Hospice Funding

Rachael Maskell Excerpts

Monday 22nd April 2024 Commons Chamber

[Rachael Maskell (York Central) (Lab/Co-op)]

I congratulate everyone who has spoken in the debate. The House has come together to highlight something that I am struggling with: when people are at their most vulnerable, they are having to beg for money to fund important services. That should not be the case, yet here we are with an NHS that is clearly not functioning and other services are also feeling the pain. The reorganisation of the NHS devolved powers to ICBs, but we must remember that it is the responsibility of the Government to ensure that the structures function. That is not happening at the moment, and our constituents are losing out. A word that keeps echoing in my mind, rolling off our lips as it always does, is the NHS: the “national” health service. Yet we are hearing about a postcode lottery, where different areas have different experiences, with different ICBs funding to different tunes and where you live accounts for how you die. Surely, we are better than that? In the words of one clinician about the extraordinary provision at St Leonard’s Hospice in York:

“Having worked with people at the end of life through my career, I didn’t know care like that was possible.”

However, as with all hospices, if funding is not addressed, such care will not be possible.

It was this Parliament that inferred the duty, through the Health and Care Act 2022, to address the inequality in access to palliative and end of life care, so that everyone can have the best clinical and holistic support possible, if the right funding is stabilised and put in place. Currently, however, we know that many people—Hospice UK says one in four—are not accessing palliative care. That is 150,000 people every year who die without the support they require. That number is set to rise 25% by 2048 and, according to Marie Curie, by 13% in the next decade. This debate cannot just be about what happens now, but what happens in the future.

In York, the hospice ran an £800,000 deficit last year. The hospice at home funding has remained static for the past seven years, while demand has doubled and the ICB has provided just a 1.2% increase. Sue Ryder believes that the real cost increase over the past year was 10%. Hospice UK figures released say there has been an 11% increase for the payroll this year to around £130 million. Martin House, the local children’s hospice, costs £9.9 million to run. With a total income of £8.6 million, it had a £1.3 million deficit. Only 18% of its funding came from the statutory sources, £1.1 million came from the national children’s hospice grant and £700,000 came from the ICB. Hospice UK estimates a £77 million deficit for the financial year just past—the worst for 20 years.

As demand and costs are rising, the funding is not rising to match. As of 12 April 2024, St Leonard’s hospice in York did not know how much money it was getting from the ICB: left to carry all the risk and left to depend on its reserves, and that, of course, not guaranteed for the future. Martin House, which is also using its reserves to expand its services, knows that it will have only six months of reserves. It certainly does not know what is happening with its funding after this financial year.

The children’s sector, yes, has received a grant, but what comes next? We cannot just run our hospices by running marathons and running charity shops. It is driving inequality. In areas of greater deprivation, fundraising is even harder and therefore the hospices are getting even less money.

[Ms Rimmer]

I thank my hon. Friend for giving way and I thank the hon. Member for Hastings and Rye (Sally-Ann Hart) for securing the debate. It has been a wonderful and sincere debate, but does my hon. Friend agree that there should be more equality between care at home—hospice at home—and care at the hospice? There is no doubt that there is nothing better than care in a hospice—absolutely no doubt. I have nursed four members of my family at end of life, and getting clinical support at home when it was needed was always a problem—my brother had to search for morphine at night. Does she agree that staff are funded even less and are on the minimum wage?

[Rachael Maskell]

I am really grateful to my hon. Friend for raising those points and I will come on to the issue of hospice at home. We know it is absolutely vital that people can choose where they die. Not everyone wants to die in a clinical setting—indeed, a hospice is barely a clinical setting—but many choose to die at home and they should be able to receive the care they need. She is right. We must have integration with the rest of the NHS. A district nurse may not be able to push palliative care to the extent that a palliative care specialist would in providing pain relief and the support somebody needs at the end of life at home. We need it to be timely and we need to ensure it is fully funded. The Health and Social Care Committee found that when it visited Royal Trinity hospice, as part its assisted dying inquiry. The point was made that we need to ensure we have the training so that clinicians have the competencies and the confidence to administer the pain relief and the palliative care that is necessary, and to ensure that the service is available universally. It is not and that must be addressed.

In York, of the 1,000 people who benefited from St Leonard’s hospice last year, 50% received hospice care at home. That number will grow over time and we need to ensure those services are there as they are needed. Of course, we know that if people are not on that pathway they end up in the acute service. They are put through the trauma of A&E, costing the NHS goodness knows how much, and then they do not get the care they need. Trinity Hospice talked about what it was doing to divert people away from that pathway and into proper care, either at home or within its wider services. There is much still to secure on that front.

If I may, Mr Deputy Speaker, I will raise just one more major point before I close, which relates to inequality. We know there is real inequality at the end of people’s lives. Some of it is based along socioeconomic lines, and some of it is emphasised within minority communities. We need to deal with that to ensure we have universal provision, address the death literacy of our nation, and ensure the support is there when it is needed. I am particularly concerned about the lack of comprehensive funding for our palliative care services.

I urge the Minister to look at funding staffing costs, which are 69% of all funding. It has been suggested by Marie Curie that 70% of funding come from the state, and I think that is about right. We can phase that in, but we need to ensure we address the inequality that is driven through the system. We need to put in the research that is needed, so there is better data on who is accessing care and who is not, and we need to ensure that we are pushing palliative care as far as we can. If we do not, and we debate assisted dying, I am worried that people will be fearful that they will not be able to access the care that could be possible should that service be properly funded. I really urge the Minister to make that a priority before that debate takes place. Mr Deputy Speaker, I will end on that point.

[Several hon. Members rose—]

Tobacco and Vapes Bill

Rachael Maskell Excerpts

2nd reading
Tuesday 16th April 2024 Commons Chamber

[Alex Cunningham (Stockton North) (Lab)]

rose—

[Rachael Maskell (York Central) (Lab/Co-op)]

rose—

[Victoria Atkins]

I am going to make some progress and then I will give way.

As I have said, the tobacco industry questions the necessity of the Bill on the grounds that smoking rates are already falling. It is absolutely correct that smoking rates are down, but as I said, there is nothing inevitable about that. Smoking remains the largest preventable cause of death, disability and ill health. In England alone, creating a smoke-free generation could prevent almost half a million cases of heart disease, stroke, lung cancer and other deadly diseases by the turn of the century, increasing thousands of people’s quality of life and reducing pressure on our NHS. An independent review has found that if we stand by and do nothing, nearly half a million more people will die from smoking by the end of this decade. We must therefore ask what place this addiction has in our society, and we are not the only ones to ask that question of ourselves. We know that our policy of creating a smoke-free generation is supported by the majority of retailers, and by about 70% of the public.

The economic case for creating a smoke-free generation is also profound. Each year smoking costs our economy a minimum of £17 billion, which is far more than the £10 billion of tax revenue that it attracts. It costs the average smoker £2,500 a year—money that those people could spend on other goods and services or put towards buying a new car or home. It costs our entire economy by stalling productivity and driving economic inactivity, to the extent that the damage caused by smoking accounts for almost 7p in every £1 of income tax we pay. As Conservatives we are committed to reducing the tax burden on hard-working people and improving the productivity of the state, which is why this Government have cut the double taxation on work not once but twice, giving our hard-working constituents a £900 average tax cut. That is a moral and principled approach.

Having celebrated the first 75 years of the NHS last year, I am determined to reform it to make it faster, simpler and fairer for the next 75 years, and part of that productivity work involves recognising that we must reduce the single most preventable cause of ill health, disability and death in the UK. This reform will benefit not just our children but anyone who may be affected by passive smoking, and, indeed, future taxpayers whose hard-earned income helps to fund our health service. Today we are taking a historic step in that direction. Creating a smoke-free generation could deliver productivity gains of £16 billion by 2056. It will prevent illness and promote good health, help people to get into work and drive economic growth, all the while reducing pressure on the NHS.

