Liverpool Care Pathway

Robert Flello Excerpts

Tuesday 8th January 2013 Westminster Hall

[Rosie Cooper (West Lancashire) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Weir. I congratulate the hon. Member for Montgomeryshire (Glyn Davies) on securing this essential and timely debate.

As hon. Members and the Minister will know, opinions on this end-of-life care framework tend to be polarised, but I believe that fundamental questions need to be answered about how the Liverpool care pathway has fallen into such disrepute, when it was developed to help doctors and nurses provide quality end-of-life care for the dying. That involves palliative care options for patients in the final hours or days of life, not a procedure that some members of the public now regard as a way prematurely to kill off the terminally ill or senior citizens.

The hon. Member for Montgomeryshire has outlined the process in which the Liverpool care pathway should work, involving significant communication if possible with the patient, but certainly with their next of kin and family. I share his support for the framework when it operates properly and allows the dying to die with dignity and free of pain. Why are there so many stories in the press of distressed families complaining that they did not know that a relative had been put on the pathway? The huge problem lies in the human application of the rules, not necessarily in the rules themselves. One in three families of those dying say that they never received the leaflet explaining the LCP process that they should have been given. Why is it not mandatory to evidence in the notes discussions with the patient or the family about the Liverpool care pathway?

Some would say that the difference between a multidisciplinary team decision, taken with the family’s knowledge and consent, and a decision taken in isolation could be seen as murder or at least manslaughter. The stark reality of the Liverpool care pathway is that 57,000 patients a year are dying without being told that efforts to keep them alive have been stopped. In some respects, there are parallels with the cases of Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust, which were supposed to be operating the same system as that in every other NHS trust in the country and yet somehow ended up abjectly failing their patients, so that people died unnecessarily. The sheer scale of the failure to inform people, or their relatives, that they are on the pathway opens up the practice to attack.

People talk about back-door euthanasia and some say that it is tantamount to assisted death, except that in 57,000 cases people were not aware that they were being assisted. That has to be added to the cocktail of the timing and the context of where we are now. The NHS is saving £20 billion over four years. There are service pressures—the lack of available beds and severe cuts in social services budgets that result in bed blocking, together with the demands of an aging society—but, frighteningly, as we have become aware via the press, at the same time hospital trusts receive financial incentives for achieving certain performance targets in putting people on the Liverpool care pathway.

Let me be clear—not for one second am I suggesting that those factors are part of the decision-making process; I use them merely to highlight the fundamental problem of the pathway and the perception that exists in the wider public, especially among the elderly.

Why do hospital trusts require any financial incentive to follow the Liverpool care pathway? For me, that question goes to the very heart of our national health service and our absolute understanding of what the medical profession stands for in people’s eyes. We believe that it is the role of the NHS and medical professionals to take every conceivable step to preserve life until the options are exhausted. The Department of Health has proposed to enshrine in the NHS constitution, as a patient right, an entitlement to be informed of any consideration about placing a patient on the Liverpool care pathway. Why can that not be made a legal requirement, so that everybody knows—and we are sure that everybody knows—and can be assured that taking such a decision is right?

[Robert Flello (Stoke-on-Trent South) (Lab)]

I add my congratulations to the hon. Member for Montgomeryshire (Glyn Davies) on securing this important debate. To go back to the hon. Lady’s point about the financial incentives for hospitals, it appals me, too. Surely, if patients or their families are not consulted, the Liverpool care pathway is not being followed, so any payment by the Department of Health to a hospital for having supposedly had someone supported by the pathway is money paid wrongfully, deceitfully and possibly unlawfully. Does she therefore agree that the Department should tell hospitals that have failed to consult family and friends or the patients themselves that the Department wants back some of that money?

[Rosie Cooper]

That takes me back to my earlier point that we should document the conversations with families, so that that would be the tick box for payments. I am running out of time, so I shall move on quickly.

Will the Minister elucidate how the NHS constitution requirement will make a difference? Procedures are already in place, yet 50% of patients on the pathway were not informed, or their families were not consulted. It is time that the soundbite, “No decision about me without me” became a principle and a value, rather than the vacuous phrase that it currently is. There is no politics in that—it is really important; it is the core of everything.

Through Lord Alton of Liverpool, I am aware that Liverpool medical school requires all its students to undertake one month’s training in the care pathway, working in a hospice during their fourth year. Such good practice should surely be a core component nationwide, and in the light of a recent study, there is perhaps an argument for making it mandatory across the country. That kind of training needs to be given to those already qualified and working on our wards—not just doctors, but nurses and all members of the multidisciplinary team who are called on to make decisions. If there have to be financial incentives, they should follow the training to ensure that all those who care for the terminally ill and dying are properly equipped with the skills that they need, in what for all concerned are traumatic and often complex situations. Good training costs money and must be externally validated, and I invite the Minister to respond specifically about that need.

I see merits in a system that manages end-of-life care effectively—it is a measure of our humanity that we seek ways to ease suffering—but my concerns about the application of the Liverpool care pathway remain. There is far too little reassurance in the system, which has allowed the pathway to move from an end-of-life care system to one that is held up as hastening death. We can talk about the theory of how the LCP should be followed, but the fact remains that, in practice, it is not always implemented as intended. It should never be seen as a conveyor belt to the cemetery. Some 80,000 patients are supported by—not put on—the Liverpool care pathway, and many receive the finest care, but many is not good enough. It is said that about 1% of cases go badly wrong, but just one case—never mind 1% of cases—is one too many. Those who founded the pathway did so because of their respect for the dignity of patients; those who implement it need to understand and share that view or face the legal consequences and their own consciences.

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[Mr Edward Leigh (Gainsborough) (Con)]

I am glad to have this opportunity and I thank my hon. Friend the Member for Montgomeryshire (Glyn Davies) for raising this important subject. We all know that the Liverpool care pathway was devised with the best of intentions. I assure my hon. Friend the Member for Banbury (Sir Tony Baldry) that none of us wants to end or take away palliative care. We all want to relieve pain and we all want people to die with dignity, but there are serious concerns about the Liverpool care pathway and that is why this debate is so important. Those concerns have been expressed by physicians. It was physicians—ethicists—who started this debate, not the newspapers. The newspapers did not start the ball rolling and we should be aware of that. Professor Peter Millard, emeritus professor of geriatrics at the university of London, and Dr Peter Hargreaves, palliative care consultant at St Luke’s cancer centre in Guildford, have warned of the risk of “backdoor euthanasia”—their words—and that economic factors are being included when treatment is considered. We must be aware of these concerns, which were originally expressed by clinicians. However, I believe that it is one of the chief duties of those of us in this House who are not clinicians to speak up in defence of the vulnerable, the voiceless and those who are sometimes forgotten.

