Assessment and Treatment Units: Vulnerable People

Sarah Wollaston Excerpts

Tuesday 6th November 2018 Commons Chamber

[Caroline Dinenage]

Hon. Members will be very aware of and concerned about the report published this week by University College London. As the hon. Lady said, the report, which was commissioned by the NHS, draws attention to how people with learning disabilities die on average 15 to 20 years sooner than the general population, often for reasons that are not an inevitable consequence of any underlying medical condition. I was reassured that this report shows that programmes and opportunities that Government are putting in place to improve outcomes for people with learning disabilities and autism are addressing some of the concerns. However, I share very strongly her views and the views of this report that there is still much further to go and that now is the time to take action.

As hon. Members will know, the LeDeR report—the learning disabilities mortality review—is looking into the deaths of all people with a learning disability. It published its second annual report in May and in their response in September the Government accepted all the recommendations and included detailed actions for implementing them. NHS England has also committed that the long-term plan for the NHS will include learning disability and autism as one of the four clinical priorities. The long-term plan will also set out the future of the transforming care programme, which the hon. Lady raised.

Government policy on restrictive practices, including seclusion, is to reduce their use. Where such interventions have to be used, they must be a last resort and the intervention should always be represented as the least restrictive option to meet immediate needs. Incidents of restrictive intervention are recorded in the mental health services dataset and this data is published. The Mental Health Act code of practice highlights the particularly adverse impact of seclusion on children and young people. It advises careful assessment and periodic reviews.

I want to turn to the Care Quality Commission review into the inappropriate use of prolonged seclusion and long-term segregation. The first stage of the review will focus on settings that relate most closely to Bethany’s circumstances, focusing on people of all ages receiving care on NHS and independent sector wards for people with learning disabilities and/or autism and on child and adolescent mental health wards. That will start immediately and this stage will report in May next year. It is very important that service users, their families and people with lived experience are able to contribute to that. The second stage will report in the winter and will examine other settings in which segregation and prolonged seclusion are used. That stage will include NHS and independent sector mental health rehabilitation wards and low secure mental health wards for people of all ages, as well as residential care homes designated for the care of people with learning difficulties and/or autism. As I have said, individuals who have been subject to segregation and/or long-term seclusion and their families and carers will be invited to provide evidence, including through interviews. The Care Quality Commission will make recommendations at the end of both stages, which will seek to eliminate system-wide inappropriate use of prolonged seclusion and long-term segregation, and ensure that vulnerable adults and children supported by health and social care are accorded the best possible care.

I should point out that not all the numbers that the hon. Lady spoke about are in separately identified assessment and treatment units. The data reports there being 2,315 in-patients with a learning disability and/or autism in mental health in-patient settings as of September, but some 360 of them were in in-patient settings described as for people with acute learning disabilities

It is important that commissioners should be able to access very high-quality, value-for-money care in their local area, whichever organisation provides it. We recognise the concern that people have expressed about what happens in the transforming care process, but I see it very much as a process and not as an event that will continue. The NHS has transferred more than £50 million to ensure that the right care is put in place in respect of community support, so that people are better cared for when they are out in the community.

[Dr Sarah Wollaston (Totnes) (Con)]

Does the Minister accept that, fundamentally, far too many people are ending up in terrible conditions in secure settings because of the inadequacy of social care? Will she commit to include in the Green Paper, which is to be brought forward before Christmas, the Green Paper for young adults as well as for older people? Will she absolutely commit to that coming forward before Christmas?

[Caroline Dinenage]

My hon. Friend is absolutely right to recognise that the cases in which people end up in a long-term residential setting often reveal a failure of joint working—of the wraparound services that people need to keep them in the community. We are looking at working-age adults as part of the social care Green Paper, and it will be published before Christmas.

Prevention of Ill Health: Government Vision

Sarah Wollaston Excerpts

Monday 5th November 2018 Commons Chamber

[Mr Speaker]

I am grateful to the Secretary of State for what he has just said. A lot of Members wish to take part in this exchange, but I remind the House that there are two debates to follow. The Government have chosen to put on two ministerial statements, which is entirely their prerogative. Naturally, people do then tend to stand to ask questions, as that is what we do here, but I have also to protect the subsequent business. I therefore politely say to colleagues: if you have a long question in mind, cut it or do not bother. That would be really helpful. Let us start with the Chair of the Select Committee, Dr Sarah Wollaston.

[Dr Sarah Wollaston (Totnes) (Con)]

In the Secretary of State’s vision for prevention he rightly points out that £14 of social benefit accrues from every £1 spent in public health. Therefore it is going to be much more challenging for him to deliver on his objectives if there is a further transfer from the public health budgets into NHS England budgets. However, I recognise that this requires action across all Departments, so will he set out what he is going to do to encourage cross-government action on physical activity, because we all know that that is a vital part of public health and prevention?

[Matt Hancock]

I agree with my hon. Friend the Chair of the Select Committee on that. Of course, the public health budgets for local authorities and Public Health England will be settled as part of the spending review, and there was no change to them in the Budget last week. There are also much wider responsibilities on activity—on cycling and walking—on which I am working with the Department for Transport. The document is all about the cross-government action, and the NHS will come forward with its long-term plan for the NHS-specific action. If there are aspects of cross-departmental working that she suggests we have not yet taken up, I will be looking forward to listening to her on that.

Health and Social Care Committee

Sarah Wollaston Excerpts

Thursday 1st November 2018 Westminster Hall

[Dr Sarah Wollaston (Totnes) (Con)]

I would like to present a report on “Prison health” by the Select Committee on Health and Social Care. I start by thanking my fellow Committee members and the Committee staff, particularly Huw Yardley and Lewis Pickett. I also particularly thank all those who gave evidence to our inquiry, both in person and in writing. We visited HMP Isis, HMP Belmarsh and HMP Thameside, and I thank the staff, healthcare staff and all the people in prison who spoke to us about their experiences.

A prison sentence is a deprivation of liberty, not a sentence to poorer health or healthcare, yet sadly that was the picture that we found in our inquiry. Too many prisoners are still in overcrowded, unsanitary prisons with overstretched workforces. Those poor conditions contribute to even worse outcomes and health for those who arrive in prison, who are often from very deprived backgrounds and suffering from serious health inequalities. Violence and self-harm are at record highs, and most prisons exceed their certified normal accommodation level, with a quarter of prisoners living in overcrowded cells over the last two years. Staffing shortages have led to restricted regimes that severely limit prisoner activity, as well as their access to health and care services, both in and outside our prisons.

Too many prisoners still die in custody or shortly after their release. Although deaths in custody have fallen slightly since peaking in 2016 as a result of increased suicides, so-called natural-cause deaths are the highest cause of mortality in prisons and, I am afraid, reflect serious lapses in care. Every suicide should be regarded as preventable. It is simply unacceptable that those known to be at risk face unacceptable delays while awaiting transfer to more appropriate settings. We see that happen time and again, without appropriate action being taken.

