Junior Doctors Contracts

Sarah Wollaston Excerpts

Monday 18th April 2016 Commons Chamber

[Mr Hunt]

Well, if planting a story in a newspaper is reprehensible, I do not think many Members of this House would survive the scrutiny of the hon. Gentleman’s very high code of moral conduct for long. Let me say this to him and to all Labour Members: we should be honest about the problems we face in the NHS, whatever those problems might be, and we should not sweep them under the carpet. One problem that we face—not the only one—is the excess mortality rates for people admitted at weekends. There was a time when Labour Members would have recognised that their own constituents were the people who depended most on services such as the NHS and who had the most to gain from a full seven-day NHS. Labour Members should be supporting us, not opposing us.

[Dr Sarah Wollaston (Totnes) (Con)]

We are eight days away from an unprecedented full walkout of junior doctors, including the withdrawal of emergency care. Our constituents want to know whether they will be safe on the strike days. Will the Secretary of State and the shadow Secretary of State join me in calling on the BMA at least to exempt casualty departments and maternity units from this walkout? We know that, even with goodwill arrangements in place to bring people back in when hospitals are overwhelmed, the delays will cost lives.

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 22nd March 2016 Commons Chamber

[Mr Speaker]

I call Dr Sarah Wollaston, the Chair of the Health Committee.

[Dr Sarah Wollaston (Totnes) (Con)]

Following the very welcome announcement of a graduated levy on sugar, sweet and drinks manufacturers, will the Minister please tell the House what discussions she is having with manufacturers to speed up the reformulation process and also to introduce a differential in price at the point of sale? Given the importance of childhood obesity, will the Department welcome the opportunity to take over the lead on this strategy so that we can make progress on this vital issue?

[Jane Ellison]

There are a number of invitations there, some of which I will resist. My hon. Friend is absolutely right to highlight the importance of this announcement. Obviously, it is the first step towards the Government’s comprehensive childhood obesity strategy, which we will be launching in the summer. The Chancellor of the Exchequer was absolutely right to go ahead with this and to move forward. The burden of childhood obesity, as she knows all too well, falls very, very heavily on poorer communities, and my right hon. Friend was absolutely right to champion that measure, because it will make the most difference in the poorest areas.

End of Life Care

Sarah Wollaston Excerpts

Wednesday 2nd March 2016 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

The care that people receive at the end of their lives has a profound impact, not only on them but on their families and carers. All Members of the House want people to be able to access the highest quality care, irrespective of their age, diagnosis, where they live or the setting in which they are treated. We know how to deliver world-class care—indeed, we know how to deliver globally inspiring care. To start on a positive note, I should say that The Economist ranks Britain as the best in the world, from among 80 nations, for delivering end-of-life care, and we should be proud of that. The disadvantage is that that care is not available everywhere to everyone, and that is the challenge we face today.

In the 2015 report “Dying without dignity”, the Parliamentary and Health Service Ombudsman set out some starkly worrying cases of poor care that highlighted a theme, and she was clear that it is a recurring and consistent theme in her casework. For that reason, the Minister must look carefully at the themes in that report, and also at other reports that have been produced.

At the end of the previous Parliament, the Health Committee produced a report on end-of-life care, and I thank all members of that Committee, the Committee staff and our Committee specialist advisors for their valuable input, as well as the very many people and organisations from around the country who contributed.

[Mark Tami (Alyn and Deeside) (Lab)]

Does the hon. Lady agree that we must also consider the families of those children who unfortunately have very short lives? We need support for them as well, and it should be available across the country.

[Dr Wollaston]

I agree entirely with the hon. Gentleman that this care should apply irrespective of someone’s age or the setting in which they are treated. Social care will be integral to that, and I will expand further on that issue later on.

Another report the Minister will be aware of—it was commissioned by the previous Government from the Choice in End of Life Care Programme board—is “What’s Important to Me. A Review of Choice in End of Life Care”. It is now exactly a year since that report was launched. When can we see a timetable and a response to that long-awaited report?

I know other Members want to speak, so I will just touch on four key themes today: variation, communication, choice and control, and funding—including funding for social care. On variation, dying does not make equals of us. People with cancer are currently accessing about 75% of specialist palliative care. We are making great progress in that regard, but we need to make such palliative care available to people with other diagnoses. Our report touched on poor access for elderly people, particularly those with a diagnosis of dementia. The Minister will be aware of the “National Care of the Dying Audit for Hospitals,” which showed that 21% of hospital trusts are meeting National Institute for Health and Care Excellence guidance for providing seven-day-a-week, face-to-face specialist palliative care between the hours of nine and five. In fact, only 2% of trusts are making that care available around the clock, seven days a week. We have a long way to go.

Tackling variation means understanding where the gaps exist. The VOICES survey, which collects the views of informal carers and evaluates the services available to them, has been invaluable in setting out the issues important to those who have been bereaved and the experience of their loved ones after a bereavement. A point that has been made to me very forcefully is that we could do so much better in addressing the gaps in provision if the VOICES survey was expanded. Currently, it does not have enough power to be able to identify where there is variation around the country. Will the Minister address that point when he sums up?

[John Redwood (Wokingham) (Con)]

I wonder whether my hon. Friend could give me some guidance. Ideally, when should end-of-life care begin? What sort of time period are we talking about and how much uncertainty is there over the diagnosis? There are all sorts of complications: we cannot be sure whether someone is terminally ill and is going to die within a limited number of days.

[Dr Wollaston]

My right hon. Friend raises a very important point. It should start as soon as possible—as soon as someone receives a life-limiting diagnosis. We need to start those conversations much earlier on. We need to get better at identifying, towards the very end of life, when people are in the final stages of an illness. I will touch on that point in greater depth in a minute.

We should recognise some successes and welcome the changes made by the Care Quality Commission, in one of its thematic reviews, to prioritise end-of-life care. Does the Minister have any plans to roll out that rather successful approach in prioritising end-of-life care to out-of-hospital settings? The CQC has highlighted successfully the critical importance of leadership in improving end-of-life care, examining how having a named individual—not as a tick in a box—translates into their leading change within the hospital and identifying other individuals there who can improve the quality of care at the end of life. Recognising it as a thematic review would be very helpful in other fields.

