give way to Norman.

[Norman Lamb]

I am grateful to the hon. Lady for giving way, even if she used my first name. Does she share my concern that, out of the original sum allocated for this sustainability and transformation process, the vast bulk appears to be going, in effect, to propping up acute trusts that face substantial deficits, and that little is available for transformation?

[Dr Whitford]

As I said, the proposals leave only £300 million. We cannot transform a system on the scale that is being considered with £300 million.

As I said, the guidance talks about prevention. We need to be tackling health inequalities. We need to be focusing on health and wellbeing—and by that I do mean physical and mental wellbeing. We need to be strengthening public health—something else that has been cut. We need to be looking at the quality of health and care, and that means right across into social care. We must fund social care, because it can make a difference to things like delayed discharges. We are not even three years into the integration in Scotland—we are only two and a half years into it—but delayed discharges have dropped 9%. Yet, the last time the Secretary of State was in the Health Committee, they had gone up 32% in NHS England. So literally just moving things around and allowing one part of the system to fail will mean that the entire system fails.

Contaminated Blood

Debate between Philippa Whitford and Norman Lamb

Tuesday 12th April 2016 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

I, too, pay tribute to the hon. Member for Kingston upon Hull North (Diana Johnson) for her amazing campaigning work, and indeed to the other hon. Members who helped secure this debate. I also pay tribute to the organisations Tainted Blood, the Contaminated Blood Campaign and the Haemophilia Society, which have campaigned for years to get justice for so many people. We should also pay tribute to the many individuals who have fought on and on for justice, often in very difficult circumstances.

The Minister should reflect on the extraordinary unanimity of view in this debate, on the reflections in the consultation, on the proposals that the Government have put forward and on the need to think again. This is not a party political issue, because all Governments are to some extent culpable—Labour Governments, Conservative Governments and, indeed, the coalition Government. This is a moral imperative—there is no doubt about that. We have to offer these people justice, and the Government must accept that.

The Government set out the principle right at the start, in their introduction to the consultation, by stating that they accept and recognise their responsibility to everyone infected as a result of NHS treatment, but that leaves out those people affected. This is about not only those infected, but those affected. What about all the loved ones, the children, the spouses and the partners bereaved as a result of loss of life? The Government should accept responsibility for them as well. They have to accept that when they respond to this consultation exercise.

Serious concerns have been raised about this set of proposals. The Prime Minister said—his words were very clear—that:

“We will help them more”—[Official Report, 11 March 2015; Vol. 594, C. 289.]

Yet the proposals, when we see the detail, include a proposal to cut the amount of money that individuals receive. That is not consistent with what the Prime Minister said, so surely the Government must think again. It is surely unconscionable that people in very real need will lose out financially as a result of these proposals. What assessment have the Government made of the winners and the losers? How much will some people lose? It is really important that the Government are open about that. If the Minister cannot respond today, I would be grateful if she wrote to hon. Members to set out the assessment of the amount some people will lose, and of how many people are likely to lose, as a result of these proposals.

As my right hon. Friend the Member for Orkney and Shetland (Mr Carmichael) and others have said, it is surely not right that people in Scotland benefit more than people in England. Surely everyone should be treated exactly the same as a result of this scandal.

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

Will the right hon. Gentleman give way?

[Norman Lamb]

I will not, because I am concerned about the time.

Ending inflation-proofing actually means that we plan a cut to what people are paid every year for as long as there is inflation. Surely we cannot begin to justify that.

I have a problem with the principle of funding new medical treatments at an early stage by taking money from people’s financial support. That surely confuses two principles. We should leave intact the money that is available for people’s financial security.

I am concerned that the money will come from the Department of Health. The impact assessment talks about the other things that cannot be done as a result. Surely the money should come from the Treasury. In the Budget, the Government cut capital gains tax. I heard recently of one individual who will benefit to the tune of nearly £1 million as a result. These are political choices. Do we as a country want to cut capital gains tax and give large sums to very wealthy people at the same time as cutting financial support for people who have lost out as a result of a national scandal? That is surely unacceptable.

I therefore say to the Minister: accept what the Haemophilia Society says, withdraw these proposals and think again.