--- Later in debate ---

[Victoria Atkins]

I have already taken an intervention from the hon. Member for North Antrim (Ian Paisley). I will take one more, from the hon. Member for York Central (Rachael Maskell), and then I will make some progress—although I will give way to my hon. Friend the Member for Dartford (Gareth Johnson) in a moment.

[Rachael Maskell]

The Secretary of State has talked about addiction to nicotine. If, as she has suggested, vaping is a pathway to stopping smoking, why does she not envisage a vape-free generation arriving in parallel with a smoke-free generation, so that we can have a nicotine-free generation across the board? Why does she not expand her legislation to ensure that young people take up neither smoking nor vaping?

[Victoria Atkins]

The House has already legislated to ensure that vapes cannot be sold to people under 18. However, as we are seeing in our local shops, the vaping industry is finding ways of marketing its products that seem designed for younger minds and younger preferences. Once the Bill has been passed, that age limit will be maintained for vaping but, importantly, from January 2027 onwards we will not see the sale of legal cigarettes or tobacco to those aged 18 or less.

--- Later in debate ---

[Rachael Maskell (York Central) (Lab/Co-op)]

Let me first put on record that I worked in respiratory medicine for 20 years before coming to this place, and every single patient I treated regretted being where he or she was. Let me also put on record my thanks to Javed Khan for his excellent report. It is important for us to follow the science and the facts in this debate, and to ensure that we take the harm reduction approach that is so necessary.

The Bill is both bold and the right thing to do. Smoking kills one person every five minutes in the UK, and kills 7.69 million people globally every year. It is a leading cause of preventable death and disability and is responsible for one in four cancer deaths, alongside heart and circulatory diseases and strokes. We must do everything we can to prevent the tobacco industry from exploiting another generation to max out its profits, leaving people financially impoverished and in poor physical health.

Public health teams need the resources that are necessary to support adults into a smoke-free future, and I echo what the hon. Member for Dewsbury (Mark Eastwood) said: we need a focus on resourcing to achieve that. In my constituency 9,100 people continue to smoke, and they deserve better. We need a targeted approach, because passive smoking is still costly to people’s lives. We know that smoking in pregnancy is harmful to the unborn; we also know that it targets the very poorest in our society, driving greater health inequalities, and affecting people with mental health conditions as well. It is urgent, indeed imperative, for the Government to turn their attention to addressing the inequalities that are seen in all areas of healthcare.

Let me now turn to the issue of vaping. York’s schools survey showed that 19 % of children had tried vaping, while 5% in the city vaped regularly. Schools are battling to stamp out the practice. While much of the detail in the Bill will be set out in secondary legislation, I urge the Government to go toe to toe with the approach taken on tobacco products: plain packaging, health warnings, and no designer products, attractive flavours, descriptions or colours. When it comes to sales, the approach should be no less stringent, putting products out of sight and out of mind. The aim must be to create a vape-free generation too. I urge Ministers to address the reasons why Gen Z have turned to vaping on a large scale, to develop the interventions that are needed to help them make better choices, and to expose the blatant exploitation by vape companies that profit from the creation of a new generation of addicts. We are yet to know the extent of the translation of non-nicotine vaping to nicotine-based products, but researchers are examining the relationship between vaping and moving on to tobacco products, and it is extremely worrying. Clearly, the industry has worked out the correlation. To profit, it needs the next generation to be addicted to its goods—to nicotine—so non-nicotine vapes must be seen as the first step for those moving into forms of nicotine addiction.

Where I believe the Bill falls short is in its approach to adults taking up vaping. As the Minister recognises, vapes are seen as an important public health measure to stop smoking, so there must be greater ambition to prevent people over 18, as well as those under 18, from starting vaping, yet the Bill is silent on that. We know that vapes are not harm free, and I urge the Minister to broaden her ambition for a nicotine-free generation by instituting vaping cessation programmes through a public health model.

Where people are allowed to vape should be no different from where they can smoke. Indeed, people who already have poor respiratory health are impacted by vaping. Therefore, let us make things simple by introducing one set of rules for public places such as bars and so on, and for private vehicles where they are children..

May I urge the Minister to look again at the enforcement proposals? I support investment in strengthening local authorities’ trading standards teams. The team in York have just seized 1,000 vapes, worth £13,000. They need funding and the tools to do their work. I question the paucity of the fixed penalty notice, which is just £100. This is not a sufficient deterrent for illegal traders, and I urge the Government to increase the amount and review it annually. Placing that in secondary legislation would enable more flexibility.

That takes me to my last point about where I believe the legislation falls short. A vaping company came before the Health and Social Care Committee. It promoted its products through a relationship with Blackburn Rovers. The arguments it used for doing so mirrored those that the tobacco industry has propagated for decades. We saw right through them—we tested their reasoning and they failed at every turn. There must be an outright ban on all forms of vaping advertising for nicotine and non-nicotine products, and it should be no less stringent than the ban on tobacco advertising. We must legislate for a complete advertising ban, and I trust that the Minister will look at that when bringing the Bill into Committee.

The reason why I sound the warning bells is that the limitation on the available science does not mean that there is none. The Health and Social Care Committee has met academics at the University of London who have undertaken a study of 3,500 samples of tissue to show that vaping can cause changes in epithelial cells in the oral cavity. They want to look at lung tissue, but access is available only via a bronchoscopy. They observed DNA methylation changes, which provide a very early indication that cells will grow more quickly and are biomarkers for early identification of the onset of disease, such as cancer. In researching the impact of smoking on tobacco users, the researchers have also demonstrated the impact of vaping. This powerful, peer-reviewed research is the first of its kind. I urge the Minister to read the paper by Professor Martin Weschwendler and Dr Chiara Herzog.

Smoking kills, and while vaping may be less harmful than smoking, it is not without significant risk. We cannot use ignorance—the excuse used by past Governments—as a reason for getting this wrong. We must follow the science, be on our guard and recognise that where people are being exploited, it is the duty of this Parliament to protect them. This industry is driven by a profit motive—one of exploitation. It is our job to protect our constituents.

Oral Answers to Questions

Rachael Maskell Excerpts

Tuesday 5th March 2024 Commons Chamber

[Dame Andrea Leadsom]

I have had a number of meetings with my hon. Friend and know that he is determined to resolve some of these long-standing issues in his constituency. I have assured him that ICBs have the freedom to increase capital for primary care in their region, so long as their plans remain within their overall capital allocation. I will certainly be happy to meet him again to talk about what more measures we can take to support his constituents.

[Rachael Maskell (York Central) (Lab/Co-op)]

T4. I held my first dental summit since the publication of the Government’s dental recovery plan, which I have to say was met with disappointment and frustration. The reason for that is that is not enough funding or flexibility, or the resolution to the contract. Will the Minister set out the timetable for when the dental contract will be resolved?

[Dame Andrea Leadsom]

I am very surprised and disappointed to hear the hon. Lady say that. We are delivering 2.5 million more appointments through the new patient premium, which started last Friday. We will have information within a month to see which dentists have taken up this generous new patient premium to ensure that many more people get access to dentistry. Not only that, but we have golden hellos to attract dentists to areas that are underserved, mobile dental vans and, importantly, a new focus on Smile4life. That is going to ensure that all babies and young children have that fabulous smile for life.

NHS Dentistry: Recovery and Reform

Rachael Maskell Excerpts

Wednesday 7th February 2024 Commons Chamber

[Victoria Atkins]

We have focused this plan on introducing the new patient premium—a bonus for new patients. Having discussed this carefully with professionals, we think that is one way that we can incentivise people into NHS practice. Dentists can already work up to 104% of the contract. Many do that, but some sadly do not, so we are trying to encourage those dentists who already have NHS contracts to go the extra mile and use the full slot available to them.

[Rachael Maskell (York Central) (Lab/Co-op)]

The Health and Social Care Committee took months gathering evidence and putting together a recovery plan, which the Government should have adopted. Dentists wanted that plan put in place. Central to it was reform of the NHS dental contract. However, the Secretary of State has completely failed to even mention reform of that contract. As a result, dentistry in my constituency in York, where constituents are waiting seven years to see a dentist, will not have the recovery that she talks about. Why did she not adopt our plan?

