Derbyshire CCGs’ Finances

Ruth George Excerpts

Tuesday 4th September 2018 Westminster Hall

[Ruth George (High Peak) (Lab)]

I beg to move,

That this House has considered Derbyshire clinical commissioning groups’ finances.

It does not give me great pleasure to raise this matter of great importance: the finances of our local health services and the clinical commissioning groups in Derbyshire. Two months ago—ironically on the 70th anniversary of the NHS—all the voluntary sector organisations in Derbyshire were shocked to receive letters stating that their funding from the clinical commissioning groups was to be cut. Our voluntary services provide much-needed support to thousands of frail, elderly and disabled people across Derbyshire, including support when they come home from hospital, befriending services, respite care, overnight stays and community transport.

Thousands of volunteers give their time to help vulnerable people, often in very rural areas where no other services are available, to live independently and stay well. They provide a constant check on those people’s physical and mental wellbeing. I thank all the volunteers across Derbyshire and the services that support them in helping people. They help older people to manage on their own, reducing the calls on GPs, visits to accident and emergency, and stays in hospitals or care homes for a fraction of the cost of those services. For example, the night-sitting service in High Peak provides emergency and respite care overnight—for example, when a carer is ill or to prevent a patient who would otherwise have to go into hospital from being admitted.

[Toby Perkins (Chesterfield) (Lab)]

I congratulate my hon. Friend on securing this important debate. Does she agree that, alongside the financial consequences of their cheaper cost, many voluntary organisations, such as Age Concern, which I saw last week, keep old people well and prevent them from having to use health services by providing services such as the befriending service in Chesterfield?

[Ruth George]

Absolutely. Age Concern and other voluntary services work fantastically well with thousands of older people.

Last year, the night-sitting service supported 93 people with more than 2,000 hours of care at a cost of just £34,000. That works out at just £369 per person for an average of three nights’ support each. Just one of those nights in a hospital would have cost the CCG more than that.

The CCG says that the county council provides an alternative service, and it may do on paper, but as we have a drastic shortage of social carers, like so many other places, no other help is available. The voluntary sector provides friendly, personalised, local care for far less than any other service could. For example, New Mills and District Volunteer Centre told me that it supports 550 mostly elderly, widowed and disabled clients for an average cost, between the staff and the volunteers, of just £2.26 an hour. If just two of those 550 clients have to go into a care home as a result of losing the volunteer services—in practice, it is likely to be many times that—the cut will cost more than has been saved.

[Nigel Mills (Amber Valley) (Con)]

I congratulate the hon. Lady on securing this important debate. I agree with her: the work that volunteers do in my constituency and the support they get from the centre for voluntary services is vital. Does she agree that it is short-sighted in the extreme to try to fix a medium-term funding issue by creating irreversible long-term damage to voluntary services in the area? The way it was done—with the threat of little notice—was equally crazy, as there was no way of replicating the structures in that time. We need a long-term, sustainable solution, not a short-term quick fix that does long-term damage.

[Ruth George]

The hon. Gentleman has just summarised the next 11 minutes of my speech extremely well. I absolutely agree with him.

Having asked their commissioners to make a decision about all the cuts to voluntary services two weeks ago, after just four weeks of consultation over the summer, and in the face of challenges from Healthwatch Derbyshire and the county council’s health scrutiny committee and a large public outcry, the CCGs are now being forced to look again at some of the cuts, but they are still on the table. They come on top of all the other cuts to health and social care in Derbyshire, where the county council has lost more than half of its funding since 2010.

[Lee Rowley (North East Derbyshire) (Con)]

I share the concerns outlined by the hon. Lady and my hon. Friend the Member for Amber Valley (Nigel Mills), and I absolutely regret what the CCGs are proposing for the voluntary budgets. I hope they think again, as I am sure everybody in this Chamber does. However, does the hon. Lady agree that contextualising this issue with a wider point about cuts, which she is about to start doing, is not as accurate as it could be? The litany of historical poor management decisions by the four CCGs got us to this place and is the problem we are dealing with now. As my hon. Friend said, we need a long-term solution, and we should not default to a narrative of Government cuts when we know that is not quite correct.

[Ruth George]

Actually, the alternative is correct. The CCGs in Derbyshire were managing absolutely fine until the five-year forward review in 2016-17. They were making surpluses, and there was no problem—particularly with North Derbyshire CCG, which covers my area and the hon. Gentleman’s area. It had surpluses and hit the 1% target underspend—[Interruption.]

[Sir Christopher Chope (in the Chair)]

Order. It is intolerable that the hon. Member for North East Derbyshire (Lee Rowley) should seek to intervene from a sedentary position.

[Ruth George]

The figures speak for themselves, as do the cuts to the county council, and as do all the other cuts that the CCG has had to make since the reduction in its funding increase in 2017, which I will set out in detail.

Last year, just after I was elected, our local dementia assessment and support ward in Buxton was axed. It was a gold-standard service that took the most difficult patients with dementia and helped them back into care in their own home in an average of less than six weeks. Our rehabilitation and support ward at Buxton, Fenton ward—the only place where acute patients in High Peak can be sent, as we have no nursing homes at all—is due to lose more than half its beds, despite the fact that a waiting list of patients in our acute hospital need those beds, even during the summer.

Community hospitals across Derbyshire are facing the loss of 84 beds. Bolsover Hospital and Bakewell have already closed, and staff at Clay Cross and Ilkeston hospitals are living with a threat to their wards. Anyone would think we were seeing a reduction in the number of patients with dementia, or elderly and frail people who need rehabilitation to get them home from hospital. Of course we are not. Instead, there has been an explosion in the need for those services at a time when our NHS is being forced to make short-term cuts that will have long-term implications for the care of our patients and for the skilled staff we need to keep in the NHS.

I had thought that the Government’s aim was to keep our long-term health costs down. Instead, cut after cut is forcing up costs—not just in the long term but immediately. The hours have been cut at our minor injuries units at Buxton and in Erewash. Our local A&E had an immediate increase in patients, which is costing the NHS even more. That A&E department, which usually sees 200 cases a day on average, rising to 250 in winter, has been seeing 300 patients a day over the summer. There has not been a spate of accidents; those patients have long-term illnesses that are not being managed because our local health services cannot keep up with the increased demand as they are not now being funded to do so.

It seems that, whichever service that helps people to stay out of hospital or long-term care one thinks of, it is being reviewed or cut. Our respite care for people with severe learning disabilities is one of the services that patients have been told is being reviewed due to the challenges it faces. My constituent Christine told me that her daughter Julie, who is 38 but has a mental age of eight, receives four or five days of respite care a month, and that is all that enables Christine and her husband to continue to care for her at home, as Christine is 62 and her husband 75. The alternative of permanent residential care would be far more expensive for the state to provide.

Specialist nurses who help people to manage very serious long-term conditions, including heart failure, diabetes and Parkinson’s disease, are also proposed for cuts. After more outcries, especially from the GPs who would be shouldering that huge extra burden, those cuts have been put on hold until next year. The threat, however, is still there, and the specialists and the committed staff who run the service do not feel secure in their jobs.

Even funding for wound dressings has been removed. After suture removal and the first dressing, GPs are supposed to send patients with suppurating wounds to clinics many miles away, although often those patients have no transport. Otherwise, GPs have to pick up the burden themselves to prevent their patients from suffering serious infections, ending up in constant pain and back in hospital. In the case of our average small rural GP practice, that is 1.5 days of practice-nurse time a week. To keep that up is not sustainable.

Given all the rhetoric from the Department of Health and Social Care about sustainability, why is that happening? Why are short-term financial decisions impacting so hard on our frontline health services, on our voluntary services—which are vital as part of a long-term sustainable service—and on the frail and vulnerable people who need them? The short answer is finance. Finance has become the be-all and end-all for decisions on healthcare in Derbyshire. It is not an unusual area and we do not have particularly unusual health needs, apart from being more rural and having a slightly older age profile. The cost of our health needs, as in most areas, increases by about 3.5% a year.

Our CCGs were doing absolutely fine—meeting all their targets, delivering the required underspends and building up reserves—until the funding formula changed in 2016. North Derbyshire, for example, had a reserve of £20 million until, instead of the average CCG increase of 3.75%, North Derbyshire received only 1.6%. With a flat budget for 2017-18 and only a 2% increase for 2019-20, that is disastrous. The CCG was told by NHS England to find £16 million in cuts over six months during 2016-17. When that did not happen, it was placed in special measures and told to find cuts of 7% in 2017-18. However, long-term services with loyal staff cannot be cut that quickly, so again the deficit mounted.

Now Derbyshire’s four CCGs are applying to merge so that they can achieve the required efficiencies of scale and organisation. However, their combined deficit is now £95 million. NHS England has stipulated that if they can make £51 million of cuts, the other £44 million will be written off. That is all well and good, but it is dependent on those £51 million of cuts being made in just seven months. If the CCGs cannot make those cuts, they will have to find not only the £51 million but another £44 million. That is on top of the unmet extra costs of services next year of a further £21 million.

