SS Mendi

Debate between Jim Shannon and Andrew Murrison

Tuesday 21st February 2017 Commons Chamber

[Dr Murrison]

Indeed. We have to be very grateful to Mr Woodward. He was, I believe, a self-taught diver who dived in an old hard hat rig. In those days—the 1960s—diving off the Isle of Wight was quite something. It would have been difficult work. I am yet to visit his museum in Arreton, but I will certainly make it my business to do so when I am next on the island.

In 2009, the Mendi was designated as a war grave by the Ministry of Defence. In 2012, English Heritage commissioned the excellent Wessex Archaeology, which is based near my constituency, to research the wreck and produce a report.

[Jim Shannon (Strangford) (DUP)]

I commend the hon. Gentleman for bringing this subject forward for debate. Does he agree that it is only right and proper to remember those who sailed off to fight in a war that, it could be argued, was theirs not by fact, but by the principles of freedom and democracy? It is fitting that we in this House play our part by commemorating the souls lost on that fateful night.

[Dr Murrison]

Yes, the hon. Gentleman is absolutely correct. These volunteers—they were all volunteers—could have seen this as somebody else’s war on the other side of the world, but they did not. For whatever reason—I suspect there was a mixture of reasons and motives—they travelled 6,000 miles to serve in the conflict on the western front, while others served in other theatres of the great war. We have to be extremely grateful to them for their work and, in many cases, their sacrifice.

The Wessex Archaeology report produced in 2012 and the board of inquiry report serve as the authoritative primary sources on this tragedy. It is good to note that from today, the 100th anniversary, the Mendi qualifies under the 2001 UNESCO convention on the protection of the underwater cultural heritage.

Today’s centenary is an occasion, first and foremost, for us to commemorate brave men who lost their lives in Britain’s icy waters, but it also gives us an opportunity to reflect on the world as well as the war, since the war to end all wars drew many thousands from around the globe to its killing fields. The historiography and remembrance of the great war have, for 100 years, been overwhelmingly of the white war fought by white men in Europe, but the jigsaw has some missing pieces. The centenary is an opportunity to find them and fit them. Drawn from India, China, the Caribbean, Egypt and across Africa, as well as the UK, the labour corps were an essential part of the great war story. Neglected for too long, they must now be heard.

Some 100,000 men served in the Chinese Labour Corps and 40,000 in the French equivalent under arrangements with the Chinese Government. They were seen as cheap labour and dismissed as “coolies”, and the UK trade unions resisted their employment in the British Isles. In 1917, there was a reluctance to allow black men to raise a hand against whites, even against the enemy on the western front—they might, after all, develop a portable taste for it, which was an alarming prospect for the Union Government of Louis Botha.

The South African Native National Congress, the predecessor of the African National Congress, sensing an opportunity to advance the prestige of black people and further its political ambitions, offered to raise combatant troops but was rebuffed by Pretoria. So although non-whites did fight in theatres where the enemy, too, was likely to be non-white, they served on the western front as unarmed labourers. In France and Flanders, they were treated as second class and were penned up in compounds like prisoners of war. When they returned home, the Government in Pretoria failed to live up to earlier promises, denying them campaign medals bearing the relief of a monarch in whose name they had been prepared to sacrifice all. One veteran said he felt

“just like a stone which, after killing a bird, nobody bothers about, nobody cares to see where it falls”.

None the less, South African Native Labour Corps members returned to their homeland utterly changed, with perspectives, horizons and ambitions that would not suit their rulers. One white officer told his men:

“When you people get back to South Africa, don’t start thinking that you are whites, just because this place has spoiled you. You are black, and you will stay black.”

Some will say that this is inconvenient history, that we must not judge yesterday by the standards of today, and that we have no business raking it all up, but I would argue that the great war centenary is the last opportunity to shine a light on the unremembered. The story will be incomplete and partial for as long as they remain in the shadows.

The experience of the great war centenary so far has been that the candid and respectful exploration of shared history, however uncomfortable, has not driven people apart or reignited hurt and grievance, but brought them together. We saw that so well last year in the island of Ireland, in the commemorations surrounding the centenary of the Easter Rising and the Somme offensive. To my mind, the Mendi tragedy is primarily a heartrending story of stoicism and bravery in the face of adversity, but inevitably it also prompts difficult questions about attitudes to race in the early 20th century, the progress made over 100 years and where we are today.

