Anti-TNF Drugs

Andrew Smith Excerpts

Wednesday 9th December 2015 Westminster Hall

[Fabian Hamilton]

I thank the hon. Gentleman for that intervention. He is right. The more studies carried out across the country at university level, the better it will be for patients suffering from refractory uveitis.

The anti-TNF drugs switch off the molecule that creates the inflammation in the first place and are therefore far more effective than corticosteroids in cases such as Samara’s. I am sure that Queen’s University Belfast and many others can confirm that.

Last year, Samara married her fiancé, Ben, and the couple now want to start a family. However, it is not at all advisable for her to become pregnant while taking mycophenolate, because it may well cause a miscarriage or birth defects. An anti-TNF drug could allow her to retain her eyesight and probably to conceive safely and be able to see her child grow up.

Let me move on to why adalimumab or infliximab should be available immediately on NHS prescription for adults with sight-threatening uveitis. I am aware that the National Institute for Health and Care Excellence is about to conduct a multiple-technology appraisal of adalimumab and infliximab and that responses to the draft must be received by 16 December—this time next week. From my conversations with Teifi James, one of the country’s leading eye surgeons, and from my research into that treatment it would seem that drugs such as Humira are highly effective in the treatment of uveitis, so much so that researchers in the Sycamore trial in Bristol, to which the Minister referred in his letter to me of 4 November, have stopped recruiting to it because the children being treated are doing so well on the drug. However, NHS England did not take that into account when it made its most recent decision on the use of adalimumab and infliximab for the treatment of adult uveitis alone.

According to Mr James, approximately 120 patients with sight-threatening uveitis are waiting for anti-TNF treatments in England, whereas patients in Scotland currently have access to adalimumab and infliximab. Treatment using Humira costs just under £10,000 a year per patient, which means that approval of the use of this drug for treating refractory uveitis alone would cost no more than £1.2 million a year.

[Mr Andrew Smith (Oxford East) (Lab)]

I commend the argument that my hon. Friend is making on behalf of his constituents. I too have been contacted by a constituent about this issue, who points to the excellent work being done by the Olivia’s Vision charity, which my hon. Friend may have heard of. My constituent says:

“My daughter currently suffers from Uveitis and is receiving Infliximab to treat the condition, so far successfully. I would like to live in the hope that this would be available to her in the future should her conditions change, and indeed others to whom this could be a sight saving drug.”

Is it not important that patients such as my constituent’s daughter have that assurance?

[Fabian Hamilton]

I agree with my right hon. Friend. In fact, the Olivia’s Vision charity has been in touch with me and offered its full support for this debate and any future effects of it, which will hopefully include a decision from the Government that both infliximab and adalimumab will be available on the NHS. Those anti-TNF drugs are clearly completely effective in the treatment of refractory uveitis alone. I will talk a bit about the effects of anti-TNF drugs on other conditions.

Junior Doctors’ Contracts

Andrew Smith Excerpts

Wednesday 28th October 2015 Commons Chamber

[Mr Andrew Smith (Oxford East) (Lab)]

It is a pleasure to follow two such thoughtful speeches, and, in particular, the powerful speech made by my hon. Friend the Member for Lewisham East (Heidi Alexander). I congratulate her on her appointment, and on the vigour with which she put the argument.

Three weeks ago, I went to a “keep in touch” meeting with doctors at the John Radcliffe hospital in Oxford. Two hundred and fifty doctors turned up, and their anger at the Government’s threatened imposition of this contract had to be seen to be believed. They were so alienated that I had a hard job trying to persuade them that it was just the Secretary of State’s incompetence which was to blame, and not a malevolent wish on his part to dismantle the NHS.

At a time when doctors, like other staff in the NHS, are working under such pressure, and when the Secretary of State knows that he needs to carry staff with him if further reform and efficiencies are to be delivered—including the better seven-day hospital services that we all want to see—it is beyond belief that he has simply stumbled into picking a fight with the core clinical work force in our hospitals, threatening to impose a contract that will leave some of them earning significantly less and many vulnerable to working significantly longer hours, thus risking a return to the dangers of the past.

No one, including doctors themselves, wants to see this degenerate into industrial action, but, as with other groups of workers whom we do not expect to strike, a particular responsibility is imposed on employers and the Government to listen, to be fair, and to negotiate in good faith. That is why it is so damaging that the Secretary of State gives such a strong impression of doing the opposite: threatening when he should be listening, and using weasel words when he should be showing how assurances can be delivered. As the public well understand, the success of the NHS is hugely dependent on the dedication, good will and trust of its staff. By mishandling the contract in this way, the Secretary of State is putting all those at risk, and, once lost, they could be hard to win back.

No one should be under any illusion about the damage that the contract—were it to be imposed in the way that the Government want—could do to patient care, and would certainly do to recruitment and retention in the English NHS, especially in high-cost areas such as Oxford. I already know of local GPs who have moved away, including one who found that he had a better quality of life as a locum than as member of a practice, and then found that it would be better still in Canada than in our NHS. At my meeting with doctors at the John Radcliffe, a show of hands was taken to find out how many of those who qualified would move to other parts of the UK or abroad if the contract were imposed. A sea of hands went up.

If the Government want to make good the damage that they have been inflicting and settle the issue of this contract, it should not be hard. In his letter to the chair of the BMA junior doctors committee, the Secretary of State said:

“I share exactly the same aims for the new contract as you do.”

If that is the case, the way forward is clear. First, the Secretary of State should reopen negotiations, without preconditions, lifting the imposition of the contract. Secondly, he should keep the financial penalties that protect staff from working excessive hours. Thirdly, he should show flexibility on the reimbursement for Saturday working. Fourthly, he should give a clear guarantee that no junior doctor’s pay will be cut as a result of the contract. That is what our motion calls for: it would deliver a new contract with safety for patients and fairness for doctors. It is what the Government would do if they had any sense, it is what the public wants, and I urge the House to vote for it.

Cancer Drugs

Andrew Smith Excerpts

Tuesday 20th October 2015 Westminster Hall

[Jim Shannon]

I absolutely agree. The hon. Lady mentioned ovarian cancer. Most of us from Northern Ireland will know of Una McCrudden, who passed away earlier this year. She was an energetic person who spoke out on behalf of those with ovarian cancer. She survived six years after she was first diagnosed, and all her latter years were put into that campaign. I know that the hon. Lady knew her as well as the rest of us did.

Great work has been done on ovarian cancer. Only last week, I heard of one of my constituents who had been diagnosed with ovarian cancer and undergone surgery. The operation was successful, and we thank God for that, but many others do not survive. Survival rates are improving, and given that one in two people diagnosed with cancer in the UK survives, we are on the right track. The fact remains, however, that we could and must do so much better.

With innovation in cancer treatments making great strides, it is imperative that we, as representatives of the people the length and breadth of this nation of the United Kingdom of Great Britain and Northern Ireland, campaign to increase the availability of cancer drugs to our constituents. The Minister and I have discussed this many times. Queen’s University in Belfast is one of the leading advocates for innovation in the search for new cancer drugs, and it leads the way in cancer treatment, as it does in many other spheres of life. Today the Chinese President is visiting Parliament, and we have all sorts of other contacts with China, so it is particularly appropriate to highlight the fact that Queen’s University works in partnership with organisations and universities in China to move that work forward.

Cancer knows no creed, colour, race, religion or class. It is an enemy that we have all come together to fight. With that in mind, I hope that we can all come together to give our constituents up and down this nation access to the very best treatment for that common enemy. We are united in our desire to see greater availability of cancer drugs in every postcode area across the United Kingdom.