The critical importance of training has been raised by all those who have commented. We need to provide adequate training for medical, nursing and caring staff across the board. Has the Minister had any conversations with Health Education England about what progress can be made in rolling out further training?

On communication, which my right hon. Friend the Member for Wokingham (John Redwood) touched on, early identification will be crucial to rolling out end-of-life care to other groups beyond the traditional groups who access specialist end-of-life care. That means health professionals having the confidence and training to raise these issues at a much earlier stage and to start those difficult conversations that are too often put off.

We know that having an end-of-life care plan enables people to exercise much greater choice and control. We could go further in looking at explaining to people the differences between, for example, advance statements of wishes and advance decisions to refuse treatment. We could help people to put in place lasting powers of attorney, and nowhere is that more important than when people have been diagnosed with dementia. These conversations need, critically, to start at a much earlier point.

The sharing of communication between professionals is another issue. I know that the Minister has taken an interest in electronic care planning. When people have a life-limiting diagnosis, how can we ensure that at whatever point in the system they access care, they will not have to keep repeating their story? People’s wishes need to be understood at the earliest possible stage. We know that electronic care planning can help to reduce unnecessary hospital admissions. It is crucial for ambulance staff, for example, to have access to people’s records—with the patients’ consent, of course—so that they can be shared widely. Will the Minister update us in his summing up on what progress he has made with respect to electronic care planning and recording people’s wishes?

We can also improve communication by putting in place care co-ordinators. This point has been made to me repeatedly by people who are suffering from life-limiting illnesses. The system can sometimes appear to be terribly confusing, so allowing families to have a single point of contact to advocate on their behalf at a time when they are in distress can make a huge difference, as can having a named clinician who is taking overall responsibility for the care.

On care for people at the very end of life, the Minister will know that over the years we have much debated the Liverpool care pathway and its success. Other Members may wish to talk in greater detail about that, but emergency care treatment plans are important so that people can clearly document their wishes well in advance—not as a tick-box exercise, but as a considered exercise of having discussions with individuals and their loved ones about what their wishes are and then ensuring that they are respected. Will the Minister tell us where we are now with emergency care treatment planning?

At a time when people so often feel that they are losing control towards the end of their lives, it is vital to give people more choice and more control. That was the key theme of the so-called “Choice” review, on which I hope the Minister will update us. Where are we now with all who need it having a “national choice offer”, as it was termed? We know that about a half of the 470,000 people who died in 2014 died in hospital, yet we know from the VOICES survey that of those who expressed a preference, only 3% wanted to be in hospital. We are a long way from allowing people the kind of choice and control they want about where to be at the end of their lives. Most people would prefer to be at home, surrounded by their loved ones. We can do far better.

Many practical issues need to be addressed. One that I have seen first hand in my clinical experience is where families are exhausted and overwhelmed by caring responsibilities. Sometimes the individual at the heart of this will opt to go into hospital because they feel bad about the burden they feel, often wrongly, they are placing on their families. One key theme of our Health Committee report was that nobody should have to end their life in hospital for want of a social care package. That will mean being much more generous about providing free social care at the end of life, or much more rapid access to the assessments needed to allow people to continue in care, as they are sometimes very delayed. I hope the Minister will update us on that, too.

The Minister will be familiar with the work of the Nuffield Trust. Its report on the use of Marie Curie nurses, for example, pointed out that the service could save total care costs of £500 per patient and also allow many more people to be where they wanted to be at the end of their lives. Not only is the service good value for the overall health and care system, but it provides the choice and control that people desperately need and deserve at the end of their lives.

Funding lies at the heart of this issue, and it is not just a question of social care packages. I know the whole House agrees that we owe an enormous debt of gratitude to the hospice movement. Hospices play a pivotal role in outreach, providing specialist support not just for hospitals but, critically, throughout the community. Rowcroft hospice, in my constituency, is hugely valued in the community. It provides extraordinary levels of care and supplies many specialist services to the NHS to deal with—cases of lymphoedema, for instance. This week, however, it informed me that it faces a funding shortfall of £1 million next year. While about a third of its funding comes from the NHS, about 60% comes from charitable giving.

Hospices do not want to lose their link with the voluntary sector, because it is deeply embedded in the way in which they work in communities. However, it makes them rather vulnerable, because the level of charitable giving and legacies can vary greatly. What they need is a higher percentage of stable core funding to allow them to expand the important work that they do. The Minister will probably want to comment on the so-called currencies that are being developed to replace funding for palliative care. The feedback that I am receiving suggests that there is a risk that that will become a rather bureaucratic process, and there is also a worry that its implementation by clinical commissioning groups will not be compulsory. An update from the Minister would be helpful.

Will the Minister also assure us that, if the Government intend to implement all the recommendations of the “Choice” review—which I hope they do—he is satisfied that, across NHS England, the business plans that have been established will allow sufficient funding for a full implementation?

I know that other Members wish to speak. There are many other issues that I could raise, including bereavement support and research, but let me end by asking the Minister to be truly ambitious. I think that we can achieve seven-day, 24-hour access to specialist palliative care in all settings, and that we can address variation and give people choice and control at the end of their lives. It would be an extraordinary achievement for the Government to go further. We should not rest on our laurels because we are leading the world; we should say that we lead the world not just for some people, but for everyone.

--- Later in debate ---

[Dr Wollaston]

I thank all Members who have contributed to this debate and for making so many important points about how we can roll out the very best care and make it available to all of our constituents. I am disappointed that the Minister has not told us when he will respond to the “Choice” review, because it has been a year since its publication. As we have heard, a number of reports have set out what needs to be done. This is now the time for action and for the Minister to set out when it will take place.

Question deferred (Standing Order No. 54).