--- Later in debate ---

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

We have paid tribute to many of the people who have come from across the UK to listen to today’s debate, but there is one group missing: members of Haemophilia Scotland, who are in Tayside attending a funeral of one of their members, the second of three brothers who have haemophilia. The remaining brother has had a transplant because of liver damage. I expect that everyone here would want to send their condolences to the family.

Let us recall that this scandal has been going on for over 40 years. People have been dying without being recognised and without being looked after for all that time. It really is a disgrace. We talk about not accepting liability. I have my specs on because I want to read out some quotations, which, as Members know, I do not normally do. I have a letter here. According to a leading doctor in the Food and Drug Administration in America, in May 1985, heat treatment of blood products had been available for some time, but non-heat-treated blood could continue to be produced with the current licences because the FDA was not going to do anything about it. It could have regulated the practice out, but it wanted things to be tidied up quietly. The doctor explained that although the FDA could revoke the licences through regulatory process, it did not want any attention to be paid to the fact that the practice had been allowed to continue for so long; it wanted the issue to be

“quietly solved without alerting the Congress, the medical community and the public.”

I have a copy of a letter from John Major, the former Prime Minister, who was at the time Chief Secretary to the Treasury. In 1997, he wrote to Tony Newton, then a Health Minister, raising the possible consequences of a sympathetic response to the Haemophilia Society:

“It could lead to an open-ended commitment of huge dimensions

and

“give rise to court action against the Government because of the implication of negligence”.

He asked Tony Newton to “consider the points” made by the society, but

“with no implication that the Government will take action.”

Here we are, nearly 30 years on, in almost exactly the same situation.

As has frequently been mentioned, this is the biggest treatment disaster in the NHS, and it happened because we were importing American coagulation products and American blood—blood taken from prisoners, or units of blood that were sold. Who sells their blood for donation? People living on the streets; people who are drug addicts. The main reason haemophiliacs and others are suffering is that making factor VIII meant using the blood products of multiple donors, which meant an increase in the risk of a positive result. Moreover, the haemophiliacs received those products over and over again.

Here we are, all these years on. When I graduated in 1982, and when I worked as a young surgeon throughout the 1980s, this was just beginning to emerge and be discovered. It certainly left me, as a surgeon, with an absolute fear of transfusing blood. I used to go to great lengths to use electrocautery and other techniques to avoid shedding blood in elective cases, because we did not know what other problems were there.

Some of my colleagues have drawn attention to the exact terms of the Scottish settlement, but the first three can be summarised thus. People who are suffering from hepatitis C, HIV or co-infection will receive more money, allowing them to receive at least the equivalent of an average income of £27,000. People with stage 1 hepatitis C will receive £50,000 instead of £20,000, and those who have received compensation of £20,000 in the past will be eligible for £30,000 now. It is totally accepted by the Scottish Government that focusing solely on cirrhosis is a rather bizarre way of assessing people, and they are entirely open to an evidence-based piece of work in the future looking into how people should really be assessed.

I think that one of the biggest differences in Scotland is the recognition of the bereaved families. They will receive the money for another year, and will then receive a lifelong pension of 75%. Our flexible fund will continue to be topped up to the point of £1 million a year. As has already been said, that will not give people back their lives, but it can allow them to live with dignity.

The right hon. Member for Orkney and Shetland (Mr Carmichael) and the right hon. Member for North Norfolk (Norman Lamb) suggested, with a degree of criticism, that Scotland had gone ahead rather than seeking a United Kingdom solution. How long should we wait? Scotland was criticised because although we were ready to screen blood in 1990, we waited until 1991 so that there would be UK screening of blood donations. We made that mistake then, and we cannot make it again now.

[Norman Lamb]

Will the hon. Lady give way?

[Dr Whitford]

I am sorry, but I do not have enough time.

I do not think that we would be debating this matter with the same urgency if there were not the contrast with what Scotland is doing. This is not just about financial support and recognition. All patients in Scotland with hepatitis C for whom Sofosbuvir is appropriate can receive it. I find it shocking that people in England who have been infected with contaminated blood should have to use any of their funding to buy a drug that can increase their quality of life and reduce the risk of giving the condition to their family. We are doing this not just for those patients but as a public health measure. If we reduce the burden of virus in the community, we will reduce the number of new cases.