The Government claim that they are increasing spending on the NHS, but that is not what we see locally. Our communities see cut after cut after cut. Even the long-promised uplift of 3.5% a year from 2020 will only meet that one year’s increase in need; it will do nothing to deal with the huge backlog of cuts from a decade of austerity for our NHS.

Healthwatch Derbyshire has challenged the legality of the cuts, because they are being made at such speed that there is little assessment of the impact, let alone proper consultation. Much of the problem is that the benefits of the services that are being cut will not be measured financially—only their immediate cost. As far as NHS England is concerned, as long as £51 million of cuts are made, it does not matter that those cuts will increase costs by £151 million next year and every year thereafter. Furthermore, in the case of our voluntary sector and of our skilled specialist staff, when they are gone, they are gone. Voluntary services such as ours in Derbyshire take years of building up, of working with volunteers and of recruiting staff who are often prepared to be paid for only a few hours a week but who show absolute commitment to looking after their clients and volunteers. No one wants to make those cuts, but as the chair of one of our CCGs said:

“I wish that we had a regulator who would walk the path with us, and would look at the impact of these cuts, instead of simply demanding savings.”

That brings me to my question for the Minister. We should be nurturing our voluntary services and supporting our hard-working NHS staff, whose pay has been declining while their workloads have soared. We should be protecting our ever-growing numbers of frail, elderly and disabled patients, who have seen huge cuts to their social care and become ever more reliant on the health service, and working to integrate our health and social care budgets properly so that we do not see one service making cuts that cost the other even more. We should be building a sustainable health service fit for the 21st century. Please will the Minister tell me that NHS England will enable that to happen in Derbyshire?

[The Minister for Health (Stephen Barclay)]

It is a pleasure to serve once again under your chairmanship, Sir Christopher. I congratulate the hon. Member for High Peak (Ruth George) on securing this important debate. She has effectively put on record her concerns about the financial challenge faced by the Derbyshire CCGs.

The hon. Lady is right to recognise that the Government are committing more money to the NHS. That is why the Prime Minister has announced a funding increase of, on average, 3.4% each year to 2023-24. The NHS budget will therefore increase by more than £20 billion a year compared with today. Alongside that, it is also right for NHS England, the independent organisation that allocates funding, to question the efficiency of CCGs, in particular by comparison with other CCGs, looking for what efficiencies can be found. Indeed, the four CCGs in Derbyshire have already identified £39 million of savings, against our target which is 3% of their overall budgets. Significant progress has therefore been made to meet the challenge set by NHS England.

[Ruth George]

Part of that £39 million is £5 million of decommissioning, which includes those voluntary services, so they are now having to be reviewed. That £39 million in cuts is not good news—it is pretty bad news for the NHS, as I have set out.

[Stephen Barclay]

I was just about to come on to the voluntary sector, because that is where the hon. Lady’s speech started, but in her remarks she talked about the four CCGs coming together as part of the “efficiencies of scale”—her precise phrase—so I shall come back to the voluntary sector later.

--- Later in debate ---

[Stephen Barclay]

To some extent, that is already happening in the form of the £45 million of the deficit that is being absorbed by NHS England, but part of the NHS England consultation is assessing where the CCGs are against their target allocation—it is part of the consideration of the £40 million of capital bids for Derbyshire and part of the £12.5 million that was secured for the improvements at Derby county. It is also part of other issues in the NHS such as length of stay—43% of patients in acute hospitals do not clinically need to be there and would be better served in the community, which is where those value for money assessments need to play a part.

[Ruth George]

Why are 84 community beds, and my beds in Buxton at Fenton ward, which are the only place where patients in acute care can be transferred, being cut?

[Stephen Barclay]

Again, local clinical decisions are taken by the CCGs, which is the correct approach. This goes to the heart of the point raised by my hon. Friend the Member for North East Derbyshire. Driving efficiency as part of spending more on the NHS is not about not having any change. Indeed, the hon. Lady previously expressed concerns about the specialist dementia inpatient beds in her constituency. Again, those are specific commissioning decisions—it is inappropriate for a Minister to comment on specific decisions—but, although I understand her concerns in relation to the number of specialist dementia inpatient beds, I am assured that the model implemented in Derbyshire reflects the changing needs and approaches to providing health and care for dementia patients. Patients benefit from structured care in their homes or in an adult care-led facility—that model is supported by clinicians.

We need to differentiate legitimate questions from NHS England in an area that is receiving more than its target allocation and where there are opportunities for efficiency, while taking on board the concerns raised by my hon. Friend the for Amber Valley about the transition as the additional Government funding comes, and while allowing the NHS in Derbyshire to change. Just as the additional funding to Derby will unlock efficiencies, so will the vanguard programme and other local initiatives on, for example, dementia care to deliver an NHS that is fit for the future. It needs to evolve but is also needs to take the community with it. That is why it is right that we have a discussion about the voluntary sector without scaring people that decisions have been taken, when services such as the three I mentioned have already been protected and I am told that no decisions have been taken on the other voluntary’s services.

We are committed to spending more on the NHS in Derbyshire. That is the clear commitment the Prime Minister made. The CCG has made significant progress on delivering efficiencies against its 3% target, but we are building an NHS fit for the future, which includes ensuring that we give more money to Derbyshire. As part of the 10-year plan being devised by NHS England and NHS Improvement, Derbyshire will receive its fair share of that additional funding.

Question put and agreed to.

Complex Regional Pain Syndrome

Ruth George Excerpts

Tuesday 19th June 2018 Commons Chamber

[Ruth George (High Peak) (Lab)]

It gives me great pleasure to speak in my first Adjournment debate since being elected last year.

Complex regional pain syndrome—CRPS—is one of the most painful conditions known, registering a staggering 42 out of 50 on the McGill pain scale. That is worse than the pain of the amputation of a finger or toe with no anaesthetic, which registers as 40 out of 50, and it is worse than childbirth—the Minister may sympathise with me on that. CRPS is not a short-term pain that will heal in time. The most excruciating part is that the pain is long-term, and likely to be for life. In fact, CRPS is known as the world’s most painful incurable condition. In the United States, it is referred to as the “suicide disease” as it can lead sufferers to resort to suicide as the only means to escape the huge pain that they bear.

CRPS is a chronic neuropathic pain condition—a disease of the nervous system—and it usually starts with a minor injury or fracture to a limb. The major indicator is the huge amount of pain involved, which is out of all proportion with the original injury. The affected limb can swell, change colour and change in temperature and, instead of reducing in time, the pain just gets worse. It can lead to weakness of the limb, ulceration of the skin, wasting tissue and bone thinning. The pain caused by CRPS spreads over time and may even develop in the opposite limb or in other limbs. Patients with CRPS most likely live with anxiety and depression because of the amount of high-level pain they are in 24/7.

CRPS is not a well-known condition, although awareness of it is increasing thanks to the national charities that work hard to support sufferers and to promote the need for treatment. Six months ago, I was not aware of CRPS, so I want to pay tribute to my constituent Victoria Abbott-Fleming, whom I have met. Victoria qualified as a barrister, but six months after a minor accident at work, at the age of just 24, she received a diagnosis of CRPS. The symptoms included a burning, severe pain in her lower leg, a freezing cold sensation, and a stabbing feeling that she said was like 1,000 ice picks pushed into the skin and bone. Victoria described it as like having petrol put through one’s veins and set alight. Her other symptoms included major swelling, hair and nail loss, hypersensitivity, temperature change and stiffness that prevented her from walking.

[Alex Chalk (Cheltenham) (Con)]

The hon. Lady, through her constituent’s experience, is painting a vivid picture of the pain. Does she agree that hearing accounts such as that of my constituent Helena Stone—she said it was like barbed wire being tightened across one’s leg—give an insight into the viciousness of this debilitating condition and make it all the more important that we raise awareness of it?

[Ruth George]

I thank the hon. Gentleman for his intervention. While we can listen to descriptions of the pain, we can never really have any idea of what it is like. The worst thing about CRPS is that the pain is not occasional and something that a person knows will get better—they know it may be with them for the rest of their life.

[Jim Shannon (Strangford) (DUP)]

I sought the hon. Lady’s permission to make an intervention before the debate.

Whenever I say in my office that I am in pain, my girls say to me, “You don’t know what pain is. If you had given birth, you would know what pain is.” The girls in my office tell me that chronic regional pain syndrome is even more painful than labour and giving birth, so I understand just how extreme it is.

We look to the Minister for support and help, as we always do—and we always get it, by the way. Does the hon. Member for High Peak (Ruth George) agree there is an onus on GPs to be more aware of the illness and to see how they can provide help in their surgeries? The Minister can give some direction to the NHS as a wee bit more needs to be done in surgeries and health clinics.

[Ruth George]

I thank the hon. Gentleman for his intervention, and I know that he has made inquiries and asked questions about CRPS over the years. All the sufferers thank every MP who raises the issue and helps them to feel that they have hope.