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

On a point of order, Mr Deputy Speaker. We have just concluded two days of debate on the Government’s estimates, but the estimated expenditure itself has not been debated. At 7 o’clock, we will be asked to authorise the Government’s spending plans for Departments of State—some £600 billion of public money—without there having been any debate whatsoever about them. How can that possibly be right, and what should Scottish Members of Parliament do now that we are effectively banned from voting on English-only legislation that may have a Barnett consequential? We were told that that would be considered in the estimates process, but we are not getting the chance—

Mental Health Taskforce

Sarah Wollaston Excerpts

Tuesday 23rd February 2016 Commons Chamber

[Alistair Burt]

I thank the hon. Lady for her usual well-informed contribution to the debate on these issues, and for what she says about stigma and the general approach the Government have been taking. She is absolutely right about that. We have supported the Time to Change anti-stigma campaign, which has had some success, although we have to do more.

The hon. Lady is also right about children and wider cross-government work. On children and young people, for the first time we have a Minister in the Department for Education in England who has responsibilities for mental health, and the Under-Secretary of State for the Home Department, my hon. Friend the Member for Staffordshire Moorlands (Karen Bradley) is here to demonstrate that we take those cross-government responsibilities very seriously. One way in which we are going to manage the response to the taskforce is by having a cross-governmental team to make sure that Departments are joined up. Housing has something to do with this, as do education and work and pensions, as the hon. Lady said. We will make sure that that is done.

I should have said, but did not do so for reasons of time, that what has been said by the taskforce and what the Prime Minister has said is in addition to the £1.25 billion announced in March for the development of the child and adolescent mental health services in England and the £30 million a year eating disorder work, in order to recognise the increased pressures on children. As the hon. Lady rightly says, the more prevention work that can be done earlier, the better.

[Dr Sarah Wollaston (Totnes) (Con)]

I remind the House that I am married to the registrar of the Royal College of Psychiatrists. I join the Minister in thanking the independent mental health taskforce for the work it has done. Will he go further on how we are going to track this money, with greater transparency, to ensure it is spent in the right place, not just within health, but within social care? He will know that many of those who are suffering from mental health problems are cared for in the community, under social care, and it is therefore vital that we have parity of esteem across both health and social care.

[Alistair Burt]

Yes, I thank my hon. Friend for that and recognise the work of the royal college. Its president, Simon Wessely, was also much involved in the report, as was the college, so I thank them for that. It is very important to track this money. The CCG assessment framework will help us to do that through the health service. The money that the Prime Minister announced in relation to community crisis care—the extra £400 million announced in January—will be spent throughout the community, and it is essential that we track it.

There has been a data lack; the hon. Member for Liverpool, Wavertree (Luciana Berger) knows about that well, because I answer far too many of her questions by saying, “This information is not collected” or, “This information is not collected centrally”. [Interruption.] I have noticed that. We are in the process of changing that situation; the dataset was in the process of being changed and more information will be available. In order to track things properly, we have to have the information available. The question is right and we are improving the data. It is important to track this, both in local authority work and in NHS work.

Junior Doctors Contracts

Sarah Wollaston Excerpts

Thursday 11th February 2016 Commons Chamber

[Mr Hunt]

I welcome the tone of the hon. Lady’s comments. I do not agree with everything that she has said, and I shall explain why, but they were immensely more constructive than the comments that we have heard from other Opposition spokesmen. She is right to say that the studies talk about mortality rates for people admitted at weekends. There have been eight studies in the past five years, or 15 since 2010 if we include international studies. She is right to say that we need to look at why we have these problems.

The clinical standards state that when someone is admitted, they should be seen by a senior decision-maker within 14 hours of admission. They will be seen by a doctor before then, but they should be seen by someone senior within 14 hours. The standards also state that vulnerable people should be checked twice a day by a senior doctor. Now, across the seven days of the week, the first of those standards is being met in only one in eight of our hospitals and the second in only one in 20. That is why it is important that junior doctors should be part of the group of people who constitute those senior decision-makers—consultants are also part of it—and that is why contract reform is essential.

The hon. Lady is right to say that this is also about nurse presence, and the terms that we are offering today for junior doctors are better on average than those for the nurses working in the very same hospitals, and better than those for the midwives and the paramedics. That is why Sir David Dalton and many others say that this is a fair and reasonable offer.

With respect to A&E recruitment, the impact of the contract change we are proposing is that people who regularly work nights and weekends will actually see their pay go up, relatively, compared to the current contract. These are the people who are delivering a seven-day NHS and we must support them every step of the way.

[Dr Sarah Wollaston (Totnes) (Con)]

I know colleagues across the House will want to join me in thanking junior doctors for the valuable work they do for patients across the NHS. [Hon. Members: “Hear, hear.”] I hope that they will look very carefully at the improvements in the offer, with a 13.5% increase in the basic rate and the very important safeguard that will discourage over-rostering at weekends by giving them premium rates if they have to work more than, or including, one in four weekends. I hope the BMA will also recognise and welcome the very important appointment of Professor Dame Sue Bailey to lead an inquiry into all the other aspects that lead to discontent with junior doctors. I wonder if the Secretary of State agrees that what we now need is to move forward in a positive spirit that brings this dispute to an end, takes the temperature down and recognises that we all want the same thing: safety for patients.

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 9th February 2016 Commons Chamber

[Alistair Burt]

The consultation is ongoing between Departments. A unit has been set up by the Department of Health and the DWP to look at a range of issues that concern us both. The actual detail of the future attendance allowance has not been finalised yet, but it is a matter of concern and discussion between Departments.

[Dr Sarah Wollaston (Totnes) (Con)]

In asking a question about mental health, may I remind the House that I am married to an NHS forensic psychiatrist, who is also registrar of the Royal College of Psychiatrists? Have the Government looked carefully at today’s report from the independent commission on improving mental health services, particularly its finding that provision nationally for the most severely ill acute patients is inadequate? Will the Government set out what measures they will take to make sure we really see progress on parity of esteem and on improving access to such severely ill patients?