It is simply unacceptable that vulnerable people, including the poor, the elderly and those who do not have close friends and family to look after them, come to a premature death—an unnecessarily early death. As my hon. Friend the Member for Congleton (Fiona Bruce) and others have said, in numerous cases, even friends and family caring for a loved one have not been informed that they have been put on the LCP. May I say that my hon. Friend’s speech was a wonderful speech? It drew on her personal experience and was one of the most moving speeches that I have heard in this place over many years.

I sat with my best friend, Piers Merchant, as he was dying; he was a former MP and my hon. Friend the Member for Banbury (Sir Tony Baldry) will remember him well. I saw the morphine being pumped through his body. I am sure that he died early—perhaps a few hours or even a few days early, I do not know—from the morphine. Those of us who loved him wanted him to be cared for properly, but we also did not want him, or any of our loved ones, to be put on an irreversible path to death where that was avoidable.

I welcome the statement by the Department of Health that it

“has consistently made clear that care provision, including for people at the end of life, should be based on need.”

But the question that we need to ask in this debate is this: how are the Department’s intentions implemented on the front line of medicine and hospital care? No doubt there is wonderful care being given in many hospices, but is that gold standard being replicated in all our hospitals?

It is undoubtedly true that the LCP has led to the premature death—it may not be premature by much, but it is still a premature death—of as many as 130,000 hospital patients each year. This is a vital issue that we must address in this House; with 450,000 hospital deaths in Britain each year, that figure of 130,000 is about 29% of the total number of hospital deaths. In fact, this is a frightfully serious issue.

[Robert Flello]

Will the hon. Gentleman give way?

[Mr Leigh]

Does the hon. Gentleman mind if I do not give way? I just want to make my speech and give my hon. Friend the Member for Plymouth, Sutton and Devonport (Oliver Colvile) a chance to speak too.

Professor Pullicino, who was quoted earlier, has himself personally intervened to have a patient taken off the LCP who went on to be successfully treated. So, despite the fact that we must listen to clinicians, it is simply impossible to determine satisfactorily that a patient has hours or days left to live, which is one of the worrying flaws of the LCP.

In November, an independent inquiry into the LCP was announced, and I welcome that announcement. My hon. Friend the Minister is doing his job extremely well in this regard, and we respect him as somebody who will genuinely try to get to the truth. He himself has said that there have been too many cases of patients dying on the pathway while their families were not informed, so he is quite right to zero in on that issue. He has said, “This is simply unacceptable.” I echo those words and I hope that he will repeat them when he winds up the debate.

Of course there are people who speak on both sides of this issue, but I believe that any inquiry must be conducted by a suitable variety of individuals and not just by supporters of the LCP. It is not good enough to state, as the Department of Health sometimes does, that the LCP is not euthanasia. It might not be euthanasia and, of course, if it is implemented properly it is not euthanasia. However, it has become obvious to many people that the LCP can be employed, and indeed has been employed, in cases that are highly questionable.

I say to those who have spoken today that what worries me is this: why is it that the average time to death on the LCP is 33 hours? An identical figure for average time to death was found in two consecutive national audits that were conducted two years apart. In the view of many people, that shows that the LCP has a machine-like efficiency in producing death within 33 hours, and that is why some people say that the LCP is in effect a “lethal care pathway”. Statistics suggest that fewer than 5% of patients put on the LCP are taken off it. Why only 5%? There is something wrong here, and the inquiry needs to get to the bottom of it.

I believe that we should appoint a member of the judiciary rather than a medical expert, to carry out the inquiry. Of course, they will have medical advisers, but we should appoint a member of the judiciary rather than just a medical expert to lead the inquiry, so that they can look at this complicated issue with a fresh perspective and a judicial mind.

Thank you for calling me to speak, Mr Weir. In conclusion, I believe that we have a duty to instil confidence in each of the citizens and residents of this country that they live in a society that believes in their inviolable dignity as human beings, and that takes the necessary steps to ensure that they are cared for and looked after when they are ill, especially in the closing moments of their life.

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[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Weir. I congratulate the hon. Member for Montgomeryshire (Glyn Davies) on securing this extremely important debate and on his heartfelt but calm and thoughtful opening speech, which set exactly the right tone. How we care for the dying is a measure of how we care for all sick and vulnerable people. It is a litmus test not only for the NHS and the wider care system but for society as whole.

This debate comes at an important time because, as the hon. Gentleman said, in recent months growing media attention has been paid to the Liverpool care pathway. Several Members have talked about the misconceptions and the inaccurate information that has been published about it. I have read the recent consensus statement from 22 patient and professional organisations and also the full care pathway documentation, and it is clear to me that the Liverpool care pathway is not in any way about ending someone’s life but about supporting the delivery of excellent end-of-life care.

The pathway does not seek to replace clinical judgment; it is not a treatment but a framework for good practice. It does not seek to hasten or indeed delay death, but to ensure that the right type of care is available for people in the last days or hours of life, when all the reversible possibilities for their condition have been considered. I do not believe that it is a deadly or lethal one-way street. Precisely because it is not always easy to tell whether someone is very close to death, the pathway emphasises the need for constant and regular review, and if a patient’s prognosis changes, their care needs should be reassessed and, if appropriate, the use of the pathway stopped.

The pathway does not preclude the use of clinically assisted nutrition or hydration; in fact, it explicitly states that patients will be supported to eat and drink for as long as possible. It absolutely emphasises that wherever possible patients must be involved in decisions about their care, and that carers and families should always be included in decision making. Such involvement of patients and families is enshrined at the very heart of the Liverpool care pathway.

[Robert Flello]

Does my hon. Friend agree that if there is no consultation, and there is denial of care and of treatment that eases pain, it is not the Liverpool care pathway?