Apart from the physical and mental pain suffered due to CRPS, a severe part of the torture that my constituent Victoria experienced was the judgmental attitudes of medical professionals who did not understand or were not aware of the condition and the shame that she felt. She says, “The medical profession sometimes don’t believe your symptoms, or try to fob you off by saying, ‘Are you sure it is not in your head?’ or, ‘You look well. Are you sure you’re actually ill?’” Those problems are even worse now that we see children being diagnosed with CRPS, because children are often not believed when they say that they are in excruciating pain.

[Alex Chalk]

The hon. Lady is being extremely generous in giving way. My constituent experienced the problem of not being believed. Does the hon. Lady agree it is all the more galling that the NHS website recognises the condition and states that it is “poorly understood”? Does that not make the point that the situation needs to change?

[Ruth George]

The hon. Gentleman makes the pertinent point that CRPS is poorly understood, and that more understanding and awareness is needed from medical professionals.

After Victoria developed ulcers and total skin breakdown, she was told in 2006 that she needed to have her leg amputated above the knee at just 27 years old. Like many CRPS sufferers, she was unable to use a prosthetic limb because the prosthetic was too tight, pressing hard on the hypersensitive skin where she had had CRPS and inducing excruciating pain in her stump.

Victoria was left wheelchair-bound and unable to work as a barrister because many courts are completely inaccessible to wheelchair users, and because of her strong medication and her mental unwellness due to her situation. She pays tribute to her husband Michael, who saw her through the toughest of times and still supports her.

In 2014, Victoria received the even more devastating news that the condition had spread to her remaining leg, which she needed to have amputated. Amazingly, as a dual amputee, she has come through the experience and set up a national charity, Burning Nights, which offers support, understanding and explanation to CRPS sufferers. The charity offers a voice at the end of the phone, as well as very important advice when sufferers feel they cannot take any more.

The trouble is that we do not know how many people are living with CRPS. When I asked a parliamentary question, I was shocked to be told that the Department of Health and Social Care does not collect data on the number of people diagnosed with CRPS as it

“is not classifiable within the ICD10 clinical coding”.

That means that a box on an NHS computer cannot be ticked for CRPS. Various statistics have been suggested by the health profession and in the light of experience in other countries, but the most widely accepted figure is that there are about 26 people in 100,000 living with CRPS, which would equate to more than 15,000 sufferers in the UK. That means that CRPS does not even qualify as a rare disease but, as other hon. Members have said, many medical professionals have not even heard of it, let alone are aware of its symptoms and signs that would lead to diagnosis.

Too many patients are made to feel that they are making a fuss when they are actually in agony. That is not surprising, given that only 20 minutes during a medical degree concentrate on chronic pain—it is only 90 minutes for physios, who deal with people in pain all the time. Diagnosis takes an average of six months, but it may take even longer, especially for children, who are less likely to be believed when they are in severe pain. Once a diagnosis has occurred, it can take two years, or even three in some parts of the country, for a referral to a specialist pain clinic. I cannot imagine the pain of CRPS, let alone the added pain of knowing that nothing will be done to help for two or three years when every day, and especially every night, is agony—that does not bear thinking about.

Many treatments are effective only in the early stages of the disease, such as neuromodulation or DRG—dorsal root ganglion—treatment. Pain clinics usually offer medication and some physio for about six months, but sufferers are then usually discharged and told that there is nothing more that can be done. Unsurprisingly, they therefore may seek whatever they can, and in some cases that is amputation. I am afraid that private surgeons are offering amputations to people with CRPS at the knockdown price of £5,000 below the knee and £10,000 above it. People with CRPS are in such agony that they are prepared to undergo such an amputation because they think it may get rid of their pain. Unfortunately, as my constituent Victoria has told me, it does not, and often the pain does not go away. However, serious problems can arise when such amputations and major surgery are carried out by private surgeons. At the moment, the NHS picks up the bill for that. I very much hope that it will continue to do so, but this really makes the case that what we actually need is some hope, proper diagnosis and proper support, and a clinical pathway for people with CRPS that will see them through not only their diagnosis, but long-term and lifelong treatment.

I have various proposals for the Minister, as I am sure she was expecting. They are based on the parliamentary questions I have been asking over the past few months. The first and perhaps most important is for her to put that tick-box on the NHS computer so that we can collect data for CRPS diagnoses. Without data on diagnoses, it is difficult to make a proper case for research and for the increased training and awareness of the medical profession that is needed.

In response to my parliamentary question about research, the Minister said:

“The NIHR is committed to maximising the potential impact of research that it funds for patients and the public. Applications to NIHR for research funding are subject to scientific peer review, with awards being made on the basis of value for money, scientific quality and the importance of the topic to patients and health and care services.”

Unless we know the numbers of patients who are suffering, however, it is impossible to decide whether an application for research is value for money.

My second request is on the protocols for diagnosis. Yes, we need to raise awareness among health professionals, as other Members have stated, but we also need to introduce protocols such as the one used at Liverpool’s fracture clinic. CRPS is common after a fracture, and at Liverpool the limb is checked after a plaster cast comes off if it looks unusual, or if unusual pain is reported. In that way, a diagnosis can be made early.

My third request is for an increase in the capacity of pain clinics. It is not acceptable that people have to wait an average of two years, and up to three years, to get the support that they so desperately need. That would probably help to address my fourth request, which is for mental health support for CRPS sufferers, with a 24-hour helpline—the pain is particularly excruciating at night—to help them to get through without feeling that they have to resort to amputation or even suicide.

My final request is for the Minister to meet my constituent, Victoria Abbott-Fleming. In spite of the difficulty involved in travelling with her condition, she has come down from Derbyshire to hear the debate. She has done so much to support and fight for other sufferers. CRPS is not a diagnosis that we would wish on anyone, and I hope that the Minister can offer some hope to its thousands of sufferers.

[The Minister for Care (Caroline Dinenage)]

I congratulate the hon. Member for High Peak (Ruth George) on securing this debate on such an incredibly important issue. She has articulated quite beautifully the hell that people suffering from complex regional pain syndrome go through. The only thing that I can even slightly identify with is the pain of childbirth, but even after that it is unimaginable for us to conceive of the sort of day-by-day endurance and the relentless pain that people suffer. It is a devastating condition and can lead to an overwhelming impact on sufferers and their families, so I thank the hon. Lady for bringing this subject to the House.

The potentially extreme nature of the condition and its symptoms, some of which the hon. Lady described—the excruciating pain, burning, swelling and skin discolouration —can be totally disruptive to everyday living and destroy a person’s quality of life. She spoke very movingly about her constituent Victoria Abbott-Fleming, whose story is incredibly upsetting. I very much forward to meeting Victoria and assuring her that I will do everything I can to move forward on the issues that the hon. Lady mentioned. In circumstances in which extreme decisions have to be considered, high-quality care and support can sometimes make a huge difference to someone’s experience of our health and care services.

I hope that, as I am sure the hon. Lady intended, this debate will help to raise awareness of this very debilitating and extremely painful condition. It has actually been recognised as a medical condition for around 150 years, but problems remain with the diagnosis of CRPS in its very earliest stages. Diagnosis involves excluding a lot of other more common conditions—such as infection or things like rheumatoid arthritis—that can have similar symptoms, and the causes remain largely unknown. Precipitating factors can include injury or surgery, but there is no relationship to the severity of trauma and the development of the pain. In some cases, there is no precipitating trauma at all. It is considered likely that because of the complex nature of the condition, there is absolutely no one single cause. That means that it is difficult to estimate how prevalent CRPS is, as many cases may not have been correctly diagnosed in the first instance.

To improve public awareness, the NHS Choices website provides comprehensive advice on the causes, symptoms and treatment of CRPS. In addition to that, various charities work in this area. The hon. Lady mentioned Burning Nights, which was set up by her incredibly brave constituent; if someone is in unimaginable pain, I can only imagine what a comfort it is for them to be able to speak to or hear from somebody who has experienced it themselves. The charities do great work to support not only the patients who have the condition but their families.

As the hon. Lady says, general practice is where patients with CRPS are most likely to be seen in the first instance. CRPS is a key part of the GP curriculum; it is identified as a key area of clinical knowledge in the Royal College of General Practitioners’ applied knowledge test content guide. The test is a key part of GPs’ qualifying exams, and it ensures that they have the knowledge needed to work as a GP in the NHS.

To improve identification and management of the condition, in 2013 the Royal College of Physicians published best practice guidance for clinicians on the diagnosis, referral and management of CRPS. This guidance was developed with the involvement and endorsement of 21 key organisations involved with the care of people with CRPS, including the Royal College of General Practitioners, the British Orthopaedic Association, the British Pain Society, the British Society for Rehabilitation Medicine and so on.

The guidance, as the hon. Lady says, recommends prompt diagnosis and early treatment. This is to avoid the secondary physical problems associated with disuse of an affected limb and the incredible psychological consequences of living with undiagnosed chronic pain. It has been shown that an early referral to physiotherapy, for example, and encouraging gentle movement as early as possible, may prevent progression of the symptoms. Patients with CRPS are generally best managed in specialist pain management clinics.

