Oral Answers to Questions
Clive Efford Excerpts(4 years, 9 months ago)
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Matt Hancock
Yes, emphatically we do, and there is a drive across the country for more of the sort of social prescribing that the hon. Lady talks about. The clinical solution to many people’s health issues, and in particular mental health challenges, is often about changes in behaviour and activity, and the support people are given, rather than just drugs. On the face of it, the project the hon. Lady mentions sounds very good; of course I do not know the details, but I would be very happy to look into it. However, we wholeheartedly and emphatically support the broad direction of travel of helping people to tackle mental illness both through drugs where they are needed and through activity and social prescribing.
Clive Efford (Eltham) (Lab)
I recently met three care workers who work for Sanctuary Care. Between them, they have 60 years of experience of, and dedication to, caring for vulnerable people, but Sanctuary Care has decided to cut their pay and conditions because they were TUPE-ed over from the Borough of Greenwich. Is this the way to treat dedicated care staff? Will the Minister meet me and those care staff to discuss what is going on at Sanctuary Care, whose chief executive gets a handout of almost a quarter of a million pounds a year, while it cuts low-paid staff’s wages?
Health
Clive Efford Excerpts(5 years ago)
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Rebecca Pow (Taunton Deane) (Con)
The Secretary of State is making a really powerful case. On mortality, I would say that, far from the age going down in Somerset, it is going up. This is a good thing, but the conditions from which people are suffering are getting more complex. This is something we have to address. Indeed, I know the Government are seriously looking at it with many of the models they are bringing in.
Matt Hancock
I will give way in a moment, if I may just make a bit of progress.
Of course extending healthy life expectancies is a central goal of the Government, and we will move heaven and earth to make it happen. Yes, that does involve ensuring that the entire budget of the NHS—not just the public health budget, important though it is, but the entire budget of the NHS—and all those who work in it are focused more on preventing ill health. The entire long-term plan of the NHS, which sets out how we are going to spend all the extra taxpayers’ money that is going in, is about focusing the entire NHS more on prevention than on cure. To choose just to look at the public health grant—it is important, but it is smaller by far than the entire budget of the NHS—is entirely to miss the point.
Clive Efford
The right hon. Gentleman must accept that it is not acceptable that, in the fifth richest economy in the world, life expectancy has flatlined across the country and in some areas has actually gone backwards. Is that not an indication that wider policy approaches by this Government than just those on health are not working?
Matt Hancock
It is true that across the western world the incredible rise in life expectancy is continuing but the rate of improvement has slowed. Our task here is to ensure that we extend healthy life expectancies.
Matt Hancock
I have taken the hon. Gentleman’s point. That is the purpose of the entire prevention agenda: to help people to stay healthy in the first place.
Let me give a few examples. The hon. Member for Leicester South talked about deaths of despair, and each one of those suicides is a preventable tragedy, but he did not mention that the suicide rate in this country is the lowest it has been in seven years. We should be celebrating that while also resolving to drive it down further. Similarly, he talked about some of the sexually transmitted infections that are rising around the world, including in America, France and Belgium, but he did not mention that STIs overall are down. Indeed, HIV is down very significantly, and the UK is one of the leading countries in tackling HIV. It is important to look at the objective facts and not just pick out some. Of course there are STIs that we must tackle, and we will, but we must look at the overall picture. I will give one more objective fact: the number of attendances at sexual health clinics has gone up. That is one of the reasons why STIs overall are down.
The Source NHS Drop-in Centre
Clive Efford Excerpts(5 years, 4 months ago)
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Clive Efford (Eltham) (Lab)
I realise that the House has just been debating a very important subject, so I will not be offended if my hon. Friends leave the Chamber, despite my debating a very important issue for my constituents. I wish them on their way out a very happy Christmas and a prosperous new year.
The Source drop-in health centre is a nurse-led centre on the Horn Park estate in my constituency. It was opened in a partnership between the local council and health service under the single regeneration budget early in the 2000s in recognition of the unique situation of the Horn Park estate and its residents and the need to improve access to health services. The council provided a shop premises at a peppercorn rent, round five of the SRB paid for the refurbishment, and the NHS provided the staff and equipment.