[Victoria Atkins]

I hope the hon. Lady will, as usual, be the help that I expect her to be to her constituents in publicising this plan. We are getting graphics and information out to all Members of Parliament, so that they can help their constituents understand what will be available in their area, because each and every one of us wants the very best for our constituents. She will be interested in the new patient premium, which is encouraging dentists back into NHS practice, or into NHS practice for the first time, and in the increased price for units of dental activity. Reform of the dental contract is part of our agenda, but we realised that we needed to give immediate help to communities such as hers.

Physician Associates

Rachael Maskell Excerpts

Wednesday 7th February 2024 Commons Chamber

[Dr Poulter]

I completely agree with the hon. Member. He advocates strongly for his constituents, as always, and for the need to better retain our medical workforce in general, our junior doctors in particular. The Government will have heard his comments. I am sure that things can be done to improve the current offer to junior doctors in England. Indeed, things can be looked at in Northern Ireland, too, with the restoration of political arrangements.

An agreement could be put in place that will properly renumerate junior doctors, and also look at the other terms and conditions of employment that are important in respect of retaining the medical and healthcare workforce. These situations are not always about pay; it is also about wider terms and conditions. The Government could certainly look in more detail at student debt, for example, as the Times Health Commission outlined this week, which may incentivise people to stay in medicine for longer.

We have diverged slightly into the broader healthcare challenges, so I will return to physician associates, which was the point of this evening’s debate. There are concerns about the regulation and training of this particular group in the medical workforce. Physician associates and anaesthesia associates are not currently regulated. There have been a number of recent high-profile cases of patient harm as a result of being seen by medical associate professionals, including, sadly, some deaths. We know, for example, of the tragic case of Emily Chesterton from Salford who died of a pulmonary embolism having been seen twice and had her deep vein thrombosis misdiagnosed as a musculoskeletal problem by a physician associate at her local GP practice.

Anybody who watches the TV programme “24 Hours in A&E” may have seen some fairly enlightening scenes in respect of the clinical skills of some medical associate professionals, including physician associates. There are many examples of poor clinical diagnosis and judgment, including, for example, making initial decisions to send patients with compound fractures home without an X-ray when the patient actually required surgery.

In my own clinical practice, I have worked alongside some very competent physician associates, but there is a high degree of variability in their training and skills. Only last year, I was forced to directly intervene to prevent patient harm following a paracetamol overdose by a patient who attended A&E. The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose. Of course, at that time, the patient’s liver function tests were normal, but they would not have been for very long. The consequences of that diagnostic decision by the physician associate could have been fatal. The key issue for me is that many physician associates do not know or have the self-awareness to understand the limits of their knowledge and practice, but this is perhaps understandable in a health system that fails to adequately regulate and indeed define its scope of practice.

There are many other areas of concern that have been highlighted in a recent British Medical Association survey of 18,000 doctors, an overwhelming majority of whom work with physician associates. In November 2023, due to severe concerns around patient safety, the BMA called a halt to the recruitment of medical associate professionals to allow proper time for the extent of patient safety claims to be investigated and the scope of the role to be considered.

When the physician associate role was introduced, it was clearly seen as part of the solution to a shortage of doctors, which currently stands at in excess of 8,500. By freeing up doctors from administrative tasks and minor clinical roles, it allowed them to see more complex patients and get the training required to become excellent consultants or GPs.

Unfortunately, physician associates and anaesthesia assistants have been employed in the NHS in roles that stretch far beyond that original remit, and in many cases that were reported in the recent BMA survey that I mentioned, they appear to be working well beyond their competence. That has raised serious patient safety concerns—I gave some examples earlier—and led to calls to review the role, limit the scope of practice, and protect training for the doctors that the NHS desperately needs. When consultant time is taken by supervising physician associates, that is to the detriment of training and supervising junior doctors. That has not yet been addressed or even considered in the NHS England workforce plan.

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful to the hon. Member for introducing this evening’s debate. I sat on the Committee that considered the Anaesthesia Associates and Physician Associates Order 2024. He is drawing out several issues. One is competency; another is patient literacy. A lot of new roles are emerging—technicians, assistants, associates, and advanced practitioners—and to the public this is now becoming a blurred space. People do not understand the competences that individuals possess, their scope of practice, and where they fit into the medical family, or indeed professions allied to health. Does he agree that we need to define those roles clearly, and that associate roles should be around professions allied to health, rather than associated directly with the medical profession?

[Dr Poulter]

I fully agree with the hon. Lady, and I will expand on that a little later. There is certainly confusion among the public about what a physician associate is. Many members of the public assume them to be doctors or other healthcare professionals. They therefore lack a much greater degree of competence. Given that it is envisaged that the role will be significantly expanded, the public understanding and awareness of it, and people’s expectations when being treated by somebody in that role, are really important. That needs to be better addressed through the current proposals for regulation, which I will come to in a moment.

I will talk briefly about general practice and the additional roles reimbursement scheme. Through the ARRS, the Government have provided funding to GP practices that can be used to pay for physician associates and other clinical staff, but not for hiring additional doctors and nurses. That is quite extraordinary, and results in GP practices having physician associates rather than fully qualified GPs. Currently, most physician associates in general practice are funded through the additional roles reimbursement scheme: an NHS scheme that funds primary care networks to support recruitment across a very limited set of eligible roles. The current rules for ARRS funding are causing inefficiencies as they are not flexible enough to respond to locality needs for healthcare staff. In particular, the rules do not allow practices to hire primary care nurses, practice nurses, or indeed GPs, as I mentioned.

Over the past year, there have been many developments in how the Government and the profession view the roles of physician and anaesthesia associates, but it seems extraordinary that when we are talking about supporting general practice in developing the right skills and competences, and delivering the right service for patients, one of the key funding schemes does not allow for the hiring of the GPs and practice nurses that are needed, and is skewed towards physician associates. I wonder whether the Minister might take that away, look at the scheme, and help to provide additional flexibility, which general practice would like and which seems eminently sensible, to allow recruitment at a local level, in line with patient need.

There are significant concerns connected with the roll-out of the anaesthesia associates project. While the GMC addressed some of those issues in its recent letter to NHS England, a number of concerns remain. In particular, the NHS long-term workforce plan suddenly projected a huge expansion in the number of anaesthesia associates, but no expansion in the number of doctors in anaesthesia—or, as we are talking about position assessments, in the number of doctors in other specialities. To many, that looks like a replacement of doctors with anaesthesia associates, rather than anaesthesia associates being employed to complement the anaesthesia team, which was the idea previously portrayed.

There are many examples of medical associate professionals in the wider sense working in ways that have caused concern, as we have discussed in this debate, particularly with regard to their scope of practice. Anaesthesia provision in the UK must continue to be led and delivered by doctors, who are properly trained and properly regulated. Anaesthesia associates are valuable members of the anaesthesia team in addition to doctors, but they are not a solution to the challenges of low workforce numbers in anaesthesia and growing waiting lists.

The answer is to expand consultant numbers, an expansion in training scheme places for doctors in anaesthesia, and the development of the large number of speciality doctors and locally employed doctors already in post. Creation of speciality and specialist doctors and consultants via the General Medical Council’s new portfolio pathway could result in our having many more independent doctors in anaesthesia and other medical disciplines. It seems extraordinary that we are not looking at that first, given that we have a properly regulated and properly trained profession, rather than at expanding a workforce that is not subject to proper regulation to date, does not have a certified training pathway, and has been associated with a significant number of adverse patient outcomes and incidents.

Regulation ensures consistent standards for training, and for the practice of physician associates and anaesthesia associates. It maintains standards and, critically, contributes to patient safety. As per the recent Anaesthesia Associates and Physician Associates Order 2024 laid before the UK and Scottish Parliaments, those associates will be registered with the General Medical Council. However, there are increasing concerns that that could further blur the distinction between doctors and anaesthesia associates.