[Mr Andrew Smith (Oxford East) (Lab)]

I join other hon. Members in congratulating the hon. Gentleman on securing the debate, and I support what he is saying about access to cancer drugs. Is it not also important to underline the fact that the overwhelming majority of successful treatment of cancer is by surgery or radiotherapy, often supported by drugs?

[Jim Shannon]

Absolutely. My father survived cancer three times because of the surgeon, the chemotherapy, the radiotherapy and all the other treatment that he received, and the drugs helped. So, by the way, does a good diet; there are lots of things that we need to do to tackle the disease. I draw the House’s attention to the recent developments in Northern Ireland. Hon. Members will know that health is a devolved matter. My party colleague, Simon Hamilton MLA, the Minister for Health, Social Service and Public Safety, has taken the initiative to release £1.5 million to fund specialist cancer drugs. That will allow for NICE-approved cancer drugs and treatment to go ahead this year.

Care Workers

Andrew Smith Excerpts

Wednesday 5th November 2014 Westminster Hall

[Mr Andrew Smith (Oxford East) (Lab)]

It is good to see you presiding over us this morning, Mr Robertson.

They do some of the most vital jobs in our country. They go unsupervised into the homes of the most frail, make sure they take the right drugs, help them with washing and the toilet, prepare their meals and often provide the only human warmth and companionship an elderly person will have all day. For all that, many are paid only £6 or £7 an hour, with no guaranteed work, zero-hours contracts even when they do not want them, and zero respect from some employers. They are home care workers. The way many are treated is an utter and shameful disgrace, and it is the job of the House and the Government to do something about that.

Given the problems, it is amazing that there is so much good home care out there. I have done surveys of my constituents’ experience, and many rate well the service they have had. They talk of caring and compassion at its best, and workers paid for a 15-minute visit staying that bit longer to do a proper job—often a stressful and difficult job. I remember the care worker who apologised for arriving a bit late to look after my mum while I was visiting. She looked a bit stressed, so I asked, “Are you okay?” She said, “Yes, it’s just that the last person I called on died while I was there.” We are not talking about an easy job.

In a privatised and competitive industry, good providers—and there are many—often face the conditions Winston Churchill described in this House 105 years ago, when he said:

“It is a serious national evil that any class of His Majesty’s subjects should receive less than a living wage in return for their utmost exertions…where you have what we call sweated trades, you have no organisation, no parity of bargaining, the good employer is undercut by the bad and the bad by the worst; the worker, whose whole livelihood depends upon the industry, is undersold by the worker who only takes up the trade as a second string…where these conditions prevail you have not a condition of progress, but a condition of progressive degeneration.”—[Official Report, 28 April 1909; Vol. 4, c. 388.]

Now, of course, we have the national minimum wage to prevent the progressive degeneration Churchill described, but the scandal is that it is not being enforced. The excellent briefing Unison supplied for the debate brings out the key disgraceful facts. An investigation by Her Majesty’s Revenue and Customs of home care companies between 2011 and 2013 found that half were guilty of non-compliance with the national minimum wage. This year, the National Audit Office reported that up to 220,000 home care workers in England are illegally paid below the minimum wage. Using the dodges of zero-hours contracts and bogus self-employment, more than half of home care companies pay workers only for the exact time they spend in clients’ homes, with no pay for travel time and no travel allowance.

[Mark Lazarowicz (Edinburgh North and Leith) (Lab/Co-op)]

I am grateful to my right hon. Friend for raising this important issue. On workers not being paid for their travel time, he mentioned the Unison survey in England, but I can assure him that the situation is, regrettably, the same throughout the country. A Unison survey in Scotland found that more than 50% of care workers were not paid for travel time under their contracts.

[Mr Smith]

My hon. Friend’s point is well made. We are undoubtedly talking about a United Kingdom-wide problem. A Freedom of Information Act request from Unison this year showed that a staggering 93% of councils in England and Wales—I dare say that the situation is not so different in Scotland and Northern Ireland—do not make it a contractual condition that the home care providers that they commission must pay home care workers for their travel time.

[David Simpson (Upper Bann) (DUP)]

I congratulate the right hon. Gentleman on obtaining the debate, and I declare an interest because my wife is a carer. One of the biggest problems, certainly in my constituency in Northern Ireland, is the recruitment and consistency of staff. They are under so much pressure because of their terms and conditions, but at the end of the day, they save the Department of Health and the Government a lot of money.

[Mr Smith]

Yes, indeed. The hon. Gentleman makes a good point, and I will say more about that later. Of course, there will be massive increased need for these workers in the future. One reason recruitment and retention are so difficult is that terms and conditions are often so poor.

Let me develop my argument further. Only 21% of councils have ever asked to see documentary evidence relating to the pay of care workers employed by their contractors. In the face of that and the other evidence I have cited, it is appalling that the Government are doing so little to uphold the legal rights of home care workers. It is indefensible that HMRC has stopped carrying out proactive investigations of national minimum wage compliance in home care, despite having revealed the extent of the breaches itself.

[Grahame M. Morris (Easington) (Lab)]

I congratulate my right hon. Friend on bringing this debate to the Commons at such an important time. In my area, Durham county council has had to implement £135 million of cuts over three years, with another £44 million in the pipeline. It is commissioning home care at £11 an hour, whereas the commissioning rate in some more affluent areas is £15 an hour. Does my right hon. Friend agree that the Government’s cuts in support for local government are compounding the problem?

[Mr Smith]

Most certainly they are, and I will say more about that later. I support, and the House ought to support, the key action that Unison and others are calling for. First, the Government should make ending illegally low pay for care workers a key priority. Secondly, HMRC should be instructed and resourced to do a proper job in ending the widespread breaches of the national minimum wage. Thirdly, care providers and the councils that commission them should be named and shamed when they do not pay the minimum wage.

It is not just trade unionists, local councillors and those whose loved ones use care services who are concerned about all this. In preparation for the debate, I spoke to local private care providers, and I will share with Members some of the points they made. They told me that care workers’ salaries do not reflect the responsibility they have; that luck and money are all too likely to decide people’s quality of care; that too many staff are on poor contracts, but that often reflects poor profit margins; that zero-hours contracts can be a barrier to recruitment, but that some employees want them; that staff turnover is high because of the high cost of living and shortage of affordable housing, which is an issue in my constituency; and that pressure on council budgets—the point made by my hon. Friend the Member for Easington (Grahame M. Morris)—means that restricted funding is available for front-line care.

Local providers also drew my attention to the fact that in six out of 14 areas in Oxfordshire, the county council is offering rates of funding for front-line care that are below the living wage, even though it has rightly pledged to pay its own staff above the living wage. Providers also told me that upper-tier councils such as Oxfordshire, which are responsible for home care, have their hands tied by the local government squeeze. Members should remember that all these points have been put to me by providers.

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

May I, too, declare an interest, as a Unison member, and say how important it is that this issue has been flagged up in the debate? Given the concerns about this issue, should home care not be part and parcel of the discussions about the future of the NHS? We need to keep people out of accident and emergency and out of hospitals. If there is no care in the community, we will put more expense on the NHS and provide worse care. Does my right hon. Friend agree that, in discussions about the future of the NHS, we should make absolutely sure that these workers are paid a proper rate for the job and that travelling time is included? The Care Quality Commission has a vital role in this.

[John Robertson (in the Chair)]

Order. I ask hon. Members to keep interventions a bit shorter.