[Liz Kendall]

I absolutely agree. The issue we face is less about the pathway itself and absolutely about how it is implemented in practice. The pathway document states on its very first page that the pathway is only as good as the teams who use it.

There has clearly been an issue about taking a pathway that was developed by experts in one part of the country over several years, with regular training and audit, and trying to implement it across the wider NHS. Individual patients and families—as we have heard—and also the national audit of the Liverpool care pathway, suggest that there are genuine problems with communication. Too many patients and families are not properly informed about what the pathway is and how it works, and they are not effectively involved and their consent not sought at every stage and on all the necessary decisions. One incident in which patients and families are not fully and sensitively involved is one too many. It is not acceptable, and it directly contradicts the very essence of the Liverpool care pathway and its key principles and values.

NHS Funding

Robert Flello Excerpts

Wednesday 12th December 2012 Commons Chamber

[Andy Burnham]

That is what the letter says, but it is a cut; that is what the letter says. The right hon. Gentleman might say that, in the context of the NHS budget, £1.9 billion is not very much, but it is still a change, and it is a cut. He stood for election on a manifesto promising a real-terms increase. He has just acknowledged that there has been a real-terms cut. Does he acknowledge that there has been a real-terms cut? I think he will have to. I am amazed; the Conservatives come here today to try to con the public, yet again, into thinking that they are fulfilling their promise.

[Robert Flello (Stoke-on-Trent South) (Lab)]

I enjoy every moment in which a blow is landed on the Government; they squirm and try to come back. Will my right hon. Friend comment on how much of the budget is being thrown away and wasted on top-down reorganisation, redundancy payments and everything else that is going on?

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

We need short interventions. There are a lot of Members who wish to speak. I am a little bothered by the comments made; I am sure that the right hon. Member for Leigh (Andy Burnham) did not want to suggest that the Prime Minister conned people.

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[Andy Burnham]

Yes, I have done so, Mr Deputy Speaker.

If in future any Minister mentions the NHS and real-terms increases in the same sentence at the Dispatch Box, Members on all sides will at least have the facts. Better still, by carrying our simple motion this evening, we can give the House the opportunity to make sure that Ministers take much more care than they have previously shown with their statements on NHS spending.

Let us look to the future. What does all this mean for the NHS and what effect is the Government’s cut to its budget having in the real world? In its briefing for today’s debate, the NHS Confederation refers to a survey of NHS leaders which found that a full 74% described the current financial position as “the worst they had ever experienced” or “very serious”. The reason why the Government’s cuts feel much deeper to people working in the NHS, as we heard a moment ago, is that they are contending with the added effect of a reorganisation that nobody wanted and that they pleaded with the former Secretary of State to stop.

Cuts and reorganisation are a toxic mix. According to the Government’s own figures, a full £1.6 billion has been diverted from patient care and the NHS front line and spent on back-office restructuring. Look at the waste already: a full £1 billion spent on managerial redundancies—1,300 six-figure pay-outs and, scandalously, 173 pay-outs over £200,000. [Interruption.] The Secretary of State chunters away. I am surprised he has the nerve even to be here. Such pay-outs are unforgivable and unjustifiable when patients are seeing treatment restricted and nurses laid off in their thousands. But it is not just the financial cost. It is the opportunity cost—the colossal distraction this has proved to be from having the focus where it should be—on the money.

After the election, the £20 billion Nicholson challenge should have been the only show in town. Instead, no one stood up in Cabinet to the previous Secretary of State, who was allowed to proceed with his vanity reorganisation of the NHS. The consequence has been two years of drift, where no one knows who is making the decisions. The danger of this unwieldy and unmanaged approach to the efficiency drive is that, as trusts start to panic about the future, increasingly drastic cuts are being offered up that could have serious consequences for patient care.

I want to end by focusing on four such consequences. First, let us look at staffing levels on the NHS front-line. For two years, we have had the mismatch of Ministers making boasts about rising spending while the number of staff was dropping at an alarming rate. A full 7,134 nursing posts have been lost since the coalition came in, with 943 in the past month alone. [Interruption.] Government Members keep mentioning doctors. We left those plans for doctors coming through. The Secretary of State has not done anything about the training of those doctors, but on his watch he has seen more than 7,000 nursing posts cut.

Training places are being been cut by 4.6% this year, after a 9.4% cut in 2011-12. No wonder the chief executive of the Royal College of Nursing warns that we are “sleepwalking” into a crisis. Peter Carter says:

“On a daily basis, nurses are telling us they do not have enough staff to deliver good quality care.”

The situation has taken a serious turn. In its annual report, the Care Quality Commission found that 16% of hospitals in England did not have adequate staffing levels. I am surprised that a warning of this seriousness has not received more attention. It cannot go ignored. It would seem that the NHS is failing to learn the lessons of the failure at Mid Staffordshire, where the first Francis inquiry found inadequate staffing levels to be one of the main reasons why care standards fell so low.

The Health Secretary tells the Health Service Journal today that he is not going to interfere with the day-to-day running of hospitals, but let me remind him that it is his responsibility to ensure that our hospitals are safe. He must develop an urgent plan to stop the job losses and protect the NHS front line. He should tell us which hospitals do not have enough staff and explain what action he is taking on the CQC’s warning to ensure that all hospitals in England have safe staffing levels.

The second consequence of Government cuts to the NHS is the growing number of restrictions on treatment. We have revealed how 125 separate treatments have been restricted or stopped altogether since 2010, including cataracts, knee replacement and varicose veins. Just as they make false boasts about increasing NHS spending, so we hear repeated claims about reducing waiting lists. But that is because people cannot get on the waiting list in the first place.

Figures from the House of Commons Library show the effect of those restrictions on patients. More than 50,000 patients are being denied treatment and kept off NHS waiting lists, and there have been big falls in operations for cataracts, varicose veins and carpal tunnel syndrome. Ministers have promised to stop cost-based rationing if they are given evidence of it, but we have presented them with the evidence on a number of occasions, so let us now see some action.