The Horn Park estate is among the 20% most deprived communities in England, according to the index of multiple deprivation’s latest figures, for 2015, and ranks 5,591 out of 32,844, which actually makes it one of the 18% most deprived. The estate is largely made up of council-built housing, and residents are mostly council and housing association tenants. It is located at the south-west edge of the Royal Borough of Greenwich and borders directly the London Boroughs of Lewisham and Bromley.
Being on the periphery of three boroughs always puts the community at a disadvantage when it comes to public services, as was recently highlighted by Professor Tony Travers of the London School of Economics. To the north, the boundary of the estate is marked by the A20 Sidcup dual carriageway and the A102 south circular, a similar dual carriageway. The community is therefore very isolated from its neighbouring communities in the Borough of Greenwich.
There is a small parade of shops that used to include convenience stores, a chip shop and post office. The post office moved into the convenience store, but that has now virtually completely closed, and there is now just the chip shop. An attempt was made to put in a satellite Sure Start centre in one of those shops, but that has since been closed, and the Source occupied one of those other empty shops in the middle of the estate. For everything else, the residents have to leave the estate, and there are many elderly people and families with young children on the estate, and 30% of them do not have access to a car.
The Horn Park estate lost its only GP practice in 1990, when Dr Denis retired. I remember campaigning to keep the practice open at the time. The Greenwich district health authority, which was then in charge of the health service in Greenwich, decided that the practice at Horn Park should be taken over by the Evans practice, based in Court Yard, central Eltham, over one and a half miles away. The Evans practice closed Dr Denis’s satellite surgery on the estate and never provided any services locally. This was the beginning of a trend of gentrification in the location of surgeries, as a succession of GP practices closed surgeries based on council housing estates.
I have several communities in my constituency among the most deprived in England on the index of multiple deprivation. The Page estate, made up of four communities, is among the 20% most deprived, and the Middle Park estate, made up of three communities, has one among the 10% most deprived. The Brook estate is among the 30% most deprived. Lower Brook estate is among the 40% most deprived and the Horn Park estate has two communities among the 20% most deprived. With the exception of one community on the Page estate, they all have one thing in common: they do not have a GP practice.
When the clinical commissioning group closed the Source in 2016, it decided to invite expressions of interest from GPs in Greenwich to establish a branch surgery on the site as a replacement for the Source. No GPs stepped forward. In an attempt to justify its decision, the CCG claimed that there were six GPs within a “manageable distance”—less than 1 mile—from the Source’s location in Sibthorpe Road. In fact, there are no GPs less than 1 mile’s walking distance away. The nearest is actually 1 mile away, and the rest are more than 1 mile away—up to 1.5 miles away. There is no pharmacy on the estate, and the nearest one is 1.5 miles away, in a direct walk, at Newmarket Green on the neighbouring Middle Park estate. However, that is not a suitable walk for anyone with mobility problems or for a parent with children.
If the CCG truly wants to tackle health inequalities in Eltham, it could start by making services more accessible in the communities where they are most needed. It is unacceptable that it is possible to walk to five different practices within ten minutes in the most affluent area of my constituency, while the Greenwich CCG says that it cannot afford to keep a nurse-led service available on the Horn Park estate. Before its closure, the Source was dealing with over 5,000 patient visits per year, at an average cost of £26 per visit. This compares with £45 for the average cost to visit a GP, and over £80 for a visit to an A&E. These facts were completely disregarded by the GPs on the CCG when the decision to close the Source was made.
The Source was closed in 2016. Greenwich CCG’s then chief officer explained that Greenwich CCG was forced by NHS England to reduce its planned spending by £15.5 million by March 2017. Closing the Source, she claimed, would save £75,000 a year. The total CCG budget for Greenwich in 2016 was just under £370 million.
The opposition from the local community forced the CCG to hold a consultation. I attended it with my constituents as, one after another, they stated how they valued the support, advice and treatment they got from the nurses at the Source. Each and every one of them told the CCG that it took at least three weeks to get an appointment with a GP. Rather than be concerned about this fact, the CCG just told the residents of the estate that they were completely wrong about the waiting times for GP appointments.
Further misinformation was circulated by the CCG to justify its decision. It suggested that the nurses at the Source lacked the necessary qualifications to prescribe or sign prescriptions. Oxleas NHS Foundation Trust, which employed the nurses at the Source, has confirmed that this was not correct, and that the nurses were in fact qualified as independent prescribers.