Our report refers to the impact of the increasingly widespread use of novel psychoactive substances, not just on prisoners but on prison staff; dealing with violent incidents takes time away from the work that we would otherwise expect prison staff to do. We heard time and again from people in prison who we met of not being able to attend appointments, either within or outside the prison, because there simply were not the staff there, because they had been diverted to other cases.

We have made recommendations for the National Prison Healthcare Board. We would like it to agree a definition of equivalent care, and to tackle the health inequalities that we know prisoners face. It also needs to take a more comprehensive and robust approach to identifying and dealing with the healthcare needs of people in prison. However, many of our recommendations will not be met until sufficient prison officers are in post. That is an overriding issue, because the cut in prison officer numbers—I know the Government are starting to address that—lies at the root of so many problems in our jails.

Health, wellbeing, care and recovery need to be a core part of the Government’s plans for prison reform. It is in all our interests to care about the health and wellbeing of prisoners, because they will later be back in our communities. If more of them become dependent on drugs during their time in prison, and these problems worsen, they will come back into our communities with even worse health issues, health inequalities and mental health problems. I know it is difficult, because it sometimes seems that the public do not care about our prisoners, but it is absolutely in everybody’s interest to care about the health and wellbeing of our prison population.

I am afraid that our report highlights a system in which, time and again, reports from Her Majesty’s inspectorate of prisons are not acted on. We need those reports to have real teeth, and for people to be able to take action, or to be held accountable for not taking action. We heard time and again of governors not having the levers—even if they had the financial powers—to take the necessary action.

We call on the Government to regard the health of our prison population as a serious public health crisis requiring a whole-systems approach that takes root in sentencing and release, making sure that people are only in prison if absolutely necessary, that those with serious mental health problems are transferred in a timely manner and that sees time in prison as an opportunity to act and to address serious health inequalities. That is not only in their interest but in all our interests.

[Mr Ben Bradshaw (Exeter) (Lab)]

Given the picture the hon. Lady just described, she will be aware of the serious problems in Exeter Prison, which the staff there are doing their utmost to try to address. Does she agree that, as we face voting on the Budget later this afternoon, it might have been better, rather than giving tax cuts to the richest 10%, for the Chancellor to spend that money on helping our prisons to deliver the kind of services that she would like to see?

[Dr Wollaston]

I thank the right hon. Gentleman for his contribution towards the report. He identifies that this is an area that is often deprioritised in favour of other issues. However, we absolutely have to prioritise the health of our prison population. I agree that we should address staffing levels. We should also look at the health and wellbeing of our prison staff. Too many leave because of the pressures and the violence that they face in prison.

[Kate Green (Stretford and Urmston) (Lab)]

Although a disproportionate number of prisoners are young males, as the hon. Lady will know, the prison population is ageing, with more much older prisoners serving custodial sentences than previously. What observations did her Committee make of healthcare provision for that ageing prisoner population, and what does she think the Government need to do to make sure that those people are properly cared for?

[Dr Wollaston]

I thank the hon. Lady for drawing attention to that. Our report mentions that the prison population is ageing, particularly as a result of older sex offenders coming into our jails. It is about dealing not only with healthcare in our prisons but with social care. We call on the Government to look specifically at how we commission for that age group and their special needs. She will also know that the average age of death in prison is 56. We really have to look at the excess mortality, which is 50% higher for people in prison than for the background population.

[Robert Neill (Bromley and Chislehurst) (Con)]

It is a pleasure to see you in the Chair, Sir Henry. I very much welcome my hon. Friend’s statement and the report, in which I thank her for involving Select Committee on Justice. The evidence that she received entirely mirrors that which the Justice Committee is receiving for our inquiry into the make-up of the prison population in 2022. Does she agree that it is absolutely essential that we turn around the inadequate provision of health services across our prison estate, not only because it is morally right but because it is impossible to effectively rehabilitate people when there is endemic ill health in many parts of the prison population? That means that people are discharged back into the community often in poor health and leads to a cycle of reoffending that costs the community more, as well as destroying and blighting lives.

[Dr Wollaston]

I absolutely agree with what my hon. Friend has said and I welcome the ongoing interest that the Justice Committee is taking in this issue. He will know that one very depressing aspect of this situation is that report after report is published highlighting the issue, but we are just not seeing the progress needed. There needs to be real accountability and consequences for progress not being made on all these issues.

[Andy Slaughter (Hammersmith) (Lab)]

We all know that the suicide rate in prisons has increased markedly, but also, because of ageing prisoners and addiction problems, more people are dying. Was the Health and Social Care Committee able to assess whether the standards of healthcare mean that people go into prison and simply do not come out?

[Dr Wollaston]

I thank the hon. Gentleman for his question. The point is that if someone goes into prison with a serious underlying medical problem, it is simply unacceptable that they cannot access the healthcare that they should be receiving. That is what we heard time and again: people’s appointments are cancelled, issues are not addressed and thing are not followed up. Sometimes an outside appointment with a specialist, for very serious conditions at times, will simply be cancelled, and then there is no continuity and follow-up, so the person simply falls out of the system. Undoubtedly, therefore, people’s health is suffering and, as I said at the beginning, no one is sentenced to worse healthcare when they are sentenced to deprivation of their liberty. The situation is unacceptable.

[Dr Paul Williams (Stockton South) (Lab)]

I thank the hon. Lady not just for her presentation today, but for so ably chairing the inquiry. Her presentation put across very eloquently the fact that we put in prison a population of people who are very unhealthy already, but unfortunately our prison environment makes them even less healthy instead of taking the opportunity to reduce health inequalities and improve their health. It makes them even less healthy for two reasons. One is the prison environment that they are in, which is very unhealthy. The second is prison health services. Despite some excellent prison health services that really work, we found that on the whole prison health services are not adequate. The hon. Lady has already talked about the need for accountability and consequences. Can she say something about the role that we recommend the Care Quality Commission might play in that?

[Dr Wollaston]

I thank the hon. Gentleman for his own really important role in the course of our inquiry. He highlights the point about the CQC. The CQC has no powers of entry into our prisons. We now know that it can carry out unannounced inspections just about anywhere else, but it cannot in prisons. The other challenge that it faces is being able to take a whole-system approach to the way services are commissioned. We heard from it again, in relation to a separate inquiry, earlier this week that it would like to have the powers independently to look at a whole-system approach, rather than just very narrowly looking at one aspect of it. It was very clear to us that a whole-system public health approach needs to be taken to the commissioning and provision of healthcare.

The hon. Gentleman’s other point was about the conditions in our jails. Keeping people in conditions where there are broken windows, cockroach infestations and so on is wholly unacceptable. No one should be living in those conditions in Britain today.