Thirdly, the lethal mix of cuts and reorganisation is destabilising our hospitals. They are the first to feel the full effects of the free-market ideology that the Government have unleashed on the NHS. There is no longer one NHS approach in which spending is managed across the system; there is a broken-down, market-based NHS. The Government’s message to England’s hospitals is this: “You’re on your own. There’ll be no bail-outs. Sink or swim. But if it helps, you can devote half your beds to treating private patients.” We see the signs of increasing panic as hospitals struggle to survive in this harsh new world. In Bolton, South Tees, and Maidstone and Tunbridge Wells, a large number of staff have been given 90-day redundancy notices, and we see half-baked plans coming forward to reconfigure services with efforts to short-circuit public consultation.

Will the Secretary of State today remove the immediate threat to Lewisham A and E by stating clearly that it is a straightforward breach of the administration process rules to solve the problems in one trust through the back-door reconfiguration of another? Will he ensure that the future of all A and E provision in Greater Manchester is considered in the round as part of a city-wide review, rather than allowing the A and E at Trafford to be picked off in advance. In St Helens and Knowsley Hospitals NHS Trust, will he reverse the comments of the previous Secretary of State, who told the clinical commissioning groups that they had no obligation to honour financial commitments to the hospitals entered into by the previous primary care trusts? It is chaos out there. The Secretary of State urgently needs—[Interruption.] In fact, all the Health Ministers urgently need to get a grip, not just the Secretary of State.

[Robert Flello]

Is my right hon. Friend aware that the West Midlands ambulance service only yesterday advised that there are about half a dozen hospitals in the west midlands whose A and E staffing situation is so critical that it is having a knock-on effect on their ambulance turnaround times?

[Andy Burnham]

I hear reports from ambulance services all over the country that they simply cannot hand over patients at the door of A and E departments and are having to queue outside. Consequently, large swathes of the country are being left without adequate ambulance cover. That is unacceptable, especially as we go into winter and temperatures drop. We need to see some evidence that the Government have a grip on these things. I have been told that large parts of my constituency have occasionally been left without adequate ambulance cover. We must have answers on these matters today.

Oral Answers to Questions

Robert Flello Excerpts

Tuesday 12th June 2012 Commons Chamber

[Paul Burstow]

On the day that the Government have confirmed that from October there will be a complete ban on age discrimination within the national health service, except when it can be objectively justified, the answer to the hon. Gentleman’s question is that the evidence used to determine who is eligible for a screening programme is the basis on which recommendations are made to the Government, and they will be extended in future.

[Robert Flello (Stoke-on-Trent South) (Lab)]

7. What assessment he has made of the potential effect of regional pay on recruitment in the NHS.

[Shabana Mahmood (Birmingham, Ladywood) (Lab)]

16. What recent representations he has received on regional pay variation in the NHS.

[The Secretary of State for Health (Mr Andrew Lansley)]

I have not received any such representations. The Government’s evidence to the NHS Pay Review Body shows that market-facing pay has the potential to enable NHS organisations better to achieve their need to recruit and retain staff within the “Agenda for Change” framework for pay. The pay review body will take evidence from all parties and make its recommendations in July.

[Robert Flello]

It can often be harder to work on the NHS front line in more deprived parts of our country, so would the Secretary of State like to join me on a busy Friday night in A and E in Stoke-on-Trent, where he can explain to the staff why their work is worth less than that of someone working in a more affluent part of the country?

Health and Social Care Bill

Robert Flello Excerpts

Tuesday 13th March 2012 Commons Chamber

[Robert Flello (Stoke-on-Trent South) (Lab)]

Will my hon. Friend give way on that point?

[Valerie Vaz]

No, I am sorry. [Interruption.] Okay.

[Robert Flello]

I am most grateful to my hon. Friend. My persuasive charms work. Does my hon. Friend share the concerns of my constituents? They often find it difficult already to get a GP appointment. With GPs spending so much time with commissioning boards and more to come, will that not make it even harder to get time in front of a GP?

[Valerie Vaz]

My hon. Friend makes an important point. He should read the front page of the left-leaning newspapers, and he will see how much money is being spent on locums.

The GP in Walsall said that the pace of change is too fast. GPs are being forced into larger organisations. They have no experience of managing a business model. The Secretary of State says he wants to cut the numbers of managers. If the number of managers has been cut, why are the management consultants crawling all over the NHS? A group of consultants including McKinsey, KPMG and PricewaterhouseCoopers sealed a £7.1 million contract with 31 groups of GPs. Pulse found that four in 10 clinical commissioning groups across England have begun to enlist commissioning support from the private sector. That was the work that the PCTs did.

The Secretary of State says that change is happening anyway. So why have the Bill? The Secretary of State says that Monitor did not have a duty to promote competition. So why did the Government not approve the amendment tabled by Lord Clement-Jones that sought to designate the health service as

“a service of general economic interest”,

taking it out of EU competition law? That was not accepted.

The Government said that the role of Monitor is like that of Ofgem, Ofwat and Ofcom. David Bennett said:

“We did it in gas, we did it in power”.

Who are the shareholders? Look at Centrica. Its shareholders include Bank of New York Mellon, the Government of Singapore, the Government of Norway, the state of California, the Government of Saudi Arabia, and Goldman Sachs. The shareholders of the NHS are the people of Britain—but for how long?

The Secretary of State says he wants integration, but the Bill will effectively repeal the integration that started with the Health and Social Care Act 2001. Torbay is a classic example of that. What about the cost, which is £1.2 billion and counting?

Care of the Dying

Robert Flello Excerpts

Tuesday 17th January 2012 Westminster Hall

[Robert Halfon]

My hon. Friend makes a good point that is exactly right; his constituency is lucky to have him serving it so well.

I want to highlight bereavement counselling services. St Clare offers such a service, and about 40% of families that become involved with it receive bereavement counselling. That is a huge extra cost for something that the hospice does not have to provide but nevertheless offers as an extra service. Hospices receive little recognition for their work on bereavement care, and a UK study has shown that such care is often overlooked. In 2010, more than half of hospital maternity units still lacked dedicated bereavement support, thus leading families to turn to their local hospices. In 2007, an Oxford university survey of bereavement care in 10 Marie Curie hospices around the country showed that, although there are some great services, such care is patchy or non-existent in other areas. That is why hospices such as St Clare that go above and beyond the call of duty in the bereavement services that they offer deserve recognition and extra financial support.

To conclude, I should like to comment on the remarks made by my hon. Friend the Member for Hexham (Guy Opperman) who is no longer in his place. I have huge respect for him, but he mentioned choice in death. The problem with assisted dying and the move towards euthanasia is that people will be pressured into making choices. That is why I am passionately against any move towards assisted dying.