The CCG’s determination to close the Source generated such overwhelming opposition that it was forced to commission a report from the Picker Institute about the use of primary care services and the Source. This report concluded that
“the Source is a highly valued service”
by the local community. People were very positive about the wide range of services offered, the convenience and ease of getting an appointment, and the friendliness and approachability of the staff. The report found that local people were very concerned that local needs would not be met if the threatened closure was carried out, and that existing GP surgeries would be even more pressurised as a result. The report also found that GPs themselves recognised the value of the Source in relieving the pressure on their practices.
The report quotes a local resident saying:
“When you need to see a practice nurse quickly at my GP surgery, they just say—go to The Source”.
Another resident said:
“Receptionists are the ones sending people to the Source”.
Another said that
“within Sherard Road surgery there are posters up signposting people to attend the Source”.
In fact, most GP surgeries in the area had posters advising people to use the Source. The report also found that ease of access and the ability to be seen on the day were very popular with local people, especially those with young children and the elderly. The Horn Park estate has many elderly and vulnerable residents. It is among the 30% most deprived areas in England for income deprivation affecting older people, according to the 2015 indices of deprivation. One resident explained:
“As a carer I find it easier to get my mother to the Source in her wheelchair than taking her all the way to Eltham on and off buses as I do not drive.”
Many residents complained of having to wait three weeks for a GP appointment.
The Picker Institute took a month to compile its report, which was published in September 2016. It clearly showed that the Source was a highly valuable local facility, providing a vital service for local people, but that was not what the CCG wanted to hear. The day before the Picker report was published, it confirmed its decision to close the Source without even bothering to wait for the results of the consultation. The CCG announced the immediate closure of the Source and stripped all of the equipment out of the building.
In its 2016-17 annual report, the CCG acknowledged that
“as commissioners we have ambitious aspirations to put patients, carers and local people of Greenwich at the heart of our commissioning. We recognise that we have fallen short of our aspirations this year, especially on some of our work to reduce our expenditure as part of the Quality, Innovation, Prevention and Productivity programme, e.g. on decommissioning the Stroke Association and the Source as well as our plans to commission a musculoskeletal service where our consultation was very limited. We know that we still have a long way to go to improve our patient participation activity.”
The issue here is what the words mean. If that is what the CCG believes, how is it that it is not listening to patients about the Source? The CCG claimed that 80% of the work carried out by the Source fell outside the CCG’s delegated authority—for example, sexual health. It said that the three nearest GPs in Greenwich offer nurse-led services and encourage patient participation in the same way as the Source. It said:
“There are also pharmacists close by.”
None of that was accurate.
In 2016, NHS England and the CCG finally acknowledged the healthcare needs of the estate and the harm that the closure of the Source would cause. Moreover, the CCG recognised that Horn Park should be
“considered as an exceptional case”,
because of the
“inaccessibility of general medical services for this deprived community, isolated as it is by its unique geographical location”.
While opening a new branch surgery was
“not in alignment with the GP Five Year Forward View or the Greenwich CCG Estates Strategy, with their direction of travel towards larger and more sustainable general practices”,
this was not, according to the report,
“sufficient reason to set aside”
the accessibility issues. That is the conclusion of the South East London Commissioning Partnership Group.
I also want to draw the attention of the Minister to a couple of reports that bear out the case for the Source. The Primary Care Workforce Commission found that nurse-led surgeries could mitigate the effects of GP shortages, helping
“address workload issues, improve the patient experience and sometimes deliver savings.”
That was published in 2015. In 2010, the King’s Fund talked about those surgeries supporting the value of continuity of care and patient experience showing improved patient outcomes and job satisfaction and professional development of the staff involved. It pointed to the fact that the quality of the service that the Source provided not only improved the health outcomes for the patients who use it, but gave greater job satisfaction, which, in turn, fed back as a valued service that the patients enjoyed. I can vouch for the committed staff who ran the Source and pay tribute to the excellent relationship that it had with the local community. This is how local health services should be delivered.
Since the closure, I have continued to receive complaints from residents on the estate about poor access to health services. In response, I recently consulted with local residents. We delivered a survey and introductory letter to every door on the estate that was on the electoral register—991 in total. We asked people either to complete the paper copy and return it to our freepost address or to complete it online, and we received over 200 responses, which is a response rate of over 20%. I am sure that the Minister will acknowledge that that is a very high response rate for a campaign of this sort. I also organised a petition calling for the Source to be reopened in Horn Park that has so far garnered nearly 700 signatures. Somewhere in the region of 900 local people have called for the centre to be reopened. Given that 1,964 people in Horn Park are on the electoral register, this means that something in the region of 45% of all adults on the estate have put their names forward to support this campaign.
