NHS Workforce: England

Tim Farron Excerpts

Wednesday 17th July 2019 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is a pleasure to serve under your chairmanship, Mrs Moon. I congratulate the hon. Members for Wolverhampton South West (Eleanor Smith), for Lincoln (Karen Lee) and for St Ives (Derek Thomas) on their eloquent speeches.

The crisis in the NHS workforce is deeply concerning. Its effects are felt nationally, locally and personally. Like others here, I want to pay tribute to the people working at every level of my national health service within the south lakes: the hospital in Kendal, Westmoreland General Hospital, and the district generals that we travel to in Barrow and in Lancaster. Of course, there are the GPs, dentists, paramedics and those providing mental health services. They do an outstanding job, but it is particularly challenging in rural areas, where we have specific problems with workforce planning and supply, which are at the heart of the problems that we are challenged by.

There are several key elements to workforce planning, including accessible and high quality training, as well as affordable training, as has just been mentioned so eloquently. Effective recruitment is another. Alongside both of those is the issue of staff retention. The Secretary of State must surely be held to account for each of those. The huge shortages in the NHS workforce are felt heavily in numerous areas of healthcare provision in the local communities in Cumbria, and I briefly want to touch on a few of them.

The provision of ambulances and ambulance crews has been hit particularly hard. It is vital that we recruit and deploy more paramedics and ambulance technicians. Rural communities such as mine suffer because of the sheer distances that ambulances have to travel to reach patients. According to the review of NHS access standards, it is the responsibility of ambulance trusts to respond to category 1 calls within seven minutes on average. That is a tall order when there are half the number of ambulances per head in the north-west of England as there are in London, despite the fact that my constituency alone is bigger than the whole of Greater London. It leaves communities living in fear for their safety and takes a serious toll on the physical and mental health of our outstanding ambulance crews. Our local paramedics and ambulance technicians are being pushed beyond their capacity. As a result, I have had an influx of local people contacting me about having to wait hours for an ambulance to arrive to give them the treatment that they so desperately need. That is why local health campaigners have been calling on the Government to deliver two new fully crewed ambulances to south Lakeland to stem the crisis and ensure the safety of the community. It is not right that people in Grasmere, Dent or Hawkshead might be an hour away from the nearest available ambulance.

We met the Minister to raise the issue a few weeks ago. He was incredibly helpful and I thank him for his time and his response. I very much welcome the commitment to procure additional emergency ambulances. I understand that as a result of our campaigns an additional £8 million has been allocated to the North West Ambulance Service. That could be good news for south Cumbria, but only if the ambulance service allocates it in the way that we have asked. Ministers should be held to account for whether the ambulances materialise.

Mental health is another element of workforce planning that I want to raise—particularly provision for children. Four years ago the Government promised a bespoke one-to-one eating disorder service for young people in Cumbria. For young people in south Cumbria that promise remains nothing more than words. The specialists have not been recruited and the service still does not exist. I should love it if the Minister would tell me exactly when we can expect our young people to have access to the service. When will the promises be kept?

I welcome the Government’s commitment to preventive healthcare, set out in the NHS long-term plan. However, again, promises are not being fulfilled. In our area, cuts to the public health budget mean that the NHS in Cumbria currently spends only £75,000 a year on tier 1 mental health preventive care for children. That works out at just 75p per child per year. Proper investment in public health would ensure enough money for a mental health professional for every school and college, if we could recruit them, keeping young people mentally healthy and making sure that problems did not become so severe further down the line. It would also ease the burden on our massively oversubscribed local child and adolescent mental health services, and relieve the pressure on our brilliant but overworked teachers.

In our area, there is a problem with people moving out of NHS provision to work privately, particularly in the delivery of dental services. More than half of adults in Cumbria have not had access to an NHS dentist in the past two years, while one in three children locally does not even have a place with an NHS dentist. Much as with ambulances, the impact of the lack of a workforce of sufficient size is felt particularly acutely in rural areas. Insufficient NHS dentistry provision has resulted in families having to make ludicrously long journeys to reach the nearest surgery with an available NHS place. Often, people are unable to make those long journeys, or to afford to make them.

[Mike Hill (Hartlepool) (Lab)]

The hon. Gentleman raises an important issue about dentistry. There are frightening figures about my constituency showing a lack of take-up of NHS dental treatment among children in particular. That is a real worry. I wonder whether it is reflected in the hon. Gentleman’s constituency and whether he agrees that we need at least to tackle NHS provision for dental treatment for young people. It is important.

[Tim Farron]

Yes, the hon. Gentleman makes an extremely important point. I am certain it is felt across the country. If it is made too difficult to get to the nearest NHS dental surgery—if that is 60 or even 100 miles away, as has been the case on occasion for constituents of mine—people go without treatment, and so do their children.

Last November I managed to secure the agreement of the commissioners to increase the value of the contracts to NHS dentists in Kendal so they could see and treat more patients. “Brilliant,” we thought, “that is really good news.” When NHS England contacted our local NHS dentists they found that not one of them was able to take up their offer. I was told that the practices were already working to capacity within the staffing resources they had available, and were reporting difficulties in recruiting additional staff. Those staff exist, by the way. They are working in the private sector. The treadmill of a contract that is unfair to patients and dentists, and not fit for purpose, keeps them out of the NHS. As the hon. Member for Hartlepool (Mike Hill) says, that hits young people particularly.