[Robert Flello (Stoke-on-Trent South) (Lab)]

I congratulate the hon. Member for Enfield, Southgate (Mr Burrowes) on securing this debate, and I have been listening carefully to the hon. Member for Harlow (Robert Halfon). Is not part of the problem the fact that if this House eventually—sadly—legislates in favour of assisted dying, that would normalise the situation and mean that people and families who are vulnerable or in desperate straits may think, “That is normality; we will go down that route”? Does the hon. Gentleman agree that that is a dangerous route down which to go?

[Robert Halfon]

I agree passionately with the hon. Gentleman; we would be taking a hugely dangerous step were we to go down the road of assisted dying. We as a society devalue human life, whether through fiction, computer games or television, or in real life. I often wonder whether Harold Shipman would have got away with killing one patient after another if we as a society had not devalued human life in such a way. We need to move away from that in a big way and back towards dignity for the dying and strong support for palliative care.

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[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

Thank you very much, Sir Roger. May I say what a pleasure it is to be able to say “Sir Roger”? I congratulate my hon. Friend the Member for Enfield, Southgate (Mr Burrowes) on securing this debate. It is timely that the House is reminded of the excellent work that goes on, and we have had tributes from all parts of the House this morning for individual hospices and the work of individuals. I also want to congratulate my hon. Friend on his comments on the fears that surround death. Death is an inevitable consequence of life, albeit for some it is tragically premature. We do not find death and dying a comfortable subject. It is thought frightening and mysterious. If nothing else, debates such as this may demystify some of the issues around death.

I also want to mention in particular the hon. Member for Hampstead and Kilburn (Glenda Jackson) and her comments on the privilege it is to be present at a member of one’s family’s death. The hospice movement, as she rightly said, has enabled that to be possible for so many more people today.

Services in some parts of the country are excellent and in some parts of the country they are patchy at best. As my hon. Friend the Member for Portsmouth North (Penny Mordaunt) pointed out, the quality of care does not always live up to what we expect. It also does not live up to what we expect in the treatment of certain conditions and in end-of-life care.

The Department of Health’s end-of-life care strategy was published in 2008 under the previous Government. I want to pay tribute to the progress that they made. It remains the blueprint for improving this area. Last September we published the third annual progress report on implementing the strategy. It is on the Department of Health’s website and I urge hon. Members to have a look at that.

[Robert Flello]

Will the Minister give way?

[Anne Milton]

I will not for the moment, because I have so little time.

Our plans for the NHS mean that we want people to have as much choice as possible in treatment in life but also in death. We want commissioners and providers to ensure that the right services, which include 24/7 community-based services, are available to support people at home.

Progress is frustratingly slow, but the examples around the country where it is working well are of note. We will review progress regularly to ensure that this becomes a reality for people. It is much overdue.

One development is the electronic palliative care co-ordination systems. I hate these names, but they can be effective tools. Through those, care providers can instantly share care plans and express preferences for care. We piloted that approach successfully in eight sites across the country and it is now being adopted more widely. We are also working to make sure care planning is a routine part of care for people who are dying. It is dreadful that care planning is not a routine part of care for all people. That has not been the case for some years, but it should be.

In November, NICE published its quality standard for end-of-life care of adults. That is an important contribution to this issue. It covers the whole of the end-of-care pathway, not just the medical bit. The 16 statements include social, practical, emotional and spiritual and religious support. We have also developed a national survey of bereaved relatives to get first-hand experiences of people’s care. The first survey should be completed by March. That will inform a new indicator on end-of-life care in the NHS outcomes framework.

To provide quality services, where and how people want them, hospices and other palliative care providers need support and funding. We will introduce a new per-patient funding system for all providers of palliative care, covering both adults’ and children’s services. We set up the independent palliative care funding review to help take that forward. The final report was published last year. It came up with some significant proposals, which we will consider in detail to ensure that we get that right. It is the first major step in local palliative care funding. We will have pilots to collect data and test the review’s recommendations, which will be established from April this year. The aim is to have the new funding system in place by 2015, which is a year earlier than was anticipated.

I also want to pay tribute to the voluntary sector. Palliative care was first developed in the voluntary sector and it still provides us with those beacons of best practice. Dame Cicely Saunders has already been mentioned and had tributes paid to her. She founded St Christopher’s hospice in 1967 and I want to associate myself with those tributes. I also pay tribute to people such as Dr Colin Murray Parkes, who has done so much in the area of bereavement and grief. That has been mentioned, but it possibly did not get the mention that it should.

The hon. Member for Strangford (Jim Shannon) and my hon. Friends the Members for Southend West (Mr Amess), for Congleton (Fiona Bruce), for Harlow (Robert Halfon), for Montgomeryshire (Glyn Davies) and for Portsmouth North all paid similar tributes. I would love to mention every contribution in detail, but they all surrounded the same issues: this is about dignity; this is about choice; this is about life. It is also about bereavement and the care of the relatives who live beyond the death.

My hon. Friend the hon. Member for Banbury (Tony Baldry) specifically mentioned assisted suicide, as have other hon. Members. This is a matter for Parliament as a whole to decide, not the Government. He talked about the perception of failure when someone dies. On a personal level, to be present at a good death is a privilege and an opportunity, not a failure. We need to right that balance a bit and see the success in someone dying well. As I have said, it is such an important part of the bereavement process.

We have a comparatively smaller number of people who die in a hospice, but so many more benefit from their services and expertise. We want to see hospices flourish and develop. In particular, we want to see them continuing to expand the care they give to those with illnesses other than cancer, as well as expanding into community-based support for patients, their families and their carers. That is where the work that we are doing on palliative care funding is so important. It will be key to moving us towards a fairer funding system for all providers, including hospices.

It would be remiss of me not to mention the one issue that has not been mentioned. In accepting that death is part of life, we also need to consider those who can be given the chance of life through another’s death. As I have ministerial responsibility for organ transplants, I have to mention that we need to make organ donation a normal part of end-of-life care. We need to recognise that through a sensitive approach to the family, we can, in death, give life to many others.

In conclusion, we come to this place to give our constituents and this country a better life, because we believe that everybody deserves a good life.