A year ago, the Prime Minister and our First Minister responded to the Penrose inquiry. That inquiry was carried out in Scotland; the UK has never had a public inquiry on this matter. Both of them apologised, and our First Minister has used this first year to set up a group to look into changing support, and ensuring that people can access treatment and that families are recognised. I call on the Prime Minister to honour his apology and to ensure that patients in the rest of the UK receive the same treatment.

NHS and Social Care Commission

Debate between Philippa Whitford and Norman Lamb

Thursday 28th January 2016 Commons Chamber

[Norman Lamb]

I said at the start that I am primarily focused on England because health is a devolved responsibility, but I also said that the same pressures apply everywhere, and so the case for a process of this sort in Wales, in Scotland and in Northern Ireland is just as strong as it is England. I would encourage this debate to take place in Wales as well. We must overcome the clashes between the parties to recognise that something bigger is going on and we need to work together.

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

I want to return to the right hon. Gentleman’s point about the data. Last June, we had a debate about moving from weekly to monthly data, and we were told that the NHS would still know what was going on. We now have a six-week delay in the publication of those monthly data, which results in a total of 10 weeks. Having asked about this at the most recent Health questions, I understand that people within the NHS can access the data, so why are they not being shared with this place? The last data we had was in November.

--- Later in debate ---

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

I, too, attended the debate on 2 June last year, and I remember expressing my shock at the violence that was taking place between the Dispatch Boxes. I considered leaving the Chamber, because it did not seem to be a very useful debate and I did not see the point of taking part in it, but then I thought “No, let us get in and tackle this”, and I did make a comment. I said that, regardless of the differences in the way in which politicians would “do” the NHS, the public absolutely believed in it. We have had a fantastic debate today, because people have expressed different views and different outlooks, but have done so calmly.

As was mentioned by the right hon. Member for North Norfolk (Norman Lamb), the challenges of increasing demand caused by age and multi-morbidity are found not just north and south of the border, but throughout the developed world. We also face the challenge of not having enough doctors, in both primary and secondary care. That, too, applies throughout the nations of the United Kingdom.

There are some challenges that we do not face in Scotland. We have not experienced the fragmentation that resulted from the Health and Social Care Act 2012. Indeed, we got rid of hospital trusts back in 2004. We have gone, therefore, to geographical boards—we just have health boards—so there is no barrier between primary and secondary care, which people used to pitch across. Since April of last year our joint integration boards have become active. They ran in a theoretical way for about a year, but the vast majority of them went live last year and the last one will go live in April this year. That is putting the pot of money into a joint space where health and social care work together, break down the barriers and realise there is no benefit in sticking a person in a bed and then looking to see who should pay for it. What purse the money is in has often been the biggest problem.

We cannot develop integration if what we are actually developing is fragmentation and competition. That is why we have not gone down the route of outsourcing to private providers. It wastes a lot money and effort, and people are competing instead of co-operating.

We obviously have different systems in Scotland. We have free personal care, the level of which has been increased to allow us to keep at home people with more complicated conditions. That is important. Since June of last year we have been going through a national conversation. Whether we have a commission, a committee or whatever, it is important that the public and the staff are involved, as well as the people who have written all the reports—Marmot, Wanless, Barker, the King’s Fund, the Nuffield Trust. There must be a way of bringing these together and picking out the good bits to get a shape. Our piece of work is looking towards 2030; that is what we are working on at the moment.

We did a piece of work that started in 2011-12 called “2020 Vision”. It was very like “Five Year Forward View” and addressed where we wanted to be and what shape we wanted. That identified that the No. 1 thing was integrating health and social care.

Talking about the money for this and where it comes from is always going to be political. At the moment national insurance is bizarre; it starts when people earn £7,000 when we would not tax them, and it stops when people retire, although they might be incredibly wealthy. I do not think people see it as national health insurance, which is how it started. Where the money comes from and what it is put towards is a political decision.

To get some kind of shared view of where NHS England and indeed the NHS in all the nations want to be in 2030 could be a useful piece of work. I totally agree with the hon. Members who have expressed anxiety about kicking this into the long grass. I certainly do not think it needs to stop any piece of work going forward. To me, this provides a place where that can come. One of the features in Scotland in developing quality measures is bringing groups of people together for an annual conference; I am a great believer in getting people into a room—maybe not always a room like this one; maybe a more co-operative room—so that people can say “This is what we found difficult. This is how we fixed it. This is where we are stuck. I see you solved that.”