The reasons for those difficulties include a contract that pays a set amount for a particular type of treatment, regardless of the number of teeth that a dentist treats. A dentist will get paid, on average, £75 for an entire course of treatment including six fillings, three extractions and a root canal. That is not enough to cover overheads. That is a serious disincentive to people entering NHS dentistry. It hits all areas, but particularly deprived areas, and has a massive impact on the size of the workforce. According to the Department’s website, the Secretary of State for Health and Social Care is responsible for

“oversight of NHS delivery and performance”

but if he is unable or unwilling to intervene to correct such absurd commissioning we have to ask what real power he has to perform the role. That is the kind of systemic problem that adds up to the workforce crisis we have all talked about and which proper accountability would go some way to solving.

The website states that the other part of the Secretary of State’s role is

“oversight of social care policy”.

Social care policy is key to NHS workforce planning and supply in England. We all recognise that social care provision is in crisis, and that the crisis gets worse the longer we do not address it. As it grows, so does the pressure on the NHS, which is left dealing with the serious health problems of those who did not receive the routine care they needed. The Government cannot go on delaying simply because of the personal embarrassment of having failed so far. To be fair, they are not the only ones responsible. Neither are they the only ones who can come up with a solution. We need to reach across divides and look for a cross-party solution.

I have written to the Secretary of State for Housing, Communities and Local Government and to the hon. Member for Denton and Reddish (Andrew Gwynne), the shadow Secretary of State, to invite them to join me so that between us we can constructively use this deadlocked Parliament to reimagine and then redesign a social care system that could provide us with the care we might want for our parents, ourselves or, indeed, in the future, our children. I hope that we can work together to create a new deal for social care and a chance to turn this logjammed Parliament into one of the most productive in history.

The lack in the workforce has a profound impact in each of the areas I have talked about. Common themes and problems emerge: there is a lack of planning, as well as short-sightedness and a failure to invest in preventive care or to understand that providing healthcare is harder in rural areas, as are recruitment and retention. The Government must plan to overcome those specific challenges as part of their overall strategy. The Government, in not taking responsibility for the workforce crisis, are creating huge problems for generations to come. We need accountability, both for the current workforce crisis and to ensure that we invest in long-term solutions beyond the next Prime Minister, the next Government and even the next generation.

NHS Dentists: Cumbria

Tim Farron Excerpts

Wednesday 3rd July 2019 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

I beg to move,

That this House has considered the provision of NHS dentists in Cumbria.

It is a pleasure to serve under your chairmanship, Sir David. I am grateful for the opportunity to raise an issue of enormous importance to my constituents and many others around Cumbria.

NHS dentistry in Cumbria has reached breaking point. More than half of all adults in our county have not had access to an NHS dentist in the last two years, while one in three of our children does not even have a place with an NHS dentist. In rural areas such as ours, lack of access to an NHS dentist results in families having to make ludicrously long journeys to reach the nearest surgery with an available NHS place. Often, people are not able to make, and simply cannot afford, those journeys for a simple check-up.

[Jim Shannon (Strangford) (DUP)]

The hon. Gentleman refers to his constituency, but the problems occur across the United Kingdom of Great Britain and Northern Ireland. Does he agree that the lack of dentists in rural areas is incredibly disconcerting? Perhaps we need to look at bigger incentives for those willing to open a rural practice, and incentivise those training in dental surgery, since one in five has to wait three months to have dental surgery. In other words, a rural strategy is needed.

[Tim Farron]

The hon. Gentleman makes a good point; in a moment I will come to some answers to those problems. The challenge is especially acute in rural communities when it comes to attracting and retaining dentists to work in NHS practices in places that are relatively close to people’s homes.

[John Woodcock (Barrow and Furness) (Ind)]

I congratulate the hon. Gentleman on securing this debate on all our behalves. The problem affects not just rural areas but more remote urban areas such as Barrow. Does he share my huge concern that people in Barrow face a 90-mile trip to Whitehaven if they want access to a new NHS dentist? That is the longest trip in England, for a town where more a third of young people suffer tooth decay, compared with 5% in more affluent areas.

[Tim Farron]

The hon. Gentleman makes an excellent point, which I will come to. He is absolutely right that the distance from the nearest available treatment affects urban as well as rural areas. It is a problem across the country that relates specifically to the NHS dental contract, which I will come to in a moment.

According to the most recent data available, taking a child living in Windermere to their nearest NHS dentist will involve a 60-mile round trip to Morecambe in Lancashire. That will mean a three to four-hour journey by public transport, with multiple changes. However, poor signposting by the NHS—it was not easy to decipher—means that that place is not obviously available. The nearest place advertising for new child NHS patients is in Appleby, which is an 87-mile round trip—two hours in the car or a five to six-hour round trip by public transport. It was only with the help of the British Dental Association that we managed to identify availability at the far-distant yet ever so slightly closer practice in Morecambe.

I am sure hon. Members will agree that this is beyond ridiculous. NHS dentistry is a public service. It should not take scouring the internet forensically with a fine-toothed comb and with the expert help of a national professional body to find a space for a child with an NHS dentist. That space has already been paid for through our taxes. Let us imagine for a moment the outrage if it were similarly impossible for people to get access to a GP.

For adults, the situation in Cumbria is even worse. I was appalled to discover that the nearest practice with available NHS provision for a new adult patient in Windermere involves a 98-mile round trip by car to Wigton—a six-hour round trip by public transport, involving three different trains and bus rides. The nearest practice that is adverting is even further away and involves a 104-mile trip, there and back, to Alston, taking over six hours by public transport. After that, the next option listed involved going 123 miles there and back to Blackpool.