[Mr Smith]

I agree with my hon. Friend on all points. If this country is to get the standard of care we want, social care—home as well as residential—must be regarded as a central part of health service provision. The debate on health provision cannot be confined to the future of the NHS.

Providers made the point to me that 15-minute visits should be banned, except perhaps for check-up visits when other visits are being made to the person on the same day. I am pleased to say that since I raised that issue in our previous Westminster Hall debate about care, Oxfordshire county council has decided to phase them out. Others must do so too. There is a need for sustained funding and a co-ordinated push for training, to bring social care staff up to the standards required for commissioned services.

We need a scheme of accreditation that makes crossover into the NHS and back possible if we are to provide a career pathway to attract young people, and indeed some older people, into the care profession. Training should be part of an overall package that attracts people into care work. A carer who has had training should have certification that they can take with them to another employer. Those are points that providers have put to me. They point out that too many agencies do not even give carers their certificates, so they have no proof, and must go through the assessment—where it is provided—again. We must also have regard to the fact that the public and media perception of care too often stops at the NHS, and does not include social care. Protecting the NHS goes only part way to protecting our care system. We will protect the NHS by protecting social care, and that means that more money must go to local government. That is another point put to me by providers.

On the question of zero-hours contracts, I have been in touch with two local providers who have tried to offer salaried employment as an alternative, but have had little take-up, partly because employees are juggling a second job, and partly because they value the flexibility that allows them not to work, for example, on certain weekends. The zero-hours culture is deeply entrenched in home care work, and it will not be easy to change it, but I believe we must. The key priorities must be to ensure: that the contract does not preclude the employee from taking other work—it is disgraceful that it ever could; that the employee has reasonable freedom to take or refuse work as they like, to have time with their own family, for example; and that an exclusive zero-hours contract is not imposed. Let us also remember, however, the point of view of the person being cared for, the most important person in the debate. They usually want continuity in care, and they are less likely to get that with zero-hours contracts, under which a different carer will be sent to them time after time.

As well as the bigger reforms that I have mentioned, there are practical steps, which may vary a bit from locality to locality, that can make home carers’ jobs a little less of a struggle, and I will talk about some that are relevant in Oxfordshire. In Oxford, we have extensive residents parking zones. Home care workers must find one of the sparse two-hour spaces or get a visitor permit from the client and stick it on their car. That is one third of their 15-minute visit gone. Otherwise, they risk a fine—which is of course levied by the same county council that pays their employer to send them on the call. A way of recognising the value of home carers’ work would be to give them a permit to park in residents parking zones when visiting clients.

Another example, which is probably even more widely relevant, is that people who work in the NHS branch of the care system get a free winter flu jab. A home care worker on the minimum wage often will not get a jab unless they spend two or three hours’ worth of their meagre pay on buying one. Recognition of the value of their work could include giving them a free jab, either on the NHS or by requiring employers to make them available. I checked the 2014-15 Public Health England flu immunisation programme guidance, to which the Minister may want to refer. It states that flu immunisation should of course be offered to health and social care staff who are in direct contact with patients and service users. It states that they should be vaccinated by their employer as part of an occupational health programme. However, that raises the question of what happens when an employer does not offer the vaccination: is it the same as when an employer does not pay the minimum wage, and nothing happens?

I think there is a growing consensus among clients and providers, councils and trade unions, about what needs to be done in the vital service area of care. First, better funding is needed for social and home care. People will not get the standard of care that they need and deserve without it. The NHS chief executive’s vision of more care being provided in the community will be a mirage unless we raise care workers’ status and terms and conditions. Secondly, we need rigorous enforcement of the minimum wage and promotion of the living wage. Thirdly, care workers should have the right not to have a zero-hours contract forced on them. Fourthly, commissioning should encourage responsible providers. Fifthly, there should be investment in training and career pathways for care workers, with proper accreditation of care work. Sixthly, there should be regulation of the social care work force. That could start with the record of those unfit to practise that the Health and Care Professions Council has advocated.

We should all recognise the enormous value of the work that home carers do, and translate that recognition into action to improve their status, pay and training, to nurture good providers who are good employers, and to drive out the rogue operators. We would do well to remember every day that our loved ones, and we ourselves, are likely to need a home carer some day. Much good work is done by front-line carers, but too many of them are treated shabbily. That must be stopped. We must make sure that carers get the status, training and pay that they deserve, so that those who need care and those who give it can enjoy better lives, with dignity and respect.

[Several hon. Members]

rose—

--- Later in debate ---

[Mrs Lewell-Buck]

I thank the Minister for that intervention. If that is the case, why is the guidance not stronger? What I read out is not the language of the minimum wage. The minimum wage is not a target, but a right.

[Mr Andrew Smith]

Does my hon. Friend agree that it is not good enough for the Minister simply to say “It is a criminal offence”, as though that solves the problem? It is not solving the problem, because hundreds of thousands of workers are not having their legal rights protected. In his speech, he needs to tell us what he is going to do about that.

[Mrs Lewell-Buck]

I could not agree more. The guidance should include a proper requirement for compliance with the minimum wage law; otherwise it will simply be ignored, as it currently is. I hope that the Minister will commit to strengthening that requirement when he sums up the debate.

Providers might also be convinced to pay their staff a fair wage if they thought that they might suffer consequences for non-payment, but it seems, sadly, that under this Government there are no consequences. The Government told us that they would “name and shame” companies that failed to pay the minimum wage, but so far only a handful have been named and not one of them has been from the social care sector. That is unbelievable when we consider that HMRC believes that half of providers are non-compliant. The Government’s relaxed attitude lets providers know that they can continue to ignore minimum wage laws with no consequences.

In all this, we have to remember that what affects care staff also affects the people they care for. Quality social care needs well trained, motivated staff who are able to build a strong relationship with those they care for. All the evidence suggests that things are moving in the opposite direction. The care sector is not an attractive place to work right now.

The weak requirements on the minimum wage create an unfair playing field for care providers. With the funding pressures facing councils, the incentive to commission on cost is stronger than ever, and as long as the wage is considered a target and not a requirement, providers that pay a fair wage will be at a disadvantage, compared with those that break the rules. The providers that win contracts will be those that are least able to attract and retain well trained staff, and service users will lose out as a result.

Pay is not the only problem. Care workers have told me horror stories about the way in which they are managed and the effect that that has on the people they care for. Timetabling of visits is a disaster. Appointments are booked back to back, so staff do not get to spend the time with clients that they are allocated. If a client needs a little extra help, dedicated care workers often go back in their free time. I have also heard of cases in which incompetent management has meant that multiple staff have been booked to cover the same appointment. After they have all shown up at the client’s home, only one of them has been paid. Not only is that bad for staff, but it means that clients sometimes do not see the same carer twice in a week, and they never get a proper introduction to a new staff member. Clients are expected to let a stranger into their home because they say that they come from an agency. The system owes people better than that.

Staff have told me that the training and supervision offered by some providers is close to non-existent. One employee told me that their training consisted of being given a set of forms to fill in, after which they were given no feedback and no professional advice or support. Not only were they not paid for that training, but they were told that they would be financially penalised if it was not completed in time. Essentially, they were training themselves, and the provider took no responsibility for making sure that its staff were fit to do their jobs.

Even on important matters of safeguarding, some staff received no training, and they were entirely unprepared to deal with situations in which they thought a client was at risk of harm. Worse still, although staff in such a situation should be able to refer the matter to a manager, in some cases even the managers did not appear to understand how safeguarding procedures worked or how to proceed, with the result that at-risk clients were left in serious danger. As many care staff work on zero-hours contracts, they are afraid to speak out. They cannot afford to challenge their employer or properly advocate on behalf of their clients, because if they do, they find that they are denied shifts.