In response to those concerns, the GMC has said that physician associates and anaesthesia associates will be issued with a registration number format that distinguishes them from doctors. That is to be welcomed. However, it must go further and present doctors on a separate register from physician associates and anaesthesia associates, whether we are talking about a register online or in print—that aligns with the point that the hon. Member for York Central (Rachael Maskell) made—so that it is very clear that the different professions are regulated under separate registers. That is important for both accountability and transparency, and it is important that patients understand that.

There should be a clear distinction between the register of doctors and other registers. That is necessary to provide absolute clarity for patients and others who wish to access the registers, and it is essential to protect everyone from accidental or deliberate misrepresentation. With modern information technology systems, there is no legitimate reason why that cannot be done. It would be simple, and it is about transparency, openness and patients better understanding the difference between the responsibilities of doctors, and those of physician associates and anaesthesia associates. I hope the GMC is listening to this debate and will ensure properly separate registers. That does not cost much, but is very important.

Perhaps the crucial point in this debate is the scope of practice. There should be a national scope of practice for physician associates and anaesthesia associates, both on qualification and after any post-qualification extension of practice. Any future changes to scope of practice should be developed in conjunction with the regulator and should be agreed at national level. I understand that currently the GMC will not regulate extended scopes of practice, which is very regrettable. For example, we are aware of whether a doctor is on the GP register or a specialist register, or just has a licence to practise. Those levels of expertise are part of the regulatory framework. It seems extraordinary that although the GMC has been asked to look at regulating physician associates, there is no understanding of the scope of a physician associate’s practice. That needs to be properly mapped out and explored.

[Rachael Maskell]

I am grateful to the hon. Gentleman for making those points. It is particularly concerning that a prescribing nurse, say, could become a physician associate, but perhaps without the ability to prescribe. That would create even greater confusion. Does he agree that we need clarity and distinctions to be drawn on those kinds of issues?

[Dr Poulter]

I fully agree; the hon. Lady is absolutely right. I was going to address that very point about prescribers a little later. There is clear agreement on the challenges. Those issues should be thought through before a workforce plan is brought forward, and before there is a significant expansion of the workforce, for reasons of patient safety, particularly as concerns have consistently been raised about the scope of practice and adverse incidents. It is rather putting the cart before the horse to say, “We want to expand the workforce without dealing with the important issues of how that workforce is trained, how it can properly be regulated, and what its scope of practice is.” That is unfortunately a regrettable failing of NHS England’s plan, which I hope it will consider.

If the GMC cannot regulate extended scopes of practice, they should be devised according to a national framework. There needs to be an understanding of what that should be. It is unacceptable for employing organisations in the NHS to devise their own extended scopes of practice without reference to at least some national framework—one that has the confidence of regulators and standard setters—so that we know and understand what good practice looks like.

Doctors should be directly involved in devising any changes to the scope of physician associate and anaesthesia associate practice, whether on qualification or at extended level. There should be no extension of roles beyond the scope of practice on qualification until national guidance is issued. Where organisations are planning such an extension, it should be paused for reasons of patient safety. Where physician associates or anaesthesia associates are already working in an extended role, it should be recorded on the healthcare organisation’s risk register, and the organisation should ensure that it has full confidence in its standards of supervision, access to support, indemnity of the anaesthesia or physician associate and the supervising doctor, and patient information and consent. Anaesthesia associates have a role to play as part of the wider anaesthesia team, but it is important to ensure that it is a complementary role as an addition to the workforce, not as a replacement for doctors and nurses, as the hon. Lady rightly underlined. Expansion in the number of anaesthesia and physician associates should not be at the expense of expansion in the number of doctors in specialist posts.

Let me come briefly to assessment, which is another area that has not been well thought through. It is important that assessment for anaesthesia associate roles is standardised at national level. The Royal College of Physicians does a national exam for physician associates, but a national body needs to be established to undertake the assessment process for anaesthesia associates if we are to ensure confidence in their competencies. It may be possible for that to be delivered locally, if there are stringent controls in place to ensure consistency. However, before the anaesthesia associate workforce is expanded, there needs to be some process for assessing competency.

On indemnity, which was also addressed by the hon. Lady, further information is needed around indemnity cover for both physician associates and anaesthesia associates, as well as for any doctors supervising them. “Good medical practice” expects all doctors to ensure that they are fully indemnified. The same standard should apply to physician associates and anaesthesia associates. Many doctors in anaesthesia, in general practice and in emergency departments are already worried about medicolegal liability when working with physician associates, and clear guidance is urgently needed. Although reference is made to accountability, more information is required in this area, given the challenges that we know have arisen.

The hon. Lady mentioned prescribing rights. Some physician and anaesthesia associates—for example, those with a nursing background—may already have those rights from their parent profession. The Commission on Human Medicines is responsible for deciding which professions are able to prescribe, and it is important that it is clear in its guidance and reasoning in respect of physician and anaesthesia associates before there is a wider roll-out of those roles.

I draw the Minister’s attention to key findings from the British Medical Association’s recent survey, which sought the views of over 18,000 doctors about the role of the medical associate professions. Almost 80% of respondents—that is well in excess of 15,000 doctors—had worked with or trained medical associate professionals, which means that contact with those professionals is widespread throughout the NHS. Medical associate professionals are currently unregulated and have a poorly defined scope of practice. The BMA survey respondents were very concerned about that, as well as about the fact that MAPs have been employed in the NHS in a variety of roles, which go well beyond what was originally envisioned as an assistant role. A staggering 87% of doctors surveyed believed that the way that physician and anaesthesia associates work in the NHS is a risk to patient safety. For the Minister’s benefit, that is the best part of 18,000 doctors who work with this workforce raising concerns about working practice and patient safety.

[Rachael Maskell]

Once again, I am grateful to the hon. Member for giving way. Doctors in training need a very clear career pathway, but because of the rise in anaesthesia associates in particular, but also in physician associates, the pathway to many more senior roles will be blocked. As a result, people will stagnate as doctors in training, as opposed to getting a consultancy. Does he agree that that is highly problematic, and that the career pathway needs working through before there is any increase in the number of physician and anaesthesia associates?

[Dr Poulter]

That is absolutely essential. At the moment, the prerequisite appears to be a biomedical science degree, which is incredibly variable—depending on whether a person went to Hull, Newcastle or a London university, a biomedical science degree could be very different—and then two years of study. A physician associate would then have to pass an exam set by the Royal College of Physicians, but when a person passes that exam, it does not necessarily mean that they had standardised or good training; potentially, it just means that they prepared well to pass their exam. The difference with doctors in medical school—and indeed the difference with nurses going through nursing school—is that they are consistently assessed, all the way through their undergraduate training. When they graduate at the end of that training, they are consistently assessed as they progress.

None of that exists in the training pathway for physician or anaesthesia associates; in fact, as we have discussed, there is not even an exam for anaesthesia associates at the end of the process. It is absolutely essential that those issues are addressed as a priority, and it is little wonder that patient deaths and adverse incidents are occurring on such a scale. Perhaps when the Minister is suffering from insomnia late at night, he may wish to watch old episodes of “24 Hours in A&E”. He will see the huge variability in the expertise of physician associates. Some are very good, but some are not, and we should not be dealing with variability in the British health system. That is what we are trying to address, so the hon. Member for York Central is absolutely right in everything she has said.

That highlights the last point I am going to draw to the House’s attention from the BMA survey of 18,000 doctors. Some 75% of respondents said that the quality of training among medical associate professions—physician and anaesthesia associates—was woefully inadequate; 84% said that the quality of their supervision when they are at work was inadequate; 91% outlined the fact that they work outside their competence; and 86% of respondents confirmed that the public would confuse them with doctors, as the hon. Lady outlined. This is not just a few hundred doctors; this is 18,000 doctors saying in a survey that they have serious patient safety concerns due to the variability in training of anaesthesia associates. There have been far too many adverse incidents where things have gone wrong, and it is time for the Government to give NHS England some clear direction that this area needs to be looked at, and some proper planning and consideration of the expansion of this workforce put in place.