Despite those obstacles, families in our communities are still trying to secure places at dental practices but are refused. In Sedbergh, Windermere, Grange, Ambleside and Kendal, dentists are working to their full capacity and even beyond, and are doing a brilliant job, but they simply do not have the numbers or the funding to meet demand. The Government have, cleverly or accidentally, dodged confronting the extent of the problem by doing away with official waiting lists. For the last six years, the NHS has held no waiting lists locally or nationally, and patients cannot depend on their clinical commissioning group or NHS England to support them in their quest to find a dentist who will treat them or their children. Will the Minister rectify that and ensure that reliable and up-to-date waiting lists are kept from now on?

We took the matter into our own hands locally. The Westmorland Gazette and I rang round our local dental surgeries to see whether there was availability, and found that in Kendal, not one of the 10 dental practices in our biggest town had a single space available for an NHS patient. Some 33% of new patients tried and failed to get a dentist appointment in the wider Morecambe bay CCG area last year. That is the equivalent of nearly 16,000 people. When we include those already on the books with a dentist, that figure rises to 18,000 people, and they are just the ones who have tried. That is a disgrace, and the situation is only getting worse.

The consequences should not be underestimated. Children across Cumbria have some of the worst dental health in England, with one in three suffering tooth decay by the age of five. In some areas, almost 20% of children under three have tooth decay, and a fifth have tooth decay when they are still toddlers. Often, that does long-term damage to their oral health before they even have the opportunity to make decisions for themselves. If children cannot see a dentist in a regular and timely way, preventable conditions become emergency conditions and the pressure is piled on NHS services, along with all their other responsibilities.

Nationally, tooth decay is the leading reason for hospital admissions among young children, despite being almost entirely preventable. In 2017-18, over 45,000 children were admitted to hospital to have multiple teeth extracted under general anaesthetic because of tooth decay. Children face completely unnecessary pain and distress, and the NHS faces a £36 million annual spend for that dental work. Dentistry in Cumbria is understaffed, underfunded and overstretched. Although this a local problem, it is a symptom of a systematic one, the effects of which are felt right across the country.

The primary cause of the increasing problems with dental access in Cumbria and across England is the way that this Government choose to commission dentistry. The NHS dental contract is completely perverse. Based on units of dental activity, it sets quotas on the number of patients an NHS dentist can see and the number of dental procedures they can perform in any given year. If a dentist delivers more than they have been commissioned to do, not only are they not remunerated for the extra work, but they have to bear the cost of any materials used, any necessary laboratory work or other overheads from their own pockets.

That is not the only issue. Last November, I managed to secure the agreement of health bosses to increase the contracts of local NHS dentists in Kendal, so that they could see and treat more patients. It was great news—I thought. However, when NHS England contacted our local dentists, it found that not one of them was able to take up its offer because, as it told me,

“the practices are already working to capacity within the staffing resources they have available, reporting they are having difficulties recruiting additional staff.”

Additional resources were made available, but there were not the dentists to provide the service for local people.

The problem is at least in part the result of the contract, which pays a set amount for particular types of treatment, in some cases regardless of the number of teeth the dentist is treating. In practice, that means that a dentist gets paid an average of £75 for an entire course of treatment, including six fillings, three extractions and a root canal, but that is not enough to cover their overheads. They get paid exactly the same amount of money for a single filling. That acts as a serious disincentive for dentistry, full stop, but especially in more deprived areas, where evidence shows that more significant treatment is often required.

Perhaps the most significant issue with the current dental contract is that it totally fails to provide any serious recognition or budget for preventive work. The work of educating adults, parents and children to maintain good dental health receives no funding, despite the fact that that would significantly ease the burden on dentists and the NHS as a whole further down the line. Indeed, check-ups are the smallest and least-remunerated part of the unit of dental activity worksheet. As a consequence, there is no massive incentive to up the number that a dentist does.

None of that is helped by the Government’s decision to cut £500,000 in the last few months from Cumbria’s public health budget this year, undermining vital preventive work, especially in our schools. Nor does it help that we are currently in limbo when it comes to the future of emergency dental services under the soon to be defunct Cumbria Partnership NHS Foundation Trust. Will the Minister tell me which trust will be responsible for emergency dentistry in south Cumbria after October?

Morale among dentists practising in the NHS is at an all-time low. The latest British Dental Association membership survey shows that nearly three in five dental practitioners in England are planning to scale down or leave NHS work entirely in the next five years. Those with the highest NHS commitments are the most likely to want to leave. In recent months, I have received countless letters at an increasing rate from residents, many of them very elderly, asking where they can go for dental treatment, as their current dentist has gone private and they have effectively been kicked off the list. A lot of parents have contacted me saying that they have been asked to pay now that they have been kicked off their local dentist’s NHS list. If they pay, the dentist might provide NHS provision for their children. It strikes me that that is a form of bribery. Many parents cannot afford to pay for themselves just so their children can get free care. That is not right.

The current system also fails to use the skills of all dental staff to their full potential. The NHS dentist contract restricts the initiation of a course of treatment to dentists alone. I met the British Association of Dental Therapists, which explained that dentists often refer the patient to a therapist to carry out the treatment if it is within the remit of their qualification. The fact that that can be begun only by a dentist creates a bottleneck that prevents patients from receiving the treatment that they need when they need it. The dental therapists made the case to me—and, I believe, to the Government—for reforming the system to allow them to initiate a course of treatment, ease some of the burden on dentists, and enable patients to be seen more quickly. I ask the Minister to action that request, or at least to look into it as a matter of urgency.

I welcome the Government’s steps to reform the system by beginning to carry out a few pilots and trials in different forms of commissioning, but the pilots have not gone far enough, there are not many of them, and the proposed systems do not provide a complete break from the old “unit of dental activity” system. Rather, they blend it with new systems. In the face of the crisis that we have on our hands, I am afraid that a piecemeal change is simply not enough for the people of Cumbria. We need total system reform. The Government need to sit up, take notice and change the contract so that people get the dental treatment they need. The current system is unjust, not fair to dentists and patients, and not fit for purpose. It is not good enough for Cumbria.