The story of the SS Mendi, like the battle of Delville Wood during the Somme offensive of 1916 has, of course, particular resonance in South Africa, but we must commemorate it, too, in the United Kingdom. There is a danger—

Comparative Healthcare Economics/NHS Finance

Debate between Jim Shannon and Andrew Murrison

Tuesday 7th June 2016 Commons Chamber

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I need to start by confessing an interest as a doctor. We are now 18 months into the five year forward view, and the big question really is: what next? “What next?” really means bringing English healthcare outcomes up to the standard enjoyed in peer group European nations, and I am afraid that means much more money. I hope that, in the next few minutes, I can suggest how we might go about achieving that.

The average age of Members of Parliament is 51. That means that most Members of this House have tipped, or are tipping, into the demographic twilight zone in which the incidence of common and chronic diseases begins to accelerate—it is sad but true. That focuses the mind on what a successful healthcare economy looks like and what it delivers for patients.

When those 51-year-olds enter the danger zone in a few years’ time, what will success look like? Success will mean accommodating the great advances in medicine that we believe we are on the cusp of achieving, and that we hope will add years to life and life to years, and I know that my hon. Friend the Minister is particularly exercised about those matters. Success will mean dealing with the healthcare needs of an ageing demographic, an expanding population, and more chronic diseases of lifestyle, which will amount to a 3% per annum uplift in demand, according to NHS England and the Nuffield Trust. Success will mean satisfying the legitimate demands of a less deferential, consumerist, better educated society that will not be content with second best. Success will mean closing the gap between healthcare outcomes here and in northern European countries with which we can reasonably be compared, and therein lies the “What next?”

In July 2010, the Government White Paper “Equity and excellence” exposed relatively poor health outcomes in the UK, compared with other countries. Our healthcare system was delivering poorer results in terms of mortality and morbidity. The most recent OECD statistics, published last year, have confirmed Britain’s relatively poor performance across pretty well the complete spectrum of common diseases—common cancers, ischaemic heart disease, cerebrovascular disease and the rest. Crucially, the number of unnecessary deaths—mortality amenable to healthcare—is substantially higher in the UK than in neighbouring countries.

However, healthcare is not just about reducing deaths. What about other measures of quality? Measures such as post-operative sepsis, pulmonary embolism, deep vein thrombosis, obstetric trauma and diabetic complications are worryingly unimpressive in the UK, compared with countries we would consider to be in our peer group. Although the teenage pregnancy rate has improved in recent years, the UK bumps along the bottom of the EU league table with recent accession states. The list goes on.

The Swedish-based and well-respected, if drug firm-funded, Health Consumer Powerhouse has been reporting on the performance of Europe’s healthcare economies since 2005. The UK’s position in its Euro Health Consumer Index has always been mediocre, but in January the UK was ranked 14th out of 35—just above Slovenia, Croatia and Estonia, and below European countries that most Britons would regard as peers.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on bringing this matter forward. This may seem a bit like politicking, but it none the less needs to be said. There is no doubt that the Transatlantic Trade and Investment Partnership has the potential to threaten the very nature of our NHS. What is even clearer is that we are sending millions of pounds every week to the EU that could be invested in our NHS, where that money is much needed. Does the hon. Gentleman agree that there is great potential to properly resource and liberate our great NHS, were we to vote to leave the EU?

[Dr Murrison]

I think the hon. Gentleman and I are on the same side of the Brexit debate, and I certainly would welcome the extra money that would be spent on the NHS in the event that we leave the European Union, so fingers crossed for 23 June.

The Health Consumer Powerhouse report highlights poor accessibility and an “autocratic top-down management culture” here, in contrast to top-performing Holland’s removal of what Health Consumer Powerhouse calls “healthcare amateurs”—that is to say, politicians and bureaucrats—from decision making. Unhappily, that sounds rather familiar. Earlier this year, Dame Julie Moore slated fellow senior NHS managers for “gross incompetence” and poor leadership.