[Liz Saville Roberts (Dwyfor Meirionnydd) (PC)]

The Select Committee on Welsh Affairs is undertaking an ongoing inquiry into the prison estate in Wales, and one issue that has been raised is the fact that health is of course devolved, but there appears to be relatively little consideration of how health is managed differently there from how it is managed in English prisons—of the difference between Wales and England. There is a particular anomaly with the only private prison in Wales, the question of answerability to the health ombudsman, and to whom actually that prison is answerable. Has the hon. Lady made any assessment of accountability between the Welsh and English regimes and to what degree we should perhaps be measuring the difference between health provision in prisons in Wales and that in England?

[Dr Wollaston]

I thank the hon. Lady for making that point. We did not look at devolved issues, because the remit of the Health and Social Care Committee is England only, but the hon. Lady makes a very important point. As the Justice Committee has an ongoing interest in this issue, there might be an opportunity for that Committee to take the matter up more quickly than we would be able to, but I would be very interested if the hon. Lady wanted to write to me about it.

I again thank all those who contributed to the inquiry, and I look forward to hearing the ongoing thoughts of the Justice Committee.

[Sir Henry Bellingham (in the Chair)]

Would the Minister like to say anything?

Budget Resolutions

Sarah Wollaston Excerpts

Tuesday 30th October 2018 Commons Chamber

[Matt Hancock]

My hon. Friend is absolutely right. People want to see more funding for our NHS, and they are going to get it, but they also want to see all the money being well spent.

The Budget confirms that the NHS is the Government’s No. 1 spending priority, just as it is the British people’s No.1 spending priority. This Budget places the Government four-square in the centre of British politics. It is progressive and optimistic and focused on the future, not just for the many but for the whole country that we serve.

[Dr Sarah Wollaston (Totnes) (Con)]

I absolutely welcome the uplift to NHS funding, but will the Secretary of State answer a small technical question, please? In the Red Book, there are separate entries for the increases in the resource departmental expenditure limits for health and for NHS England? Can he confirm that the difference—£6.3 billion versus £7.2 billion—will not result in a transfer from Public Health England, from Health Education England or from capital budgets to fund the discrepancy? That has happened in the past.

[Matt Hancock]

Yes, I can confirm that. The £20.5 billion real-terms funding for the NHS in the Budget is for the NHS itself and will be channelled through NHS England. Of course there are budgets in the Department that are outside the NHS envelope, and they will be settled in the spending review. This is exactly as has been planned, and it was made clear in June. I can tell the House that the £20.5 billion is both the longest and the largest settlement for any public service in the history of this country.

--- Later in debate ---

[Dr Sarah Wollaston (Totnes) (Con)]

May I start by apologising for being absent for much of this debate because I was chairing the Health and Social Care Committee? I also declare a personal interest, as three members of my immediate family are employed as NHS doctors.

We need to take a whole-system approach to health— to think of it not just as the NHS, but as a system including social care, public health, the prevention arm and training budgets. I return to a point that I made in an intervention: I wholly welcome the uplift in the NHS budget, but the increase in the NHS England budget that will take place between 2018-19 and 2019-20 is £7.2 billion, whereas the uplift in the wider health budget in the Red Book is only £6.3 billion. It concerns me that this might indicate that some of the uplift in the NHS England budget will come by way of being taken out of other aspects of the health budget, particularly the Public Health England budget, as we have seen in previous years. I hope that the Minister will touch on that in his response.

[Jonathan Ashworth]

I think that the hon. Lady may have left the debate to attend her Committee when I re-emphasised her point directly to the Secretary of State, who told us that we would have to wait for the spending review. Would she share my disappointment if the Government tried to pull the same trick that they pulled three years ago, and actually misled us or gave us bogus figures for NHS spending that did not include public health expenditure, capital and training?

[Dr Wollaston]

We need absolute transparency around health spending, and to take not only a whole-system approach but a long-term view.

Public health is the prevention arm of the system, and taking money out of public health has a serious impact on future spending and our ability to tackle health inequalities. It would be very troubling indeed if much of this uplift came directly from a public health cut. We need to be specific about that, and it is not sufficient to wait for the spending review to clarify that point; I hope that the Minister will be able to tell us further about what it means. People need to plan for the future, so if £900 million is going to be taken out of public health grants, we need to know that now.

When we ask the public which parts of the system they prioritise, public health tends to be at the bottom of the list. It is up to the Government to look at the evidence, and they must be clear that the evidence shows that we must focus unrelentingly on the prevention arm of healthcare. That is the right thing to do, and it is where we have the greatest chance of tackling the burning injustices of health inequality, so it is an important point to address.

The other aspect I want to touch on is social care. The Health and Social Care Committee has just had a sitting with the Care Quality Commission on its excellent “State of Care” report. The report comments on “fragility,” and the report of a couple of years ago talked about “a tipping point.” The CQC told us that that tipping point has been passed for many people in social care. The interaction between social care and the health service is so close that, if we do not focus on social care, we are simply tipping more costs on to the health service.

Of course it is welcome that there will be an in-year increase for adult social care of £240 million this year and £650 million next year, but it is widely recognised that, because of the extraordinary increase in demand and pressure—driven not just by the welcome fact that we are living longer but by the great increase in the number of people with multiple long-term conditions living to an older age and by younger, working-age adults living with multiple complex needs—social care needs more than £1 billion a year just to stand still, so we need to go further.

I recognise that much of this will come alongside next year’s social care Green Paper, which we are all looking forward to, but the system is under considerable challenge. I hope the Minister will recognise in his closing remarks that we are not there yet on social care. He needs to say what we are going to do in the long term to address our social care needs. As I have said before, we will require an approach that involves the Labour Front Benchers, too. We need to see political consensus, otherwise the politically difficult decisions on funding will not get through the House.

If there are to be cuts to public health, the Government will have an even greater responsibility to provide other levers in their public health policy to reduce demand in the system. The Chancellor specifically referred to wanting to reduce the tragedy of lives lost to suicide. Unfortunately, at the same time, the delay in the reduction of the maximum stake for fixed odds betting terminals means that we have passed up on an important opportunity to address the misery of gambling addiction. That is a hugely wasted opportunity. Likewise, there is a missed opportunity to look at what has happened in Scotland on minimum unit pricing to make sure we are addressing some of the key drivers of public health problems. The Government cannot duck that if we are to see cuts to the public health grant.