Urgent action is needed to roll out a system that fairly rewards dentists for the work they do, includes incentives for preventive work and allows all dental practitioners to use their skills to their full capacity. If we want our NHS dentists to feel that their vital work is valued and not to feel encouraged to move into working privately or give up the profession altogether, we need to take swift, far-reaching action. We need a funding system that does not feel like a treadmill, that rewards preventive care and that is not riddled with unfairness, idiosyncrasies and perverse incentives.

Those of us living in Cumbria are seeing the colossal impact of the current system on the health of children and adults alike, and we are further affected by the huge distances that we have to travel to get care, if we are lucky enough to stumble across an NHS dentists with available space. My question to the Minister is this: what action will she take to provide my constituents with the NHS dental healthcare that they desperately need and that their taxes have already paid for?

[The Parliamentary Under-Secretary of State for Health and Social Care (Seema Kennedy)]

It is a pleasure to serve under your chairmanship, Sir David. I thank the hon. Member for Westmorland and Lonsdale (Tim Farron) for securing this debate. He raised some important issues about dentistry, some of which are national problems that I have been looking at since I came into this role about three months ago, and some of which are pertinent to both the urban and rural areas of Cumbria—I know that there are problems in the constituency of the hon. Member for Barrow and Furness (John Woodcock) relating to geography and economics. I will talk a bit about what we are doing nationally, but of course there are some distinct issues to do with the geography in Cumbria.

Cumbria has struggled to attract dentists. The hon. Member for Westmorland and Lonsdale has raised that issue, which I take very seriously, on many occasions. National access to NHS dentistry is high, but I know from my conversations with colleagues from across the House that there are notspots, and that in isolated areas it is very difficult to get to a dentist. We are taking steps to address that issue to ensure that everyone has access to an NHS dentist. It is NHS England’s responsibility to commission dentist services to meet the needs of local people, and it has been actively looking into dental access issues in Cumbria. Its regional team covers my constituency, so it is looking at Lancashire and south Cumbria together. It has urgent work in hand to explore and implement schemes to improve local access.

In south Cumbria, NHSE will be working to help practices that are under-delivering on their contracted levels of dental services. If despite that support a practice remains unable to deliver its full contracted level of dental activity, the unused funds will be diverted into other local practices. NHS England believes that that could support care for about 3,000 patients. Alongside that, work is being taken forward across Lancashire and south Cumbria to integrate dental services within primary care networks. It is important that dentists are part of the integrated primary care network team, enabling oral health advice and prevention work to be offered across the primary care network. Oral health needs, including gaps in services and access difficulties, must be part of the wider health picture. The hon. Gentleman touched on that when he talked about access to GPs.

That is the local action. I want to touch on what we are doing nationally.

[Tim Farron]

The Minister made a very interesting point about people who under-deliver on their contract. It is important that we do not misunderstand what that means. A dental surgery can be working flat out, but if it is, for example, spending more of its time doing preventive work or reacting to people who want consultations and so on, it gets only one unit of dental activity for that. It could be absolutely full to the brim but be doing the lower-tier work just because that is how it is, reactively. That dental surgery is not failing or not working hard enough. It is doing the preventive stuff that we want it to do more of, but the UDA system, with its perverse incentives, does not reward that.

[Seema Kennedy]

The hon. Gentleman anticipates my speech: I will talk about contract reform later. He knows much better than me that the problem with the previous contract was that it was introduced with perhaps a bit too much haste, and we are now living with the consequences. We are mindful that we need a contract that works well and is sustainable for the future.

Nationally, we are introducing so-called flexible commissioning, which allows local NHS commissioners to commission a wider range of services from dental practices. That is expected to make NHS dentistry more attractive to new performers. Another key recruitment and retention challenge—of course, this is not confined to dentists; it applies to a whole range of healthcare and other professionals—is the growing demand among younger dentists for more varied portfolio careers. NHSE is working closely with Health Education England and a wide range of stakeholders to make portfolio careers a reality for dental professionals, allowing dentists to move between specialities such as prevention, restorative work, oral health and special care dentistry.

We want UK-trained dentists in the NHS, and we want them to stay in those careers, but dentists from overseas also play an important part in delivering NHS care. I am pleased that the NHS and the Government have taken steps through the launch of the EU settlement scheme to maintain that essential supply of dedicated and skilled workers, including European economic area-trained dentists, when we leave the EU. Last summer, doctors and nurses were removed from the tier 2 cap, leaving more places for other highly skilled professionals, including dentists.

The interim NHS people plan, which was published early last month, commits to creating a capable and motivated multidisciplinary dental workforce of a sufficient size to meet population health needs. The full people plan will be published later this year.

We are working closely with NHSE to reform the current dental contract. Feedback from dentists who are testing the prototype contract suggests it is a more satisfying way of delivering care. It supports a better skills mix, allowing dental care to be supported by a wider range of staff, such as therapists and hygienists. At a meeting a couple of weeks ago with a wide range of dental stakeholders, I announced that a further 28 dental practices had joined the programme, bringing to 102 the number of practices that are testing the new prevention-focused way of delivering care. NHSE is considering carefully when that approach can be rolled out more widely across the NHS. It is important that we get the new contract right, but I am hopeful that the roll-out will happen as soon as possible.