That is why there should be a proper system of oversight, and it is why Opposition colleagues and I tabled amendments to the Care Bill to give the Care Quality Commission responsibility for overseeing the commissioning of services. It is not enough for the CQC simply to inspect services on the ground, because by the time an inspection is carried out, serious failings could have occurred. The CQC should look at the standards on which local authorities commission, to make sure that the providers to which they award contracts can do the job properly.

Between low pay, stressful working conditions and lack of support, it is no wonder that many skilled care staff are leaving the sector as fast as they can. To stand up for vulnerable people in care, we have to stand up for our dedicated and hard-working care staff. If the Government want to show that they value high-quality care, they need to start holding providers to account and making sure that they take their obligations to staff seriously.

--- Later in debate ---

[Norman Lamb]

I am grateful to the shadow Minister for raising that issue. When I was a Minister in the Department for Business, Innovation and Skills, I specifically pushed for a change in the rules to make it easier to name and shame poor employers. That process was not completed by the time I left BIS to go into the Department of Health, but I continue to push for it. Indeed, the rules were changed, so that whenever there is a notice of underpayment of the minimum wage, the employer is named.

There is a complication in the care sector, in that arrangements are often quite complex and reaching a final decision often requires an investigation to be carried out. However, I can assure right hon. and hon. Members that I anticipate the naming of poor companies within this sector in the relevantly near future. I totally support that process; there should be no hiding places for employers who break the law in that way.

[Mr Andrew Smith]

What we all want to hear is a commitment that HMRC will proactively go out, uproot and stop these illegal practices. The thought comes to my mind that in other sectors where the Government have been shown to be negligent in regulating areas of activity—such as investment, with Equitable Life and so on—the Government end up having to pay back the victims. Why do the Government not pay back all these care workers who have lost so much money because of the incompetence of HMRC?

[Norman Lamb]

I thank the right hon. Gentleman for that intervention. However, I repeat the point that it was this Government who arranged for that themed work in the care sector. A substantial sum of money was collected from employers who had broken the law and returned to their employees who had been underpaid. I repeat that I have requested that that themed work should start again. As he will understand, I do not have responsibility for HMRC. However, I have made that request and I will continue to push for that themed work to happen. Where it seems that there is clear evidence that a problem is endemic in a sector, we ought to be prepared to focus on it.

The hon. Member for Blaydon (Mr Anderson) talked about outsourcing. That problem did not start in 2010. Most of the outsourcing—the creation of a predominantly private sector work force—happened before 2010, and we all have to acknowledge that. It is an endemic and deep-rooted problem in the sector, which needs to be challenged effectively.

I will talk briefly about the care certificate, because another issue raised by right hon. and hon. Members is the fact that training standards are often inadequate. I must say that when I came into this job I was rather shocked to discover that there were no proper mechanisms for ensuring that employers were required to provide proper training for their staff. We are changing that situation. We commissioned Camilla Cavendish to produce a report on this issue, and we have now legislated through the Care Act 2014 for a care certificate, which will come into force next April. That certificate will set a national standard for minimum training and competence levels that every employer will have to meet. They will have to ensure that their staff either have the care certificate or something equivalent, and they will have to satisfy the Care Quality Commission that that is the case. If they cannot satisfy the CQC, it can take enforcement action against them. I am proud of the fact that we are taking decisive action to improve training standards.

Hon. Members have also raised the issue of the role of the CQC. It has the power—and Ministers have the power to request it to use that power—to carry out themed inspections of local authorities where there is evidence that commissioning is falling short, resulting in poor care. Part of poor care can sometimes be the terms and conditions offered by employers. I am determined that, if evidence of poor practice emerges, we use those powers to ensure that local authorities, as well as providers, are held to account, in order to raise the standards in this sector. We all agree that that is necessary, and that the underpayment of wages to care workers is not an acceptable practice.

Pancreatic Cancer

Andrew Smith Excerpts

Monday 8th September 2014 Westminster Hall

[Nic Dakin]

The hon. Gentleman is absolutely right. The campaign must go on, beyond today and into the future. Campaigners are here today in strong heart and with a strong determination to ensure that that is the case.

Breaking down the NCRI spend into contributions from individual partner members is difficult, but we know from evidence given to the all-party group that in 2013, Cancer Research UK provided £2.3 million and the Medical Research Council provided £750,000. The contribution from the Department of Health was therefore just £700,000. In its 2012 policy briefing, “Study for Survival”, Pancreatic Cancer UK calculated that at least £10 million of investment is needed by 2015 and that £12 million is needed by 2017. The target is £25 million by 2022. The minimum figure of £10 million to £12 million has not been plucked out of the air; it comes from a high-level analysis of other cancers, such as prostate and bowel, which suggests that there is a point where funding starts to grow in a more rapid and, importantly, more sustainable manner. A critical mass is needed to generate a solid research infrastructure—for example, through the establishment of centres of research excellence. A critical mass of researchers generating competitive research proposals needs to accrue, and those investment targets are a key starting point for such progress.

Maggie told me that she considers herself in a way to be lucky. She said that she and Kevin had 20 months post-diagnosis and that he was an incredibly positive man, who refused to give in to the disease. Maggie said:

“When I say we were ‘lucky’ I mean because we got 20 months to do and say everything we wanted to. People that I have met whilst I’ve been working on the e-petition lost their loved ones weeks or even days from diagnosis. They were only just getting their heads around a terminal cancer diagnosis when they were having to deal with death. I’ve heard some incredibly sad stories around pancreatic cancer and I’ve heard lots of them.”

Stories of such shattering losses are not rare. One quick look at the tributes left online for victims is testament to that.

[Mr Andrew Smith (Oxford East) (Lab)]

I congratulate my hon. Friend and the others who have raised this debate, as well as those who have petitioned on this vital matter. Does he agree that, as well as the general need for more research funding, screening tools, which are not presently available, need to be developed to make early diagnosis possible? Such developments have been responsible for so much progress with other cancers.

[Nic Dakin]

My right hon. Friend is absolutely right that the nub of the issue is how to get early diagnosis—the difficult-to-achieve holy grail.

In evidence to the all-party group a week after celebrating six years of survival, pancreatic cancer survivor Ali Stunt said:

“We need to focus on early diagnosis… Those of us who are diagnosed in time for surgery, which is what we want to achieve, have a tenfold increase in the chance of surviving five years… I was lucky. I was told that surgery was an option and that my operation would be booked in for a week’s time. I was told I needed chemotherapy and a week later was in my consultant oncologist’s office. I told him that I wanted to live to see my boys graduate. Following combination chemotherapy for 6 months and then chemo-radiotherapy, my scans were clear. Regular check-ups followed with scans and blood tests—all of which revealed ‘no evidence of disease’. My oncologist finally ‘signed me off’ in April 2013.

This is a story not often heard when pancreatic cancer is involved. These past 4 years since I founded Pancreatic Cancer Action I have met and got to know some fabulous people who have bravely fought and helped me raise awareness of this cruel disease. Not many of them are still alive, but all will have a special place in my heart. It is and always will be my mission to get more people diagnosed sooner—so more can have the same outcome as me.”

I first became aware of pancreatic cancer many years ago when my friend and colleague Martin Newbould became ill with it. Martin was an inspirational individual, a wonderful family man and an outstanding head of maths. More recently, my witty local newsagent Mick Emerson retired only to be diagnosed with pancreatic cancer soon after and then pass away. My friend Sir John Mason passed away just before the summer after a dignified battle against the disease, leaving a massive legacy of good work in the community. Having been ill for some time with an undiagnosed condition, John’s pancreatic cancer was, I understand, finally diagnosed after an emergency admission at Scunthorpe hospital’s A and E.