These are the asks I have of my right hon. Friend the Minister. First, we should ensure there is a standardised and quality assured training programme for physician associates, anaesthesia associates, surgical care practitioners and all other medical associate professionals, and indeed that there is ongoing training and supervision to a nationally standardised level when that group is in the workplace post qualification. Secondly, we should ensure that the General Medical Council sets up a register for the regulation of medical associate professionals, separate from the register for doctors. Thirdly, as is the case with all other healthcare professionals, we should ensure that the scope of practice of physician associates is clearly set out to make sure that we can develop appropriate training pathways and supervisory pathways, but, more importantly, to ensure patient safety. Finally, the Government should support the introduction of a system with greater flexibility to hire GPs and general practice nurses using the ARRS funding. I thank the House, and I look forward to the Minister’s response.

--- Later in debate ---

[Andrew Stephenson]

My hon. Friend makes a valid point, and that is one reason why regulation is so important. The GMC has assured me that although draft regulations are out there, it will be consulting further on them later this year, so my hon. Friend, the BMA and various others can make strong representations about how the training framework should be provided. With that introductory regulation, the GMC will be responsible for setting, owning and maintaining a shared outcomes framework for physician associates, which will set a combination of professional and clinical outcomes. The outcomes framework will help to establish and maintain consistency, embed flexibility, and establish principles and expectations to support career development and lifelong learning. While at the moment there is significant variability in the system, I hope that the regulations we passed in this House on 17 January will help to provide that clarity and give the GMC the powers it needs to ensure that the training provided to physician associates is of the appropriate quality for the roles we are expecting them to undertake in our NHS.

Physician associates can work autonomously with appropriate support, but always under the supervision of a fully trained and experienced doctor. As with any regulated profession, an individual’s scope of practice is determined by their experience and training, and will normally expand as they spend longer in the role. That must be coupled with appropriate local governance arrangements to ensure that healthcare professionals only carry out tasks that they have received the necessary training to perform. Statutory regulation is an important part of ensuring patient safety, but that is also achieved through robust clinical governance processes within healthcare organisations, which are required to have systems of oversight and supervision for their staff.

NHS England is working with the relevant professional colleges and regulators, to ensure that the use of associate roles is expanded safely and effectively. That includes working with the GMC, royal colleges and other stakeholders to develop appropriate curriculums, core capabilities and career frameworks, standards for continual professional development, assessment and appraisal, and supervision guidance for anaesthetist and physician associates. NHS England will also work with colleges, doctors’ representative organisations, AAs and PAs to identify areas of concern. Specifically, the NHS has committed to working with the Academy of Medical Royal Colleges and individual professional bodies to develop and implement recommendations as a result.

Regulation will give the GMC responsibility and oversight of AAs and PAs, in addition to doctors, allowing it to take a holistic approach to education, training and standards. That will enable a more coherent and co-ordinated approach to regulation and, by making it easier for employers, patients and the public to understand the relationship between the roles of associates and doctors, help to embed such roles in the workforce. Indeed, regulation addresses many of the concerns that we have heard in the debate last month and today. The GMC will set standards of practice, education and training and operate the fitness to practice procedures, ensuring that PAs meet the right standards and can be held to account if serious concerns are raised. GMC guidance sets out the principles and standards expected of all its registrants, and that will apply to PAs once regulation commences. Those standards will give assurance that PA students have demonstrated the core knowledge, skills and professional and ethical behaviours necessary to work safely and competently in their areas of practice and in a care context as newly qualified practitioners.

[Rachael Maskell]

On that point, can the Minister clarify where the liability will sit if error does occur? Will it sit with the clinician or the consultant who is supervising them? I am not clear on that particular issue.

[Andrew Stephenson]

In many ways, it will be the same as with many medical professionals. Once we have the situation clarified in regulation, it will not be any different from the personal liability of a doctor or others working in an organisation. Those are the kind of things that the GMC will be consulting on and discussing with stakeholders in the coming months, and is important that all these points are clarified. The hon. Lady was in the debate we had in January, where the tragic case of Emily Chesterton was raised. In that case, unfortunately we saw a PA move from one practice to work in another, and we need to ensure that there is a proper, robust fitness-to-practice regime so that any medical professional can be held to account in such cases for what has happened and, if necessary, struck off the register and no longer able to practice.

Oral Answers to Questions

Rachael Maskell Excerpts

Tuesday 23rd January 2024 Commons Chamber

[Giles Watling (Clacton) (Con)]

7. What recent steps she has taken to increase capacity in NHS dental care.

[Rachael Maskell (York Central) (Lab/Co-op)]

18. What progress she has made on introducing a dentistry recovery plan.

[The Parliamentary Under-Secretary of State for Health and Social Care (Dame Andrea Leadsom)]

I am determined to ensure that everybody who needs NHS dental care can receive it. We have already implemented a package of reforms to improve access and provide fairer remuneration for dentists. That has had an effect, with 1.7 million more adults being seen, 800,000 more children being seen and a 23% increase in NHS activity in the past year. We know we need to do much more, and our dentistry recovery plan will be published shortly, setting out a big package of change.

--- Later in debate ---

[Dame Andrea Leadsom]

As my hon. Friend will know, this is a local matter, and it is for his ICB to determine whether it wishes to support the excellent pilot proposal for overseas dental students in Clacton. At the same time, it needs to ensure that its actions are compliant with current legislation and within the delegation agreement with NHS England. I have just written to my hon. Friend about that, and my letter should address his concerns, but of course I would be happy to see him again if he has any further questions.

[Rachael Maskell]

We were promised “before the summer”, we were promised “after the summer”, we were promised “before Christmas”, we were promised “soon” and now we have been promised “shortly”. The reality is that Labour has a plan and the Government have not. In York, we cannot get an NHS dentist either. Blossom Family Dental Care is just handing back its contract. My constituents have nowhere to go. What is the Minister going to do to ensure that my constituents can access NHS dentistry?

[Dame Andrea Leadsom]

As I said to the hon. Member for Oxford West and Abingdon (Layla Moran), I absolutely understand the challenge for some people. The situation has improved over the last year. Since the covid pandemic, where almost every dentist had to stop working altogether, we have not seen the recovery we want. We are putting in plans—not a paper ambition like the one Labour has put forward, but significant reforms that will enable many more people to be seen by NHS dentists. I say gently to the hon. Member for York Central (Rachael Maskell) that a recent Health Service Journal article states that Humber and North Yorkshire ICB

“have indicated in board papers that dentistry funding will be squeezed to help them balance their books.”

I encourage her to talk to her ICB about that too.

Draft Anaesthesia Associates and Physician Associates Order 2024

Rachael Maskell Excerpts

Wednesday 17th January 2024 General Committees

[Rachael Maskell (York Central) (Lab/Co-op)]

It is a pleasure to serve on the Committee, Dame Caroline. Before I begin, I declare that I was a registered professional with the Health and Care Professions Council, and worked in the NHS for 20 years before coming to this place. I was also the head of health at Unite, so I have a strong background in understanding the regulatory frameworks in the NHS.

I understand the issues that the Government are trying to resolve, given the changing nature of the NHS, the emergence of new professions, and the need to protect patients. I agree that all NHS professionals must be registered, and regulatory reform is long overdue, including for anaesthesia associates and physician associates. When Agenda for Change was piloted in 2003 and fully instituted in 2004, a job evaluation scheme was designed for this very purpose, and was overseen by the formidable Sue Hastings. However, emergent professions cannot just be add-ons to existing regulation. They required their own registers, governance and accountability, not least to ensure professional competence. The order is the first expression of that, 20 years on.

Also, the knowledge and skills framework enabled people to grow in their professional competencies and provide a higher level of care. That could lead to hybrid roles forming. I remember Alan Milburn saying at the time that the NHS career framework should enable someone to move from the role of porter to neurosurgeon—I do not know if that has ever been achieved. It is important that at every stage there is protection for the professional and, most importantly, the patient.