I want to touch briefly on three questions hon. Members asked. The first and most important was about children’s oral health. I heartily agree with the hon. Member for Westmorland and Lonsdale about the importance of children’s oral health and all the preventive measures the Department can take to protect children’s teeth. He rightly pointed out something that not all hon. Members are aware of: the biggest cause of emergency admission for children is poor oral health. Of course, that is entirely preventable. The Government are committed to that, particularly among deprived children. We have made the Starting Well approach available to other NHS England commissioners, and that is promoting increased access and early preventive care for very young children.

--- Later in debate ---

[Tim Farron]

Just so the Minister is fully aware of the facts—I know this predates her time in this role—the NHS talked in its long-term plan about its vision for early identification of conditions of all sorts, and about preventive care, and then literally a fortnight later, just before Christmas, the settlement for public health spending for Cumbria was reduced by £500,000. I would be grateful if the Minister intervened to ensure that that does not happen again, because it has a huge impact on our ability to keep children in good practice in their early years so they have good dental health.

[Seema Kennedy]

Of course, part of prevention comes from the public health budget. That now sits back with local authorities, which is where it was historically, and of course—the hon. Gentleman knows my constituency well, having grown up there—there are different needs in different areas. What the NHS does through the immunisation and screening programmes is also part of that aspect of preventive health, but I take on board his comments about the specific public health situation in south Cumbria.

I hope the hon. Gentleman is reassured that significant action is being taken locally in Cumbria and nationally, both now and for the future, to improve access to NHS dental services. The new prevention-focused dental contract in particular, which is a key part of our reforms, should attract people to and keep people in the dental profession, and make dentistry a more varied and rewarding career. It will ensure better access to dentistry in places such as Cumbria and across the country for all our constituents.

Question put and agreed to.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 18th June 2019 Commons Chamber

[Mr Speaker]

What is not rubbish is the very pithy line of questioning typically deployed by the right hon. Member for New Forest West (Sir Desmond Swayne). I will call the hon. Member for Westmorland and Lonsdale (Tim Farron) if his question consists of a sentence, rather than a speech.

[Tim Farron (Westmorland and Lonsdale) (LD)]

Access to prescriptions is made much harder given the closure of 233 community pharmacies in the last two years, so will the Minister introduce an essential community pharmacies scheme to support rural pharmacies such as those in Cumbria and keep them open?

[Mr Speaker]

Well done.

Health

Tim Farron Excerpts

Tuesday 14th May 2019 Commons Chamber

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is an honour to follow the hon. Member for Chichester (Gillian Keegan), with whom I work closely and proudly on the all-party parliamentary group on radiotherapy.

When the NHS long-term plan was published, the emphasis on strengthening preventive care was a welcome step in the right direction. Good preventive care and public health are kinder and cheaper than the late interventions that are often caused by not addressing issues that could have been spotted earlier.

The Government’s actions since then suggest that their commitment to preventive care was little more than smoke and mirrors. Having loudly proclaimed their commitment to preventive healthcare, Ministers ever so quietly, ever so slyly, just before the Christmas recess, sneaked out £85 million-worth of cuts to public health budgets. That money is used for key services, as we have heard, such as preventive mental healthcare, preventive physical healthcare, “stop smoking” clinics, sexual health clinics, and drug and alcohol misuse services. The Government may say that public health spending is the decision of local authorities, but all they have done is give them the responsibility to care for their communities while leaching away much of the resource that would enable them to do so. Councils’ public health budgets, which fund school nurses and public mental health services, have been reduced by £600 million since 2015. In Cumbria, the public health budget is set to be slashed by half a million pounds, and it is one of the 10 local authorities receiving the least money per head from the Conservative Government. Cumbria’s spending is now set to drop to just £36 per head—barely half the national average of £63 per head, and ridiculously lower than that of the City of London, which receives £241 per head.

The impact of this has of course been tangible. School nurses not only provide a host of services but are a valuable source of health education for children and young people—a place to turn to as they try to navigate the complexities of adolescence. The removal from schools of health professionals who contribute so much to children’s health education means that children are vulnerable to slipping into bad mental, dental and physical health. In 2015, the coalition Government made a commitment to spend £25 million a year on Cumbria’s public health, but cuts to spending since then mean that Cumbria gets less than £18 million a year. Pernicious, heavy cuts to the public health budget mean that Cumbria now only spends a pathetic 75p per child per year on preventive mental health care.

In the face of this, young people themselves are determined to fight for better mental health provision. In my constituency, the CAMHS crisis service was not available at the weekend or after school hours in south Cumbria until our community campaign forced local health bosses to change this. But we still have an awfully long way to go. Proper investment in public health budgets would allow us to place a mental health worker in every school. The key to young people being resilient and healthy, and to making sure that problems do not become so severe further down the line, is surely to do just that.

The Government’s failure to take prevention seriously puts at risk a range of preventive health measures—physical as well as mental. I very much welcome the Minister to her new role. She is the most senior Blackburn Rovers supporter to sit on the Front Bench since Jack Straw; I hope she does far better than he. The question that she must answer is this: when the Government verbally prioritised preventive care but then cut public health by £85 million, were they being deliberately cynical or was it mere incompetence? Either way, will she fix this matter and restore public health funding to Cumbria and elsewhere so that we can tackle mental and physical health problems before they become tragically serious?

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 7th May 2019 Commons Chamber

[Matt Hancock]

Yes, that is exactly right. That is why we have put in place the new LINACs—linear accelerators, the equipment that is being rolled out across the country in a £130 million programme. We are always looking at what more we can do to help people to beat cancer.