One of the projects that Nicola Sturgeon has taken forward is called “once for Scotland”. It is not eternally going through local projects and experiments that never get shared with anybody, and everyone reinvents the wheel. That is a huge waste of energy.

Obviously the Government have committed to the £10 billion and that has been welcomed, but more than £2 billion of that is already gone in the deficits. That increase is focused purely on NHS England, whereas normally funding is described in all the Department of Health responsibilities. The other responsibilities are facing a cut that is described as approximately £3 billion. The King’s Fund, the Nuffield Trust and the Health Foundation identify the increase as in fact about £4.5 billion—so not exactly the headline figure.

The “Five Year Forward View” has been mentioned, and that asks for £8 billion but it also identified £22 billion that had to be found. That is fairly eye-watering. Let us think about two of the things that were identified within that. One was a change in how people worked.

[Norman Lamb]

The hon. Lady is talking a lot of sense, as she always does. The “Five Year Forward View” set out three scenarios, but it did not ask for £8 billion; that is just the narrative that has developed. The efficiency assumptions on which the £8 billion—or £10 billion, or whatever we want to call it—is based are unimaginable. They are at least 2% to 3% throughout the period between now and 2020, and everyone knows that that is not going to be delivered.

[Dr Whitford]

I thank the right hon. Gentleman for his intervention. Even without recognising that no one has ever achieved those levels of efficiency savings, we need to acknowledge that a big chunk of this is about prevention. More than £5 billion of the £22 billion has been identified as relating to people not going into hospital and not getting sick, yet public health expenditure has been cut by £200 million in-year, with another £600 million to go. That amounts to a 3.9% cut. Lots of people will think that that just means less smoking cessation and less preventive work around alcohol, but public health should be much bigger than that.

I understand that there used to be a Cabinet Committee on public health in this place. Public health should be feeding into all the decisions that are made here. We also need to ensure that our directors of public health are strategically involved in local government, because the shape of our town centres will determine whether we have car-based or active transport, how we design our schools and whether we flog off our playing fields. All those things will interact with health.

It has been said that secondary care always gets the bigger bite of the cherry. We talk about fixing the roof while the sun is shining, but in fact, when the window has just come in or the door has just come off its hinges, that is what we fix first. That is very similar to secondary care, which is actually the national illness service. It responds to people who are already ill. We are developing more complex and expensive treatments that allow us to keep people alive, and we need to recognise that. People talk about the catastrophe of ageing, but I would like Members to focus on what the alternative is. People used to say, “Age does not come alone, and it is terrible.” In the field I worked in, however, not everyone gets old. Age is something that we should value, because wisdom and a sense of community come with it.

However, we need to be ready to develop the services around older people, and that means not always just patching things up at the end. We need more intermediate care to allow step-up and step-down beds, and we are working on that in Scotland. In particular, we need to focus on primary care, as the hon. Member for Stafford (Jeremy Lefroy) said. That is the real generalism. The GP is the person who is able to make a diagnosis because they have known the patient linearly over many years. However, GPs are on their knees and that is a UK-wide problem. They are under huge pressure because of the demand and the complexity. Within that, of course, we must talk about the lack of mental health services. They have been ignored for a long time, but that is beginning to change. In Scotland, we have a waiting time target for child and adolescent mental health services. Unfortunately, it is proving very challenging to meet that target, but we have doubled the number of staff in those services and we hope eventually to see improvements.

We need to be looking at these issues more broadly. The hon. Member for Oldham East and Saddleworth (Debbie Abrahams) and I—I am not very good at learning constituencies that have two names; I find one name a challenge with 650 people here—are members of the all-party parliamentary group on health in all policies. We have been taking evidence on the health impacts of increasing child poverty, of which we are going to see even more. We need to recognise that every decision we make feeds into whether our citizens are healthier, physically and mentally, or less healthy. That is about welfare. It is particularly about housing, which has one of the biggest impacts on health. The hon. Member for Stafford mentioned those impacts in our debate yesterday on supported care. If we lose supported care in the community, we are never going to get people out of hospital. I want to make the plea, as I did in my maiden speech, that we in this place should put health and wellbeing—meaning mental health—across all our policies and measure our decisions against those factors. Far too many decisions are made in a broken up, narrow way without looking at the ramifications for everything else.