[Ruth George]

Will the Minister look at the proposal to set up protocols in fracture clinics and clinics where carpal tunnel surgery is performed? Prevalence of CRPS following such surgery or an injury is particularly pronounced.

[Caroline Dinenage]

I will certainly look at that.

The hon. Lady mentioned delays in referral to a pain clinic, which is something that concerns me. Waiting times should be about 13 weeks once a GP has referred someone, but, as she says, some people wait longer. NHS England commissions the highly specialised pain management services for adults and children, and we will raise the issue with it. The National Institute for Health and Care Excellence has also published guidance for the pharmacological management of neuropathic pain, which includes CRPS. The guidance was updated earlier this year to reflect the latest available evidence.

Patients with CRPS will usually be managed through routine access to primary or secondary care. For patients with the most chronic and intractable pain, a referral can be made to a highly specialised pain service, commissioned by NHS England. Here, patients can receive multidisciplinary expert care and specialised treatment. Once diagnosed, patients can expect access to a range of other healthcare professionals for support and on-going treatment. This includes physiotherapists, occupational therapists, neurologists, a psychologist to help with the associated psychological problems caused by living with CRPS, and other healthcare professionals trained in pain relief.

The hon. Lady spoke about research. The National Institute for Health Research welcomes research funding applications for any aspect of human health, including CRPS. The CRPS UK clinical and research network was established in 2006. It is a research collaboration between a number of UK NHS trusts and academic institutions with an interest in the disorder. Its primary aim is to raise awareness and understanding among health professionals, patients and the general public. This year it is 10 years since the network established the CRPS registry, which now holds over 500 records and contributions and has contributed to seven different national and international research studies.

I thank the hon. Lady again for bringing this important debate to the House. I have attempted to answer as many of her questions as I can, but I will come back to her with anything that I have not covered. I hope that the debate has been helpful in raising the profile of this very difficult and distressing condition.

Question put and agreed to.

Oral Answers to Questions

Ruth George Excerpts

Tuesday 8th May 2018 Commons Chamber

[Steve Brine]

I am not close to that issue, but I am told that we have some excellent candidates, and I think that my hon. Friend will be pleased.

[Ruth George (High Peak) (Lab)]

The most important service that stroke patients need is priority in getting to hospital for the treatment they need. A patient in my constituency recently had to wait five hours for an ambulance, with a GP sitting next to her begging the service to send one. East Midlands Ambulance Service has now had a review and will be getting an increase in its funding, but can that be made faster over the next two years?

[Steve Brine]

The new ambulance standards are designed to do exactly that. I note the hon. Lady’s welcome for that in her area. That is critical, but of course it is critical that people get to the right place and get the right treatment. That is why I said at the start of these exchanges that centralising stroke treatment is not always popular but is often the best thing for clinical outcomes.

Social Care Provision and the NHS

Ruth George Excerpts

Thursday 3rd May 2018 Westminster Hall

[Dame Cheryl Gillan (in the Chair)]

Unfortunately, the hon. Member for High Peak (Ruth George) was delayed, but I have taken advice and now that she has arrived, I think it is in the interests of the House and all hon. Members present if we proceed with the debate.

[Ruth George (High Peak) (Lab)]

I beg to move,

That this House has considered the effect of social care provision on the NHS.

Thank you, Dame Cheryl. I was moved to initiate this debate by the experience that I had just after Easter, when I spent a 12-hour shift with colleagues in the ambulance service based at the depot in Buxton; they are trained and very experienced paramedics. I have had a lot of cases involving constituents who have been concerned about ambulance waiting times—the time that it takes ambulances to get to patients in our very rural area—so I spent a day with staff to see what the pressures were.

I expected those pressures to be on the NHS, but what I found from spending a day with the ambulance service and the excellent and hard-working crews, who said that it was not in any sense untypical, was that we spent the day going around seeing elderly patients in their own homes. They might have had family carers or received occasional visits from professional, paid carers, but they were left on their own for a lot of the time. They often had ongoing health conditions that flared up from time to time and caused them and their carers great concern, and that would escalate to calling out an ambulance. I therefore spent a lot of the day sitting in the back of an ambulance and talking to elderly patients. That was quite a pleasant way to spend a day—I like talking to older people and have helped with care for my own family—but it is not really what we want our paramedics to be doing.

I receive calls from constituents about their family members who have to wait in dire circumstances at times. In one recent case, an elderly lady had had a stroke. The GP was begging for an ambulance to come to her, but it took five hours for it to get there. Unfortunately, that lady subsequently died. We cannot say that that was because of the delays in the ambulance arriving, but a lot of time is taken up by ambulances travelling around to elderly and isolated people, and that is happening more and more.

Age UK says that there has been an increase to about 1.2 million in the number of people who need care but whose care needs are not being met. It is a vicious circle, which ends up impacting on our NHS. The winter crisis seems to be going on and on. There are almost 4 million people on hospital waiting lists. Every week at my constituency surgeries and coffee mornings, I see constituents who are waiting for treatments such as hip replacements. I saw a lady in Buxton who had been waiting almost a year for a hip replacement. She used to be an avid walker of the countryside, but now is practically housebound. That has obviously impacted on her quality of life.

There are also waits to see a GP. We have gone from waits of 48 hours, as a maximum, eight years ago to waits of two weeks now. People have to book an appointment some way ahead; and often, if people phone any time after about 8.20 in the morning, the surgery will say that it has no appointments left, even for two weeks’ time. People have to say that it is an urgent case in order to be seen and then they are seen more quickly. The situation is impacting on GPs as well.

In accident and emergency departments, only 85% of people are seen within four hours. At my local hospital, Stepping Hill, patients are queuing on trolleys in the corridors and are given a bell to ring if they feel that their condition is deteriorating, because there are just not enough staff even to keep an eye on them. The staff rely on patients themselves being able to give an alert if they feel that they are in urgent need of care.

I saw the impact of the long ambulance waits in A&E. They are backed up, sometimes seven at a time, outside our hospitals while they wait to be able to discharge patients. The staff now face an overtime ban, despite the great demands on their service. Even two weeks into the financial year, they were already banned from overtime, so young trainee paramedics are staffing ambulances on their own at night, which is not what I want to see in my constituency and not how we should be treating the staff.

BBC 2’s “Hospital” programme showed what is happening in A&E at the moment. We saw a frantically overstretched service and every hospital bed full, but staff estimated that 80% of the patients should not actually have needed a bed; they should have been in social care. This comes back to the cuts in social care.

According to the Association of Directors of Adult Social Services, £6.3 billion has been cut from social care budgets. Nationally, 400,000 fewer people are receiving social care, more than a quarter less than in 2010, despite increasing demand. In Derbyshire, my county, the number of people needing care has risen by more than one quarter, from 32,000 to 40,000 people.

Social care cuts do not make good television, though. They are invisible to the outside world. Patients are not lined up, queuing on trolleys. No one could really make a drama about it, but it is a crisis in the homes of the 1.2 million people who need and are waiting for care and cannot get it. We see that crisis only when we step inside the NHS, with paramedics or GPs who have to visit those elderly patients or in A&E departments. Then we see the people who are falling through the gaps in social care. That is echoed in my own constituency, where one of the GP surgeries tells me that 19 patients in one small town are on a waiting list for a care package. They are either in hospital, taking up a hospital bed, or at home with family carers, who are struggling to cope.

Palliative care is particularly difficult. At the end of life, patients typically need four or five short visits a day. Particularly in a rural area, that is very hard for our care services to cope with in the way they are financed and paid for. The lack of palliative care means that patients are stuck in hospitals where they are often many miles away from their loved ones. In a tragic recent case, one of our GP surgeries told me about an elderly gentleman crying to the GP because he had never been separated from his wife before. They were both in their 80s. She was terminally ill in hospital and he could not get to see her. That GP surgery pulled out all the stops. It got its district nurses to go in and allow that lady to go home for the final few days of her life. However, they cannot do that for every patient. The NHS simply does not have the resources and it impacts on other patients it needs to see.

The surgery in Hope in my constituency in the rural Peak district tells me that patients are being cared for in the community by relatives much more than used to be the case. That is good for the individuals in many ways. That is where they want to be. However, it puts more strain on GPs having to visit more frequently those patients with more complex needs. A poll by MediConnect in 2010 found that almost nine in 10 GPs believe that the reductions in social care are leading to extra pressures on their surgeries, which is leading to extra pressures on GPs. Buxton is seeking to fill six GP vacancies out of a total of 12 across the town. That is not sustainable.

That also leads to extra pressure on A&E departments and increased delays in discharges from hospital. In 2016-17, there was a 12-month average of 188,000 days of delayed care, which is 73,000 more than the four years from 2010 to 2014, when the situation was fairly stable. The King’s Fund has estimated that patients waiting for a care package in their own home accounted for the largest number of delays—in other words, more than 20% of all delays in discharge.