[Tim Farron (Westmorland and Lonsdale) (LD)]

Will the Secretary of State agree to look personally at the case for a new satellite radiotherapy unit at Westmorland General Hospital, tied to the Rosemere unit in Preston? I had the privilege last week of driving my constituent Kate Baron to her treatment at Royal Preston Hospital. Wonderful treatment though it is, it is a three-hour round trip that she has had to take on 15 separate occasions—I went with her only the once. Hundreds of people in the south Lakes have to make debilitating, lengthy round trips to get treatment day after day, which is damaging to their long-term health and to their ability to access radiotherapy at all.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 26th March 2019 Commons Chamber

[Matt Hancock]

There is no better advocate for Hornchurch in the Chamber than my hon. Friend. She made her case with passion and commitment and I was very impressed by it. I will write to her with the full details, once they are published, of exactly how the process will work, and I look forward to working with her.

[Tim Farron (Westmorland and Lonsdale) (LD)]

The north-west of England has only half the number of ambulances per head of population as London. In rural Cumbria, the situation is far worse. Will the Secretary of State agree to our proposal for an additional two ambulances for Westmorland so that we can keep our communities safe?

[Stephen Hammond]

The hon. Gentleman will know that, in the winter funding round, extra ambulances were provided across the whole country. I am happy to meet him and discuss his proposals, which I will then consider carefully.

Eating Disorders Awareness Week

Tim Farron Excerpts

Wednesday 27th February 2019 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is a pleasure to serve under your chairmanship, Mr Bailey. I, too, pay tribute to the hon. Member for Angus (Kirstene Hair), who secured this debate and made an excellent speech, and to the other colleagues who have contributed to it so far.

Without doubt, eating disorders have acquired a greater profile in recent years, and there are two things that are apparent and that we can learn from. One is that, as a society, we are better at talking about these things, and organisations such as Beat, which has already been mentioned, do outstanding work in making people feel that the stigma around these issues is something that we, as a society, need to get over, and therefore people will feel more comfortable about coming forward, which is good.

The second lesson that we might learn is that we are a society that, for some of the reasons that have already been mentioned, increasingly breeds poor mental health. So, I will focus my remarks on the support—or lack of it—for young people living with mental health conditions and particularly for those with eating disorders in my constituency of Westmorland and Lonsdale.

Very often, it is the parents who come to me first. Parents come to me with two clear emotions: one is terror; and the other is guilt. It is absolutely essential that we are clear to people with eating disorders, and indeed to those who love and support them, that there is absolutely no need for guilt; there is no blame attached whatever. Likewise, we need to tackle the fear and the terror, which often stem from a lack of understanding or an absence of hope as to where to go next, by showing that there are things that we can do to help.

In my constituency, we estimate that three quarters of young people with eating disorders were not seen within the target time of one month, and that 100% of those with an urgent need were not seen within the target time of two weeks. That is not acceptable, but what is even more terrifying is that the numbers involved are ludicrous. In the year up to August 2018, a grand total of 13 young people in South Lakeland were registered as living with eating disorders, which is baloney: we all know that that is not true. I would comfortably say that the real number is 10 times higher. In my office, we deal with at least one new case of an eating disorder every single week. So what is happening, such that our young people with eating disorders are falling through the gaps? We need to look at a whole range of things, but I especially ask the Minister to investigate personally why this is happening, particularly in South Lakeland but—I suspect—around the country as well.

One GP got in touch with me about this issue. I will not name her, but she was very keen for me to share her experience with everyone here in Westminster Hall and everyone who is listening. She did not have any training at all in mental health while she was gaining her qualifications, but she has sought to bring herself up to speed on it in her job. She is a general practitioner. She does her best to help young people and indeed people of all ages presenting with mental health conditions, but she feeds people into the system, or refers people into it, and there is no triage.

There is no general triage once a young person has been referred for help: “Does this person have anxiety?”; “Does this person have an eating disorder?”; or, “Does this person have some other condition?” That person could be referred to the wrong silo and then sit there for months, undiagnosed or misdiagnosed. I am sure that is one window into why such pitifully low numbers of people are being diagnosed, against the backdrop of what I think are many hundreds of people living with a condition who are left in desperation and not even getting the beginnings of the support that they desperately need. We are failing to catch our children and our young people when they are at their most vulnerable, so how can we then go and help them?

Anorexia nervosa has the highest mortality rate of any psychiatric disorder in adolescence. The consequences for someone of not getting the right treatment are absolutely huge and extremely serious. However, even those who are diagnosed—this goes for younger people and for adults—may not get the help that they need. Colleagues have already referred to the fact that people will have experience—I have, with constituents of mine—of being told, “Frankly, you’re not thin enough yet. Come back when you are. You are not manifesting physical conditions to back up your mental health condition, therefore come back later on.”

Would somebody who had been fortunate enough to have been diagnosed with cancer at stage 1 be told, “Clear off till you’ve got stage 4. Come back when you’re at death’s door”? Come off it, but that is how we treat people with mental health conditions and in particular people living with eating disorders. There are people with eating disorders—I can think of some who I know myself—who may have experienced no appreciable or noticeable weight loss. They still have an eating disorder, which needs to be tackled, and tackled quickly.

In Cumbria, three years ago—to the week—we were promised a specialist one-to-one eating disorder service for young people. Three years on, it still does not exist. That is why so many people will be cynical about promises made at this time of year at events such as this. We want to see real delivery for all of our young people in every part of the country.

Finally, the Government—rightly—emphasised preventive care in the NHS long-term plan just a few weeks ago. However, just a few days before Christmas they had sneaked out the funding cuts for public health, which is genuinely preventive care. Those cuts included a £500,000 cut in preventive health care in Cumbria. At the moment in Cumbria, we spend 75p per child on preventive health care. If we want to support those people who may struggle with eating disorders in the future, it is vital that we invest early and invest now. That will be not only more efficient and more effective, but far, far kinder.