Currently, a staggering 48% of pancreatic cancer diagnoses are made by emergency admission, which is more than twice the total for other forms of cancer. That is important, as presentation via emergency admission is normally when the disease is more advanced and associated with much poorer survival rates than other routes to diagnosis. For example, one-year survival for patients presenting via emergency admission is just 9%, as opposed to 26% for those diagnosed as a result of GP referral. Over 40% of pancreatic cancer patients visit their GPs three times or more before even being referred to hospital. Some 16% have to visit their GP or hospital seven times or more before the correct diagnosis is made. By comparison, figures show that 75% of all cancer patients combined are referred to hospital after only one or two visits to their GPs.

Such data are only recently known as a result of the National Cancer Intelligence Network’s impressive work. It shows the power of data in helping us to tackle this disease. Further improvements in the collection and application of real-time data have the potential to transform medical practice in this area. Evidence given to the all-party group last week suggests that establishing a tool to collect patient data online would not be difficult to achieve. Such a robust IT system would radically improve data collection. Patients support their data being used for analysis and expect their data to be used to improve care for everyone else. London Cancer’s Dr Millar recommended that patient data be made freely available for use, within the law, for research in return for the free health care received under the NHS. Linking more GP data with that already received through secondary care and the research lab will help to improve early diagnosis in terms of the amount of data that can be analysed.

One issue highlighted throughout the all-party group’s inquiry was the disconnect between primary and secondary specialist care in achieving timely, effective treatment. Pancreatic cancer patients are not transferred quickly enough from primary to secondary care when time is of the essence if better outcomes are to be achieved. Most European countries do not have the same GP gateway as the UK; patients can see a specialist more quickly and clinical outcomes are better. One consultant surgeon and surgical oncologist told us:

“The patient turns up and the chap says, ‘Well it’s not reflux and I’m a reflux doctor. Back to your GP.’ So he goes back to the GP—more delay is coming. The GP says, ‘Well it isn’t reflux. Maybe now he has some back pain or something. We’ll try the spine doctor.’ So he goes to the spine surgeon. The spine surgeon says, ‘Well, it’s not spine pain. Back to your GP.’ This is the common scenario. The patient becomes a tennis ball.”

To get around this investigative ping-pong, it is worth seriously considering whether to allow GPs direct, easier access to CT scans, which would be much more likely to rule cancer in or out at an earlier stage than other investigative measures. One experienced GP told us:

“I think it’s about getting the right test, for the right patient, at the right time. Presently a hospital doctor who has had—no disrespect to my colleagues—two years’ medical experience can request a CT scan for a patient in hospital where I can’t.”

There is recognition that allowing GPs to refer patients directly for CT scans could accelerate diagnosis, but there is understandable concern about how it might work in practice.

Learning Disabilities (Care in the Community)

Andrew Smith Excerpts

Tuesday 8th July 2014 Westminster Hall

[Mr Clarke]

My hon. Friend makes a valid point and was right to do so.

Some £500 million of public money was spent to pay for people to be over-medicated with anti-psychotic drugs and kept in seclusion at risk of assault and self-harm. In December 2012, the Government put in place an action plan with the objective of giving people with learning disabilities support to enable them to move out of places like Winterbourne View and to return to their communities. A joint improvement programme was also put in place, and the NHS and local authorities were given a deadline of 1 June this year to make that happen.

The result is nothing short of a scandal. Not only has the deadline been missed, figures from the NHS show that more people are going into those units than coming out. Not only that, there seems little appetite to move people. Recent NHS data showed 90% had no discharge date. Meanwhile the human suffering continues. The learning disability census showed that 57% had experienced self-harm, an accident, physical assault, hands-on restraint or had been kept in seclusion.

[Mr Andrew Smith (Oxford East) (Lab)]

I, too, congratulate my right hon. Friend on this enormously important debate. Last Friday saw the first anniversary of the preventable death of Connor Sparrowhawk in the Slade unit in my constituency. One year later, we have not had the inquest or the serious case review, and his family are scrambling around to raise money so that they will be legally represented at the inquest where the public authorities will be represented at taxpayer’s expense. Does my right hon. Friend agree that more needs to be done to prevent such tragedies and, when they occur, to help the families and victims to see justice?

[Mr Clarke]

I agree entirely with my right hon. Friend. It was important that he put that case on the record.

The picture we are seeing is clearly unacceptable. Mencap, the Challenging Behaviour Foundation and Enable in Scotland have campaigned vigorously with the families of those affected, and I thank them for their advice for this debate. Many of the families have experienced the sheer pain of knowing their son, daughter, brother or sister has suffered horrific abuse and in some cases died. They have battled in many cases for years to get their loved ones out of these dreadful places, but have been blocked by an uncaring system that is often more focused on money than high-quality care and the rights and dignity of people with learning disabilities.

To mark the passing of the 1 June deadline, the families came together to write an open letter to the Prime Minister asking him to take urgent action and to meet them. I understand from them that to date there has been no reply. That is unacceptable and I hope the Prime Minister will look again at their letter and take the opportunity to meet them.

I had the privilege of meeting many of the families some time ago prior to my Adjournment debate back in autumn 2012, and more recently at last week’s all-party group on learning disability which I chair with Lord Rix, who has of course campaigned vigorously in this area. In common with all my colleagues, I cannot praise Brian more highly. I pay tribute to the families’ determination in fighting to change things for the better, not only for their loved ones, but on behalf of the thousands of others trapped far away in these places.

I turn to the case of Josh. The Wills family have campaigned for their son, and #BringJoshHome has caught the public interest, which we welcome. Phil Wills, his dad, spoke at the all-party group meeting last week and I know how moved everyone in the room was. Phil and Sarah’s son, Josh, lived in his family home in Cornwall with his siblings until July 2012 when his self-injurious behaviour increased. As a result, he was sent to a unit 260 miles away. Phil and Sarah reluctantly agreed to that because they were told there were no local services and it would be for a six-month assessment period to give everyone an understanding of the support and services Josh needed.

Almost two years later, Josh is still in Birmingham, a five-hour trip for his family. The Kernow clinical commissioning group continues to procrastinate and refuses to commission the services needed locally. Meanwhile, away from his family, Josh grows more anxious and his parents fear for his life because of the severity of his behaviour. He spent both his 12th and 13th birthdays there and has never met his newly born little sister.

I am very grateful to the Minister for his address to the all-party group meeting last week. I understand that he has met Phil and Sarah on more than one occasion and, to his great credit, many of the other families. I know he shares my deep concern over what has happened, and indeed, what has not happened. At the meeting, he shared his feelings about the lack of progress and the work he has been doing with NHS England, which has powers to intervene and address local failings. I say to him today that his views were very much appreciated.

I also welcome to the debate the shadow Minister, my hon. Friend the Member for Leicester West (Liz Kendall), and I welcome the contributions of my hon. Friend the Member for Stretford and Urmston (Kate Green) and my right hon. Friend the Member for Oxford East (Mr Smith). I look forward to what the Minister has to say, and in particular, I would like him to answer the fundamental questions that every family affected wants an answer to. Given that the June deadline has passed, what are he and other Ministers now doing, and what will the new deadline be? Where will the leadership come from across health and local government to ensure that we make progress?