[Alistair Burt]

I thank my hon. Friend for her question, and the Royal College of Psychiatrists for its work on Lord Nigel Crisp’s commission, which we have supported. The report and recommendations have only just come to us, but they certainly travel in the direction in which the Government are already going. We want to reduce out-of-area placements. The NHS is already committed to that, and is working on moving to a definitive target to reduce the number of them and, I hope, eventually to scrap them. I was up in Hull last week to look at problems in that particular area. The recommendations on waiting times are very important. As we all know, this area has been undervalued in the past. It is under greater scrutiny, and more investment and support are going in through the Government. Today’s report will help us in relation to that.

Junior Doctors’ Contract Negotiations

Sarah Wollaston Excerpts

Monday 8th February 2016 Commons Chamber

[Ben Gummer]

The hon. Lady wonders where to begin. I would say to her that where we begin is with the promise made to the electorate to deliver seven-day services in order to make care more consistent through the week and thereby bring down the rate of avoidable deaths. That has been the aim of this Government—pursued in the guise of the previous coalition and by the current Government—for some years. The junior doctors’ contract, about which negotiations have been going on for some years, has been framed partly in that respect during that time.

The hon. Lady asks a number of questions, and I will answer them directly. She asks whether the door is open and whether the Secretary of State is willing to see further talks. Of course it remains open. Throughout the entire process—from back in the summer, when the BMA made it a point of principle not to return to talks—we have asked the BMA to come back to the negotiating table time and again. I have done so, as has the Secretary of State, so the door remains open. I hope that, in the coming days up to the strike, such contacts will continue.

The hon. Lady asks whether there can be discussions about Saturdays. The Secretary of State has made it plain throughout the process that every aspect of the contract is open for discussion. What is not up for discussion is the ability of hospitals to roster clinicians on a consistent basis through the week. The one group of people who are refusing to negotiate about Saturdays or anything to do with the extension of plain time is the British Medical Association. Despite its assurance—in fact, its promise—at ACAS at the end of the November that it wished to discuss this issue, it has now refused to do precisely that with Sir David Dalton. We are therefore left at an impasse, where I am afraid that on the one item left to discuss, which is Saturdays, it is refusing point blank to open a discussion because of what it calls an issue of principle. For us, the principle is patient safety, and that is why we will not move.

The hon. Lady’s second question was about the introduction of a new contract. At some point, the Government will need to make a decision. Time and again, we have extended the point at which we will introduce the new contract, precisely so that we can give time for talks to proceed, even though the BMA, in a disjointed manner, refused to discuss it for several years until this point. At some point, we will have to make the changes necessary to get consistency of service over weekends. We cannot delay this any longer. No Health Secretary or Health Minister could stand in the face of the many academic studies that have shown there is an avoidable weekend effect and say that nothing should happen. Of course this should be done in concert with other contract changes—changing the availability of diagnostics, pharmacy and other services—and we have always said that it is part of the piece, but it has to be done at some point and that point is fast approaching.

The hon. Lady asks whether imposition will be harmful to patients. I ask her to consider whether avoiding changing rostering patterns to eliminate the weekend effect would not itself be harmful to patients to the number of several thousand a year.

The hon. Lady asks about pay protection. We have urged the BMA to put to its members the pay protection that we made clear right at the beginning of the process, but I am afraid that it wilfully misled its members about the pay offer that we put on the table. I ask her, therefore, to be careful in what she says. For this cohort of junior doctors, this is a very good deal. Those who are coming into the service can be assured that they will have a quality of contract that the current cohort has not benefited from: a reduction in the maximum number of consecutive nights from seven to four; a reduction in the maximum number of consecutive long day shifts from seven to five; a reduction in the maximum number of consecutive long late shifts from 12 to five; and a reduction in the maximum number of hours one can work in a week from 91 to 72. Those are considerable improvements in the contract that will protect the safety and working practices of future generations of junior doctors.

When the hon. Lady wrapped up her remarks, she asked whether we had any regrets about the way this process has proceeded. We do have regrets. We regret that the BMA wilfully misled its members at the beginning of the process, making them believe that there was going to be a cut to pay and an increase in hours, neither of which was true. We certainly regret the fact that the BMA refused to talk to us for months on end, when many of these issues could have been dealt with. We certainly regret the fact that the BMA has gone back on its promise to discuss plain time hours—a promise made at ACAS that it has now reneged upon. I am afraid that in dealing with the BMA, we have not been able to address the matter that is most important to doctors, which is protecting patient safety. That is why, in the end, we will have to come to a decision on this contract for the betterment of patients and the consistency of clinical standards through the week.

[Dr Sarah Wollaston (Totnes) (Con)]

Under the current contract, too many junior doctors are forced to work excessive hours and are overstretched during the hours they work. Will the Minister, having set out that the hours will be reduced, reassure the House about what measures will be put in place to make sure that managers do not let this slip and that we do not return to the days of overworked junior doctors?

[Ben Gummer]

My hon. Friend is right that new measures have been introduced in the proposed contract. A new guardian role, which was proposed by NHS Employers, will help to protect the hours of junior doctors in individual trusts. That has been a point of success in the negotiation between the BMA and NHS Employers. A new fines system, which is not currently in place, will penalise trusts and ensure that the moneys that are generated by the fines go towards enhancing the general wellbeing and training of doctors within those trusts.

NHS Trusts: Finances

Sarah Wollaston Excerpts

Monday 1st February 2016 Commons Chamber

[Ben Gummer]

The hon. Lady started by claiming that the Secretary of State and I were in a state of denial. Were she to look at the outcomes of the NHS this year compared with the last year that her party was in power, she might consider that the performance of the NHS has improved beyond measure. We have 1.9 million more accident and emergency attendances, 1.3 million more operations, 7.8 million more outpatient appointments and 4.7 million more diagnostic tests. This is an NHS that is performing more procedures, helping more patients and doing more for the people of this country than at any time since its foundation. I would therefore gently suggest that those in denial are her party and her. The service is working hard to try to deliver better patient care in a challenging environment.

The hon. Lady asked a number of subsequent questions about staffing levels and letters sent out by NHS Improvement, and I will endeavour to answer each in turn. She asked about the settlement the Treasury has reached with the NHS, and I would point out that that is precisely the settlement that the NHS itself asked for and that the Labour party refused to endorse at the last election.