The survey received 201 completed responses and 690 individuals have signed a petition calling for the Source to be reopened. Some 98% of respondents agreed that the Source must be reopened, 85% of respondents that had used the Source now find it more difficult to access health services, and 80% of respondents who had previously used the Source now rely on their GP to access the services previously provided by the Source. Over half—53%—of those who indicated how they used the Source accessed four or more different services at the centre. Some of the comments from the survey speak loudly in favour of reopening the service. Those remarks included:
“Advice close to home. If unwell no need to travel into Eltham for GPs getting an appointment can take a few weeks”,
“Reopened Source should provide all of the previous services (it can now take up to three weeks for a GP appointment)”,
“I would be happy with any walk-in service”
and
“Reopen the Source. Older people really need it”.
We need more facilities like the Source, not fewer.
On Second Reading of the Health and Social Care Bill, Andrew Lansley said, in response to Andrew George, the former MP for St Ives:
“He will see that, in the Bill, a specific duty is placed on the commissioning board and each commissioning consortium to reduce inequalities in access to health care. He will see also that, through the Bill, we will strengthen accountability where major service change takes place, because it will require not only the agreement of the commissioning consortium, representing as it were the professional view, but the endorsement of the health and wellbeing board, which includes direct, local, democratic accountability.”—[Official Report, 31 January 2011; Vol. 522, c. 610.]
The health and wellbeing board of the Borough of Greenwich is in no doubt that the Source should reopen. I pay tribute to the leader of the council, Danny Thorpe, who has committed to keeping the premises available so that we can do just that.
Reinstating the Source would address many of the objectives raised in the NHS plan such as staying healthy, ageing well, tackling clinical priorities and enabling improvement. It would also align with priorities in the Greenwich joint strategic needs assessment and would put tackling health inequalities back at the heart of this very isolated community. The CCG has acknowledged that Horn Park has “unique geographical characteristics”, and should be considered “as an exceptional case” because of the
“inaccessibility of general medical services”.
It accepts that there is a “substantial case” to treat it
“as an exception to the current direction of travel towards larger practices.”
The distances to local GPs were described by the CCG in 2016 as
“a manageable distance (around a mile or less)”,
but this is not the reality, and 85% of respondents who had used the Source said that they found it more difficult to access the health service after the centre’s closure. How is that improving healthcare? Forty-five per cent. of people on the estate have expressed support for it reopening. How is this local accountability? How is it possible to continue to ignore local residents and the health and wellbeing board about reopening the Source?
The Government claim to be putting £20 billion into the national health service. Surely some money can be found for this community that can go directly to delivering the health outcomes that the Government say they want to achieve.
In wishing the Minister a happy Christmas and a safe journey home, I ask her to join me in making a new year’s resolution to impress upon Greenwich CCG that it should reopen the Source and restore the health services that the community on Horn Park estate in my constituency so desperately needs.
Madam Deputy Speaker (Dame Eleanor Laing)
I am sorry to stop the hon. Lady when she is giving good wishes, but I think the hon. Gentleman might like to intervene. He does not have a right to speak again, but I am sure that the Minister will give way if he wishes to intervene.
Clive Efford
Yes, just briefly. I would like to stress one point. Horn Park is an extreme example of how health services have moved away from the most deprived communities. There is an issue about accessing health services. These are the communities that are most distressed and most in need of having direct access to those services. If the Minister ever has an opportunity to talk to Greenwich CCG, will she bear that in mind when she does so and draw it to its attention? I think we could improve our health outcomes a great deal if we were to address that issue.
I wish all those who serve us here in the House a very happy Christmas.
Caroline Dinenage
The hon. Gentleman makes an excellent point, and I will of course raise it in any conversation that I do have with Greenwich CCG. He is absolutely right to say that we should be doing everything we can to close the health inequalities that people experience up and down our country.
May I, Madam Deputy Speaker, wish you a very merry Christmas and a happy, healthy and peaceful new year?