Oral Answers to Questions

Tim Farron Excerpts

Tuesday 15th January 2019 Commons Chamber

[Matt Hancock]

I have not heard any of the details of that case before now. If the hon. Lady will write to me, I will be very happy to talk to her and engage with her on what we can do for her constituent.

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is 12 long months since the Government closed their consultation on whether to upgrade NHS radiotherapy facilities. Meanwhile, in south Cumbria, cancer patients have to make daily round trips of up to four hours for weeks on end to receive treatment. When will the Government respond to the consultation and when will they invest in satellite radiotherapy provision in places such as Westmorland General Hospital?

[Matt Hancock]

We will respond to the consultation very soon. We wanted to get the NHS long-term plan published first, because clearly the two are strongly linked. I pay tribute to the hon. Gentleman’s work chairing the all-party group on radiotherapy and I look forward to working with him.

Cancer Workforce and Early Diagnosis

Tim Farron Excerpts

Tuesday 8th January 2019 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

Thank you, Mr Howarth. It is a pleasure to serve under your chairmanship. I wish everyone a happy new year and congratulate the hon. Member for Poplar and Limehouse (Jim Fitzpatrick) on securing this incredibly important debate, which is timely in the light of yesterday’s announcement of the NHS long-term plan.

I will restrict my remarks on the cancer workforce to the radiotherapy workforce and other issues relating to radiotherapy. Sadly, at some point in our lives, one in two of us will have cancer of some form or other, and one in two of those with cancer will receive radiotherapy treatment, so one in four of us will need radiotherapy. Roughly speaking, 1,500 people—clinicians, medical physicists and therapeutic radiographers—make up the entire radiotherapy workforce of the United Kingdom. In the plan that we have been digesting since yesterday, there are many things worthy of remark and which are to be welcomed, but many questions remain unanswered.

On radiotherapy, the focus on survival and early detection is clearly crucial. The United Kingdom is very low down in the league table of European countries when it comes to early detection of cancer, which is the chief reason why survival is so poor compared with other nations of similar prosperity. That is tragic on a personal level and deeply humiliating on a national level. If the Government, the National Health Service and we all are successful in our bid to detect cancer earlier at stage one and stage two, treat it effectively and cure patients—radiotherapy is eight times more likely to be curative than chemotherapy and 50% of those with cancer are already having radiotherapy—it stands to reason that the need for capacity for radiotherapy will increase manifold.

There are 52 radiotherapy centres in England with a number of other satellites. There is nothing in the plan that scopes forward how the national health service will cope with the additional work required if early diagnosis becomes more successful. It is worth bearing in mind that, as things stand, there are significant pressures with a workforce of 1,500. There are two ways of looking at it: one is that the workforce is a very small and precious resource that we need to protect, and the other is to remind ourselves that those are relatively small figures, and that with a relatively small amount of investment, we could make a significant difference to increase that workforce. Relatively small numbers equals a huge percentage, which equals the ability to tackle many more cancers and, indeed, to cure many of them.

I will focus briefly on one profession within the radiotherapy workforce—therapeutic radiographers. I do not know whether hon. Members are aware, but in the current academic year, there has been a 50% drop in applications to therapeutic radiography courses at UK universities. One of the leading universities had to cancel its entire intake altogether due to under-recruitment. The cause is almost certainly—99% certainly—the removal of the bursary from that programme. The standard applicant is a mature student who chooses to do something different with their life, having done something else first, and the withdrawal of the bursary has had a huge impact on those people. If the Minister wanted to do something quickly to tackle that workforce issue, I will throw out there the suggestion that he could reinstate the bursary for radiographers.

I am chair of the all-party parliamentary group on radiotherapy, and one of our vice-chairs is here—the hon. Member for Easington (Grahame Morris). We and many other hon. Members had a really good meeting with the Minister at the end of November last year. I am very grateful to him and to his staff for their time and attention. They have yet to respond to the manifesto that we presented to them that day, although I did not expect them to have done so by now. That manifesto calls for a number of things: new investment and more money—it would be surprising if we did not ask for that, but I will put it in context.

As I have said, half of those who have cancer in the United Kingdom will require radiotherapy, yet only 5% of the cancer budget goes on radiotherapy. That compares poorly with other countries. In Australia, the figure is about 5% but the European average is something like 7% or 8%. Our cross-party proposition is that the Government invest £100 million every year into machine upgrades for high-quality, targeted, stereotactic, and other advanced forms of radiotherapy. That fund would cover all trusts, which would not have to delve into their own reserves. We also propose a £250 million up-front, one-off investment so that people who live in communities like mine an awful long way from the nearest treatment can have a satellite unit developed close to them.

Many of my constituents in South Lakeland have to make three or four-hour round trips to get good treatment at Preston, but a large percentage—up to 50%—of those who could have radiotherapy in my constituency and in other parts of south Cumbria do not get it because they are considered to be too far away for it to be a reasonable journey time. Radiotherapy is so often more curative than chemotherapy, ergo people do not live as long because they live too far from treatment. That is why the radiotherapy satellite centre at Westmorland General Hospital in Kendal is a key example. Access and travel times are a problem in other parts of the country, which is why investment in satellite units is important. They do not necessarily involve that much more staffing because, with proper IT networking, we would be able to do many of those things remotely.

In conclusion, the NHS plan announced yesterday contains much that is interesting, but when it comes to radiotherapy, it is entirely a rehash of things that we already know. Some things are welcome, but there is nothing new. I look forward to the Government’s response to its consultation on radiotherapy, which closed 12 months ago, and I ask for an update on that. I also ask that the National Cancer Advisory Group’s 2018 report is released as soon as possible. Finally, I very much look forward to the Government’s response to the manifesto by the all-party parliamentary group on radiotherapy, which was presented to them in November.