The cuts to social care are creating more expense for our NHS, but it would be cheaper to resolve such cuts. The NHS spent approximately £168 million on delayed transfers of care for patients awaiting a home care package in 2015-16. That could have funded more than 5 million hours of home care in that year—431,000 hours a month or nearly 15,000 hours a day—helping thousands of patients to stay in their own home with the care they need.

The Multiple Sclerosis Society has done a lot of work on the issue, because sufferers of MS frequently need care but a lot of that need is not being met. It says that in 2015-16, emergency hospital admissions for people with MS in England cost the NHS a total of £46 million. A large proportion of that emergency care was for problems that could have been avoided with proactive, preventive care, and earlier diagnosis and intervention in the community. For example, 14% of emergency admissions were for urinary tract infections, costing more than £2,500 per patient, which could have been avoided.

The reductions in social care are not simply down to Government cuts, hard as they have been for local authorities to sustain. There have also been huge increases in demand of more than 25% in the past eight years. The cuts to local authorities—they are gradually cutting the amount paid to care homes and to carers who provide care to people in their homes—are having a detrimental impact on the whole sector. It is really coming to a crisis point. A 2017 survey of directors of adult social services found that 39% had home care providers ceasing to trade in the previous six months and that 37% had contracts handed back.

My constituency of High Peak has real difficulty recruiting staff to work in care services. The staff do an absolutely fantastic job, but the pay is very low. Over half of staff nationally are on zero-hours contracts. Particularly in expensive rural areas, such as the Peak district, one cannot afford to live on the wages of a care worker. Ironically, however, there are more and more elderly and infirm people in those areas. In High Peak, our volunteer services run a professional, not-for-profit care service arm, but it is operating at a loss and has to cross-subsidise its care services from other services, which it cannot afford to do much longer.

This is a particular problem in rural areas. Patients are scattered, meaning more travel time and extra costs for companies. Our private care companies, the agencies, cherry-pick the areas they will cover, so they avoid the very rural areas, which cost them far more in mileage and travel time. A Rural England report found that rural councils pay 13% more on average than predominantly urban councils, but they still report more problems in commissioning services. Several home care businesses commented that they did not feel that councils paid enough and that was reflected in the handing back of contracts. Everyone says that council providers are needed, which would not cherry-pick based on areas that are profitable.

Even though Derbyshire is one of the few areas where our Labour-run council kept on directly employed care staff on the proper living wage, it cannot recruit enough staff, so we have to rely on agency staff. There are about 90,000 vacancies across the country for agency social care staff. They are at an absolute premium and our local jobcentres are always trying to recruit people into care jobs, but it is not for everyone. It is a difficult, often gruelling job, both physically and emotionally. It pays very little. Care workers often have to be able to run their own car and find their own way around. They have to like older people—the patients. That is a hard thing to do, particularly if they are caring for a parent or have other caring responsibilities. It is a lot for anyone to take on. It is no wonder that the turnover of care workers is running at nearly four in 10 every year.

Funding cuts are now having a detrimental impact on care quality as well. One in five adult social care services received the poorest overall ratings from the Care Quality Commission and almost one quarter of services had the poorest ratings for safety. Some 22% required improvement and 2% were deemed inadequate. The Government, however, do not seem to be seeking to tackle those problems of quality. Skills for Care, the skills organisation for care services, has a budget of only £21 million, or £14 per care worker, whereas Health Education England has a budget of £4.6 billion. The National Audit Office criticised the Government for failing to have an up-to-date workforce strategy for the care sector—the last work- force strategy was produced in 2009, under a Labour Government.

Last November, the Competition and Markets Authority did a study of care homes, which stated that, in general, care homes are struggling. Local authority-funded homes, which are now very much in the minority, cover their operating costs but not their total costs. That suggests that while those care homes may be able to operate in the short term, they may not be able to undertake future investment to update their existing capacity, prevent closure or increase their capacity for local authority-funded residents. The Salvation Army runs excellent not-for-profit care homes, including one in my constituency. When I visited the home over the Easter recess, the increasing gap between the rate paid by the local authority and the amount it costs to run a care home was highlighted to me.

All those cuts impact on the NHS and then the NHS cuts, as part of a vicious spiral, impact back on social care. As I have said, our own north Derbyshire clinical commissioning group is £24 million in the red, a huge sum for a relatively small CCG. It has been taken into special measures by NHS England and cuts are being imposed. Our specialist dementia care assessment unit has closed. The support that went to the families and patients who went into that ward on an ongoing basis is no longer there. The staff who were at threat of redundancy had a huge number of skills in adult mental care, mental health service care and specialist dementia care. The respite beds on that ward have also closed. One patient with early-onset dementia was managing at home, with one week in six of respite for his wife, but he now needs full-time nursing care, as his wife cannot cope at home without that week of respite.

Rehabilitation beds are no longer a halfway-house option, because they are being closed as well. Even worse, patients are being sent home from acute care without a care package in place. Many end up with infections or have a downturn in their condition and end up back in hospital unable to cope. It becomes a spiral that impacts on family carers at home.

Carers are struggling. They do an incredible job. The Carers Trust estimates that there are 5.5 million unpaid carers in England and 2,300 in High Peak alone. People do not often meet carers who are caring for someone with a long-term condition, because they are isolated. When I visit the GP surgery or the hospital with my family, I can sit down and talk to some of the carers about the isolation that they experience and how difficult it is because they cannot stop, because they love the person they are caring for and feel that they have no other option.

Some 61% of carers report having a long-term health condition. They are more likely to report problems with depression, pain and mobility, but they do not attend their own health appointments. The Carers Trust found that 57% had cancelled or postponed a health appointment because their caring role took precedent over their own health. It is no wonder that 81% of older carers surveyed said they felt lonely and isolated.

The Government are looking to do more work on carers, and have commissioned studies such as the 2014 Department of Health impact assessment, which estimated that spending an extra £300 million on carers in England would save councils £430 million in replacement care costs and would result in “monetised health benefits” of £2.3 billion. Each £1 spent on supporting carers would save councils nearly £1.50 in replacement care costs and benefit the wider health system by nearly £8. However, the money to put into those services and to make that sort of investment is not there, because the NHS, social care and local authorities are firefighting. Of course, the greatest impact is on the patients who do not receive the care they need and are left isolated, confused and sometimes in pain.

The MS Society says that one in three people living with multiple sclerosis do not get the support they need with essential everyday activities such as washing, dressing and eating. That has an adverse impact on their physical and mental health, resulting in a greater reliance and increased pressure on the NHS, which already faces significant financial and demographic strain. I hope hon. Members can see that it adds up to a vicious circle of lack of investment and funding and constant cuts. People who provide services are trying to do their best with what they have, but constant cuts in one area are offset by the other; cuts in social care lead to an increased reliance on the NHS, while cuts in NHS services lead to huge extra costs for long-term care in nursing homes or by carers.

I am pleased that the Government have combined health and social care into a single responsible Department, but until councils and the NHS are not simply trying to drive down costs to meet their savings targets by offsetting against each other, and until we have combined budgets at a local level, the vicious circle will not end, and the problems for patients and their carers, and the strain on the health service as a whole, will not end either. I hope the Government will listen and take action.

--- Later in debate ---

[Caroline Dinenage]

The hon. Lady has a surprise coming—this action plan is signed by Ministers from across Government.

The hon. Member for High Peak raised cost pressures. We can all admit that local authority budgets have faced pressures in recent years. They account for about a quarter of public spending, so they have had a part to play in dealing with the historic deficit that we all know we inherited in 2010. That means that social care funding was inevitably impacted during the previous Parliaments. However, with the deficit now under control, we have turned a corner.

Thanks to a range of actions taken since 2015, the Government have given councils access to up to £9.4 billion of more dedicated funding for social care from 2017-18 to 2019-20. Local authorities are therefore now estimated to receive about an 8% real-terms increase in access to social care funding over the spending review. In Derbyshire, the hon. Lady’s local council has seen an increase of £33 million in adult social care funding from 2017-18 to £201.8 million, which is above the 8% figure—it is a 10.3% increase on the previous year. The Care Act 2014 places obligations on local authorities and the extra funding is designed to help them meet those obligations.

[Ruth George]

I did not want to turn the debate into a political tit-for-tat, but I do not want my constituents in Derbyshire to think that suddenly there is a £33 million increase and everything is rosy for social care. The council has seen its funding cut by £157 million over the past seven years. Unfortunately, that increase is a drop in the ocean. In particular, the rise in the cost of the living wage impacts on care costs. What the council is getting back is nothing like what it has lost.

[Caroline Dinenage]

I have already recognised the fact that all local authorities have had to make some really tough decisions. We know it has been difficult for everybody. Taking that action to control the deficit and get the country’s finances under control has meant that we have turned a corner and we are now beginning to put that funding back in. I do not think we can deny that there were years that were very difficult for all local authorities. There is dedicated funding in adult social care; the funding goes to a specific cause, which is really important, and allows local authorities to support and sustain a more diverse care market. It also goes on to help relieve pressure on the NHS, including by supporting more people to be discharged from hospital as soon as they are ready.