It would be beneficial if the Minister could clarify the status of the joint improvement programme originally tasked with getting people back within their communities. Patently, that has failed and it has been dealt a further blow with the resignation of its director only yesterday. Are we to see a second joint improvement programme? Who will it consist of? How will it be successful? Critical to the solution, in my view, is also how we refocus money away from these high-risk units and into good-quality, locally based provision. If he could comment on that as well, I would be extremely grateful.

With regard to Scotland, it should be said that despite the Barnett formula, which means that 10% of the money spent in England is allocated to the Scottish Government, the widespread concern that is here in England also applies in Scotland. It is not helpful that Scottish data on these matters are poor, and that the £34 million allocated on the basis of the Barnett formula—arising from the committee that I chaired on disabled children and their families—was not spent on that purpose, but was used to keep council tax static. Scottish decisions on such placements can mean that placements out of area can also lead to placements out of Scotland. In one case, a man was sent to Carstairs, an NHS hospital for the criminally insane. He was later dispatched to Newcastle, where his elderly father finds the greatest difficulty in visiting him.

According to John White, the positive behaviour support adviser of Enable Scotland:

“The issue with assessment and treatment units can be that such environments can become the ‘setting conditions’ for people developing the challenging behaviours they are meant to be assessing and treating in the first place. We know from experience that people who had to live in NHS institutions for many years developed challenging behavioural repertoires in response to the experience of living in such environments and so it is logical that similar environments with similar institutional features are likely to encourage the development and maintenance of similar challenging repertoires.”

I would add that, important as it is, positive behaviour support is not a panacea and should be available as a part of a multi-agency health and social care collaborative approach. We need services to be designed around people, who along with their families, should have as much choice and control as possible. We need strong local crisis supports, staffed collaboratively by the NHS and local providers working in partnership, preventing hospital admission in the first place for all but those few people with a significant mental health problem that requires treatment.

For many years, we have been talking about care in the community, and there have been great strides. But the 3,250 people we are talking about today have been failed, let down by poor-quality or non-existent local services and then placed in high risk in-patient settings, where we have seen abuse, and tragically, loss of life. This is a national disgrace, and one that I hope right hon. and hon. Members from both sides will agree must be addressed decisively now.

I look forward to the Minister’s reply. I thank him for his presence, and I know he will share my view that these issues are crucial to the services that we provide, particularly in social services, remembering the rights of every individual citizen of this country.

Ambulance Resources and Response Times

Andrew Smith Excerpts

Wednesday 14th May 2014 Westminster Hall

[Mr Wright]

My hon. Friend is absolutely right that the situation is spiralling out of control. The case that she has just told the House about is simply unacceptable and downright distressing, but it is not unique.

[Mr Andrew Smith (Oxford East) (Lab)]

My hon. Friend is being very generous in giving way, and I congratulate him on securing this debate. I concur, of course, with what he has said in praise of front-line ambulance staff, and I also express my condolences to the family of his constituent.

The South Central Ambulance Service, which has a good record against targets in urban areas but a less good record in rural areas, has faced rising demand as well. One of the specific factors that it has pointed to is the increasing number of referrals it receives from the 111 service. Is that also a factor in my hon. Friend’s area?

[Mr Wright]

It could have been a factor in Mr Gouldburn’s case, because originally his family contacted the ambulance service via 999 but subsequently they went to 111. I do not think that there is sufficient join-up between the ambulance services and the contact centres about what is appropriate to 999 and what is appropriate to 111. I hope that the Minister will respond to that point.

Managing Risk in the NHS

Andrew Smith Excerpts

Wednesday 17th July 2013 Commons Chamber

[Mr Hunt]

I am going to make some progress and I will give way more later.

Francis also talked about compassionate care. We are going to follow the advice of Camilla Cavendish’s study on training for health care assistants, so we can be sure that no one is giving basic care to our NHS patients without proper training on how to treat people with dignity and respect. We have also proposed that, subject to pilots that are starting in September, every student who wants to receive NHS funding for their nursing degree will first work for up to a year as a health care assistant, so that before they open the textbooks they learn real care and compassion at the coal face.

[Mr Andrew Smith (Oxford East) (Lab)]

Will the right hon. Gentleman give way?

[Mr Hunt]

I am going to make some progress and then I will give way.

In addition, in September the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart will present their recommendations on how we can turn NHS complaints handling into an engine for improving compassionate care.

The right hon. Member for Leigh mentioned nursing numbers. Getting the right number of staff on wards does matter, and where that is not happening for hospitals in special measures it will be sorted out. However, to suggest that that is the only issue, or indeed the main issue, is completely to misunderstand what has gone wrong. Eight of the 11 failing hospitals had increases in nurse numbers since 2010, but they still needed to go into special measures. Training, values, clinical safety and, above all, leadership are often as important.

Labour has been calling for mandatory minimum staffing numbers. Let us look at what the experts say about that idea. Robert Francis said:

“To lay down in a regulation, ‘Thou shalt have N number of nurses per patient’ is not the answer. The answer is, ‘How many patients do I need today in this ward to treat these patients?’”

He also said:

“The government was criticised for not implementing one, which it is said I recommended, which I didn’t.”

--- Later in debate ---

[Mr Hunt]

I would be delighted to do so. I have studied her work and am an admirer of it, so I would be more than happy to meet my hon. Friend to discuss further the issues he wants to raise.

I want to turn to the substance of the motion, which is about risk for the NHS. Two big risks face the NHS. They face not only the NHS, but all major health care systems. The first is financial sustainability and the second is an ageing population. The litmus test for the success of the NHS in the next 65 years will be whether it confronts those huge challenges while looking after people with dignity, compassion and respect. I believe that there are three pillars on which we must build to make that possible. The first is a radical transformation of out-of-hospital care. We know that a consultant is responsible for us when we are inside hospital, but who is responsible for a vulnerable older person when they leave hospital? Too often, their care falls between the cracks, with no one being accountable. The NHS could lead the world in this, but we have made it impossible for GPs to look after people proactively because of how the GP contract works. We need to change that, so that in an integrated, joined-up system of care, there is always an accountable clinician or named GP and the patient knows who it is. In the consultation on the changes to the NHS mandate for next year, therefore, I have asked NHS England to ensure a named clinician responsible for every vulnerable older person.

The second of the three pillars we need to reduce risk in the NHS is technology. The technology revolution has transformed many other sectors, but has barely touched the NHS. A and E departments cannot access GP notes and so give medicine without knowing people’s medication history. Ambulances pick up the frail elderly without knowing whether they are diabetic or have dementia. This has to change. Technology can also cut costs. Retail banks have reduced their costs by a third, and we need those precious savings for the NHS, which is why I have said I want the NHS to go paperless by 2018 at the latest, with online prescriptions and booking of GP appointments by 2015. Technology is also a vital key to delivering integrated care, which is why data sharing will be a key condition of accessing the £3.8 billion joint health and social care fund announced by the Chancellor in the spending review.

The final pillar to help the NHS cope with new risks is science. It might surprise hon. Members that I mention that today, but the UK has a long track record as a world leader in medical science. We were the first to unlock the secrets of DNA in 1953; we did the first combined heart, liver and lung transplant; we invented in vitro fertilisation, alongside many other advances, and we must play to those strengths. Science can transform our understanding of disease, and help us deliver truly personalised care. Our aim is by 2015 to put the UK at the forefront of the genome revolution worldwide, and I have set up Genomics England, led by Sir John Chisholm, to deliver that vision.

In conclusion, the NHS faces many risks, but it also delivers many successes day in, day out. No organisation anywhere in the world has more staff dedicated to the noblest ambition anyone can have—to be there for us and our loved ones at our most vulnerable.