Draft Blood Safety and Quality (Amendment) (EU Exit) Regulations 2019
Clive Efford Excerpts(5 years, 4 months ago)
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Clive Efford (Eltham) (Lab)
It is a pleasure to serve under your chairmanship, Mr Sharma. I have a couple of brief questions of the Minister.
First and foremost, the point that has to be made about this scenario is that there is no majority in the House of Commons for us to leave with no deal. That needs to be underlined. If we do leave without a deal, it will be entirely the fault of the Prime Minister.
That aside, what implications does this treatment of the UK as a third country by the European Union have down the road? Has the Minister considered that? What about continued supply? Are we in competition with other European countries? Is supply likely to be interfered with? Will priority be given to EU countries over us for that supply? I might be worrying unnecessarily, but I would like to know whether the Minister has given that any consideration, or whether it is in fact the case.
Similarly, on future improvements in standards, technology and knowledge, will we keep up under article 29 with technical improvements in the field? Will we mirror that in this country? How will we keep ourselves at the forefront of medicine in this area to ensure that we do not fall behind our European neighbours as a consequence of not being part of the collective that deals with such issues under article 29 of the European treaty?
Oral Answers to Questions
Clive Efford Excerpts(6 years, 3 months ago)
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Mr Hunt
There are two things. First, we have succeeded in increasing the number of medical school graduates who go into general practice—a record 3,157 this year. Secondly—I know this from my conversations with GPs in my hon. Friend’s constituency—we are doing what we can to reinvigorate the partnership model. Since meeting those GPs, I have agreed with the Royal College of General Practitioners and the BMA that we will carry out a formal review of how the partnership model needs to evolve in the modern NHS.
Clive Efford (Eltham) (Lab)
Mr Hunt
I point the hon. Gentleman to what the King’s Fund says, which is that accountable care organisations and integrated care systems make a “massive difference” in care to patients. The King’s Fund is not a pro-Government organisation; it regularly holds the Government to account at election time and throughout the year. Not just the King’s Fund but Polly Toynbee and many other people are saying that.
NHS Winter Crisis
Clive Efford Excerpts(6 years, 3 months ago)
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Urgent Questions are proposed each morning by backbench MPs, and up to two may be selected each day by the Speaker. Chosen Urgent Questions are announced 30 minutes before Parliament sits each day.
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Stephen Barclay
A party preparing for a run on the pound will be in no place to give funding to the NHS. It is the agreed convention of the House that responses to Opposition day debates are provided by the Department within 12 weeks. The Secretary of State will of course do that within that period, and there is a good reason for that. As I set out in my opening remarks, the data will not be available until mid-March, so the hon. Member for Leicester South (Jonathan Ashworth) is premature in asking this urgent question.
The facts are that the NHS was better prepared for winter this year. The number of 111 calls dealt with by a clinician has doubled compared with last year. Over 1 million more people have been vaccinated for the flu virus, 99% of A&Es have GP streaming and over 3,000 more beds have been made available since November, reflecting the extent of the plan.
Stephen Barclay
If the hon. Gentleman would like to compare with the performance of the NHS in Wales, we will undertake a comparison. The reality is that this year, we have had pressure on the NHS as a result of flu. The difference is that in 2009, the Conservative party did not play politics with the flu pressures. This year, the hon. Member for Leicester South has done so. He should compare it with the pressure in Wales and see the excellent performance we have had in comparison.
Stephen Barclay
The hon. Lady raises a very valid point. It is exactly why we will have a Green Paper this summer looking at what steps need to be taken to address this issue. On both sides of the House, we recognise that more needs to be done on how we address these concerns, and that is what the Green Paper will tackle.
Clive Efford (Eltham) (Lab)
I am sure that the Minister did not mean to mislead the House regarding the impact of the flu epidemic on our A&Es, so will he confirm that the delays to people being treated in A&E, and the fact that people have been waiting on trollies in corridors and that ambulances have been queueing at the doors of A&E, predated the flu epidemic?
Stephen Barclay
The hon. Gentleman makes quite a serious allegation of my misleading the House. What I was very clear about is that there has been a 35% increase in attendances at A&E as a result of flu this year compared with last year, and that around 3,000 beds are currently occupied by patients with flu and around 700 beds are occupied by those with norovirus. Clearly, that has resulted in significant seasonal pressures this year, which have placed strain on the system. That was recognised by the Government in the additional funding that was put in place. It was recognised by the NHS, as Sir Bruce Keogh set out in the early planning that was undertaken, and it is simply wrong for the hon. Gentleman to ignore the impact of flu this year, given the way that in 2009 the then Opposition were very responsible in recognising its impact.