The question is, what, apart from its management, accounts for the UK’s lacklustre ranking? Despite the UK’s innovative cancer drugs fund, Health Consumer Powerhouse found, for example, relatively poor availability of the latest oncology interventions and therapeutics, including radiotherapy. Sadly, that rings true, and we remember the high-profile case of Ashya King, the five-year-old with medulloblastoma, who was taken by his parents in 2014 from Southampton general hospital to Spain and then the Czech Republic for proton beam therapy, which was not available here.

The much-vaunted Commonwealth Fund report that some use to claim that the NHS is super-efficient and effective actually contains just one element that deals directly with health outcomes—a composite of deaths amenable to medical care, of infant mortality and of life expectancy at 60, it puts the UK 10th out of 11, the US being bottom. Tenth out of 11 sophisticated healthcare economies is not where I want the UK to be, and not where the Minister wants the UK to be either. The British public would expect us to be doing rather better against a raft of healthcare outcomes where the UK is firmly in the wake of our immediate northern-European neighbours France, Germany, Holland, Belgium and Denmark.

Can we explain why UK healthcare outcomes are not as good as those of peer group nations through differences in the level of healthcare funding? We can expect an opinion from the House of Lords, which last week set up a Select Committee under Lord Patel to examine the sustainability of the NHS—that is, the “what next?” question. I would be very surprised if it did not conclude that the answer is to bring spend up to the level enjoyed in countries such as France, Germany and Holland. After all, closing the gap with the EU15 in health spending as a proportion of GDP was a goal explicitly set in 2000. However, Conservative Members tend to be somewhat wary of making spend a proxy for outcome. It is not enough just to write big cheques and consider the job done. Can we do better with what we have? There are apologists for our low spending on health who cite the supposed efficiency of the NHS, but simply asserting that the NHS is more efficient than health services in other countries does not make it true.

I do not know what is in the Minister’s speaking notes, but there is a very good chance that he will use the New York-based Commonwealth Fund analysis on comparative healthcare to support a contention that the NHS is very efficient and thus ameliorates the relatively low UK spend on healthcare. The report’s methodology rewards close examination. I am sure he will have read it thoroughly, but if not, I commend it to him. In my opinion, its methodology renders the sorts of deductions that have been made unsafe. The only reliable element of the analysis that is used to claim that the NHS is relatively efficient is the percentage of national expenditure spent on administration and insurance, meaning that the UK comes in at fifth out of 11. Given that the nature of our system means that insurance and transactional costs are very low, that is hardly something to crow about. Other markers of efficiency rely on patient and practitioner surveys and include items such as time spent filling out financial transaction forms. UK-relevant metrics, such as rehospitalisation rates, were found to be comparatively poor. I conclude that it would be unsafe to make claims about the relative efficiency of the NHS based on contestable reports like that of New York’s Commonwealth Fund.

Let us suppose for one moment that the NHS is fairly efficient—not very efficient, because Carter and others suggest that that would be unwise, but fairly efficient. Indeed, I have no reason to suppose that it is institutionally profligate. If it is fairly efficient, we will not be able to squeeze many more efficiencies from it beyond the Stevens assumptions, but we will still be left with relatively poor outcomes and still needing to know “what next?” Simon Stevens still believes that we can squeeze £22 billion in efficiencies from the NHS. Much of this, presumably, is predicated on productivity gains that are contingent on holding down salaries and wages—a challenge if incomes in the economy rise. This is what I think he means by “strong performance”—strong indeed, because the implied productivity gains of 2.4% are well in excess of anything that has been achieved by the NHS historically and well beyond expectations for the wider economy. It also depends on sustained spending on social services and public and preventive health. Both, in the event, have been impacted by cuts to local government funding—cuts that I supported and accept were entirely necessary to repair the public finances, but cuts nevertheless.

So “what next?” will inevitably mean a step change in input—in money—if not by the end of the five year forward view period, then without doubt during the next decade and beyond. Here again, it is instructive to look across the channel, where we find some good news for Ministers. The Office for National Statistics has just tweaked its approach to health accounting to comply more closely with that of the OECD, and obligingly, this increases the UK’s spend on public and private healthcare combined from 8.7% of GDP to 9.9%. Most of this is due to re-badging a slice of publicly funded social care as healthcare spend. Of course, none of this accountancy changes by one penny the amount spent on care, but it impacts on the international spending league table. It means that we overtake southern European countries such as Spain, Portugal, Italy and Greece. However, we still lag well behind Germany, France and the Netherlands—my chosen basket of similar European countries.