The hon. Lady’s second question—or statement—related to the fact that there are teams of management consultants. That allows me to remind her that the numbers of management consultants have been cut considerably—by the previous Government and by this one—in contrast to what happened under the Labour Government, who increased the numbers of managers in the 13 years they were in power. We will make no apology for the fact that NHS Improvement and its constituent bodies are working hard with some of the most challenged providers to help to turn them round and to try to address the issues of efficiency and quality they all have. Is the hon. Lady somehow suggesting that they should not be doing that? Should they not be going round hospitals trying to help those that are not able to control their own finances? Should they not be doing what is needed to try to improve the quality of the care those hospitals provide? If that is her suggestion, it is a quite remarkable one, and one that should be more widely shared with the people she seeks to represent.

The hon. Lady talked about the letter sent out by NHS Improvement. Yes, the Department was aware of it, as it was aware of the letter sent out the same day by Professor Sir Mike Richards, of the Care Quality Commission, addressing the issues of quality that need to be tackled across the service. I know that this is news to Opposition Members, but there are not separate parts of the NHS issuing separate diktats. The letters issued on staffing and other issues in the last few months have been co-signed by Professor Sir Mike Richards, the chief inspector of hospitals, by Dr Mike Durkin, the director of safety at NHS England, by Jim Mackey, the chief executive of NHS Improvement, and by Simon Stevens, the chief executive of NHS England. This is one system addressing the particular problems that are evident in some challenged providers and making sure that those providers level up to the best. If the hon. Lady is not convinced of that, she should look at the co-signatories of those letters to see how they correspond one with the other.

The hon. Lady asked about the line in one of the letters about reductions in headcount. I point her to the reductions in the headcount of administrators that the Government have achieved over the past five years. We have managed to reduce the number of administrators in the NHS by 24,000, while increasing the number of clinicians by 16,000. Would the hon. Lady, while not promising the money to the NHS that it has asked for, ask it to maintain the same level of administrators in the years ahead, or would she back NHS Improvement’s plan to find efficiencies across the NHS, precisely so that the money that is spent on administrators can be spent better—on clinicians, on increasing the number of clinicians and on directing resources to the frontline? I know the hon. Lady is earnest in what she says about the NHS, but I cannot believe that she is really riding out in defence of increasing spend on back office at the expense of the frontline.

The hon. Lady asked about safe staffing ratios. She made a number of statements that, in retrospect, she might feel were somewhat irresponsible. The reason for that is that the letter issued about safe staffing in October last year, which built on advice given by the National Institute for Health and Care Excellence, was co-signed by Professor Sir Mike Richards, the chief inspector of hospitals, and by NHS Improvement and its two constituent bodies. It was a co-signed letter because quality and efficiency are two sides of the same coin. Those hospitals that are providing the highest quality of care in this country tend to be those that are also in control of their finances. Likewise, those that are struggling with quality tend to be those that cannot control their finances. If the hon. Lady were to suggest that, somehow, there is a binary distinction between the two—that there is a choice to be made between quality and efficiency—I would gently say to her that she is about a decade behind all current thinking on how a successful health service is run. It is about making sure that quality and efficiency go hand in hand, and the very best hospitals can achieve both.

In all this, the hon. Lady should avoid falling into the trap that her predecessor so often did of assuming that that there is some kind of trade-off between quality and efficiency, and also attempting a pretty low-level politicising of the NHS—an approach that was roundly rejected at the last election. I ask her to consider the counterfactual—that were she standing at this Dispatch Box now, having won the last election, she would not have had the £8 billion to invest in the NHS that we have managed to have, and she would not therefore be able to assure the public of continued improvements in the number of patients treated, an increased number of operations, GP numbers in excess of 5,000, which we have promised to deliver by 2020, record numbers of A&E admittances, and record numbers of out-patient appointments. She would have been able to promise none of that. That is why Conservative Members are proud to reaffirm that we are the true party of the NHS.

[Dr Sarah Wollaston (Totnes) (Con)]

We all welcome the front-loading of the NHS settlement, and want to congratulate NHS staff on the extraordinary efforts they are putting in to improve quality, alongside coping with rising demand. If NHS Improvement is tasking management consultants to come in and advise trusts on turning around financial problems, will the Minister also task it with looking specifically at issues of social care and how the interrelation between underfunding of social care impacts on the health economies of local trusts, and with looking at improvement and prevention, because prevention was also noted by Simon Stevens to be unfinished business from the spending review?

[Ben Gummer]

My hon. Friend will be aware of the increase in the better care fund that this Government have introduced and the 2% precept on council tax bills that will deliver increases for social care. She will also be aware that “Five Year Forward View” is a holistic understanding of the healthcare system that includes transformation of the NHS and social care towards that point. That is why we are proud to fund “Five Year Forward View” in the manner that Simon Stevens requested —front-loaded, with £3.8 billion in the next year. The manner of that bottom-up integration over the next few years will ensure that the challenge around social care that my hon. Friend identifies will be addressed in years to come.

NHS and Social Care Commission

Sarah Wollaston Excerpts

Thursday 28th January 2016 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

I thank the right hon. Member for North Norfolk (Norman Lamb) and pay tribute to him, particularly for his work as a Minister in the coalition Government and for his personal commitment to mental health services. I welcome his call for real focus and cross-party agreement on this long-standing problem. We need that if we are to solve the problem and create a health and social care service that is fit for purpose for the next century.

I would sound one note of caution. I am very relieved that the right hon. Gentleman is not calling for a royal commission, as there is no shortage of commissions in this place. We are just a year from the Barker commission, the highly respected independent commission set up by the King’s Fund, which very clearly laid out the problems we face and suggested a number of options. Hard choices will have to be made if we are to raise the share of our GDP that we spend on health and social care to 11%, which I know many Members would support.

We know the options. The difficulty is a political one. I question whether we need a commission, and would ask whether we do not in fact need a commitment from the leaders of all political parties in England to come together to look at the proposals seriously, and get away from the endless bickering in this place about the choices before us and the pretence that this is somehow not going to happen. Unless we make such changes, we will have to start thinking rapidly about plan B as an alternative. What will be the consequences for all our constituents if we fail to reach a political agreement about the challenges we face?