NHS Winter Crisis
Clive Efford Excerpts(6 years, 4 months ago)
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Clive Efford (Eltham) (Lab)
I congratulate the Secretary of State on facing down the Prime Minister on Monday, when what emerged was one man, two jobs, no governor. He must accept that the £6 billion in cuts to social care since 2010 has had a major impact, particularly on winter crises. Does he regret the Government’s decision to take that money out of social care?
Mr Hunt
In 2010, we faced the worst financial crisis since the second world war. The hon. Gentleman will know which Government were in charge when that happened. People were talking about a run on the pound—I notice that the Labour party continues to talk about that—and the crisis had to be addressed. We, like other countries, had to make significant reductions in public funding, but when we got the economy back on its feet and started creating jobs—1,000 jobs a day since 2010—the first place into which we put extra money was the NHS and the social care system. There is £600 million more in the social care system than there was two years ago.
King’s College Hospital Foundation Trust
Clive Efford Excerpts(6 years, 5 months ago)
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Clive Efford (Eltham) (Lab)
The Minister has to accept that when the Government stepped in with South London Healthcare NHS Trust in 2013, they imposed their own interim director, just as they are now doing at King’s, and imposed the restructuring of south-east London health but never, ever funded it. That has led to the crisis at King’s today. The buck stops with the Tories. You just cannot trust the Tories with the NHS.
Oral Answers to Questions
Clive Efford Excerpts(6 years, 6 months ago)
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Jackie Doyle-Price
I can confirm to the hon. Lady that we have offered mutual recognition. She is right to raise this important subject because it is obviously vital that we maintain safety throughout the NHS, and access to pharmaceuticals is part of that.
Clive Efford (Eltham) (Lab)
The Parliamentary Under-Secretary of State for Health (Steve Brine)
Ministers have held no such discussions. The procurement of local health services by means of competitive tendering is a matter for the local clinical commissioning group, rather than for Ministers. Greenwich clinical commissioning group is an independent statutory organisation and is responsible for commissioning services for local people in order to ensure the best possible clinical outcomes at the best value to the taxpayers, who are the hon. Gentleman’s constituents.
Clive Efford
That is an incredibly complacent response. The cost of the contract, which was allocated to a private provider, has gone up by 14% in six months. It claimed at the Greenwich Overview and Scrutiny Committee that that was due to a 14% increase in the tariff costs of health services, but my local health care trust says that that is about 0.6%. How does the Minister explain that increase and why is the Department not looking into these private companies, which are literally naming their price once they have won the contract?
Steve Brine
It is not a complacent answer; it is a factual one. That is an important point to make. The Circle contract has been uplifted by approximately £10 million because of the increases in tariff costs, as the hon. Gentleman rightly says. That increase would have been applied to any provider, not just Circle. I am sorry that he does not support the new MS services across his constituency. My understanding is that, previously, those services were delivered by a number of different providers, with a wide variation in clinical outcomes for his constituents, in costs of care and in-patient experience. This is a step forward.
NHS Shared Business Services
Clive Efford Excerpts(6 years, 10 months ago)
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Mr Hunt
As the hon. Lady knows, I was informed at the end of March 2016. The issue with the correspondence that was destroyed relates to procedures around what it is legitimate to do when patients have been dead for 10 years. At the moment we are not aware of any specific risk to patients as a result of those sacks of mail being destroyed, but we will continue to look at the issue very closely.
Clive Efford (Eltham) (Lab)
The Secretary of State was made aware of the failings of the contract and warned about the dangers in the House in 2011, yet he did not take up two places on the company’s board. Would that not have added to the overall scrutiny of the contract? Is he not guilty of being asleep at the wheel?
Mr Hunt
I have been Health Secretary for a long time, but not since as far back as 2011. However, the hon. Gentleman asks an important question. It is true that the Department was entitled to three seats on the SBS board but took up only one, but I do not believe that would have made a difference in this case, because the board directors were intended to represent the Department as SBS shareholders. What we needed was better assurance of the implementation of the contract. That needed to happen with the NHS as a contractor. That is the lesson that needs to be learned.