So what next? Data from the Kings Fund and the Institute for Fiscal Studies suggest that income tax must rise by at least 3p in the pound simply to offset the fall in NHS spending as a proportion of GDP predicted over the rest of the decade. But all that will do is arrest the UK’s relative downward trajectory towards being the sick man of Europe. To bring spend up to the EU15 average would now involve an 8p increase. That eye-watering sum may be toned down a little bit by the new Office for National Statistics method for calculating healthcare spend, but probably not greatly if the comparison we actually want to make is with our closest European neighbours France, Germany and the Netherlands.

So, if we accept that big fistfuls of money are needed, the question becomes, “How are we to get it?” The Labour party does not know. It has yet to say how much it thinks the NHS budget should be, despite every encouragement from me and others to do so. All we know is that the party opposed the Stevens uplift at the general election. Maybe the unaccustomed reticence about pledging money from the party of fiscal incontinence is an indication of the sheer scale of the spending challenge that even Labour has perceived in a rare lucid moment.

Although I have every confidence in my right hon. Friend the Chancellor, a precipitous growth in the economy seems unlikely, and further borrowing should not be an option. In fact, half the £350 million per week that we send to the EU—a figure, net of rebate and subsidy, that I personally rely on—would, by my reckoning, halve the difference. I fervently hope that it will be in play after 23 June, but it would still leave a gap. How will that gap be closed? It is said that if we want a social healthcare system, we must choose between Bismarck and Beveridge. For my part, I cannot see how the transaction costs implicit in insurance-based models or large-scale schemes of co-payment would improve productivity or efficiency in our NHS—this despite the fact that the UK healthcare economy is distinguished from others by the small scale of its private provision.

For me, the Bismarck versus Beveridge debate is pretty much settled. However, I would expect a commission to examine all possible funding streams, drawing on experience from other countries. I would expect it to look closer to home at incentives that can be given to encourage subscription to mutuals, such as the Benenden Healthcare Society, formed in 1905 by and for Post Office workers, whose headquarters in York I visited recently.

But affirming that the great bulk of healthcare in the UK should continue to be funded through general taxation does not just mean more of the same. A variable hypothecated tax would be an easier sell to the public than a general tax hike. Treasury officials, or course, hate hypothecation, but the Treasury has been softening its approach in recent years and we are now, of course, wedded to the far less economically literate practice of hypothecated spend as a proportion of GDP for selected areas of public expenditure. Despite the Treasury’s reluctance, if we are talking about several pence in the pound to bring UK health spending up to the average of neighbouring similar countries, we have to find a politically acceptable and publicly palatable way of doing so. Either way, gathering a consensus on this most sensitive and complex of public policy areas, using a vehicle on a spectrum from royal commission to non-departmental public body, surely makes sense. As a model, may I suggest the influential Pensions Commission, chaired by Adair Turner, during the last Labour Government?

If the NHS is the closest we have to a national religion, its critical friends are often seen as heretics. We saw that even at the height of the Mid Staffs scandal. How, then, are we to uphold this rallying point for national morality, decency and righteousness with the more prosaic imperatives to save and lengthen life, make sick people better, prevent ill health and match health outcomes in comparable countries? I hope that the Minister will agree that the proposal for a commission and associated national conversation—made by me and others in this House, in the other place and elsewhere—has merit. I warmly congratulate Ministers on successfully arguing the NHS’s corner at a time of austerity. However, I urge the Government to give serious thought to establishing a commission that will examine how we can properly and sustainably fund healthcare and close the widening gap that exists between us and our European neighbours.

Upper Gastrointestinal Haemorrhage

Debate between Jim Shannon and Andrew Murrison

Monday 11th April 2016 Commons Chamber

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I am sure we are all very relieved to be having the Adjournment debate at this hour, rather than at two o’clock in the morning, as was previously rumoured.

I must first declare my interest as a doctor. I am grateful for the opportunity to bring forward this extremely important debate—it is certainly important for our constituents—about the management of acute upper gastrointestinal bleeding. I am grateful to the British Society of Gastroenterology, and particularly to its president, Dr Ian Forgacs, for helping me with research in preparing for the debate. The BSG has done a great deal of work over many years to highlight this issue.