Finally, there is the impact of Brexit. The Chancellor has said that there will be £4.2 billion for preparations for a no-deal Brexit. I am afraid that the costs will be far higher. The Health and Social Care Committee recently heard from the pharmaceutical industry that it is having to plough hundreds of millions of pounds into preparing for no deal. That is phenomenal and inexcusable waste; it is money down the drain. I hope the Government will rethink their policy, because no version of Brexit will provide more money for the NHS. There is a Brexit penalty, not a Brexit dividend, and I hope both Front-Bench teams will come together and agree that, ultimately, we need the informed consent of the British people for whatever version of Brexit we come up with, with the option to remain and properly use the money instead for tackling austerity and improving the lives and the health of our nation.

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 23rd October 2018 Commons Chamber

[Matt Hancock]

Having a flu jab is incredibly important, and I hope that Members on both sides of the House have taken the opportunity to do so, including the right hon. Gentleman, with whom I enjoyed working for many years. We have a phased roll-out of the flu jab, making sure that we get the best flu jab most appropriately to the people who need it most, and of course we keep that under review.

[Dr Sarah Wollaston (Totnes) (Con)]

Digital health tools, including decision-support software, have a great potential to increase the quality, safety and cost-effectiveness of care for patients, and nowhere is that more important than in reducing antimicrobial resistance. Will my right hon. Friend respond to the points that we on the Health and Social Care Committee make in our report about the variation in roll-out, which is wholly unacceptable, and what measures will he take to make sure that it is clear where the responsibility for this lies?

[Matt Hancock]

I pay tribute to the Select Committee for the report on AMR that was published yesterday. Of course, digital tools such as the one that my hon. Friend mentions are important in making sure that we make the best use of antibiotics and counter antimicrobial resistance as much as possible.

Social Care Funding

Sarah Wollaston Excerpts

Wednesday 17th October 2018 Commons Chamber

[Barbara Keeley]

No, I will not give way; we have very limited time.

As my hon. Friend the Member for Great Grimsby (Melanie Onn) just said, the effects of reduced access to care are very keenly felt, especially by older people, but I want to highlight what happens to young adults with learning disabilities and autism when there is too little funding to support them in the community. A recent BBC “File on 4” programme on transforming care highlighted the impact on young people with autism or a learning disability of being kept in assessment and treatment units for long periods.

The nature of these settings is chilling. A young woman with autism and extreme anxiety called Bethany, aged 17, is being kept in seclusion in St Andrew’s Hospital, Northamptonshire, in a cell-like room and fed through a hatch in a metal door, at which even her father must kneel to speak with her when he visits. She is being detained and held in seclusion despite an assessment that the current hospital setting cannot meet her needs and a recommendation that she be moved to a community residential setting with high support. As “File on 4” pointed out, however, moving a young person such as Bethany to a community setting would involve her local council paying £100,000 to £200,000 a year from the adult social care budget, instead of leaving the NHS to pay what is a much higher bill—in this case, £676,000 a year, or £13,000 a week.

The lack of funding is clearly a factor here. Bethany’s dad was told by the Walsall Council officer responsible for her placement that her care had already cost the council £1.2 million. To be frank, he said, “Walsall could do with a breather.”Bethany is being treated shamefully. It is hard to imagine someone making a similar comment about the cost of treatment for a young person with cancer.

Bethany’s case highlights a growing problem which is part of the crisis in adult social care. Underfunding social care places people with a learning disability or autism at risk of being left for long periods in institutional care settings. Now that I have raised this case, the Secretary of State must look at the state of funding, which leads to perverse incentives for private hospitals like St Andrew’s to charge the NHS for keeping vulnerable young people with autism or learning disabilities in expensive and unsuitable placements because the local council does not have the resources to fund a community placement.

The journalist Ian Birrell recently wrote about Bethany’s being kept in those appalling conditions, in seclusion in a tiny cell. He asked, “Have we moved far from Bedlam?” The answer is, I am afraid, that we have not. The transforming care programme is making hardly any progress. The most recent data, published in May this year, show that 2,400 people—people like Bethany, with a learning disability or autism—are still in in-patient units, and that is an increase from an earlier figure. Many people in such units are subject to over-medication, inappropriate restraint and seclusion. They can be far from home, and they can be kept there for a very long time. The average stay is more than five years.

As the National Audit Office found, such placements are extremely expensive. In 2012-13, the NHS spent £557 million on people with a learning disability in mental health hospitals. Will the Secretary of State tell us why the Government are still funding the institutionalisation of so many people with learning disabilities, or autism, at great cost, seven years after the scandal of Winterbourne View, after which they promised to cut those placements by half?

[Dr Sarah Wollaston (Totnes) (Con)]

The very troubling case that the hon. Lady has described illustrates why we, as a House, must get this right. Does she accept that there has been political failure to resolve the issue of how we fund social care, and will she commit herself to taking a constructive, cross-party approach to getting it right?

[Barbara Keeley]

The hon. Lady has asked me that question a number of times, and I always find it difficult to answer. She will know that my party really tried, but when we produced that White Paper in 2010—when we had a way forward and a set of funding proposals—all that we heard was “death tax”. In last year’s Budget, the Chancellor raised the issue of the “death tax” again: he said that it was not an option. I wonder how the hon. Lady thinks that Labour Members can talk to a party whose Chancellor has ruled out one of the options right at the start, before anyone sits down and discusses anything. I think that that is impossible. I value the hon. Lady’s role as Chair of the Health Committee, of which I used to be a member. Perhaps she will write to the Chancellor, and ask him to stop doing that.

[Dr Wollaston]

As the hon. Lady will know, this is a pattern that has pinged backwards and forwards with successive Administrations. I repeat that we must get it right. We cannot continue these cycles of political failure. We will only solve the problem—particularly in a hung Parliament—with a constructive, cross-party approach.

Dangerous Waste and Body Parts Disposal: NHS

Sarah Wollaston Excerpts

Tuesday 9th October 2018 Commons Chamber

[Stephen Barclay]

Let me pick up on the various points that the hon. Gentleman has raised. On when Parliament was told, as I said in my statement, the partial suspension notice was served on the company on 3 October and new contracts were put in place over the weekend. This is, therefore, the first opportunity, following what had been commercially sensitive negotiations, to notify the House. It is also right to remind Members that the key strategic objective throughout has been to maintain operations at NHS hospitals to ensure that clinical waste is being collected. That strategic objective has been maintained at all times.

The hon. Gentleman asked a number of other questions, including whether there is enough incinerator capacity in the system. The answer to that is, yes there is. There are 24 incinerators. The Department for Environment, Food and Rural Affairs estimates that there is more than 30,000 tonnes of spare capacity in the system, and that there is significant capacity over and above that required by HES to perform its contract, so I can be very clear to the House that, moving forward, there is sufficient incinerator capacity.

The hon. Gentleman used some inflammatory language. It is worth reminding the House that just 1.1% of this clinical waste is anatomical, so some of the media headlines are slightly out of step with reality. The partial suspension that has been served on Normanton is solely in respect of the incinerator; it does not apply to the other sites under HES contractual arrangements with the trust.