[Mr Andrew Smith]

rose—

[Mr Hunt]

I am concluding now. We owe it to those people to tackle head-on the risks the NHS faces alongside health care systems in every other country. We do so with confidence and optimism that by confronting failure, nurturing excellence, and supporting the brilliant work of people on the front line, we will be able to deliver an NHS that remains the envy of the world.

--- Later in debate ---

[Mr Andrew Smith]

Among the many other dangers of privatisation, is not one particularly relevant to the debate today the fact that transparency will be lost because of private commercial organisations’ unwillingness to share information and be transparent?

[Derek Twigg]

My right hon. Friend makes an important point. That is one of the things that we explored during the Committee stage of the Health and Social Care Bill and of course we got no answers. The then Minister, now Minister of State, Department for Transport, the right hon. Member for Chelmsford (Mr Burns), said that as time goes on the NHS will be more open to the competition laws of both the EU and the UK. That is the real story here, and we will not have that transparency. That is a major part of the problem we are having to deal with.

No matter what statistics we are talking about, losing a friend or loved one is a massive human tragedy that affects everybody. We want to do all we can to reduce the number of early and preventable deaths—that is absolutely right—and put patients’ interests and those of families first. Given what we have heard in the last day or so, one would think that we somehow left an NHS in crisis—an NHS that was not delivering—yet when we left office it had the highest satisfaction rate in history. We had the lowest waiting lists in history and massive reductions in early deaths from cancer, coronary problems and so on. We also saw massive increases in doctors and nurses. We hear this Government talking about increasing the number of doctors, but when did those doctors start their training? They started under Labour.

To give an example, so that we can be a bit fairer about the situation, the Commonwealth Fund produced an international health policy survey in 2010 that looked at 11 countries—and guess what? The UK health service came out best. Just as an example, when those on above average incomes and those on below average incomes were asked whether they were confident that they would receive the most effective treatment if sick, the best results—95% and 92%—were in the UK. That was an international survey. Another question was whether people were confident that they would receive the most effective treatment if sick—and guess what again? The UK came out on top, at 92%. That is the real picture of the NHS that we left behind in 2010—although it was not without its problems and challenges, because pressures were always building up.

I also noticed that pages 4 to 5 of the Keogh report say—this is an important comment that has not been looked at much in the press—the following:

“Between 2000 and 2008, the NHS was rightly focused on rebuilding capacity and improving access after decades of neglect. The key issue was not whether people were dying in our hospitals avoidably, but that they were dying whilst waiting for treatment.”

That is where Labour made one of the biggest differences. I remember regularly having people write to me back in the late 1990s and the early 2000s about having to wait over two years for an operation. People were literally dying because of that. Addressing that was one of the biggest gains that Labour made.

The Secretary of State has now left the Chamber, but earlier I raised with him the issue of mortality. He refused to correct the record. He said that there had been a “slight” improvement by 2010, yet Professor Keogh talks about a 30% improvement in mortality in all hospitals, including those that have been under investigation. That is not to say that those hospitals should not be doing better, but he was talking about all hospitals.

Augmentative and Alternative Communication Services

Andrew Smith Excerpts

Thursday 6th June 2013 Commons Chamber

[The Minister of State, Department of Health (Norman Lamb)]

I am really grateful to my hon. Friend the Member for Blackpool North and Cleveleys (Paul Maynard) for raising this issue, and for his work, together with that of colleagues, as a member of the all-party parliamentary group on speech and language difficulties. An occasion such as this is particularly valuable, as was the meeting that we had yesterday, in ensuring that Ministers focus on issues that might otherwise not get attention. I learned a lot from the meeting yesterday, and from my hon. Friend’s impassioned speech today. He clearly speaks with real authority on this subject. I was struck by his point about the lad who ended up with a PhD as a result of the support that these facilities can provide. He made the point very powerfully that they can change lives.

Augmentative and alternative or assistive communication is one of the more specialised areas of health and education provision. The number of children who will require support in this way is relatively small, perhaps less than 0.5% of the population, so it is important that we do not lose sight of them. My hon. Friend rightly made the point that the ability to speak and communicate is a pretty basic human right, and that it should be recognised as such.

Augmented communication has the potential to have a tremendous beneficial impact on the health and well-being of those whose condition places barriers between themselves and others, which until recently were insurmountable, and indeed, on their families and friends. Technological and therapeutic advances have in recent years revolutionised the support that can be given to those who have lost, or never had, the tools of speech and language that allow us all to interact and that are critical to development, to education, to work and to living one’s life. Augmentative and assistive communication—AAC—aids range from tools for paper-based communication to pretty sophisticated electronic equipment.

Support in the past has not always been of sufficient consistency and quality, and the Bercow review in 2007 and the subsequent work of the Communication Champion, Jean Gross, have helped to identify systemic improvements, culminating in a new approach to the commissioning of AAC that began just a few months ago. It is worth pointing out that the new system is in its very early days. I was pleased that my hon. Friend acknowledged that it had the potential to work effectively. It is perhaps understandable that we have not got it quite as we would want it to be, given the early stage that we are at, but I agree that it has enormous potential. There is significant clinical consensus behind the new approach, and I am proud to say that it has been developed from the new structures of commissioning that this Government have introduced into the NHS.

In April this year, NHS England took on responsibility for the direct commissioning of specialised assessment and the provision of augmentative and assistive communication aids for adults, children and young people. NHS England’s role as an independent national commissioner is particularly suited to the effective commissioning of extremely complex, yet relatively low volume, services of this kind. Let us bear in mind that the patients who require AAC aids have extremely complex needs and in many cases require bespoke equipment that has been designed for them. My hon. Friend the Member for Totnes (Dr Wollaston) mentioned the training involved in the use of such equipment. It could not feasibly be provided by small-scale local services. Assessment and provision is needed by specialised tertiary providers with their concentration of expertise.

Previously, we had no national commissioning of AAC services and improvement across the board was essential. There was no standard or nationally consistent definition of those services, which were the commissioning and funding responsibility of the NHS. The effect of that was variation in the organisations commissioning and funding specialised AAC services and, crucially, inequitable access to them. There was a mix of non-NHS commissioning agencies, including social care and the education sector, to which my hon. Friend referred, and charity and third sector funding agencies that were commissioning the assessment and provision of specialised AAC aids. It was haphazard, depending very much on where people lived. That was unfair to those in need, and far from ideal for commissioners or providers.

That has now changed. NHS England—committed to ensuring national consistent commissioning of high quality, equitable and effective specialised services—has worked with the expert partners on its clinical reference group for complex disability to develop for the first time a nationally consistent specification for specialised AAC aids, which was subject to public consultation. The specification has allowed a clear demarcation of the responsibilities of clinical commissioning groups in relation to less specialised AACs—around 90% of the total provision. The highly specialised services will be commissioned by NHS England. It will be an important role for NHS England to work to support CCGs in their commissioning of the less specialised end of the spectrum and to ensure that we build capacity rather than lose it, as my hon. Friend feared could happen. If we get this right, the potential of having this specialist team working nationally with local commissioners could be significant.

In implementing the specification, NHS England will draw on the recommendations of the Bercow review and the Government communication champion to consider, in particular, how best to ensure more consistent and responsive commissioning of AAC aids across England and the implications of meeting unmet need. We know from recent research from Communication Matters that there is variation in service provision across England—the postcode lottery to which I referred—and inconsistency in identifying, assessing and providing AAC services.