[Several hon. Members rose—]

NHS: Staffing Levels

Tim Farron Excerpts

Tuesday 11th December 2018 Westminster Hall

[Tracy Brabin]

Capacity, particularly in midwifery, is a massive issue, and midwife recruitment is also a problem. A mum who is about to have a baby wants to make sure that they are guaranteed a bed and a midwife who will be with them throughout the process, so of course that is a concern. There are almost 41,000 vacant nursing posts in the NHS and it is estimated that that number will grow to almost 48,000 by 2023—just five short years away.

[Tim Farron (Westmorland and Lonsdale) (LD)]

The hon. Lady is being generous. Does she agree that the problem with the recruitment and retention of staff also stretches to our mental health services? In Cumbria, three years ago, the Government promised a specialist one-to-one eating disorder service for young people, which has yet to be delivered. Does she agree that it is not good enough for the Government to make promises that they cannot deliver because they cannot recruit the staff?

[Tracy Brabin]

We are seeing increasing problems around recruitment and retention in mental health services, which I will go on to. We know that nurses are heroes of our health service and that they will always voice their concerns.

A survey conducted by the RCN in 2017 had some deeply worrying results. More than half of the nurses said that care was compromised on the last shift and more than 40% said that no action was taken when they raised concerns about staffing. If there was any doubt about the commitment of nurses, nine in 10 were not paid for extra unplanned time worked in the NHS. Unpaid time worked by nurses in the NHS saves the NHS hundreds of millions of pounds a year.

I am not just talking about nurses and the worryingly low levels of recruitment. The Royal College of Physicians informs me that in Yorkshire and Humber 36% of physician consultant posts advertised were not filled. Across the UK, a total of 45% of advertised consultant posts went unfilled, due to the lack of suitable applicants. The RCP believes that we need to double the medical school places to 15,000 a year to alleviate this problem in the long term and it is seriously hard to disagree with that assessment.

The RCP is also calling for investment in public health initiatives, which I am sure is another thing that we all agree on. The desperate need for more mental health staff is well reported. The consultant psychiatrist vacancy rate in the northern and Yorkshire region, which Batley and Spen falls under, is 11.7%, which is higher than the average consultant psychiatry vacancy rate in England. One in 10 consultant psychiatrist posts are vacant. Doctors specialising in mental health are uniquely placed to look at a person’s brain, body and psyche. Such specialists will only become more important, so I ask the Minister to update Members on his plans to meet the target of 570 junior doctors specialising in psychiatry by 2020-21 and to say what plans he has to ensure that all trainee doctors have experience of working in psychiatric settings?

The British Medical Association has provided information on the potential impact of Brexit on staffing levels in the NHS. Nearly 10% of doctors working in the UK are from the European economic area. Doctors, as well as many other professionals, make a massive contribution to our NHS. However, the BMA warns that many EEA doctors continue to feel unwelcome and uncertain about their future here. Given the uncertainty that we have seen in the past few days, I imagine that that feeling will not change any time soon. The results could be devastating, with more than a third of doctors from the EU considering moving away from our country. That is the last thing we need, as hospitals are already chronically understaffed, with more than one in four respondents to a BMA survey reporting that rota gaps are so serious and frequent that they cause significant problems for patient safety.

Alarmingly, some doctors feel bullied into taking on extra work. It is clear that something needs to change, particularly now we are in winter again. There are too few staff, who are too stretched, and trusts across the country are struggling to fill vacancies. However, in order to fix a problem, we need to know whose remit it is to provide a solution. Shockingly, there are no specific legal duties or responsibilities at UK Government level to ensure that health and social care providers have enough staff to provide safe and effective care to meet the needs of the population. Health Education England has some powers related to the higher education supply. In practice, however, those powers relate only to the funding for the 50% of their courses that nursing students spend on placements. Health Education England no longer commissions higher education university places, meaning that it is responsive to students signing up for nursing courses rather than proactively seeking them based on areas of need and workforce planning.

We know that the number of European workers in the NHS has fallen dramatically since the referendum. Mid Yorks recruited highly skilled workers from the Philippines, but delays to visa applications meant that 50% of them have now gone elsewhere and into other jobs. We need to do better than that.

The case is clear to me and to many others that we need a proactive and accountable power-holding body that makes robust assessments of population need, and uses that need to calculate the workforce requirements. No action has been taken to assess the level of population need for health and social care support now or in the future. Nobody has calculated how many nurses are needed to meet those needs safely and effectively. No workforce strategy is in place to set up the mechanism through which new registered nurses can be generated through a supply line.

Workforce plans are not consistently available and when they are they are based on affordability and finance, rather than on the expertise and skills mix of staff required to care for patients. Plans are limited in their ability to make effective change. Providers may identify a need for more nursing posts but then find themselves unable to fill them. Vacant posts stay vacant and gaps on the frontline are filled by more expensive bank and agency staff, and—as we heard from my hon. Friend the Member for Barnsley East (Stephanie Peacock)—by volunteers, or substituted lower-qualified staff. Patient care is left undone, with lengthening waiting lists.

That is the sad truth of where we are and when the Minister responds I would be grateful to know what plans are in place to enforce accountability for the NHS workforce. Simon Stevens has confirmed that the long-term plan for the NHS could not definitely deal with the NHS workforce and there are serious concerns that without investment a new plan will ultimately fail.

Six years on from the Health and Social Care Act 2012, it is still unclear which organisation is accountable for workforce strategy. Too often, no one is taking responsibility. Health Education England has been consulted, but it has failed to deliver a workforce strategy. Now is the time for leadership and action, and I look forward to hearing from the Minister.