The hon. Gentleman asked whether the waste was being secured safely. The answer is yes; the Environment Agency has been inspecting the situation. The issue is the overstorage of waste, not that the waste is not being stored in a safe manner. [Interruption.] Well, that is the legal remit of the Environment Agency, which is an independent body. It is right that the law is applied; the hon. Gentleman may not like to apply the law, but this is the legal process. Officials from the Department of Health have been to the major trauma sites to see the contingency plans at first hand, and the storage and capacity is in place at those sites.

The reality is that there was a contractual arrangement with a supplier that stored the waste correctly, but stored too much of it. The Environment Agency is enforcing against that. We have put in place contingency plans within the trusts and set up alternative provision in the form of a contract with Mitie. The key strategic objective of ensuring that NHS operations continue has been secured.

[Dr Sarah Wollaston (Totnes) (Con)]

I thank the Minister for the prompt action that he has taken since being notified of this situation. Will he reassure people in the community and in community settings that this issue will not affect their safety?

[Stephen Barclay]

The Chair of the Health Committee raises an important point regarding residents in the areas where the sites are located, and I see the right hon. Member for Normanton, Pontefract and Castleford (Yvette Cooper) in her place. The Environment Agency has confirmed that the waste is being stored safely; it is the amount of waste that is the issue. Many of our constituents are waiting for operations on these sites and will want reassurance that those operations can continue in a timely fashion. That has been a key focus of the Department, and I pay tribute to the work of officials in the NHS, the Department of Health, DEFRA and the Environment Agency, who have ensured that that strategic objective has been maintained.

Integrated Care

Sarah Wollaston Excerpts

Thursday 6th September 2018 Westminster Hall

[Dr Sarah Wollaston (Totnes) (Con)]

I beg to move,

That this House has considered the Seventh Report of the Health and Social Care Committee, Integrated care: organisations, partnerships and systems, HC 650, and the Government Response, Cm 9695.

It is a pleasure to serve under your chairmanship, Dame Cheryl. I thank all those who contributed to our inquiry in writing and in person, my fellow Select Committee members, and the Select Committee team, which was ably led by our Clerk, Huw Yardley, with special input from Lewis Pickett. I also thank our special advisers, Professor Sir Chris Ham, Dr Anna Charles and Professor Pauline Allen.

We are all immensely grateful to the South Yorkshire and Bassetlaw sustainability and transformation partnership, the Doncaster Royal Infirmary and the Larwood practice, not only for allowing us to meet them and their teams, but for facilitating the Committee’s meetings with local and national leaders from across the healthcare system, the third sector and many other providers to hear evidence during our inquiry. Without them, the report would not have been possible.

I will start by setting out what we are talking about, and why it matters. It is one of the greatest triumphs of our age that we are living longer but, as that happens, many more of us are living with complex, long-term conditions that require support and input not only from dedicated family and formal carer networks, but from across the health and social care system. If those systems do not join up, if they do not share information, or if they are poorly co-ordinated or inaccessible, patients’ care is poorer and everyone has a worse experience. Don Redding from National Voices said that patients and the public

“want to feel that their care is co-ordinated, that the professionals and services they meet join up around them, that they are known where they go, that they do not have to explain themselves every single time, and…that their records are available and visible.”

That is essentially what we mean by integrated care.

Integrated care can happen at three levels. It can happen directly, in the teams around the patient who deliver care in the patient’s home—for example, through joint assessments. It can happen at the service level—for example, with services brought together in a one-stop clinic. It can happen at an organisational level—for example, in commissioning or the pooling of budgets. We should all be clear, however, that none of that matters unless we keep the patient at the front and centre of those discussions. If the result is not delivering better care for patients and their families, it is not worth doing.

Integration does not save money in the short term or, sometimes, in the medium term, which acts as a key barrier to putting in place integrated systems for the long-term benefit of patients. Unfortunately, particularly with the current financial pressures, we have a system that is sometimes dictated and hampered by short-term pressures to deliver financial savings—I will come on to that later. In essence, we have to keep sight of the fact that integration is about people and families. Although our report focuses on organisations, partnerships and systems, we have tried to relate it back at every stage to why it matters to patients, rather than it being a dry discussion about systems.

[Diana Johnson (Kingston upon Hull North) (Lab)]

We are very ably led by the hon. Lady on the Health and Social Care Committee. The Committee’s approach to the public was the right one, and I hope that, in its future communications with the public, the Department of Health and Social Care might learn that lesson about having the patient at the heart. That is what this is about, because it is so complicated and difficult for the public to understand.

[Dr Wollaston]

I thank the hon. Lady, my fellow Committee member, for her input. We on the Committee heard that there is a complex spaghetti of acronyms—STPs, ICPs, ACOs—and nobody knows what they mean. Even those working in the system struggle to keep pace with them and with the changes. We have to keep bringing it back to plain English and why it matters to people and hold our attention there.

The integration of health and social care has been a long-term goal for successive Governments for decades, so we might ask why it is not happening everywhere if we have been striving for it for so long. We saw and heard about many fantastic examples of good integrated care, but they sometimes felt like oases in a desert of inactivity. It is also possible to have an area that does some things very well but others not so well.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

I commend the hon. Lady for the way she is making her remarks on our report, which I welcome. I looked closely at the Government’s response, in which they said that they

“remain keen to consider how to build political consensus on the case for reform and funding as part of the development of the NHS”

10-year plan, but we have heard no reference to exactly how any mechanism for reaching such a consensus might be pursued. We have heard a lot of talk about integrated care for many years, but we now find ourselves at a critical moment. The Government are about to launch their 10-year plan, and it must be front and centre of what they put forward.

[Dr Wollaston]

I will respond further to the hon. Lady’s remarks when I comment on legislative change and how we can get legislative change through a hung Parliament. I will also comment on the importance of engaging with the service and why that needs to come bottom-up from the service, and the importance of politicians from across the House listening to the service and being focusing on its message and the message from patients and patient representative groups. I thank her for her constructive input. The Committee has been successful in building consensus about how this should go forward. I hope the Minister has heard that intervention and that he will respond specifically to that point in his closing remarks.

[The Minister for Health (Stephen Barclay)]

indicated assent.

[Dr Wollaston]

Coming back to why integrated care does not happen, there are many deeply ingrained structural divides. Since the inception of the NHS 70 years ago, we have had a system that is free at the point of use for the NHS, but means-tested for social care. That presents an extraordinary hurdle when systems are trying to join up. It is not just that; it is different contractual arrangements and working practices. Good integration comes down to individuals and teams being prepared to work together, but it often feels like they are working together to achieve integration despite the systems around them, not because of them.