The money is already beginning to have an impact. Delays of transfers out of hospital due to adult social care hold-ups have reduced by more than a third over the past 12 months, freeing up 820 beds. A key tool in developing more and better out-of-hospital services is the better care fund, which is a mandatory, national programme for integrating health and social care. It joins up services so that they are designed around people’s needs, enabling them to manage their own wellbeing and to live as independently as possible. By mandating the pool of funds, the better care fund has helped to join up health and care services and incentivise local areas to work better together with increasing amounts of funds being used in that process. Some 90% of local leaders have reported that the better care fund has helped them to progress integration in their areas.

We know that the burden of care cannot and should not continue to fall simply on hospitals. We need to move care into the home and into the community. There are great examples of how that is working in practice up and down the country. Public Health England, the Chief Fire Officers Association, the Local Government Association, NHS England and Age UK already have a joint working approach to establish how local fire and rescue services, for example, can be commissioned to check on people in their homes, to check on the safety of people’s homes, and to check on things such as trip hazards—all things that can lead to people being admitted to hospital or needing the support of social care services. They work together to encourage joint working around intelligence-led early intervention and, in doing so, reduce preventable hospital admissions.

Evidence has indicated that longer hospital stays for older patients can lead to worse health outcomes and an increase in their care needs on discharge. We know that for a healthy older adult, 10 days of bed rest leads to a 14% reduction in leg and hip muscle strength and a 12% reduction in aerobic capacity, which is the equivalent of 10 years of their life, which is a massive incentive to make sure we get people back into their own homes and active as quickly as possible, in the interests of their own wellbeing.

I am particularly interested in understanding how intermediate care—step-up and step-down services—can reduce the impact of health crises on individuals. A relatively minor infection or a temporary worsening of a chronic condition should never spiral into a prolonged hospital stay with a detrimental impact on long-term quality of life. The real goal of integrating health and social care is not simply a benefit to the system, but an emphasis on person-centred care. We need multi-disciplinary teams working around a person to maximise the effectiveness of interventions, and therefore minimise disruption to the individual.

The hospital to home programme brings together practitioners across health and social care to develop solutions for more patient-centred care, focusing on how to keep people at home. It shows how urgent and emergency care services, community services, primary care and social care can all work together to make sure that people get the right care at the right time and, crucially, in the right place. That partnership goes through everything that local partners do, whether providing interlocking services or commissioning the right pattern of services.

How can we push forward these aims and create a sustainable settlement for social care? In March, the Secretary of State for Health and Social Care outlined seven principles for the Green Paper on care and support and for adult social care reform, and he put a key focus on the need to integrate services around the individual for a seamless, whole-person approach to both health and care. We have committed to publishing the Green Paper by the summer, and when it is published there will of course be a full public consultation, through which we want to seek the broadest possible range of views. I look forward to the contributions of Members under that national discussion.

--- Later in debate ---

[Ruth George]

I will not take up that much of hon. Members’ time, but I will thank Members who have contributed to the discussion. I am pleased to have had the opportunity to have this discussion today—thank you, Dame Cheryl, for allowing me to do so. I hope it opens the door to looking more broadly at the impact of health and social care services on one another, and on patients and their carers.

[Dame Cheryl Gillan (in the Chair)]

I am most grateful to the Clerk for his advice in Westminster Hall today. I am very glad that we were able to have the debate.

Question put and agreed to.

Resolved,

That this House has considered the effect of social care provision on the NHS.

Oral Answers to Questions

Ruth George Excerpts

Tuesday 20th March 2018 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (Steve Brine)]

We are already delivering an ambitious plan to address childhood obesity, including taxing sugary drinks and helping children to exercise more, but we need to keep a close watch on this. We have taken the first few steps in a long race, and we are always looking to learn from successful initiatives elsewhere. Last week I was in Amsterdam looking at the system-wide approach there, which has led to very impressive reductions in child obesity. We should be listening and we are.

[Ruth George (High Peak) (Lab)]

T2. Head- teachers in my constituency tell me that they are asked by the child and adolescent mental health services to prove that children have tried to commit suicide before CAMHS is prepared to accept a referral. The Minister has just admitted that less than half of children who are referred are treated, and that under the new plans less than two thirds will get treatment. There is so much rationing going on. Will the Secretary of State please commit to improving the amount of ring-fenced funding now?

[Mr Hunt]

That is totally unacceptable, which is why we announced a £300 million expansion of CAMHS in the autumn. CAMHS funding went up by 20% last year. We are specifically trying to end precisely the situation that the hon. Lady mentioned, whereby people are told that they are not yet ill enough to get treatment. We have to put a stop to that.

East Midlands Ambulance Service

Ruth George Excerpts

Wednesday 21st February 2018 Westminster Hall

[Ruth George (High Peak) (Lab)]

I beg to move,

That this House has considered the performance of East Midlands ambulance service.

It is a pleasure to serve under your chairmanship, Mr Davies. The ambulance service is the glue that holds our health service together, and it does an incredible job. I have heard some harrowing examples in recent weeks of ambulance waits, but I want to start by putting that into context. Last October, my constituent Vinnie fell down stairs in the early hours and hit his head so hard that his heart stopped. The 999 call handler talked Vinnie’s partner Jo through cardiopulmonary resuscitation to keep him alive until the ambulance arrived 15 minutes later. That crew literally saved his life. Vinnie and Jo want to say thank you to those people, but they do not know their names. On behalf of Vinnie and Jo and everyone for whom our ambulance services have done amazing things, thank you.

Ambulance crews do amazing things every day, but they are struggling, especially in the east midlands. Our response times have consistently been below the average and near the bottom of the regional tables. In January, the east midlands came ninth out of the 10 regions in responses to category 1, 2 and 3 calls. On category 2 emergency calls, which have a target average response time of 18 minutes, East Midlands ambulance’s average was 37 minutes—more than twice as long.

[Sir Edward Leigh (Gainsborough) (Con)]

We used to have a Lincolnshire ambulance service, which I thought provided a very good service, but we were told that the way to get a better service was to regionalise and effectively centralise. We now find that many ambulances are taken off to Leicestershire or Nottinghamshire—no doubt for a good cause—and they do not come back to Lincolnshire. Does that not underline the need for localism and local services run by local people?

[Ruth George]

To be honest, when I was at East Midlands ambulance HQ, the waiting time at Lincoln hospital was seven hours for patient handover. Unfortunately, in those situations ambulances are diverted to where patients who need help urgently can get the care they need. Part of the problem is the handover times, particularly at Lincoln.

The longest 10% of urgent responses took more than 82 minutes, which is twice the target of 40 minutes. For category 3 urgent calls, 10% of East Midlands calls took more than three hours 22 minutes against a target of two hours. In practice, that means that people who are very seriously ill or in pain are waiting hours and hours for an ambulance. My constituent, Debbie, contacted me on Saturday night at 10 o’clock. Her 82-year-old mum had a hairline fracture of her hip. It had not been diagnosed, and suddenly her mum found herself in excruciating pain and unable to move. Despite calls to 111 and then 999, there was simply no ambulance available.

It was only when Debbie called at midnight and said that her mum was passing out of consciousness due to exhaustion and pain that the call was upgraded to category 2 and the ambulance arrived 20 minutes later. By then her mum had been waiting in agony for more than nine hours. The ambulance crew apologised, but they had been on more urgent calls the whole time. Debbie and many other constituents have contacted me to ask, “Why is this happening?”

A few weeks ago, I visited the ambulance control centre at Nottingham to see the management of East Midlands ambulance calls across the whole region. It was a Friday lunchtime, but even at that time the emergency calls and urgent calls were stacking up. I listened in as people were calling back to find out how long an ambulance would take. Health professionals, families, neighbours and shop assistants were all caring for someone who was seriously ill and needed an ambulance. They were undergoing hours of pain, worry and uncertainty.

From that experience and from speaking to local paramedics and East Midlands ambulance managers, it seems that there are four key reasons for the issues. The first is our geography. East Midlands ambulance covers a huge area, from the border of Manchester in my constituency to the shores of Lincolnshire. It has the second lowest population density in England after the south-west, but also the second-lowest investment in transport infrastructure after the north-east. It is not only a large region; it is hard to get around.

Secondly, when ambulances do get their patient to hospital, they encounter some of the longest waits for transfers. In 2015-16—the latest figures that we can obtain—only 44% of handovers in the east midlands were completed within 15 minutes, compared with 58%, on average, across England. This winter, handover times in some hospitals have got much worse. At my constituents’ local A&E at Stepping Hill, ambulances were waiting for more than three hours. At Lincoln hospital, it was more than seven hours. When vulnerable people are waiting in severe pain for an ambulance, to have them queued up outside hospitals unable to hand over their patients is incredibly frustrating.

The third issue is the level of demand. In the east midlands, the number of responses rose from 222,000 in 2011-12, to 335,000 in 2016-17—an increase of more than 50%.