Between 50,000 and 70,000 people every year are admitted with acute upper gastrointestinal bleeding, and 10% will, sadly, die. That presents a significant challenge to our national health service.

For the avoidance of doubt, let me say that upper gastrointestinal bleeding is what was so vividly portrayed by Hugh Bonneville, as Lord Grantham, in Julian Fellowes’s “Downton Abbey”. As the New York Post said, the Downton ulcer his lordship had been moaning about for weeks finally erupted all over the dinner table and all over Lady Cora. That is at the extreme end of the spectrum, but when it happens it needs to be dealt with very quickly and proficiently.

I want to start with a little bit of good news. Lord Grantham was lucky to survive in the 1920s, but mortality from upper gastrointestinal bleeding has been falling in the UK, with modest improvements in recent years as new treatments and innovative therapies have emerged, despite an ageing demographic. That is a tribute to our NHS and to some great pioneering work in therapeutics and interventions, much of which has been trialled and researched in the UK.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for giving way; I asked him beforehand for permission to intervene. Northern Ireland has seen some improvements by allowing relatively experimental procedures, provided they are regulated, such as nitrogen treatment systems, to name just one. Does the hon. Gentleman agree that all trusts across the UK need to share such information on any and all new developments, to advance treatments nationwide so that we all gain across the whole of the United Kingdom of Great Britain and Northern Ireland?

[Dr Murrison]

I am grateful to the hon. Gentleman, who takes an interest in these matters. He is right to say that we need to do more networking, to ensure that good practice is understood and inculcated. I will deal with some of that in my remarks.

Two major studies—one by NHS England and the British Society of Gastroenterology in 2013, and the other by the National Confidential Enquiry into Patient Outcome and Death in 2015—highlighted significant shortcomings in provision, confirming earlier studies.

The foreword to the NCEPOD report is starkly entitled “A Bleeding Shame”. NCEPOD found that the clinical care of 45% of acute GI bleed patients was sub-optimal, with a similar number receiving care judged to be good overall. Alarmingly, a quarter of all hospitals treating upper gastrointestinal bleeding were found not to be accredited by the joint advisory group set up 20 years ago to set standards for endoscopy. More hospitals told NCEPOD that they could deliver open surgery of the sort Lord Grantham had in the 1920s than interventional radiology for this particular range of conditions.

Some would say that that is down to inadequate resources. That is the mantra we often hear, particularly from the Labour party, but the situation is far more complicated than that. Alarmingly, NCEPOD reported that organisational issues led to less than satisfactory care in 18% of cases. “Organisational issues” is a polite way of saying poor management, such as failure to organise rotas—the “Bleeding Rota”, as NCEPOD graphically puts it—and I will come back shortly to how that can be addressed with minimal resource implications.

I support the concept of the seven-day NHS, or at least my interpretation of what a seven-day NHS actually means. The management of this range of conditions provides an excellent case study of why seven-day working is important and why Ministers are right to pursue it.

Overall, the evidence does not support the proposition that relatively poor weekend healthcare outcomes for conditions across the board are attributable to a lack of seven-day working. As Professor Matt Sutton’s work, reported by the Office of Health Economics last year, has shown, the quality-adjusted life-year evidence just does not support the cost of translating midweek working to the weekend. Data on increased mortality for those admitted at the weekends are alone insufficient to justify organisational change. The much cited Freemantle paper on weekend deaths does not say that excess weekend deaths are avoidable. Unfortunately, it has been quoted incorrectly by some who have confused association and causation.

Sir Bruce Keogh is right to say, however, that general hospitals are under-resourced at weekends, and the Academy of Medical Royal Colleges is right to point out that junior doctors are, to a certain extent, “winging it” out of hours, because consultants do not tend to be around to the same extent and many support functions are not, either. I remember it very well indeed. Sir Bruce was also right, in his 2013 review of 14 trusts with persistently high mortality rates, to commission Professors Nick Black and Ara Darzi to try to bottom out the relationship between excess mortality rates and avoidable deaths. Sadly, the report published last year did not seem to take us much further forward, other than to call into question the basis of the selection of trusts for the original Keogh review.