We need a system where everybody is focused on helping the right kind of integration to take place, and we need to go back and look at that fundamental structural divide between the systems. I ask the Minister to look again at the joint report, “Long-term funding of adult social care”, because that is an important issue that goes to the heart of the barriers to joining up services. It is about contractual differences, different legal accountabilities and payment systems that work against the pooling of budgets, and financial pressures within the NHS.

A certain amount of financial pressure can encourage systems to come together to pool their arrangements and provide a more efficient service, but as the Minister will know, when the elastic is stretched too tight and the financial strain becomes critical, we see the opposite—systems are forced apart. I have seen that happen in my area, where people suddenly feel that they have to retreat to their organisational silos to fulfil their legal obligations. There is no doubt that, for the process to work effectively, we need the right amount of funding—and sufficient funding—and tweaks to the legislative arrangements to allow people to come together, so it does not feel as if they are working together despite the system.

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

I am grateful to the Chair of the Committee for giving way. Does she agree that when there is an attempt to elicit change through turning off the financial tap, what happens in fact is that people cut what they think is easiest to cut, which is often the most innovative solution, rather than step back with a clear head to consider where they want to get to in the end? Does she also agree that we often find that the result of that kind of cost-cutting is a backward step rather than a forward one?

[Dr Wollaston]

I thank the hon. Member for that intervention and for her own service to the Committee previously—she is very much missed. Her remarks are typical of the constructive input that she has always made to the health debate in emphasising the need to take the long view. Financial pressures so often force us into short-term solutions, not only in the way she set out but through the salami-slicing of services.

One of the points that our Committee feels strongly about and that I was going to make to the Minister is the need to ring-fence transformation funding, because it is so easy for that funding to get lost. I welcome the uplift in funding—a 3.4% increase will be very helpful—alongside a 10-year plan. However, we have to be realistic about what that uplift can achieve, because there are very many demands on that budget, as the Minister will know and as we have seen in the past. We saw it with the sustainability and transformation fund, which tended to get sucked into sustainability and not into transformation. That has been the pattern of recent decades. There is good intention to ring-fence money for transformation, but that money disappears because of other priorities around deficits and, as I have said, the many other calls on the funds available.

That is why we feel that, in order to prevent the continuation of that cycle of past mistakes, it is important that the pattern is recognised and that funding is earmarked for transformation—not only for capital projects but for things such as double-running.

I will give an example from my area. There will be a complete destruction of public trust in new models of care if money is not set aside for double-running. The community was prepared to accept that there would be a new facility—nobody wanted the closure of the local community hospital in Dartmouth, but there was an assurance that there would be a new facility. Unfortunately, despite many of us opposing the closure of the old facility, what happened was that it was closed and then there was a breakdown in the arrangements for the new facility. The community was left with nothing and there has been a huge destruction of public trust in the process, which unfortunately will have ripple effects across other communities. Had we received the money to keep the existing service while the new service was built and got up and running, it would have left us in an entirely different situation. I am afraid that we see that too often across health and social care. There is good intention, but without double-running, which is part of having a ring-fenced transformation fund, I am afraid that the system has broken down too often in the past. I would like the Minister to focus on that when he makes his remarks.

The Committee is also looking forward to the 10-year plan—we look forward to working alongside both NHS England and the Department of Health and Social Care to examine how that plan emerges—but is important to draw attention to legislative changes. Our Committee made a recommendation that legislative proposals should come from the service itself rather top-down from the Department, which would immediately run into difficulties. However, as a Committee we also offered to subject such proposals from the service to pre-legislative scrutiny.

As the hon. Member for Kingston upon Hull North (Diana Johnson) pointed out in her intervention, we need to build cross-party consensus at every point. As it has not been covered in the formal response to the Committee’s report, will the Minister say in his closing marks whether the Government would support the Committee conducting pre-legislative scrutiny?

I am pleased to have had a conversation with Simon Stevens, the chief executive of NHS England, who has confirmed that, as it emerges, the NHS assembly will consider that within its remit—NHS England hopes to produce proposals in draft form before Easter 2019. Nevertheless, as I have said, it would be helpful to receive the Minister’s assurance that proposals will come to our Committee for pre-legislative scrutiny as part of the process of building consensus.

[Diana Johnson]

Like me, the hon. Lady was in Parliament when we went through the 2012 reforms. We had to have a period of pause because of the complexity of the legislation. Pre-legislative scrutiny is absolutely essential and I wholeheartedly support what she has said as the Chair of the Committee.

[Dr Wollaston]

Hon. Members know that a lack of proper pre-legislative scrutiny that responded to concerns expressed led to many of the barriers. We have to go back and address them when they could have been addressed in a more collaborative process during the passage of the Health and Social Care Act 2012. I am thinking of the need to reconsider the legal basis for merging NHS England and NHS Improvement, and how we establish a better statutory basis for the process so that provider partnerships do not always have to go back to separate boards to gain their approval. It is about considering how we address issues such as geographical arrangements so that they make more sense to local communities. The Committee could play a constructive role in a host of areas but—I say this to the Minister—unless proposals are subjected to pre-legislative scrutiny and unless a cross-party consensus is established, proposals are likely to fail.

My final point—other Committee colleagues will probably want to develop it further—is this: what will happen around establishing a legal basis for integrated care providers? For two reasons, the Committee welcomes the change of name from “accountable care organisations” to “integrated care partnerships”. First, the original name confused the debate about Americanisation. The “accountable care organisations” proposed were not the same as those organisations in the States, and the original name caused a great deal of unnecessary anxiety. We do not see the process as Americanisation.

A concern raised with the Committee was that the process will be a vehicle for privatisation. We did not agree. In fact, we thought the opposite: we agreed with the witnesses who told us that the process provided an opportunity to row back from the internal market and away from endless contracting rounds, and move towards much more collaborative working. We would like that change to be properly reinforced within the legal status of health bodies, and are disappointed that the Government have not agreed to say categorically that these bodies would be classed as NHS bodies. When the Minister sums up the debate, I would like him to reflect on whether any form of wording can put the matter beyond doubt and ensure that these health bodies will not be taken over by large, too-big-to-fail private sector organisations.

It is not a concern that groups of GPs might want a leading role in the bodies. The Minister will know that the public concern is more about them being taken over by very large too-big-to-fail private sector organisations. It should be possible to come up with a solution. The Committee heard—the Minister knows this—that those working in the service have the view that the bodies are not likely in practice to be taken over by private sector providers. However, that public concern exists and is a barrier to change. If we can put this matter beyond doubt, we should try to do so.

[Luciana Berger]

I would add a bit of clarification on that point about the size of private organisations that might become involved. My concern is that, irrespective of size—whether private organisations are big or small—the threat of a takeover happening within our NHS has distracted the debate. Anything that would categorically rule it out would be very helpful.