[Robert Flello]

Will the Minister give way?

[Anne Milton]

Very briefly.

[Robert Flello]

I just want to touch on the point that in my constituency, the Donna Louise Children’s Hospice Trust does some fantastic work. There is this difference between it and the work of the Douglas Macmillan hospice just outside the constituency. There is a mishmash and I would be grateful if the Minister looked at that in the future.

[Anne Milton]

We want to end any mishmash. We want a consistently high quality of care for everybody. Everybody deserves a good life and that is why we came to this place. This debate has allowed us to debate, discuss and share the opportunities that exist for Parliament to allow people a good death too, with dignity, without pain, in the company of those we love and at peace in death with the lives that we have led.

Oral Answers to Questions

Robert Flello Excerpts

Tuesday 10th January 2012 Commons Chamber

[Paul Burstow]

My hon. Friend makes a very important point, which has been raised by a number of charities, including Papyrus, during the consultation on the draft strategy. It is important to stress that the internet industry has been willing to engage in positive initiatives, not the least of which is Facebook and Google’s work with the Samaritans to make sure that whenever anyone types in “suicide” a link to the Samaritans always appears first. However, more needs to be done and we need the industry to tackle those darker sides of the internet to make sure that they do not prey on vulnerable people and do not peddle suicide.

[Robert Flello (Stoke-on-Trent South) (Lab)]

Given the crucial role that the chief coroner was to have had in monitoring and advising the Department of Health on the incidence of suicide across the nation, will the Minister liaise with the Lord Chancellor to ensure that a chief coroner is appointed speedily and that powers are put in place quickly to make sure that this work can be done?

[Paul Burstow]

I will certainly pass on the hon. Gentleman’s request.

Health and Social Care Bill

Robert Flello Excerpts

Monday 31st January 2011 Commons Chamber

[Margaret Hodge (Barking) (Lab)]

I speak both as Chair of the Public Accounts Committee and as the MP for Barking. As PAC Chair, my concerns have not been allayed by the evidence sessions that we have held on these issues. I do not want to be saying in three years’ time, “I told you so.” I urge the Government to think again before they introduce changes that have not been thought through properly, that are incredibly risky, and that could result in long-term damage.

There has been insufficient focus on the risks of the changes. The NHS chief executive said in evidence that

“the risk is higher. If you try and reorganise, the risk becomes higher. I think we’d be kidding you to say that it wasn’t”.

Making Monitor an economic regulator forces it to concentrate on competition, not quality. Its purpose will be to drive down costs, not drive up health outcomes. If the spotlight is on price, the risk is that patients will lose out. The NHS chief executive agreed in his evidence that lowering tariff prices could endanger patients. Opening the health market to any willing provider will undermine the viability of many NHS foundation hospital trusts, which face immovable fixed costs, such as their private finance initiative costs. Again, that risk has not been assessed properly.

The Government appear to be driven by an ideological mission. The NHS needs pragmatism, not dogma. I fear that there is no firm grip on the costs of reform. The NHS already faces the unprecedented challenge of finding £20 billion of savings and its record is poor. Over the past decade, despite assurances to the Treasury, NHS productivity declined, with hospital productivity declining by 1.4% annually. The NHS should therefore concentrate its efforts on the enormous financial challenge, and should not be diverted by an unprecedented organisational challenge. Quality and productivity, not reorganisation and privatisation, should be the priorities.

[Robert Flello (Stoke-on-Trent South) (Lab)]

My right hon. Friend is making a good-quality speech, as usual. Surely in areas such as Stoke-on-Trent, where the cost of laying people off in the PCT will be tens or hundreds of millions of pounds, the risks that she describes already exist.

[Margaret Hodge]

Indeed, and I was going to come to that point. As I understand it, Ministers have set aside £1.7 billion to finance their reforms, but as my hon. Friend says, if the costs of redundancy are higher than planned, or if people carry on attending A and E rather than seeing their GP, the costs of reform will spiral and front-line services will have to be cut. I am not convinced that Ministers have transition costs properly under control.

Nor has anybody sorted out to our satisfaction the issue of accountability for public money. For instance, foundation trusts are supposed to be directly accountable to Parliament. With 167 trusts accountable to the PAC and the House, if there is financial failure or poor quality of care, will that accountability be good enough? In the past, Monitor could sack the board of a trust, but under the Bill it will lose that power. How can we hold the permanent secretary to account when there is a plethora of new quangos or new responsibilities for quangos? We have to know where the buck stops. I seek Ministers’ reassurances tonight that there will be clear, practical accountability that enables Parliament to hold the Executive to account.

The Government do not have effective plans to deal with failures, and there will be failures—hospitals bankrupt, GP commissioning consortia overspending. Ministers must explain how they will deal with failure, so that local services will be maintained even when trusts and consortia collapse. So far, officials have been unable to provide us with the confidence that we need to feel that the Government have got a grip.

That matter is of particular importance to my constituents. For years, our NHS trust has been in terrible trouble, and last week it was named and shamed by the Audit Commission for systematic failure on its finances. It has failed to balance its books for years, and it has a projected deficit of £29 million this year. The quality of care has deteriorated, too. In the week of the general election, 99% of people at our King George A and E and 92% at Queen’s hospital were treated within four hours. By 2 January this year, that had dropped to 83% at King George and just over 61% at Queen’s. More than 1,000 people were forced to wait for more than four hours, ambulances were queuing around the block and all but the most urgent cases were turned away. In one case, a patient died because she was sent home.

That hospital trust is not fit to become a foundation trust. Despite a stream of new chairs and chief executives, the underlying problems persist. Now, the only answer that NHS London has is to try yet again to close the A and E at King George. That is health vandalism at its worst, with patients’ needs sacrificed at the altar of financial cuts.

What would happen to my constituents under the proposed NHS reforms? King George A and E would go, forcing my neediest and poorest constituents to spend hours on three buses to get to a hospital. Queen’s hospital would become unviable, and what then? Where is the local hospital ready to meet local needs? Who would want to consider merging with a hospital trust struggling with an impossible financial burden, and even if anyone did, would they ensure that our services remained local? The current health care reforms should put the patient at the heart of the NHS, but it does not feel like that is happening in Barking. I urge the Government to think again before they act to damage the health care of the people who need it most, the people I represent here in Parliament.