[John Pugh (Southport) (LD)]

If I understand the hon. Lady correctly, she supports a commitment, but not a commission, but would a commission not be a sign of such a commitment?

[Dr Wollaston]

In this place, we sometimes push issues into commissions, which debate them endlessly and come to no agreement. I would say the urgency of this issue demands that the leaders of all political parties sit down together and agree.

[Norman Lamb]

I am very grateful to the hon. Lady for giving way, and I promise not to keep intervening. I feel that there needs to be a process to which everybody is committed. If there is just a desire for the party leaders to co-operate, the temptation to score political points when a crisis comes along will be too great and it just will not happen. We need to bind people into such a process, and they must be prepared to commit to it.

[Dr Wollaston]

I thank the right hon. Gentleman for his clarification. I agree that we are looking for a process to which everyone can commit. We are not looking for a commission that will go away and examine the problems. We know the issues, which have been set out in very stark terms. The King’s Fund’s excellent independent Barker commission set out the whole range of options. What we have always lacked is the political buy-in and determination to move forward. I would join in making a request for any process that will make that happen, but not for something that pushes it away for three years, because, as we all know, the closer we get to a general election, the more challenging it will be to have a genuine political agreement. It therefore needs to happen as rapidly as possible.

[Mr Mitchell]

I am not sure that there is that big a difference between my hon. Friend and the right hon. Member for North Norfolk (Norman Lamb). My point is that as well as getting all the political parties to focus on this issue now, we need an extremely long-term approach. The House of Commons used to accept that we had to have a long-term, all-party approach to pensions, because of the length of time involved in such important decisions. We also need that in relation to this issue: as well as getting everyone to focus on it, we need to get them to focus on the importance of reaching agreement because this is such a long-term issue.

[Dr Wollaston]

I agree with my right hon. Friend. However, in parallel with the process of looking at long-term funding arrangements and settlements, we must get on—here and now—with changes that are needed in the short term. I want to touch on a few such areas.

The first area is prevention. I absolutely agree with the right hon. Member for North Norfolk that it is bad practice to cut money from public health, simply because of the challenges we face. If we look at the NHS budget, we can see that 70% of it goes on helping those living with long-term conditions. We know that many future problems are brewing here and now.

Let us just take childhood obesity, which we discussed at length last week. A quarter of the most disadvantaged children now leave primary school not just overweight, but actually obese. Given the problems that that is saving up, in the personal cost to those children and the wider costs to the NHS—nearly 10% of the entire NHS budget already goes towards treating type 2 diabetes—how can we not be grasping that nettle as a matter of urgent prevention to save money for the whole system?

[Geraint Davies]

Does the hon. Lady agree that there is an inter-relationship between child poverty and obesity, and indeed between child poverty and other health problems that generate costs, and is not part of the solution to the dilemma of how to meet the costs of health and social care to look again at such demographic drivers?

[Dr Wollaston]

Indeed. The data from Public Heath England are absolutely stark: from looking at the index of multiple deprivation and the incidence of childhood obesity, we can see that not only is there a large gap, but that that gap is widening. As part of the strategy, the Government must aim not only to lower overall levels of childhood obesity, but to narrow that gap, particularly by looking at measures that will help to do so. I thank the hon. Gentleman for making that point.

The right hon. Member for North Norfolk referred to the need for self-care, and we know that we need a much greater focus on how we can support people to improve their own health. If we are going to raise money for the whole health and care system, there are mechanisms to do so that will also help to prevent ill health in the future. One example is a sugary drinks tax, which could lever money into a very straitened public health budget to put in place measures that we know will help. We need the NHS to get on with prevention, and in my view we need more of the funding that is available to go into saving money for the future.

[Chris Davies]

May I say what respect around the House we have for you as Chair of the Health Committee? I would therefore be very interested to hear your view of the “Five Year Forward View”—

[Chris Davies]

I apologise profusely, Madam Deputy Speaker. We of course have great respect for you, too.

The “Five Year Forward View” plan is already under way, led by the former Labour adviser Simon Stevens. It is looking at reforming heath and care services, and is backed by the funding that the NHS has already said it requires. Does my hon. Friend feel that setting up yet another body would benefit the NHS, or would it be a hindrance?

[Dr Wollaston]

I thank my hon. Friend for mentioning the “Five Year Forward View”, but I would respond by saying that Simon Stevens has referred to prevention and social care as “unfinished business” from the spending review. If we are to deliver the plan, we need to listen to his views and be mindful of the fact that spending on social care actually saves the NHS money. We cannot separate social care from the NHS, and we should not ignore his wise words on the importance of prevention in delivering the “Five Year Forward View”.

[Dr Philippa Whitford]

Is it not the case that when Simon Stevens was before the Health Committee, he said that a quarter of the £22 billion of savings that were hoped for would have to come from prevention and public health, yet that is being cut?

[Dr Wollaston]

Indeed; I remember that too. I agree that unless we up our game and redouble our efforts on prevention, we will not achieve the savings that are required to close the gap in the “Five Year Forward View”. That is why I wanted to touch on prevention first.

There is another area that we need to do much more on here and now. We need to have a relentless focus on variation across the NHS. We hear examples of local systems that are making things work, but the NHS has a long history of failing to roll out best practice. The “Growing old together” report, which was published today by a commission set up by the NHS Confederation, gives examples of good practice across the NHS and social care in which integrated practice is not only delivering better care for individuals, but saving money. The only depressing aspect of that is that one has to ask why it is not happening everywhere. Rather than endlessly focusing on the negatives in the NHS, let us focus more on the positives and on facilitating their roll-out.

[Helen Whately]

My hon. Friend is talking about work that is being done on the problems in the health service and about approaches that can improve it. Does she share my concern that although there are big challenges, there is a risk that a commission such as the one proposed could prove a distraction from getting on with the many things that we know need to happen and the very good proposals in the “Five Year Forward View”? It could therefore be unhelpful, rather than helpful, despite its objective.