--- Later in debate ---

[Dr Wollaston]

I thank the hon. Lady for her helpful clarification. I was trying to distinguish GPs, who are private contractors to the NHS. Sometimes that status is used as a reason why integration cannot be done. I do not think there is concern about that level of leadership involvement but, as she rightly points out, there is concern about other aspects of the private sector. It is acting as an unhelpful distraction when there should be a consensual approach to ensure, as I said at the beginning, that we keep focused on the purpose, which is to provide better services for patients. Anything we can do to facilitate making it easier for that to happen—rather than feeling like we are wading through treacle—will be a positive way forward.

I thank my colleagues and all who helped with the inquiry.

--- Later in debate ---

[The Minister for Health (Stephen Barclay)]

Thank you, Dame Cheryl, it is a pleasure once again to serve under your chairmanship. I join the hon. Member for Ellesmere Port and Neston (Justin Madders) in paying tribute to my hon. Friend the Member for Totnes (Dr Wollaston) as Chair of the Health and Social Care Committee, and to all the members of the Committee, for a very good report and for raising important issues regularly on behalf of the NHS and the wider health fraternity.

As a country, we are living longer, which clearly is to be celebrated. However, it means that people live with multiple long-term and more complex conditions. For the NHS to continue to deliver high-quality care as it has done for the last 70 years, it is increasingly important for NHS services to work closely with social care. We got a flavour of that from a number of the remarks made in the debate.

I very much welcome the Committee’s conclusion that fears that integration might lead to privatisation are unfounded. Indeed, the Chair of the Committee said,

“The evidence to our inquiry was that ACOs,”—

now referred to as integrated care partnerships—

“and other efforts to integrate health systems and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”

That relates to some of the points I will make on pre-legislative scrutiny and points to the value of the work done by the Health and Social Care Committee to provide a cross-party view of proposals, which has allowed us to address some of the myths built up in the past. The Committee has done the House a service by slaying some of those misconceptions.

[Dr Wollaston]

I thank the Minister for referring to my remarks, but does he accept that the Committee went on to say that we felt the issue of privatisation should be put beyond doubt in legislation?

--- Later in debate ---

[Dr Wollaston]

I thank the Minister and other Members who contributed to the debate. They spoke passionately and reminded us why this matters, particularly to patients. Everything will be judged by whether integration delivers a better service for patients and those around them. I look forward to meeting the Minister and to his appearing again before our Committee—there are a number of areas in which we would like to press him a little further, but I welcome his comments.

Question put and agreed to.

Resolved,

That this House has considered the Seventh Report of the Health and Social Care Committee, Integrated care: organisations, partnerships and systems, HC 650, and the Government Response, Cm 9695.



Backbench Business

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 24th July 2018 Commons Chamber

[Matt Hancock]

Yes, of course I will. I pay tribute to the hon. Lady for her work to raise funds for the MRI scanner in Bishop Auckland, which benefits from great levels of philanthropy in some areas. The whole purpose of having a national health service is that, wherever people live in the country, they can get high-quality healthcare, free at the point of delivery, according to need. I stand by that principle, and I honour it.

[Dr Sarah Wollaston (Totnes) (Con)]

I welcome the Secretary of State to his post. He will know that no regulator is prospectively examining the safety and effectiveness of diagnostic apps in use in the NHS. I wrote to his predecessor recently following concerns that were raised with me about Babylon’s apps, which could be missing symptoms of meningitis and heart attack, for example. What steps will the Secretary of State take to ensure that, as these technologies are rolled out, patients have can have absolute confidence that they have been properly evaluated for safety and effectiveness? Will he set out how he will take that forward?

[Matt Hancock]

The Chair of the Health and Social Care Committee makes a really important point. There is no greater enthusiast for technology than me—as you well know, Mr Speaker—but the thing about new technology is that the rules sometimes need to be updated to take changes in technology into account. The response when there are challenges such as the one my hon. Friend raises is not to reject the technology, but the opposite: to keep improving the technology so that it gets better and better, and to make sure that the rules keep up to pace. I spoke to Simon Stevens at NHS England about this only this morning—we have had a series of conversations in the past couple of weeks since I have been in post—and he is reviewing this exact question. I am absolutely sure that we will get to the right answer.

Department of Health and Social Care and Ministry of Housing, Communities and Local Government

Sarah Wollaston Excerpts

Monday 2nd July 2018 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

It is an honour to speak in this estimates day debate on the 70th anniversary of the NHS. I am privileged and proud to have worked in the NHS for 24 years before coming to this place, and I would like to start by saying thank you to all those who work in the NHS. The principle behind it is as strong now as it was on the day it first opened its doors: it should be free at the point of delivery, available to all, and based on need, not the ability to pay. That is as important now as it ever was; it is truly the thing that makes us most proud to be British. This is not just the anniversary of the NHS, however; it is also the 70th anniversary of the National Assistance Act 1948, which swept away the poor laws and introduced our system of social care, so it is absolutely right that we should be having this joint estimates day debate.

I absolutely welcome the uplift in funding announced by the Prime Minister, but I would like to talk about how we will get the most from those funds, and also how we will pay for this. One of the key challenges that we have long faced is that although the NHS is free at the point of delivery, social care has been means-tested from the outset. That has created a huge challenge in bringing the systems together and providing the integration that patients expect but often find, to their surprise, is not there. Moving towards more integration would have great benefits for patients, and would create savings and a much more logical, patient-centred approach for both systems. I urge the Minister to look closely at the report of both Committees into social care, in which we touched on that issue and made recommendations, which I will talk more about later.

[Kevin Foster (Torbay) (Con)]

My hon. Friend is providing an excellent introduction to this debate. Does she agree that both Front-Bench teams could look at the example of Torbay Council—the local authority we share—which now has an integrated care organisation that brings together adult social care and the NHS for the benefit of our local residents?

[Dr Wollaston]

Indeed; Torbay has led the way. When the Health and Social Care Committee visited Norway and Denmark, we were shown slides from Torbay, because its approach, referring to a Mrs Smith and actually trying to envisage how everything would work around the patient, has been hugely influential abroad as well as at home.

[Chris Green (Bolton West) (Con)]

Health and social care within Greater Manchester has been devolved to the Mayor. Does my hon. Friend agree that Greater Manchester will hopefully lead the way in demonstrating the opportunities presented by combining health and social care?

[Dr Wollaston]

Yes, and I am going to say more about that, because Manchester has benefited from transformation funding. I want to talk about not only the benefits of integration, but how we can ring fence transformation funding. I welcome my hon. Friend’s comments.

Returning to the recent announcement, a £20.5 billion a year uplift by 2023-24 for NHS England is welcome and represents a 3.4% average increase over five years. Importantly, it is front loaded, with 3.6% in the first two years, and comes on top of £800 million that has already been promised to fund the Agenda for Change pay rises. However, the announcement should not be the end of the story, because it refers only to NHS England and does not include social care, public health, capital or, importantly, training budgets—staffing is crucial to making all this work.