--- Later in debate ---

[Joan Walley (Stoke-on-Trent North) (Lab)]

I am pleased to speak briefly about this Bill; I know that many Members on both sides of the House still want to contribute to the debate. It seemed to me that not to speak in this debate would somehow mean not being true to the important issues surrounding the NHS. I have listened to the debate and heard some good constructive comments, but I do not think we have gained a sense of what the NHS was like when I was first elected almost 25 years ago. At that time, people simply could not get treatment because of the underinvestment during the years of the Conservative Government. As for the point about organic change and building on what has been done, it seems to me that this Bill, lengthy as it is, is doing away with the step-by-step improvements that have been made.

[Robert Flello]

I look forward to hearing more of my hon. Friend’s speech, which I know will be to her usual high standard. Does she agree that, since 1997, Stoke-on-Trent has seen the building of the first new hospital for 140 years, a brand-new oncology unit, a brand-new maternity unit and health centres developing everywhere? Is that not real investment under a Labour Government, which never happened during the previous 18 years of the Conservative Government?

[Joan Walley]

What we have seen is the university college of North Staffordshire linked to the medical college at Keele. We have never before seen that kind of medical training going on outside London in areas like Stoke-on-Trent. Hayward hospital has been rebuilt and there has been investment in clinics and a huge increase in the number of staff. That does not mean just bureaucrats—like everyone else, I do not want to see unnecessary bureaucrats. I am talking about the number of health personnel trained to do their jobs and to treat people, which has been second to none—despite what the Minister says.

--- Later in debate ---

[Derek Twigg (Halton) (Lab)]

This has been a fascinating debate with some interesting and excellent speeches. Some 17 Labour Members and a similar number on the Government Benches have given a variety of speeches, some showing great knowledge and some not so much. I particularly congratulate my hon. Friend the Member for Oldham East and Saddleworth (Debbie Abrahams) on her excellent maiden speech, in which she demonstrated her great knowledge of the health service and her background in it. I am sure that she will make many more such speeches and be a great success in this House.

I would like to thank the NHS staff for all the work they do every day in our health service. That includes those at PCTs; one might sometimes think that they were ogres, given how PCTs are described by some Government Members. They work very hard, and they, too, have to deliver the changes that will take place as a result of this Bill.

The Secretary of State is pushing ahead with the Bill despite criticism from all sides. Patient groups, professional bodies and health experts have attacked the plans as high cost, high risk, a danger to the commissioning of key health services, and a distraction from the need to find efficiencies. The heads of the British Medical Association, the Royal College of Nursing, the Royal College of Midwives and the Chartered Society of Physiotherapy, as well as union leaders, have described the reforms as extremely risky and potentially disastrous. The more they see, the more they become concerned. The clear message that we have been getting is that the proposals have come at the wrong time, they are ill conceived, and a lack of attention has been paid to stakeholders’ concerns.

The Secretary of State has ignored the massive improvements that took place under the Labour Government. One would think that he was talking about a different health service, because we had record numbers of doctors and nurses and record low waiting times. I wonder whether the Minister will confirm, as the Prime Minister and the Secretary of State have not done so, that there will be no increase in waiting times during the life of this Parliament. There have been record levels of patient satisfaction, with 71% agreeing that Britain’s national health service is one of the best in the world—the highest figure on record. That is also evidenced by the satisfaction levels recently recorded across user groups, with, for instance, 91% of GPs and 90% of out-patients satisfied. The argument that the NHS is in crisis and is not dealing with patients’ concerns does not stand up. It is important to look at some of the other improvements that have taken place. In June 2010, 90% of admitted patients and 98% of non-admitted patients were being seen within 18 weeks. The coalition has scrapped the targets that delivered those improvements to patient care.

Several Members referred to international comparisons. Let me take the example of the Commonwealth Fund, which ranked the UK first for efficiency and effective care in a study of seven top health care systems. In its 2010 international survey, it found that 92% of people were confident that they would receive the most effective treatment when sick—the No. 1 figure among comparable nations.

A lot has been said about cancer mortality. From 1997 to 2008, cancer mortality rates in all regions of England decreased by between 17.5% and 23%. Even more pronounced improvements have been observed in mortality from circulatory diseases: between 1995-97 and 2006-08, the mortality rate for England fell by 47%.

There are many uncertainties and unanswered questions about the Bill. There are concerns about who will be involved in commissioning and whether it will include other clinicians such as hospital doctors, physios and, importantly, nurses. How do nurses fit into the structural regime? In an article in today’s edition of The Times, the Prime Minister says:

“Nurses too will continue to play a vital role. GP consortia will have a statutory duty to work with nurses and other healthcare professionals, ensuring they have a real voice in shaping better care for patients”.

The Royal College of Nursing says that it was interested to see this, because it does not believe that the Bill goes far enough for it to be possible to claim that that is a statutory duty. Perhaps the Minister will respond to that, too. The only provision that the RCN believes relates to that matter is new section 14O in clause 22, which states that commissioning consortia must obtain appropriate advice. It does not believe that the Bill goes far enough in ensuring that commissioning consortia have relevant multi-disciplinary expertise to commission appropriate care.

I should like to turn to Monitor and competition—an aspect that has not been much mentioned. An ideological commitment to competition on price and to a massively increased role for the private sector is at the heart of the Conservatives’ proposals, despite their attempts to hide it. On 17 January, in a 700-word article in The Times, the Secretary of State did not mention the word “competition” once, but the Government have had to reveal where the true thrust of this legislation lies. Of course, he did not mention it much in his speech today, either. The Prime Minister told the House that

“what we want is a level playing field for other organisations to come into the NHS.”—[Official Report, 19 January 2011; Vol. 521, c. 831.]

When we appeared together on “Newsnight” a couple of weeks ago, the Minister of State, Department of Health, the hon. Member for Chelmsford (Mr Burns) said:

“It is going to be a genuine market. It is going to be genuine competition.”