The reality behind the order is that the professional silos of the last 150 years or more are rapidly evolving and morphing in new ways, and the regulatory framework has to capture that and catch up. I agree that we urgently need a system of statutory regulation for anaesthesia associates and physician associates. They are working at a significant level of decision making, and they have a duty to uphold professional standards, their training must be of the highest standard, and there must be a fitness-to-practise process through which they can be called to account. I agree with my hon. Friend the Member for Bristol South that we need to ensure that that is rigorous and upholds standards, but I also welcome the fact that they may be expedited within the new system.

I have been asked whether the GMC is the right regulatory body. I understand the arguments for and against. This is where a lot of the concern comes from, which is why regulation is important. The challenge to this order is the lack of clarity about titles, roles and the competencies associated with each role. It could be argued that, for greater distinction, the HCPC, for example, is a more relevant registrant. I believe that that should have been examined further, not least as AAs and PAs are professionals allied to health and sit within the “Agenda for Change” family.

The public are nearly universally unaware of different roles in the NHS, let alone what they can or cannot do. In a clinical setting, if someone with a stethoscope around their neck calls themselves part of the medical team and they assess, diagnose and treat a patient, it will generally be assumed that they must be a doctor. I remember that when I started practising, if you were a woman, you were a nurse, and if you were a man, you were a doctor, so I certainly know that the distinctions are not always there. However, some use the title “Dr” because they hold a doctorate in another field, and that needs to be looked at. Further, there is a new lexicon of technicians, assistants, associates, advanced practitioners, and no doubt many more. I urge the Minister to find a common language so that there is simplicity and accuracy, and so the public understand the distinctions between these roles and those of the established professions.

In talking to the British Medical Association, I heard how people are now working above their competencies as AAs and PAs—carrying the consultant’s bleep, for example. That is deeply disturbing and just reinforces the public confusion over the distinct identity and purpose of each clinical role. Boundaries must be clear and distinct and, for the sake of safety, defined nationally rather than determined locally.

While the Government are very much focused on vertical integration, which can exacerbate things such as skill mix, I urge the Minister to further consider the power of horizontal integration. We have seen some, for example with advanced practitioners reaching across professional silos, and in developing a focus on primary care it could bring strong benefits. We need to ensure that new regulatory frameworks address that. The blueprint for a future professional regulation framework must account for this opportunity.

As with all professions, medicine must not be exempt from looking at how it can be reshaped. However, when someone who has had two years’ training is paid more —ironically, 35% more; Members might recall that number—and assumes more authority than a doctor of seven years’ training with a higher level of competency, there is clearly a problem in the design of the role and cause for concern. We need to look at how we can move beyond traditional silos and create skills pathways that honour professions and the level of their skills, so that competencies can be gathered, tested and examined along the way. I believe that there needs to be a full job evaluation to understand the challenges between the professions—yes, across the two core NHS pay structures—and then a clear delineation of roles. For example, senior doctors in training in anaesthetics are now in a logjam, unable to progress to a consultant post due to the rise in the redeployment of anaesthetist competencies to AAs.

The same could be said of the Government’s prioritisation of PAs over, for instance, traditional senior house officers. There is serious concern about the diagnostic skills of PAs; there have been examples of failure, as we heard so powerfully about Emily Chesterton, the daughter of the constituent of my hon. Friend the Member for Worsley and Eccles South.

These functions need serious reconsideration and tight regulation. The GMC must ensure that their scope is clearly defined and that, before further role reforms occur, there are assurances that there will be no further scope creep. Clarity of role is really important in prescribing too. Some AAs and PAs may have transitioned from professions where they were already prescribers. We need to hear from the Minister how that situation will be managed, with clear delineation.

I want to touch on the issue of liability—where responsibility lies. With registration, AAs and PAs will be autonomous practitioners, liable for their own conduct and practice. How will the regulator ensure that liability is apportioned in the right way between them and those who provide supervision? Will they receive one-to-one supervision, and how far will liability carry on to, say, the consultant or senior registrar? That is a really important issue to consider in the immediate future, not only for AAs and PAs, but for doctors and doctors in training, who must receive supervision too. We need to ensure that a new generation of doctors in training are able to receive the support that they need, and that it is not all dedicated to AAs and PAs.

Furthermore, with the envisaged rapid expansion in the number of AAs and PAs, the GMC needs to determine that supervision is safe and appropriate, and at the level required to enable people to mature into highly skilled professionals. It must also ensure that there is not a spike in fitness-to-practise cases due to lack of investment. The call from the medical profession is for us to slow down and properly evaluate and understand the consequences, seen and unforeseen.

On part 3 of the order, which concerns the register, can the Minister clarify that the associates will be on a separate register to doctors at the GMC, and that they will have their own register, as identified in article 5(2)(a)? I note that AAs and PAs will be on one register, but in separate parts. Will he explain to the Committee exactly how that will operate? Holding information separately would enable greater access for the public to the information they seek with respect to the new associate roles. The register must be robust and easy to navigate and, like the register for doctors, provide the public with all the information that they require. I know that the GMC has agreed to put a simple prefix ahead of registration numbers, but the professions are calling for more distinction so that there can be no confusion.

I am mindful of the higher proportion of cases generated from AAs and PAs. Will the Minister ensure that the registration fees reflect that? It is vital that the Government and the GMC, in formally setting up the statutory register over the coming three years, work closely with the professionals to ensure that they are engaged in the process and that their concerns are picked up and addressed along the way. I am asking the Minister to commit to that today, as I know my hon. Friend the Member for Bristol South will when she has the opportunity later in the year.

Patients, the wider public and fellow clinicians need to understand these fine lines and distinctions for their safety and safe practice across the NHS. The culture of “get it right first time” must be central to this debate and all that flows from it. If regulation lands in the wrong place, the Minister and the GMC need to be candid and ensure that it is changed so that it is fit for purpose. I trust that Parliament will have further opportunity to scrutinise these developments.

NHS Winter Update

Rachael Maskell Excerpts

Monday 8th January 2024 Commons Chamber

[Victoria Atkins]

I welcome my right hon. Friend back. I have said throughout this that I was extremely disappointed that the committee chose to walk away from discussions. I also think that there is a lot more to discuss apart from pay—I have made it clear that I would like to look at other aspects of their working conditions—but, unfortunately, the junior doctors committee walked out. The strike action has had a real-terms impact on patients. We need to find a fair and reasonable solution, but I will not do that while the junior doctors committee maintains strikes. It will have to come to the table with reasonable expectations and change their minds on the validity of strike action.

[Rachael Maskell (York Central) (Lab/Co-op)]

We have had 14 Tory winters. One would have thought that they would learn by now that the real crisis in our NHS is that social care is not up to scratch. A quarter of patients in my local hospital are waiting for social care. As a result of jamming the back door, the front door becomes inaccessible to so many patients. After all these years, when will the Secretary of State publish a proper plan for social care, or will she leave it to my right hon. Friend to take over?

[Victoria Atkins]

I am so sorry, I do not know who the hon. Lady is referring to. On the Conservatives’ plans, at the 2022 autumn statement we announced up to £7.5 billion of additional funding—an historic increase—and we did not stop there. This summer, we announced an additional £600 million, which brings it up to £8.1 billion of additional funding over two years. That will support our care workforce, and the majority of the funding will end up in the pockets of the amazing people who provide care and support to the patients we are all concerned about.

World Stroke Day

Rachael Maskell Excerpts

Thursday 23rd November 2023 Westminster Hall

[Rachael Maskell (York Central) (Lab/Co-op)]

Thank you for those kind words, Mr Hollobone. I will open by saying that I used to be a physiotherapist working in acute care, specialising in stroke care, so I bring other experience to the debate as well. I serve on the all-party parliamentary group on stroke, and I am indebted to the hon. Member for Bromley and Chislehurst (Sir Robert Neill) for securing today’s debate. We work assiduously on this issue here in Parliament, and it is so important for all our constituents. We believe there is real scope for change within the Government’s approach to help our constituents not only to prevent stroke, but to survive stroke, and to benefit from that.