In my view, there is a firm argument for a seven-day-a-week NHS, but we need a common understanding of what that actually means beyond the soundbite. Upper GI bleeding is a good case in point, which the Government could perfectly reasonably use to support their proposals for seven-day working without resorting to selective quoting from, for example, the Freemantle paper. Most people are really not bothered about the inability to get an outpatient appointment in dermatology on a Saturday afternoon. That is a luxury bordering on an indulgence. However, if their Downton ulcer erupted on a Friday night, they would not really want to wait until a chaotic Monday morning list before getting endoscoped. They would need to be scoped on a routinely scheduled endoscopy list the following day, and they should not be subjected to delay in investigative and interventional radiology if that is necessary to manage their case optimally.

As far back as 2004, a large study by Sanders published in the European Journal of Gastroenterology and Hepatology showed that dedicated GI bleed units are associated with reduced mortality. NCEPOD asserts that patients with upper gastrointestinal bleeding should only be admitted to units with on-site endoscopy, on-site or networked interventional radiography, on-site surgery and on-site critical care. It promotes the model of comprehensive, dedicated GI bleed units in hospitals on acute medical take. We are far from achieving that.

That highlights some broader issues around right-sizing the NHS estate for optimal acute and critical care outcomes, which is a subject that I have raised before. Because critical care requires multi-specialties, because of the need for increased sub-specialisation and all that implies for populating staff rosters, and because of the better outcomes in large specialist units, not to mention the cost pressures, optimal management of this range of conditions underscores neatly the need for the model hospital concept outlined in February by Lord Carter of Coles. Why are we not moving faster towards having secondary and tertiary care in regional and sub-regional centres, where critical mass, and therefore quality of outcome, can be more readily assured?

I am proud to support a Government who are spending more on the NHS than ever before—spending, let it be remembered, that was opposed by the Labour party at the general election. However, outcomes in the UK routinely compare unfavourably with those in similar countries, with which we can reasonably be compared. I have no specific comparative data for acute upper GI bleeding, but I have no reason to suppose that they run counter to that general trend. The unavoidable truth is that our neighbours spend significantly more on healthcare than we do. The right hon. Member for North Norfolk (Norman Lamb) and I, with colleagues across the House, have called for a commission to achieve consensus on long-term funding. That is despite Simon Stevens’s five-year forward view, which does not come close to addressing what is needed to make progress, given the assumptions on which it is based, which we know we cannot rely on.

It is not just about money, however. The impression given by the studies that I have relied on is that the management of acute upper GI bleeding is a hit-and-miss affair. The BSG blames a

“lack of engagement from senior managers”

for that patchiness. That ties in with the remarks made last week by Dame Julie Moore, who said that there was a “culture of indecision” in the NHS, and that there was “gross incompetence” and a “failure of leadership”. That is pretty hard hitting from a very senior NHS manager, and I wonder how individuals can justify salaries well in excess of the Prime Minister’s if they are failing to get a grip on the sort of shortfalls described as “A Bleeding Shame” by NCEPOD. Dame Julie is right to ask why incredibly expensive senior NHS managers who are managing failure on this scale are still in post.

Last year’s NCEPOD report on acute upper GI bleeding is a wake-up call. Its first and prime recommendation —that patients with any acute GI bleed should be admitted only to hospitals with 24/7 access to on-site endoscopy, on-site or formally networked interventional radiology, on-site GI bleed surgery and on-site critical care—must be implemented without further delay. The answer is dedicated GI bleeding units that are seven-day NHS-compliant, and, with very few exceptions, no unit that cannot match the BSG’s guidelines should take patients with acute upper GI bleeding.

I look forward to hearing how the Minister will make this so. I invite him to return to the House after 12 months, if I am fortunate enough to secure another Adjournment debate of this sort, to tell us how the position has improved.

Drones in Conflict

Debate between Jim Shannon and Andrew Murrison

Tuesday 13th October 2015 Commons Chamber

[Dr Andrew Murrison (South West Wiltshire) (Con)]

After this debate there will be a small ceremony to mark the three crests in memory of three Members of this House who died during the great war and who, until this point, have not been recognised.

In the immediate aftermath of that war, the strategist J.F.C. Fuller predicted the demilitarisation of warfare as machines replaced men on the battlefield. General Fuller was well ahead of his time, but the recent use of unmanned machines to eliminate people in a country where we are not actively engaged in war fighting was described by the Prime Minister on 7 September as a “new departure”. Perhaps in time, drones will rank alongside the longbow in the hundred years war, and submarines a century ago. Both in their time were castigated as disreputable and even cowardly, on the grounds that they appeared—initially at least—to be capable of killing with little risk to the operator.