[Dr Wollaston]

If that were the case, it would be a problem. I think that the two things could happen in parallel. We could work towards a consensus about future funding at the same time as focusing relentlessly on what needs to be done in the here and now. However, I agree that if it were a distraction, it would be a problem.

As well as continuing to have a relentless focus on tackling variation, we need to follow the evidence in healthcare. When money is stretched, we must be sure not only that we spend it in a way that follows the evidence, but that we do not waste money in the system. I caution the Minister on the issue of seven-day services, which we have discussed at the Health Committee. If there is evidence that GP surgeries are empty on a Sunday afternoon because there is no demand, and in parallel with that we are being told that out-of-hours services are in danger of collapse because, in a financially stretched system, there are not the resources or manpower to offer both, we must be led by the evidence and be prepared to change what we are doing.

When money is tight, we owe it to our patients to focus on the things that really will improve their care. There must be no delay in making changes when we know that something that has been put in place with the best possible intentions may be having unintended consequences. We must be clear that we will follow the evidence on best practice and value for money, so that patients get the best outcomes in a financially stretched system.

[Geraint Davies]

The Government have decided to make Saturday a working day in a regime where a couple who are both doctors can be sent, without a choice, to different parts of the country to practise in hospitals and only have family time together at weekends. Now that Saturday will be a working day, their situation will be virtually impossible. Does the hon. Lady agree that that needs to be considered in case it causes a further leakage of doctors and, therefore, less efficiency in the system?

[Dr Wollaston]

I have to declare a personal interest here, because one reason why my daughter, who is a junior doctor, has spent a year in Australia is that there are sometimes difficulties with married couples—or, indeed, people in any relationship—being able to work in the same part of the country. There is far more that could be done to help junior doctors, in addition to the contract negotiation about money. However, as I have a personal interest, it is probably best if I do not comment further on that.

I want to draw attention to the role of the voluntary sector, which the right hon. Member for North Norfolk referred to. I pay tribute to the voluntary sector partners in my constituency—bodies such as Dartmouth Caring and Brixham Does Care. Across the constituency, a number of organisations are making a real difference to people’s lives, yet very many voluntary sector organisations are coming under extreme pressure. I could give examples of voluntary sector partners that have had to close, sometimes for the want of very small amounts of money, even though they have delivered enormous value. These are locally-facing organisations.

It was welcome that Simon Stevens gave a commitment to look at making the arrangements for commissioning voluntary sector partners easier. Even though those commissioning arrangements may have been made easier, often the resources are not there to fund such organisations. We need to look again at how we can deliver best value for patients by supporting voluntary sector partners across all our constituencies.

Those are the areas that I want the Minister to focus on in the here and now, but I agree that in the long term, we must look at funding. One challenge in this country—and I think it is a wonderful thing—is that almost all the funding for the health service comes directly from taxation or national insurance. We are almost unique in that. Only two other countries exceed us in that regard. Government funding for the NHS accounts for 7.3% of GDP and only an additional 1.5% is levered in from the private sector.

The choice before us is whether to expand the amount that we raise through charging and top-ups. Personally, I do not support that. The Barker commission did not support it either. Top-ups and charging do not raise as much as people imagine by the time the bureaucracy involved in collecting the money and the unintended consequences that are often found, such as widening health inequalities, are accounted for. I hope that we do not choose to go down that route. The most equitable funding mechanism is taxation.

There is an issue of intergenerational fairness here, as the right hon. Member for North Norfolk said, and we need to consider it. These are hard political choices, which can no longer be ducked. Given the demographic challenge and the challenge of complexity that we face, the alternatives are appalling. The alternatives are to abandon our older people. The pressures that our hospitals face from those who cannot be discharged into the community and those in the community who cannot get into hospital are mounting. We can ignore them no longer.

I call on the Government to consider very carefully working with our Opposition partners at scale and at pace to bring forward an agreement on how we will bring more money into the system as a whole, and in the meantime, to make sure that the money we do spend is spent in the best interests of patients.

--- Later in debate ---

[Debbie Abrahams]

As I teased the right hon. Gentleman last week at a Radio 5 Live interview, “so says the former Minister who was saying something quite different just a few months ago”! I do not want anyone to be under any illusion about this. I am not saying that we should not be planning for 30 and 40 years hence. I am saying that, given the vastly different ideological perspectives —I have provided one example, showing how much we disagree about the Health and Social Care Act 2012—trying to pretend that we can agree is naive.

In the last Parliament, I was chair of the parliamentary Labour party’s health committee, and we undertook an inquiry that looked into the effectiveness of international health systems—it is published on my website for everyone to have a look at. We were particularly concerned about quality and equity in access and outcomes, because we knew there was a vast difference in both those respects. The inquiry showed quite conclusively that where there was competition, privatisation or marketisation in the health system, health equities worsened. It revealed that there was no compelling evidence to show that competition, privatisation or marketisation improves healthcare quality. In fact, there is some evidence to show that it impedes quality and increases hospitalisation rates and mortality. This was peer-reviewed evidence—a review of a review of evidence—not one-off studies. It was the strongest type of evidence showing that marketisation and privatisation worsen health equity and worsen the quality of care.

We need to take a forward view, 30 or 40 years hence, about how to continue to fund the NHS and social care. This is a distraction, however, from the crisis that we have right now. We have seen A&E waits up 34% since 2015, failure to meet cancer 62-day treatment standards up 14%, and diagnostics up 36%. It goes on and on. Mental health cuts in 2014 meant the equivalent of £600 million-worth of cuts to mental health trusts. What has changed in the last few months? Delayed discharges reflect the care crisis, with £3.6 billion taken out of the budget for social care in the last Parliament. There is supposed to be £4.3 billion and a 2% precept, but it has been rightly said that it will not make up the difference. As my hon. Friend the Member for Leicester West said, since 2010, half a million fewer older and disabled people have received state-funded support.