A key priority is therefore to ensure that commissioning arrangements for this specialised service are placed on a much more robust and equitable footing across England. NHS England is working with its clinical reference groups and area teams to identify areas where there may be inequalities and where additional resources may be required to bring about better access. The clinical expertise both embedded in the organisation and accessed through its close association and close partnership working with organisations such as ACE—Aiding Communication in Education—will be decisive in this. I met Anna Reeves of ACE yesterday, and I would like to pay tribute to the amazing work she has done in leading the case for much better access to these services. She has worked tirelessly in that regard and should be credited for doing so.

I would also like to acknowledge the potential benefits of clinically-led commissioning of services for children with special educational needs as part of new joint arrangements, which will also provide far more tailored support, focused on the health and lifestyle outcomes for the child, for the developmental needs of children who require AAC aids. The Children and Families Bill sets out a framework for a new integrated approach to meeting the needs of children and young people with special educational needs. This will include many children, potentially the majority, of children in need of AAC aids.

In brief, the Bill’s provisions will get clinical commissioning groups and local authorities—and, in some cases, the NHS Commissioning Board, where it is acting as a commissioner of services for a child or young person—to enter into joint arrangements to assess, plan and commission the services needed by children and young people with special educational needs. Each child’s improvement outcomes, and the services they need to deliver them, will be captured in the education, health and care plan, to which the relevant commissioners will contribute. That is a much more joined-up approach than we have ever had in the past.

The new arrangements will be introduced in 2014, Parliament allowing. Twenty pathfinder local authorities are piloting new approaches to integrated assessments and the plans currently. The amended Bill now includes a duty on CCGs to secure the services that they agree the individual needs and which comprise the education, health and care plan. We have specifically required in the mandate for the NHS—the Government’s priorities—the need for improvement, through partnership working, to support children and young people with special educational needs and disabilities, and for ensuring that children have access to the services identified in the agreed care plan. AAC support will be a significant part of these plans for many children.

NHS England and CCGs will need to work closely with local authorities and, of course, health and wellbeing boards, which will include the local authority director of children’s services and the local healthwatch. That is the vehicle for a consensual local identification of needs and a local strategy for meeting them. The health and wellbeing board must, as our guidance makes clear, have particular regard for hard-to-reach groups and those with complex conditions, which will require more specialised health services, as well as ensuring it has an in-depth understanding of more widespread health needs among the population.

[Mr Andrew Smith (Oxford East) (Lab)]

I congratulate the hon. Member for Blackpool North and Cleveleys (Paul Maynard) on initiating this important debate. In the allocation of resources and the approval of plans, what mechanisms for appeal will there be for individuals who feel that they have not been fairly treated, or indeed for areas that feel that?

[Norman Lamb]

There will be the potential to challenge and question to ensure that the individual is satisfied that their case has been properly heard, but I will also write to the right hon. Gentleman to fill in the details further to ensure that he understands the position fully.

Let me make a quick point about the historical budgets to which my hon. Friend the Member for Blackpool North and Cleveleys referred. To start with, NHS England has worked on the basis of the amount spent hitherto. It is important to say that work is very much ongoing on this matter, and it is absolutely recognised that it is important to get it right and to assess the level of need so that we can identify how much needs to be spend on it. This is not a done deal and he should not assume that this is the end of the story. He also made a point about organisations with great expertise which could be excluded from being able to play a part in this. I can reassure him that they will be able to bid to do work. He also made the point about loss of equipment on leaving school, and it is really important that that is avoided; that sort of thing is utterly crazy and we must ensure continuity. As he rightly said, this is a health issue and it must be recognised as such. He talked about the hub-and-spoke issue. The relationship between the expert team nationally and the CCGs has the potential to work well to build capacity within the system to improve the level of expertise available and to ensure a more consistent approach.

I hope that what I have said today provides significant reassurance to hon. Members about the robustness of the new approach to deliver AAC aids, not least in the role of NHS England in leading the development of expert service specifications and implementing them in a national programme of commissioning to deliver improved and responsive communication support. We are not complacent and, together with NHS England, we understand that more needs to be done to ensure absolute consistency across England, so that everyone who needs it has access to high-quality, equitable and effective AAC support. We have in place the right system to deliver that; my profound belief is that we will shortly be able to recognise NHS England, in this regard, as an exemplar of the effective design and commissioning of specialised services.

Question put and agreed to.

Mental Health

Andrew Smith Excerpts

Thursday 16th May 2013 Commons Chamber

[Norman Lamb]

I am grateful to the hon. Gentleman for reminding me that he, too, had made that point. I knew that someone else had talked about it, but I could not remember who it was. I take his point; I have heard it.

My hon. Friend the Member for Southport (John Pugh) made a thoughtful speech in which he talked about reminiscences. Oh! He has gone! Even though it pains me, as a Norwich City supporter, to talk about Everton, it appears that Everton and even Southport have done some very good work in these areas. My hon. Friend talked about a continuum of mental health. That was a good point, well made. He also mentioned community treatment orders and the need to look at how they are working. I will certainly reflect on that.

My hon. Friend the Member for Battersea (Jane Ellison) made a powerful contribution about the mental health aspects of female genital mutilation, a most horrific experience suffered by so many young girls. I really pay tribute to her for the work that she has done on that issue. The fact that there are 66,000 females in this country who have suffered this assault was an extremely striking point.

The hon. Member for Finchley and Golders Green (Mike Freer) talked about waiting times for access to treatment. He asked if he could gently challenge the Minister—I appreciated that approach. On the mandate for the NHS Commissioning Board, NHS England has been very clear that we expect it to assess the scale of the problem of access, including for IAPT. Other Members have raised the question of whether we are meeting the IAPT programme’s four-week target. We want the NHS Commissioning Board to assess the scale of the problem with a view to setting access standards.

One of the big problems relating to what I regard as the institutional bias against mental health is that on one side of the equation we have the 18-week maximum waiting time for physical health, which is a very powerful political driver of where the money goes, yet we have nothing equivalent for mental health on the other side. That, to me, is a lack of parity of esteem. For people with mental health problems, early access is particularly important to ensure that their condition can be halted, if possible, and the deterioration stopped. The hon. Member for Finchley and Golders Green made a good point there, and he also rightly talked about the importance of consistency and continuity of care.

I want to mention four of the most important things that this Government are doing to create the environment and incentives for improving mental health across the system as a whole. The first is the Health and Social Care Act 2012, which creates a “parity of esteem” so that mental and physical health share the same importance, as we have discussed this afternoon. Changing the law is just the start, but it sends a clear signal—that mental health is important, and that the health and care system can and must play a leading role in changing attitudes across society as a whole.

Secondly, there is the mandate the Secretary of State has issued to NHS England. It shows the importance we have ascribed to mental health and makes it clear where improvements are needed. The mandate makes clear our overarching goal—that mental health must have equal priority with physical health across all aspects of NHS work. In particular, we have highlighted the need to close the gap in outcomes between people with mental illness and the population as a whole, as well as the absolute imperative to ensure that people can access the services they need when they need them. Neither of these facets of good mental health treatment is entirely up to scratch at the moment. I think we all recognise that.

[Mr Andrew Smith (Oxford East) (Lab)]

The Minister is generous in giving way, and he is making some very important points. Would he include within this the importance of access to family therapy both to repair broken relationships and to aid recovery—an issue that Oxford Mind raised with me?

[Norman Lamb]

Yes, absolutely; I understand the importance of that. Incidentally, I visited children and adolescent services in Oxford and I was very impressed by the work under way there. I am getting a message that I am under some pressure from Mr Deputy Speaker to make some progress—