[Melanie Onn (Great Grimsby) (Lab)]

I thank EMAS for coming to meet with the northern Lincolnshire and Lincolnshire group of MPs last year, when we were concerned about ambulance provision. Subsequent to that, paramedic Lee Hastie gave an account to the local Grimsby Telegraph about his experiences, particularly in relation to demand for ambulance services, saying that most of his calls on an everyday basis now relate to drug and alcohol abuse. Does my hon. Friend consider that cuts to local government drug and alcohol services have gone some way to increasing the demand on our ambulance services? They are essential services that, at a community level, simply are not there any longer.

[Ruth George]

I would certainly concur with that statement. It is one of many areas in which the lack of services at an urgent level is creating an increased demand—but in no way has East Midlands ambulance service’s funding increased to cover that level of demand, as we will see later.

Part of the increase is due to the 111 service. We saw the chaos that 111 created when the coalition Government brought it in to replace Labour’s NHS Direct with a much cheaper service with hardly any clinicians. Things have improved, but at busy times the 111 service still does not have enough qualified staff to make decisions, so the call-handlers have to be risk-averse, follow their script, and call out an ambulance if there is any doubt at all.

We have seen the number of 111 calls resulting in an ambulance call-out gradually increase from 100,000 in 2011-12 to 1.3 million across England in 2015-16. That is almost 14% of all ambulance call-outs going to people who did not request an ambulance in the first place—people such as my constituent Gemma. She suffered abdominal pain and called 111 for an out-of-hours doctor to come and see her. Even though Gemma told the call-handler that if she needed to get to hospital she would drive herself there, they still sent an ambulance to her. Gemma was diagnosed with gallstones, and next time she had an incident and needed pain relief urgently she again called 111 to tell them that she knew what the problem was and to ask for a prescription. Instead, they again insisted on an ambulance and would not accept a refusal. Gemma actually drove herself to A&E because she was so determined not to use ambulance time.

The ambulance service says that it is not allowed to reassess 111 calls that have been allocated for an ambulance response, so even if it expects that it is not necessary, it cannot use its expert clinicians to provide the telephone advice and decide whether an ambulance is really necessary. I will get on to the question of resources shortly, but besides resources, my local paramedics have asked whether the ambulance service can reassess 111 calls that it is given if it is in any doubt. I put that question, from them, to the Minister.

[Alex Norris (Nottingham North) (Lab/Co-op)]

I thank my hon. Friend for the very strong case that she is making; she is an outstanding campaigner for our region. Nottingham city MPs are very concerned about this issue; I am the only one present because my two colleagues are on other parliamentary business. We would like to see real evidence of the provider coming together with unions, clinicians and service users to try to iron out some of the issues that my hon. Friend is talking about. Does she agree that that would perhaps be a good way to manage better the resources that we have?

[Ruth George]

We can always seek to manage resources better, but East Midlands ambulance service has been seeking to manage resources for a very long time, working with Unison and the unions there.

[Karen Lee (Lincoln) (Lab)]

Does my hon. Friend agree that the closure of Lincoln’s walk-in centre, despite the fact that 94% of the people who responded to the consultation said that they did not want it to close, cannot fail to have a further impact on EMAS and local services? We are told by the clinical commissioning group that it will not have an impact and that there will be other provision, but the local ambulance teams—I will come to this point when I give my speech—told me that it will absolutely have an impact. I wonder what her thoughts are on that.

[Ruth George]

Walk-in centres were established by the last Labour Government to reduce the demand on the ambulance services and to give people the services that they actually needed on their doorstep. Every cut of every walk-in centre is hugely worrying, both for patients and the ambulance service.

[Dr Caroline Johnson (Sleaford and North Hykeham) (Con)]

Demographically, patients attending A&E, which treats accidents and emergencies, not anything and everything, are the very sickest patients, or those patients requiring treatment such as X-rays that cannot be delivered in centres such as a general practice. The review into the walk-in centre, as I understand it, and as it has been explained to me, was actually done by clinicians rather than politicians. The clinicians are telling us that it will not have an effect because, demographically, the patients going to the walk-in centre are those who are relatively well. If the walk-in centre was closed, they would be making their own way to the hospital, a general practice or a pharmacy, rather than calling 999.

[Ruth George]

The fact is that walk-in centres are open late in the evenings and at weekends, and in most GP practices it is not possible to get an urgent appointment without phoning at 8 am exactly. In my constituency, people have to wait at least two weeks to get an appointment.

[Karen Lee]

When I went out with the ambulance team, one of the people who called and got an ambulance was an elderly gentleman of 91 who had breathing problems. He called an ambulance because he could not get a GP appointment or get to the walk-in centre at that point. It is not always people who are desperately ill who call ambulances; lots of people call ambulances in sheer desperation because they cannot get anything else.

[Ruth George]

That illustrates the point completely. We have seen a lack of primary care services, and doctors’ appointments are far harder to get than the 48 hours it took under a Labour Government. In consequence, we have a hugely overburdened ambulance service.

Now we come to funding. East Midlands ambulance service is already one of the most efficient in all the regions. In spite of the relatively sparse population and demanding geography, EMAS’s costs per face-to-face response are the third-lowest of all the regions—9% lower than the average across England. The costs per call are, again, the third lowest and more than 10% below the average.

By any measure, East Midlands ambulance service is very efficient, with 99% of its staff working on the frontline. Almost all managers take shifts so that they know exactly what is going on. It has cut all that it can, and it has had to make cuts, because EMAS has the second-lowest funding of all the regions—8% lower than the average across England. Only the North East ambulance service, which serves a more densely populated area, has lower funding than the East Midlands ambulance service.

The funding has not kept pace either with inflation or with the increased demand—in fact, it has barely increased at all in the last six years. In 2010-11, EMAS received £160 million for patient care activities. By 2016-17, we had seen over 16% inflation and a 50% increase in activity. Funding should be at least two thirds higher—£105 million extra would be the proportionate cost. Instead, East Midlands ambulance service received less than £5 million extra compared with 2011. That is less than 3% extra funding when it needed 66%.

East Midlands ambulance service has never been well funded—our region has always been the poor relation, as colleagues on both sides of the House often concur—but the cuts over the last seven years have made it impossible for it to meet its targets, and to deliver the right standard of service and care to some of the most sick and injured people, and the most at risk. That is what the Nottinghamshire coroner concluded in May 2016. In an urgent case review, she said:

“Demand is clearly greater than the resources they have most of the time”.

That is not the fault of any of the staff at EMAS. Last summer, the Care Quality Commission found that although the service was in need of improvement, it was caring and responsive—but it could not be safe or effective. The report states that there were

“caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.”

The increased demand for primary care, emergency care and ambulance services is not being resourced. Our ambulance service is on the frontline. Our crews do their very best, but it is tough. Yes, staff sickness is slightly higher than average at EMAS, but I am not surprised. It is not just what the crews deal with; it is the constant stress and pressure, and the distress and anger that they sometimes face when they can finally arrive.

[Mr John Hayes (South Holland and The Deepings) (Con)]

The hon. Lady is making a very articulate and compelling case, but I think she would be the first to acknowledge that, while there may well be a resource challenge of the kind she described—she has already made that clear—there are issues around administration, management, process and protocols. She has already mentioned ambulances waiting outside hospitals for a very long time because they cannot or will not admit patients. Those are systemic problems, not just resource problems.

[Ruth George]

It might not be a resource problem at EMAS, although EMAS has been trying to fix that with staff put on especially to try to reduce the handover times at hospitals. A&E departments are struggling at absolute capacity. My local hospital had 97 A&E patients in need of a bed last weekend, and they had seven beds. The fact that the number of beds in the NHS has been reduced by 14,000 since 2010 is a resource issue. It might not be an EMAS issue, but it is very much a resource issue, and I put that to the Minister along with the issue of EMAS.

The situation is not fair on our ambulance crews. It is not fair on our patients. Our ambulance service is holding emergency care together. East Midlands is doing it with more pressure and less resources than almost anywhere else in the country. It needs support from us and it needs the resources to meet its targets. I call on the Minister to commit to that today.

[Several hon. Members rose—]

--- Later in debate ---

[Ruth George]

I thank all Members who have spoken from both sides of the House for the constructive way in which they have approached the debate and some of the constructive proposals that have been put forward. To the Minister, I say I am keen to look at the 111 service and how we can reduce those 1.3 million calls that come from 111 into the 999 service. I think that would be viewed as very helpful across the service.

On the geographical issues that have been mentioned, my constituency is High Peak, which is very rural. Yes, we take ambulances out of area to urgent and specialist areas, but we also get back. Sometimes, in rural areas in particular, such as Lincolnshire, where, as the hon. Member for Boston and Skegness (Matt Warman) said, 10 or 11 ambulances can be backed up outside a hospital, it can help to organise support on a regional basis. However, I will not go to the line on that.

It all comes down to resources at the end of the day, as we have heard. EMAS has put in more and more paramedics and squeezed the managers—7% of the 8% of the management staff are on the frontline anyway and do frontline shifts. Not only are they managers, but they are also frontline staff, so the managers know exactly the challenges facing the service. I hope we would all agree that that is needed across the NHS.