This debate takes place as we contemplate a further vote on military action in Syria, and in the meantime drones have been used to kill two British citizens in Raqqa on 21 August under article 51 of the Charter of the United Nations. Last week the Prime Minister announced that the number of RAF drones would be doubled, and yesterday the Defence Secretary issued a written ministerial statement about the Protector replacement for Reaper.

I support the development of unmanned air systems as part of the UK’s defence and security. Their endurance, the removal of personal risk from our troops, and the potential for reducing civilian casualties, together with the cost implications of simulator-based training, are all impressive. However, like any “new departure” they must be appraised critically.

Ministers have said that drones operate under existing generic rules of engagement and that nothing more is required. I would like to unpack that a bit, particularly since that assertion appears to conflict with the Ministry of Defence development, concepts and doctrine organisation’s joint doctrine note of March 2011. That JDN notes what we now know to be a “new departure”, and calls explicitly for an unmanned aerial vehicle governance road map. Will the Minister say what progress has been made in advancing the JDN’s recommendations? Will the road map be published? If so, when?

The availability of low-risk, low-cost means of delivering military effect risks lowering the bar for military intervention. It could be that the killings in Raqqa, which I volubly supported in September, illustrate the point. Would the Government have ordered this new departure without the risk-free means of delivery made possible by drones? Indeed, the absence of any obvious criminal or disruptive proceedings against collaborators of the individuals killed in Raqqa suggests that the unmanned aerial vehicle action was not as pressing as we initially understood it to be. Were it otherwise, one would have expected a highly sophisticated delivery and support system in the UK where the offence or offences were to be committed. As yet, we have seen no evidence of that.

In its response to the Defence Committee’s report, the Government denied that the availability of drones lowers the bar for military intervention. I expect the Minister to reiterate that today. However, unless Ministers are prepared to say that risk to our own troops is immaterial in determining whether to embark on military action, which I do not think she will, that line will have to be finessed in due course.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for giving way and for securing this important debate. He has clearly outlined the issue for military use, but there is an opportunity to use drones for surveillance. In Northern Ireland, we have very active dissident republicans and the threat level is severe. Does he feel that drones could be used, for example by the Police Service of Northern Ireland, to enable better surveillance and to catch terrorists involved in illegal activity?

[Dr Murrison]

The hon. Gentleman makes his point in his normal fashion. He will understand that Northern Ireland falls outwith the scope of today’s debate, but those responsible for security in Northern Ireland will no doubt examine all the options open to them to safeguard the people living in Northern Ireland.

I hope the newly repopulated Intelligence and Security Committee will be assisted by Ministers in applying its forensic skills to investigate the Raqqa killings. I am confident that the action was only taken, as the Prime Minister said on 7 September, as there was “no alternative”, so it should be able to reassure the public fairly easily. However, it or others must substantiate or refute the hypothesis that, in the Raqqa case, the availability of drones lowered the bar for intervention under article 51 on 21 August. If the former is the case, UAVs will indeed be a new departure in the tradition of J.F.C. Fuller, and the argument for tailored doctrine and rules of engagement will be overwhelming.

This is especially important as what may seem like surgical, low-risk interventions have an unnerving history of altogether bigger consequences that are difficult to predict and control. What is more, the use of particular systems by the UK legitimises their use by other states. The quality of our doctrine and our rules of engagement have a direct bearing on those of others. If we are seen to be relaxed about this new departure, we cannot be surprised if others take a similar line.

The use of drones by the US to eliminate operatives in Pakistan and Yemen is highly controversial. I am one of the greatest admirers of the United States, but its post-war history of what has become known as blowback —provoking sometimes game-changing retaliation through the generation of civilian collateral—is alarming. America’s allies are at risk of being seen as colluding to the point that the Defence Committee has called for a clear demarcation in the operation of drones where, of course, interchangeability of US and UK personnel and airframes is very advanced. The Birmingham Policy Commission was assured that UK personnel releasing a weapon from a United States air force vehicle remain subject to UK rules of engagement. Will the Minister confirm that that is the case, since manned air operations in Syria—despite the express will of this House two years ago, however right or wrong—suggest otherwise?