The Government have hidden the great bulk of the ideological market and competition changes from public view. There is the introduction of competition on price. Monitor will have the power to direct consortia to put the provision of services out to tender, irrespective of what the GP consortia say. The Minister wants to deny that, but it is what we read in the Bill. Monitor will be driving this, not the GP consortia. Government Members should be reading that part very carefully. NHS resources, such as beds and staff, will be used without limit to treat private patients as the cap on private patients in hospitals is lifted. That means that private patients may jump the queue while NHS patients are waiting for treatment. Services or whole hospitals may be forced to close as the most profitable patients are cherry-picked by private providers.

[Robert Flello]

Does my hon. Friend recognise the effect when a local MP sets up a big campaign? In my constituency, I may well be doing that with the Sutherland centre, which is under threat. The local MP will have no influence or power at all because of Monitor’s role.

[Derek Twigg]

The issue of accountability for this House—what we can and cannot do—is important and I will come on to it if I have time.

I turn to the Liberal Democrats. The hon. Members for Burnley (Gordon Birtwistle) and for Manchester, Withington (Mr Leech) suggested that the Bill will protect hospitals and wards from closure. I am afraid that it will not. They need to read the Bill again. Monitor will be driving a lot of this, and they need to be clear about what the Bill actually does. They should join the hon. Member for St Ives (Andrew George), who is taking the interesting stance of not voting for the Bill tonight. He understands it better than other Government Members.

Concerns over fragmentation and obstacles to integrated working have been raised by numerous bodies in the health service and by those who work in the health service. The Commonwealth Fund states that the UK has the best co-ordination between health care providers and professionals, with the lowest percentage of patients having experienced co-ordination problems in their care. Only 10% of patients have received conflicting information. The more privatised, competition-driven systems in Australia and the US experience greater co-ordination problems.

The King’s Fund brief for this debate states:

“The Bill signals a significant shift towards a more competitive market for health care. While we support increased competition in areas where it demonstrates benefits to patients, the Bill appears to move towards promoting competition at the expense of collaboration and integration.”

That is from one of the most respected think-tanks.

One cannot underestimate the huge powers that will be given to Monitor. It will expose the NHS to a rigorous competition regime, with services going out to tender. The explanatory notes state that Monitor will become the

“economic regulator for all NHS-funded health services”,

with the power to

“do anything it needs to in order to exercise its functions.”

In other words, the NHS will become like a utility.

Of course, the Government are full of broken promises. The Prime Minister said that there would be real-terms increases in NHS spending, but there are not. He said that there would be no cuts, but there are. He said that there would be no top-down reorganisations, but we have a top-down reorganisation. David Nicholson said that

“no one could come up with a scale of change like the one we are embarking on at the moment. Someone said to me ‘it is the only change management system you can actually see from space’—it is that large.”

This is a massive change. There are other issues, such as the cuts in staff that are taking place and the vacancies that are not being filled. We are being told about that by people who work in the health service. That is the true nature of the health service under the Conservatives and the coalition.

We are in favour of improving the quality of care, driving up standards, greater clinical involvement and giving a greater say to patients. We are therefore not anti-reform, but we are against this reckless, top-down reorganisation with a cost of £3 billion, which was hidden away during the general election campaign. It is reckless, it is not in our best interests and many believe that it will be the end of the NHS as we know it.

Contaminated Blood and Blood Products

Robert Flello Excerpts

Thursday 14th October 2010 Commons Chamber

[Mr Robinson]

I agree entirely with my hon. Friend, who makes a most poignant and correct intervention, if I may say so. We had a unique opportunity. The issue had moved right up in the public’s awareness. The sort of thing that we get in these debates is everybody saying how terrible it is, but then heaving a sigh of relief that they have not been affected, and on we go. The months and years drag by, and so the number comes down, from 4,600 to 2,700. Perhaps not many will be affected, but as my hon. Friend said, the nature of the diseases is that they spread, and the suffering will continue long after most of us have left this House.

[Robert Flello (Stoke-on-Trent South) (Lab)]

I am grateful to my hon. Friend for giving way. At the end of the 1980s, I worked with someone called Colin, who had been injured abroad, had a blood transfusion and got haemophilia. He then returned to the UK for ongoing treatment, but ended up getting contaminated blood and dying from HIV at the beginning of the 1990s. It is for people such as Colin that we are here today. This is not a partisan issue; it is an issue that we should have dealt with in the past 13 years—it should have been dealt with before that—but let us deal with it now.

[Mr Robinson]

I am grateful for my hon. Friend’s intervention, which I wholly accept and entirely agree with.

Mid Staffordshire NHS Foundation Trust

Robert Flello Excerpts

Wednesday 9th June 2010 Commons Chamber

[Mr Lansley]

If I may, Mr Speaker, I shall content myself with saying that my hon. Friend made it clear from the outset that an Inquiries Act inquiry was the right idea. He said that more than a year ago, and had we gone down that route then, we would have been much further towards getting to the whole truth now. Matters relating to the Inquiries Act and the panel membership are ones that will now be determined by Robert Francis. I have published the terms of reference to which he will be working, and under the Inquiries Act issues such as legal representation and its funding are determined under those.

[Robert Flello (Stoke-on-Trent South) (Lab)]

My constituents who were affected will also be following very carefully what happens in this public inquiry, and I associate myself with what has been said about David Kidney, who worked extremely hard and effectively on this horrific issue.

I am concerned that the horrific failure at this hospital is being used as a hook in a most appalling way for the proposals to scrap targets, which the Conservatives have talked about for a long time. In any system there will always be people who try to manipulate it; in a culture of fear and bullying, as there was in this hospital, that is exactly when systems will be manipulated. Will the right hon. Gentleman therefore take into account as wide a spectrum of advice as possible when he is considering the new outcome proposals, to ensure that whatever system he brings in is not also open to abuse and manipulation?

[Mr Lansley]

One of the hon. Gentleman’s friends says that we should take action on the basis of the first Francis inquiry, and we will, and the hon. Gentleman says that we should not take action on targets. The first Francis report made it clear that targets compromise patient care, so we do need to take action.

The hon. Gentleman asked a further question. Robert Francis and I have had two discussions and the terms of reference are very clear. He is looking beyond the structures and processes to how the culture of bullying, fear and secrecy came to pass, what effect it had and how we can move beyond that. The report will be very important, if it is successful, not just for the people of Staffordshire but right across the country in showing how we can move from a top-down, secretive, bullying culture to one that is absolutely open, transparent, focused on patient safety and entirely responsive to the needs of patients.