In my constituency, I was doing my regular door knocks when I encountered an elderly lady in her 70s. She opened the door and presented me with a bubble pack of medicines and told me that she did not know what she had to do. She had never met me before. She was dishevelled and wearing a dressing-gown in the middle of the afternoon. This was a woman who clearly needed our help and needed support. She was all on her own and did not know what the medications were. I managed to get somebody there. I wonder, though, how much more this is likely to be happening up and down the country. The system is in a crisis, which is a real concern.

[Dr Wollaston]

In many instances around the country, the use of care co-ordinators and the existence of a single point of contact are not only providing better care for individuals, but saving money for the whole system by avoiding the need for admissions and allowing people to go home early. We should focus on the good examples, and on how services can be made available in a more co-ordinated way.

[Debbie Abrahams]

I entirely agree. That was another of our manifesto pledges. I also thought that what the hon. Lady said in her speech was spot on.

Let me return to what I was saying about distractions. We also need to look at the issue of funding and resources. The hon. Member for Totnes (Dr Wollaston) said something about that as well. Real-terms growth in spending in the last Parliament was the lowest in the history of the NHS, at less than 1%, whereas between 1997 and 2009 it was about 6%. The figure in the last Parliament was about 7.5% of GDP, slipping below the European Union average. We are now moving towards the bottom of the league, which is where we started in 1997.

So far, we have not even talked about devolution. I am a Greater Manchester Member of Parliament. The devolution offer to Greater Manchester was £6 billion, although the current collective health and social care economy is worth £10 billion. There has been no talk of contingency arrangements for, say, a flu pandemic. It is an absolute disgrace.

I also agree with the hon. Member for Totnes about the lack of an evidence base for decisions. I have provided an evidence base: our committee looked into resources and funding and how both quality and equity could be improved, and found vast disparities across the country, as well as disparities in outcomes for different groups of people. We should repeal the Health and Social Care Act and ensure that the NHS is the preferred provider.

William Mead: 111 Helpline

Sarah Wollaston Excerpts

Tuesday 26th January 2016 Commons Chamber

[Mr Hunt]

I hope I can reassure the shadow Health Secretary on all the points she raised.

First, there has been a sustained effort across the NHS since September 2013 to improve the standard of safety in the care we offer in our hospitals. An entirely new inspection system was set up that year. It has now nearly completed inspections of every hospital, and it has caused a sea change in the attitudes towards patient safety. Sepsis is one of the areas that is looked at. In particular it is incredibly important that when signs of sepsis are identified in A&E departments the right antibiotic treatment is started within 60 minutes. That is not happening everywhere, but we need to raise awareness urgently to make that happen, and that inspection regime is helping to focus minds on that.

On top of that—I will come to the issues around 111, and I agree that there are some important things that need to be addressed—a year ago I announced an important package to raise awareness of sepsis. It covers the different parts of the NHS. For example, in hospitals a big package on spotting it quickly has been followed from December 2015, with NHS England publishing the cross-system sepsis programme board report, which is looking at how to improve identification of sepsis across the care pathway.

The hon. Lady is right to raise the issue of faster identification by GPs. That is why, in January 2015, I announced that we will be developing an audit tool for GPs, because it is difficult to identify sepsis even for trained clinicians, and we need to give GPs the help and support to do that. We are also talking to Public Health England about a public awareness campaign, because it is not just clinicians in the NHS, but it is also members of the public and particularly parents of young children, who need to be aware of some of those tell-tale signs.

So a lot is happening, but the root cause of the issue is understanding by clinicians on the frontline of this horrible disease, and it does take some time to develop that greater understanding that everyone accepts we need. I can reassure the hon. Lady, however, that there is a total focus in the NHS now on reducing the number of avoidable deaths from sepsis and other causes, and that is something the NHS and everyone who works in it are totally committed to.

With respect to 111, there are some things that we can, and must, do quickly in response to this report, but there is a more fundamental change that we need in 111 as well. One thing we can do quickly is look at the algorithms used by the call-handlers to make sure they are sensitive to the red-flag signs of sepsis. That is a very important thing that needs to happen. NHS 111 has in some ways been a victim of its own success: it is taking three times more calls than were being taken by NHS Direct just three years ago—12 million calls a year as opposed to 4 million—and nearly nine of out 10 of those calls are being answered within 60 seconds.

When it comes to the identification of diseases such sepsis, we need to do better and to look urgently at the algorithm followed by the call-handlers. Fundamentally, when we look at the totality of what the Mead family suffered, we will see that there is a confusion in the public’s mind about what exactly we do when we have an urgent care need, and the NHS needs to address that. For example, if we have a child with a high temperature, we might not know whether they need Calpol or serious clinical attention.

The issue is that there are too many choices, and that we cannot always get through quickly to the help that we need. We must improve the simplicity of the system, so that when a person gets through to 111, they are not asked a barrage of questions, some of which seem quite meaningless, and they get to the point more quickly and are referred to clinical care more quickly. We must simplify the options so that people know what to do, and that is happening as part of the urgent emergency care review. It is a big priority, and this tragic case will make us accelerate that process even faster.

[Dr Sarah Wollaston (Totnes) (Con)]

I join colleagues from across the House in sending deepest condolences to William’s parents. I welcome the Secretary of State’s response that he will put into action the recommendation from today’s report. May I draw out one aspect that has not been touched on so far, which is the comment in the report that out-of-hours services did not have access to William’s clinical records, and that had they been able to do so they would have seen how many times a doctor had been consulted, and that that would have been a clear red flag? Will he reassure me that that matter will be addressed across the NHS, so that all services have access to patients’ clinical records—of course with their consent?

[Mr Hunt]

My hon. Friend is absolutely right. There is so much in this report, but we must not let some very important recommendation slip under the carpet, and that is one of them. We have a commitment to a paperless NHS, which involves the proper sharing of electronic medical records across the system. We have also instructed clinical commissioning groups to integrate the commissioning of out-of-hours care with the commissioning of their 111 services to ensure that those are joined up. It is a big IT project, and we are making progress. Two thirds of A&E departments can now access GP medical records, but she is absolutely right to say that it is a priority.