We cannot directly influence our allies’ ROEs, but we can ensure that joint operations are conducted appropriately, that NATO doctrine is acceptable and that UK personnel are not compromised. Will the Minister say how many UK servicemen are involved in the operational use of drones with US or other forces and what arrangements she has made to ensure that the ROEs they are required to use do not fall short of the standards applicable in the UK? What will be done to ensure that data acquired using drones are not then used by allies to act against targets in a way that the UK public might find objectionable? The Defence Committee has suggested that the Intelligence and Security Committee look at this. Without wishing to overburden the ISC, would she agree that that suggestion is sound and do what she can to facilitate it?

Drones are all controlled by human beings, but concern remains over the development of autonomous airframes and so-called killer robots. Some level of independence already applies to a few of our existing weapon systems, such as Phalanx, but it would be useful if the Minister delineated the bounds of acceptability. Can she confirm that the UK is bound by the missile technology control regime, the Wassenaar arrangement and not least the consolidated criteria? What is her view of the future for unmanned technology exploitation in the UK aerospace and defence sector? Will she confirm that the UK Government would be unlikely to license the export of autonomous weapon systems?

Can I tempt the Minister to indicate how UAVs will feature in the upcoming strategic defence and security review? It sometimes seems that the only defence policy the Scottish National party has is the restoration of maritime patrol aircraft. Manned airframes for that purpose seem increasingly last century, so will she say whether UAVs—perhaps the US systems Poseidon or Triton, or NATO’s high altitude long endurance proposition —are being actively considered to restore capability taken at risk on withdrawal of Nimrod? Will the MOD now undertake to publish the study we understand is being conducted by the MOD into that matter?

Will the Minister say where we are with the future combat air system? A joint BAE Systems and Dassault post-Typhoon and Rafael unmanned combat air system concept trailed in the Lancaster House treaties and launched in 2012 appears to have stalled. Will she say what has happened to it and the extent to which the challenges of evolving technology designed for permissive airspace and data feeds to deal with hostile environments and semi-autonomy are delaying progress?

Will the Minister confirm that the UK has no interest in the European Defence Agency’s medium altitude long endurance remotely piloted aircraft systems project? I remember being distinctly lukewarm about that, as I am with “more Europe” in defence generally, at the Foreign Affairs Council when I was at the MOD. When will the Navy’s maritime UAV strategy paper be finished and published? If drones are relatively cheap, easy to control, low risk and readily deployable, they may well become a weapon of choice for non-state actors. What assessment has been made of this and, while spending on UAVs is bucking the defence spending trend in this country, what investment is being made in countermeasures?

I would like to consider the implications of emerging technology on military software—on uniformed men and women who serve this country. With the SDSR pending, it is important for Ministers to understand where technological advances are taking not only defence hardware but its software—the human beings who populate the military today and will do so over the next two decades. Air marshals gamely tried to convince us that a drone pilot playing with his joystick in the Nevada desert or Lincolnshire is the lineal descendent of “the few” and of airmen in conflicts since—that is, people who engage directly with or are engaged by the enemy in the air.

Although the mental challenge to a person who logs off and goes home after a shift in Lincolnshire should not be equated with an infanteer in Basra or Helmand, the psychological implications of killing the enemy at a distance rather than at close quarters merit close examination, particularly since operators lack the unit cohesion and support systems of those physically on the frontline.

If Fuller is right, military practitioners will increasingly be technicians, not tough men at the end of a bayonet. “Professional spirit” will replace “fighting spirit”: it will be as if the Royal Army Dental Corps has taken over from the Black Watch. If so, in the sanitised operations of the future, “fighting spirit” may become a positive disadvantage. The military covenant exists because of the extraordinary risks run by fighting forces. If there are few risks beyond the expectation of routine civilian employment, there is no need for a covenant.

General Fuller’s prediction of the end of the infantry was premature, but it may yet have its day as we shift from hand-to-hand to hands-off combat in an environment where societal tolerance for taking and inflicting casualties is low. If so, there are profound implications for how we structure our armed forces, the sort of people we recruit to them and the implicit deal struck between servicemen and the nation, reflected in the military covenant.