As the hon. Member for Bromley and Chislehurst said, every single five minutes, somebody will experience a stroke. For some people, it will be brief—a transient ischaemic attack. For other people, it will clearly be very serious indeed, and for some people it will lead to mortality. To bring that home, during the course of the debate another 18 people will have experienced strokes. The urgency is now, and we cannot lose time. Over the course of a year, around 100,000 individuals experience stroke, but that means that 100,000 families also come into contact with the NHS. As a result, it is really important that the Government renew their focus. Although we welcome the major conditions strategy, it is simply not enough. Of course, the major conditions strategy is so major that the necessary focus needs to be brought to the fore. I suggest that we make 2024 a year of stroke, so that we really bring that focus down to deliver. If we had that focus across the system, we could make such a difference.

I will not go into all the statistics that my hon. Friend the Member for Bromley and Chislehurst did, but I just want to say that stroke is very avoidable. Of the people who experience it, 80% will have risk factors that can be controlled. We must talk about prevention. As a vice-chair of the Health and Social Care Committee, I must mention our inquiry into prevention in health and social care, which I am sure the Minister will pay much attention to. We must look at how we prevent individuals having stroke. Of course, we can undertake monitoring, for instance around blood pressure, with high blood pressure being an indicator and also atrial fibrillation. This is also about lifestyle choices; it is really important that we remember that smoking is still a major cause of stroke. We must ensure that individuals have early help, not least if there is a familial issue with stroke, to see how we can avoid that.

I also want to talk about health checks. It is really important to make those early interventions. We heard today about a 41-year-old who experienced a stroke, and one in four people who experience a stroke are under retirement age, so we must remember that it is often younger people who experience the need for this process. As a result, we should monitor people. The health checks that came in for those aged 40 are not often applied within integrated care board areas. We need a real sea change there, because monitoring things such as what is happening with blood pressure as early as we can, with really quick tests, can make a sizeable difference.

The Health and Social Care Committee has just returned from Singapore, where we heard about the early healthcare interventions being made there and, of course, saw the outcomes. If the Minister is determined to make a difference in his short time in the role before my hon. Friend the Member for Denton and Reddish (Andrew Gwynne) takes charge, introducing those interventions to monitor what is happening could be a life-changer.

I also want to highlight how we need to respond. Response is too slow, and I want to challenge the system. For ambulances, a stroke is currently a category 2 call. I would like it to be made a category 1 call and the response expedited, because every minute that passes in the golden hour can make a difference to somebody’s future and whether they will experience severe disability—or, indeed, die—or receive interventions that could prevent such disability. Changing the categorisation would save both money and lives. It is important to look at that again. It could make a difference, not least because the time lags for the ambulance service on category 1 and category 2 calls at the moment mean that categorisations are insufficient to get patients to the right place at the right time in order to get the right interventions. I hope that the Minister will take that away and carry out some work in that area to expedite the process towards diagnosis and treatment.

I turn to diagnosis. In a country like Germany, individuals are diagnosed at the kerbside, at home, or wherever they have their stroke, and the process will start immediately. At the point that the patient is experiencing deficits—perhaps they are still going through a cerebral event—or as soon as the ambulance is called, the clock starts on the diagnostic process and then treatment. Using the best diagnostic techniques to scan at the kerbside, using AI to help, we know—[Interruption.] It looks like the Minister is in some pain; perhaps he needs my physio skills.

[The Minister of State, Department of Health and Social Care (Andrew Stephenson)]

Sorry; it is my shoulder.

[Rachael Maskell]

Being able to undertake the diagnostic process really early means being able to get the information into the stroke unit of the hospital as early as possible, so that when the patient arrives at the door, they are whipped through the system and interventions can start. The problem is that we have such a time lag that intervention is often too late. Will the Minister look at what is happening on a global scale with interventions that could really make a difference?

Of course, there are two types of stroke: some people have a cerebral bleed and some have an infarct, or a blockage, where the brain is starved of oxygen. As a result, different treatments are undertaken. There is thrombolysis, which is a medical intervention to blast a clot through, and mechanical thrombectomy, which the hon. Member for Bromley and Chislehurst talked about, where a wire is fed through the femoral artery into the brain, captures the clot and withdraws it. As a result, the brain can receive the oxygen it needs so that it does not experience the damage that we have heard about.

We need to increase the specialist interventional neuroradiologist workforce. It is a highly trained specialism; we need enough of them, and a sufficient supply. We should have a workforce plan for the specialism to ensure we are training sufficiently and expanding the workforce. In other countries, there has been a real increase in the number of people able to access this treatment. As we have heard, the average across the UK is 3.3%, but in other countries it is 10%. Not all patients can benefit from this life-saving treatment, but of those who can, only about a third get access to it.

We need to think about where the centres are based. It is important that they are in major centres because doctors need to do a lot of these procedures to be expert in them. We need people to be expert in them, but we also need more centres. I ask the Minister to look at the mapping of that, and at specialist commissioning through NHS England to ensure provision right across the country. Will he also work with the ICBs in this area?

We need a specialist workforce. It is positive that we are training more people in stroke specialisms, but in physiotherapy, for example, significant further training is needed on Bobath—a technique used in stroke rehabilitation—and we need to ensure that it is easily accessible. Other professionals do not get the same access to training budgets as medics, so there is often a lag in getting people through the specialist training that is needed. I ask the Minister to look at that to ensure that the workforce is trained in the best techniques to treat stroke, and to carry that specialism.

This is all about investing to save money, because the better the intervention, the better the outcome for the patient. We need physios, occupational therapists, speech and language specialists—there is a significant shortage of them—and clinical psychologists to work as a team around the patient. They often work together. To give hon. Members an idea of how long it takes, a physio can spend an hour a day with a patient, because they have to break down and rebuild their tone and spasticity, which takes time. But as they are sitting the patient up, the speech therapist often comes along and does a swallow test, and an OT may do some function work. That team needs to come together. Unfortunately, the gaps in the workforce mean that it is hard to have the quality of treatment that will benefit the patient, from the most acute phases of the stroke right through to rehabilitation.

Of course, we want patients to go to stroke units—specialist rehabilitation places—where they can benefit from therapeutic intervention and get the best outcomes possible to optimise their baseline before they are discharged back home. Being in that environment is really important, but at the point of discharge, after all that cost—we have talked about diagnosis, intervention and therapy—what happens? Well, experiences are very varied, and 45% of survivors feel abandoned, so we know something is going wrong. Individuals can easily lose confidence and function.

If an individual is on a pathway to a care home, the care home should be properly trained in supporting people who have had a stroke. Everything matters: the person’s positioning, how they lie in bed, how they sit in a chair and how their hand rests can make a real difference to their function, and their hygiene and personal care. It is necessary to ensure that, if they are mobilising, it has an impact. How patients are transferred can make a difference to those outcomes, so it is important that a person is discharged not just to a care home, but to a care home that has undergone proper training. If someone is moving to the community, we need to ensure that the family around them are trained in how to support them, just as carers who provide domiciliary care must be.

I want to pick up on what the hon. Member for Bromley and Chislehurst said about people seeing improvements in their baseline functioning. It is possible that individuals do and will. Through the process of neuroplasticity, a person’s brain changes and can make alterations and repair, so we need to ensure that, when somebody gets home, there is ongoing therapeutic intervention. It is easy to slip into bad ways and take shortcuts, which can undo some of that good work, and those interventions to top people up can make a difference and keep people functional, mobile and independent. If people miss out on those interventions, they will rapidly require more acute care.

I draw the Minister’s attention to that and ask him to look at the whole pipeline. The lack of support is clear: only 37% of patients got their six-month check last year, which is completely insufficient. We need the figure to be 100%, so there is clearly some work for the Government to do. We are talking about 40,000 people who missed out altogether, which affects ongoing care and support. In the same way that a cancer care navigator works with patients, we need somebody who co-ordinates care and individual support on the stroke pathway, as a permanent process.

As I have already said, we have an opportunity next year to make a seismic difference to individuals by focusing on stroke. I hope that the Minister will take that opportunity, with a laser focus on a new stroke strategy across the country. If he does not, I will badger my hon. Friend the Member for Denton and Reddish to take that on, whenever he gets the first opportunity. It is important that we do that.