The debate has shown the pressures on not only the ambulance service but GPs, A&E departments and the NHS as a whole, and I hope the Minister will take that up across the board.

Oral Answers to Questions

Ruth George Excerpts

Tuesday 19th December 2017 Commons Chamber

[Mr Dunne]

My hon. Friend has worked tirelessly with his neighbouring colleagues in Essex to secure not only the £41 million to which he refers. In fact, that figure is a component of the £118 million capital allocation made to the Mid and South Essex Sustainability and Transformation Partnership area in the Budget. This will provide significant investment not only in his local hospital in Southend, as he as mentioned, but in Basildon and in Broomfield Hospital in Chelmsford. I am sure that he and his colleagues in Essex welcome that.

[Ruth George (High Peak) (Lab)]

My local clinical commissioning group in north Derbyshire has been placed in special measures by NHS England. It has been forced to cut £16 million over just six months and to bring forward the closure of the Spencer ward in Buxton before any proper alternative is in place due to a lack of funding. Does the Minister not agree that the Budget funding is too little, too late?

[Mr Dunne]

The hon. Lady will be aware that the special measures regime was introduced to help trusts that are having difficulty in meeting quality performance standards to improve their quality. They receive support from NHS Improvement in order to do that. If she would like to write to me with the specific details of her trust’s situation, I would be happy to take up the case. But as far as I am concerned, her trust is on an improvement journey.

Mental Health Units (Use of Force) Bill

Ruth George Excerpts

2nd reading: House of Commons
Friday 3rd November 2017 Commons Chamber

[Mr Reed]

I thank the hon. Gentleman for his very helpful intervention. The only way to go forward with the Bill is through consensus. I have made it absolutely clear to both Ministers sitting on the Government Front Bench that I want to work with them constructively in Committee, as they have worked with me so far, so that we can secure an outcome that is supported by both sides of the House and right across the profession.

This week, the chief executives of 29 mental health organisations published a letter urging Parliament to back the Bill. It is supported by the Royal College of Nursing, the Royal College of Psychiatrists, the Care Quality Commission, NHS England and trade unions representing staff who do such an incredible job working in the mental health services. I must add my thanks to the Minister, the Under-Secretary of State for Health, the hon. Member for Thurrock (Jackie Doyle-Price), for working with me so constructively; as well as my right hon. Friend the Member for Islington North (Jeremy Corbyn), who supported the campaign long before he became the Leader of the Opposition.

[Ruth George (High Peak) (Lab)]

I congratulate my hon. Friend on bringing forward the Bill. Seni Lewis was a young man who grew up in my constituency of High Peak. His cousin was telling me yesterday what a lovely young man he was, that he was never in trouble with the law, and what a loss to society he is. Does my hon. Friend agree that his family should not have had to fight for six years to get an inquest? Will he pay tribute to them for all they have done to make sure that this never happens to another family?

[Mr Reed]

I absolutely agree. There is an old line that justice delayed is justice denied. No family who have lost their child in these circumstances should then have to fight the state to find out what went wrong, or to secure a modicum of justice for what happened.

Before I continue, I want to put on record my thanks also to the Prime Minister, who has met the Lewis family on more than one occasion and who I know supports the objectives of the Bill.

I have come to know Seni Lewis’s parents, Aji and Conrad, very well over the past few years. They are two of the most dignified and inspirational people I have ever met, but they have suffered pain and anguish that no parent should ever have to face. When I asked Aji and Conrad what they hoped for after all they have been through, they told me that they do not want Seni’s death to be in vain. They do not want any other family to suffer as they have suffered. I say to this House now, and to his parents, that Seni Lewis did not die in vain. We can honour his memory by making sure that no one else suffers the way he did, and by making our mental health services equal and safe for everyone. I dedicate this Bill to Seni Lewis. This is Seni’s Law. I commend it to the House.

Oral Answers to Questions

Ruth George Excerpts

Tuesday 10th October 2017 Commons Chamber

[Mr Dunne]

The hon. Gentleman will be aware that private and independent providers of patient transport services provide services all across the country and support the ambulance services in that work. I will look into the case that he raises in relation to Bedford and write to him.

[Ruth George (High Peak) (Lab)]

All of the local dementia and rehabilitation beds in my rural constituency of High Peak are earmarked for closure. In some cases, patients and their families will have to travel 25 miles across the moors to Chesterfield. Given the importance of staff being able to work with families to support patients to return home, will the Minister agree to look again at such decisions, which make this work practically impossible?

[Mr Dunne]

The hon. Lady will be aware that the STP plans being considered for her area include providing more services in the community by community nurses and other nurses in our community hospitals being reassigned, which will allow them to undertake care for more patients than they can at present within community hospitals.

NHS Pay

Ruth George Excerpts

Wednesday 13th September 2017 Commons Chamber

[Chris Stephens (Glasgow South West) (SNP)]

As the Member of Parliament with the highest percentage of workers in public sector employment in the UK, I will be supporting the motion today in the name of the shadow Front-Bench team.

The Government’s public sector pay policy can best be described by the Glasgow word “guddle”. Translation: a tangled mess. The Government, seeking to deflect criticism, and no doubt as a direct result of tricky doorstep conversations in the election, yesterday announced a policy that was spun as ending the public sector pay cap. It was no such thing, however, and instantly attracted criticism from the very set of workers they were hoping to silence. The Prison Officers Association correctly pointed out that the so-called increase on offer would amount to a real-terms pay cut since inflation had just hit 2.9 %.

The title of this Opposition day debate is “NHS Pay”, and it is right that today there is a focus on a vital set of workers providing life-saving services, but I feel that the whole subject of public sector pay cannot be debated in a silo and in the context of one particular set of workers without reference to others. This week at the TUC conference, all the public sector unions came together in a collective call for parity and fairness in pay awards, not selective cherry picking.

I come from a public sector background and a trade union, Unison, that has always recognised that not rewarding and supporting public service workers properly is a political choice. It is a choice that the Government are trying to avoid being called out on, as from time to time token efforts are made to imply they understand and value public service. The Prime Minister told the Tory party conference last year:

“Our economy should work for everyone, but if your pay has stagnated for several years in a row and fixed items of spending keep going up, it doesn’t feel like it’s working for you.”

That sounds good, but it is at odds with the very heart of Conservatism and the shareholder mentality that puts pounds and profits before a public sector ethos. The privatisation of public services is a case in point. Turning public assets into private shareholdings, rather than investing in quality, and targeting public sector pay for quick savings is a hallmark of every Tory Government. I was a public sector worker under John Major’s Government when they, too, had a public sector pay cap.

We would not be having this debate if the Government really valued public service workers and recognised that although many could earn more in the private sector, they have chosen to contribute their skills to helping others. The systematic punishment inflicted on them year on year by a Government who have chosen to make public sector workers pay the price for the failings of the private sector when the economy crashed in 2008 is morally unjust and unfair and has tested their patience to the limit.

I strongly believe that cuts to public sector pay is an issue that affects everyone—not just the workers, their families and service users but the wider community and local businesses. Local economies suffer when wages are held down and jobs are lost, and given the scale of the money involved, this is also a national economic issue. The TUC has produced an excellent report, “Lift the Cap”, that outlines in detail the knock-on economic impact on local economies through wages being systematically depressed.

How can the national economic picture be anything other than bleak if hundreds of thousands of people are on a low-pay subsistence existence and struggling to afford the basics, never mind boost consumer spending, without plunging even further into debt? All the time the cost of living is rising and hitting low-paid workers hardest, especially on energy and transport costs. The question is not: can we afford it? I advocate turning that miserable ideological argument on its head to say that we cannot not afford it. Paying public sector workers properly works for everyone: it generates tax revenues, reduces social security spending and creates jobs in the private and voluntary sectors.

I am concerned about the Government’s direction of travel in making announcements on police and prison officer pay over that of other public sector jobs. There is a danger that they are targeting professions dominated by men and not dealing with those public services where employment is dominated by women. I would like to hear from the Minister how they plan to tackle that issue. There is a risk of the gender pay gap increasing if the Government do not get their public sector pay policy correct.

[Ruth George (High Peak) (Lab)]

I agree with the hon. Gentleman’s comments about the Government seeking to divide public services between those with more men and those with more women. That said, regarding the increase in police pay, an officer in my constituency wrote to me that it was only a 1% increase with a 1% bonus and that they did not get it on their overtime or shift allowances, and that it felt like another kick in the teeth, because it was being sold as 2%.

[Chris Stephens]

That is a fair point. Two years ago, three months after I was elected, I received a 10% pay increase followed by another uplift of 1.3% last year. As a trade unionist, I believe in a rate for the job and in accepting independent pay review processes, so I donated to local charities following the pay rise. It sticks in my craw, however, that there appears to be one rule for MPs and another for public servants. How much more must it offend my constituents?

Every Member who has spoken today against raising public sector pay while having accepted their own increase must have a different set of values, and they are entitled to their views. Equally, however, their low-paid public sector constituents are entitled to pass judgement on them, and no doubt they will draw their own conclusions. I say: lift the cap, lift it now and fund it properly.