Of course, the Prime Minister acknowledged that and promised to come forward with a settlement for social care and public health in the autumn. However, we need to be clear right from the outset that we must have a social care settlement that reflects demographic changes, because we will need an increase of 3.9% in funding just to stand still. If we want to do something to address quality and to allow social care to do more, we need to go substantially further. That will be essential if we want to get the most out of the settlement that has already been announced for NHS England.

[Diana Johnson (Kingston upon Hull North) (Lab)]

Returning to the hon. Lady’s point about public health not being part of the recent announcement, has she seen the 2017 review that highlighted that there is a return of over £14 for every pound spent on local and national public health policies? It therefore makes economic sense to invest in public health, not to cut it in any future announcement.

[Dr Wollaston]

I absolutely agree. This is about not just funding for public health, but the policy levers. We do not need lots of talk about the “nanny state” that denigrates important national public policy drivers, because although we need funding for local services, as the hon. Lady says, this is also about the policy environment that is necessary to make important changes. Investing in public health makes a huge difference for people.

One of the problems here is that when the public are asked where they would like the priorities to fall, we often hear, understandably, about the importance of cancer outcomes, mental health and emergency waiting times. Public health is often bottom of the list because nobody necessarily knows when their life has been saved by a public health policy. The reality is that the major changes and achievements relating to life expectancy have arisen largely thanks to public health policy, but we rarely turn on the television and see a programme called “24 Hours in Public Health”, which is a shame.

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

In the air quality debate last Thursday, I touched on the need for health in all policies. From active transport to quality of housing, is that not where we need to drive public health?

[Dr Wollaston]

The hon. Lady is absolutely right. Health in all policies means using every opportunity to maximise public health. When Departments work together, such as on the childhood obesity strategy, we need maximum engagement across the whole of Government to make that effective. The way it was put to us when the Committee visited Amsterdam was that it should be viewed as a sandbag wall, and if any part of it is missing, we are not going to achieve what we want. That applies to all of public health.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

To echo the point that has just been made, the hon. Lady will be aware that I presented a ten-minute rule Bill in April about having health in all policies. Does she agree that the Government should reinstate the Cabinet Office Sub-Committee on public health so that the entire machinery of government can come together to ensure that we do everything possible to keep people well, rather than having a service that treats people when they are sick?

[Dr Wollaston]

Absolutely. It is essential that we use every mechanism at our disposal to ensure that Departments work together. Public health is mostly delivered in the community, so we need that to happen at the local level, too. Councils should be reaching out into their communities and ensuring that they use every opportunity to deliver health in all areas when it comes to prevention.

One of the most welcome aspects of the funding settlement is that it is long term. For too long we have limped from one short-term sticking plaster to another, so I particularly welcome the fact that we now have certainty over five years combined with a 10-year long-term plan. In the Minister’s response, I ask her to reflect on the recommendation from the House of Lords Select Committee on the Long-Term Sustainability of the NHS for an office of health and care sustainability to do long-term horizon scanning. That means not just future demographic challenges, but long-term workforce planning, which has always been a huge challenge within the health service. Brexit, for example, has implications for not just the workforce, and there are many other challenges ahead, so it would be helpful to have an independent body that could consider such things and help to work out the necessary long-term funding.

My final points are about how we fund the new system. I would be delighted if there was a Brexit dividend, but I am afraid that I do not believe that there will be. I think there will be a Brexit penalty. The difficulty with people thinking that everything might be solved by a mythical future fund means that we are not levelling with them right at the outset that we are all going to have to pay for it. The challenge should be about how to distribute the cost fairly. That is the key point here.

I want to stop here to thank the citizens’ assembly that worked with my Committee and the Housing, Communities and Local Government Committee. I also thank the Chair of that Committee, the hon. Member for Sheffield South East (Mr Betts), for the Committee’s diligent work on this issue.

Going back to fairness, when I was in practice, it always came as a huge shock to my patients when they realised that if they had what might be really quite modest assets, they would have to fund all their social care. That shock was striking when the citizens’ assembly considered the matter. If we are to move to a properly funded system, it must look at the quality of social care, which is precarious in nature, and at the provider challenge. We must be realistic, and we have to make it clear that somebody has to pay. We cannot just put it off to future generations; we have to think about it and explain to the public what that means.

That is why, unusually, our Select Committee makes recommendations to both Front-Bench teams, because the failure to address this has been a political failure. On the one hand, measures suggested by the Labour party have been denounced by my party as a “death tax” and, on the other, my party’s suggestions have been denounced as a “dementia tax”, and that means we get nowhere.

If we are to avoid having the same discussion in five years’ time, we need to be clear about how we will get this across the line. That will require, particularly in a hung Parliament, the co-operation of both sides of the House. I therefore urge both Front-Bench spokespeople to commit to working together.

Members on both sides of the House have repeatedly said that we are prepared to form a parliamentary commission to go out and engage with the public, rather as Adair Turner did on the difficult issue of pensions, regarding what fairness means. We cannot offload this entire cost on to a relatively shrinking pool of working-age employed adults. We need to have a conversation that reaches out to everybody and asks, “What is the fair payment?”, and in return we must make sure those extra payments are earmarked for the NHS and do not just disappear into wider Government funding.

How we do that will mean conversations about national insurance with the self-employed, and it will mean conversations with people in retirement about their own contributions. We cannot put the cost entirely on to young people, many of whom are already, in effect, paying a graduate tax of 9% on everything they earn over £25,000. That would not pass the fairness test.

I am afraid that least fair thing of all would be for us to duck this challenge and leave even more people without the care they need, with disastrous consequences for them, for their loved ones and for their carers, because it falls into the “too difficult” box. This is difficult, but we need to grasp it, explain it to people and come to a decision.

[Several hon. Members rose—]

--- Later in debate ---

[Dr Wollaston]

I again thank all the staff who work in health and care, and the carers and volunteers who work as partners with our health and care service. I thank the Minister for her constructive response to the debate and colleagues from all parties for their contributions.

We are all looking forward to seeing the detail of the 10-year plan in November, and we look forward to that plan being worked up with those working in the service and those who represent patients, so that we get the very best from the funding we have. May I leave the Minister with some thoughts? I really hope that transformation funding will be ring-fenced. It is about not just the money that we put into social care but how we make sure that when we change the packages of care better to suit individuals, the transformation is there. We have seen how effective that is in areas such as Manchester. I hope that the Minister recognises that the workforce lies at the heart of everything that is delivered in health and social care. In thanking again the health and social care workforce, in this 70th anniversary year, I ask the Minister to put them at the heart of everything that we do.

Question deferred (Standing Order No. 54(4)).