Finally, research in this area could be improved, and investment in research is needed. As we have seen in recent times, investment in thrombectomy has been a game changer. It gives people who experience a stroke real hope. Other interventions can and will be made: we need to understand more about our brain health, therapeutic interventions, and how to use new technologies to help people to be independent and live full and comprehensive lives. I trust that the Government will look at the research base and at investment in research as an opportunity. I trust that they will also work with the voluntary organisations that work so hard in this area—they are real experts—to ensure that we have the best stroke strategy and stroke outcomes that any country could ever have.

[Mr Philip Hollobone (in the Chair)]

No Westminster Hall debate would be complete without a contribution from Jim Shannon.

--- Later in debate ---

[Andrew Gwynne (Denton and Reddish) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Hollobone. Like others, I begin by thanking my hon. Friend—I will call him that, because we are friends—the Member for Bromley and Chislehurst (Sir Robert Neill) for securing this important debate to mark World Stroke Day. I thank him for not just his continued advocacy and the work he does here in Parliament, but sharing his personal experiences. On behalf of the whole House, we send our love to his wife and to him for the work he does to look after her.

We have had a small but perfectly formed debate. I want to thank my hon. Friend the Member for York Central (Rachael Maskell) in particular for her powerful contribution. She speaks with experience that I could only ever dream of; it is so important that her expertise, knowledge and past experiences should shape and inform the debate. I thank her for that. Likewise, I thank the hon. Member for Strangford (Jim Shannon) and the hon. Member for Motherwell and Wishaw (Marion Fellows), who leads on health issues for the SNP, for their contributions. We have had a good, thorough debate, covering a lot of issues. Hopefully we have marked World Stroke Day well in this place today.

It is stating the obvious to say that stroke can have a life-changing impact. As we have already heard, the statistics show that in the time we are here this afternoon, 14 people across the United Kingdom will have had a stroke—that is one stroke every five minutes. Although often a sudden event, the lasting impact of stroke for patients can be devastating. It is one of the leading causes of adult disability across the United Kingdom. Two thirds of stroke patients—let that sink in—will leave hospital with a permanent disability, often needing lifelong care. Sadly, stroke is often fatal, causing around 35,000 fatalities across the UK every year, making it the fourth leading cause of adult death.

What those statistics demonstrate to me is that however far we have come on the journey with stroke, we need more concerted action going forwards—not just from a patient care perspective, but given the significant impact that not acting on stroke has on the economy. There is an economic argument, not just a patient care argument.

I pay tribute to the work of the Stroke Association, which does incredible advocacy, campaigning and research in this area, as well as other organisations across the UK. Stroke Association research shows that by 2035, stroke is expected to cost the British economy £75 billion a year. That is up from £26 billion as recently as 2015—a rise of 190% in just two decades. Given the strain already on stroke pathways across our health and care system, that is simply unsustainable. The need is clear, and the need is now.

One of the issues holding us back in our fight against stroke is the workforce, as is so often the case and as we have heard today in other contributions. A well-skilled, well-resourced workforce is vital to saving lives and improving the outcomes for patients. However, for too many across the United Kingdom, the workforce is simply not there for them or not there for them in adequate numbers. Half of all stroke units across the country have at least one vacant consultancy post, with the average vacancy being left open for 18 months.

When it comes to thrombectomy—a life-changing treatment that can have a fundamental impact on patient outcomes, as the hon. Member for Bromley and Chislehurst set out—the postcode lottery for care only gets worse. A third of clinicians in this country who can perform thrombectomy are based in London. That is good for Londoners but not for other parts of the country. Given that speed of treatment is critical when it comes to long-term outcomes for strokes, this lottery facing so many people cannot be allowed to continue.

Further along the stroke treatment pathway, other issues persist. Only a quarter of community rehab teams and early supported discharge services are offering support seven days a week. That is not good enough. With patients waiting too long for treatment when they need it and too long for support in the community following treatment, it is clear that the system is broken. That is why I am proud of Labour’s firm commitments on giving our NHS the workforce it needs to get patients seen on time, by delivering an extra 7,500 medical school places, training an extra 700 district nurses each year and ensuring that at every stage of the treatment pathway stroke patients will have access to the care they need when they need it.

But there is so much more work we can do to break down the barriers that too many stroke patients face on their care journey. Breaking down those barriers will take innovation and all parts of the system to be pulling in the same direction. For stroke patients, that is exactly what is needed. Given the crucial role played by primary, acute and social care services in delivering positive, long-term outcomes for stroke patients, co-ordination is the key. However, in too many cases, that co-ordination is simply not happening, and patients are suffering as a result.

We have a primary care system with vast variety in detection of key stroke indicators, such as heart conditions, atrial fibrillation and so on. We have people not getting to the right place in hospital, with only 40% of stroke patients admitted to a stroke unit within four hours of arrival. We have a community care system without the resources it needs to deliver for patients, with the Stroke Association’s report about life after stroke highlighting that only 37% of stroke patients receive a six-month post-stroke review of their needs. It smacks of a system that is not working for anyone.

[Rachael Maskell]

My hon. Friend is making an excellent speech. When it comes to social care, people are often untrained and as a result could cause more harm than good if they do not know how to care for a patient who has had a stroke. Will he ensure that Labour discusses how it will train our care workforce to have the right skills to deliver ongoing care?

[Andrew Gwynne]

My hon. Friend makes an important point. Some of the discussions that I have had, including this week, with professionals in the care sector have been about how we upskill care professionals working in our social care system so that they are able to genuinely—in an integrated fashion, with the NHS—work in accordance with the interests of the person they are caring for and take that person’s needs as a whole. It is also important for these workers to have the professional development, and parity of esteem, terms and conditions and so on with the NHS, to be able to take on those extra responsibilities. My hon. Friend is absolutely right, and that issue is certainly on the radar of the shadow health and social care team as we develop our plans—not just Labour’s workforce plan for coming into government, but our plans on the road map to a national care service.

Whether it is by training more GPs to ease the immense pressure on our primary care system, by putting an end to dangerous hospital waits or through a 10-year plan for fundamental social care reform delivered in partnership with users and their families, Labour is determined to get the system working again. We are determined to build a national health service that is fit for the future, with a long-term vision for a national care service firmly integrated within it. Only by doing all that, getting it right and taking people with us on that journey can we deliver on our long-term mission of cutting stroke deaths by a quarter within the next decade. That is a mission. It is something we are determined to do, because at the heart of this are people’s lives and we want to ensure that we have in place the stroke services that patients deserve.

Oral Answers to Questions

Rachael Maskell Excerpts

Tuesday 17th October 2023 Commons Chamber

[Will Quince]

We will always work with my hon. Friend and the trust on capital improvements where needed, but I am pleased to note that the trust has been allocated significant investment from national programmes in recent years, which my hon. Friend fought hard for, including £32.2 million from our community diagnostic centres programme, which will provide vital testing to local residents close to home, and £3 million from our A&E upgrade programme. We will of course continue to work closely with colleagues in the NHS and the local trust to continue delivering for the people of Stockton.

[Rachael Maskell (York Central) (Lab/Co-op)]

Ten years on from the Francis report, the National Guardian’s Office—for freedom to speak up—reports that last year there were 937 cases where whistleblowers were not listened to and experienced detriment. If we add that to 170,000 complaints, with 30,000 reaching the Parliamentary and Health Service Ombudsman, we can see that the complaints system across the NHS is defensive and dangerous. Will the Secretary of State review the NHS complaints system, and embed a listening and learning culture and early intervention?

[Steve Barclay]

I discussed this with Henrietta Hughes, the patient safety champion, just yesterday as part of the sprint that we have commissioned in the Department in response to Martha’s rule. We are doing considerable work with NHSE colleagues on how we better respond to the concerns of patients, whether it is through the work on Martha’s rule or the complaints process, and a significant amount of work is ongoing as part of that.