Mental Health: Pharmacists

Kevan Jones Excerpts

Wednesday 25th October 2017 Commons Chamber

[Mr Kevan Jones (North Durham) (Lab)]

I wish to use tonight’s Adjournment debate to raise the sad case of my constituent Alison Stamps, a 33-year-old pharmacist who sadly took her own life on 25 May 2015. I will outline the circumstances of the case, but will also raise wider concerns that I and her family have around the operation of Boots UK and how it dealt with her death, as well as my broader concerns concerning pharmacists and mental health issues.

Alison was clearly an exceptionally bright and talented individual. After finishing at Pelton Roseberry comprehensive school in my constituency in 2000, she went on to study—

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Motion made, and Question proposed, That this House do now adjourn.—(Rebecca Harris.)

[Mr Jones]

Alison went on to study biology at Durham University and graduated in 2003. She then began work as an audit and accounting technician at Sunderland city hospital before choosing to return to university—the University of Sunderland—to study for a four-year masters degree in pharmacy. While she was at Sunderland, Alison was awarded the prize for the best overall student in the first year, before going on to be awarded the Royal Pharmaceutical Society’s award for the best student on a masters degree programme in 2012. Her achievements were remarkable, and clearly she was dedicated to public health and the pharmacy profession.

Alison began work at Boots’ Tindale store in Bishop Auckland in August 2013. Her parents tell me that she enjoyed the work but increasingly complained about the long hours and demands it placed upon her. By mid-December 2014 she was clearly overwhelmed by what she was having to do. Her store manager noticed that she was losing weight and looking unwell. Following a conversation with the store manager, Alison expressed how down she felt. The store manager provided her with a phone number for an independent counselling service and encouraged her to speak to her GP and her family. Like many people in Alison’s position, she felt she could not speak to her family or strangers about her situation. Still concerned, her manager arranged an appointment with a GP for Alison and even attended the appointment with her. I understand that the GP indicated that she should take antidepressants, but Alison did not wish to do that. The GP gave her a crisis number to ring and also suggested some other coping mechanisms.

At this point, I would like to commend the actions of the store manager, who I think genuinely tried to help Alison. I understand that she reported her concerns about Alison to her area manager, and I have had it confirmed by the director of human resources at Boots that this case was referred and flagged up with the firm’s central HR department. It appears that all that happened, however, is that the store manager was advised about what counselling was available, but no alarm bells rang in Boots’ central HR department that one of its pharmacists was in a crisis situation and no action seems to have been taken. Instead, it was left to the store manager to do her best to assist Alison in her time of crisis.

This raises serious concerns about how Boots as a company handled the case. Having been made aware of Alison’s situation, no attempt seems to have been made centrally or high up in the organisation to intervene directly. This was a young woman not only holding down a responsible job dispensing medicines but who was clearly in a severe mental health crisis. Throughout this time, the store manager was also aware that Alison was self-harming—she had confided in her that she had cut her legs. For six months, Boots was aware of Alison’s situation but simply left it to the store manager to deal with it, although I put it on the record again that she did a great job in trying to help, and she did it to the best of her ability.

Sadly, on 25 May 2015, Alison took her own life in a room at the Hardwick Hall hotel, having taken an overdose of prescription medication. At the coroner’s inquest, it was determined that Alison had taken her own life while suffering from depression. Her parents, Mr and Mrs Stamps, attended the inquest. So did representatives from Boots, who made no attempt whatsoever to offer sympathy or speak to the family. The coroner invited those present to introduce themselves, but because it was a public hearing, the Boots representatives chose not to do so. Mr and Mrs Stamps felt, I think understandably, that their attitude was very legalistic—that they were concerned with their fears about the possibility of a legal case as a result of Alison’s death, rather than with having a compassionate understanding of how her death had occurred.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on raising an issue in which he takes a great interest, as is clear from other occasions when he has spoken in the House. I believe that this very sad case highlights for all of us the need to ensure that those in the workplace are given adequate training to offer support to workers with depression or other mental health issues. Does the hon. Gentleman agree that the Government must initiate, or make available, courses for all small and medium-sized enterprises, which would be free of charge and which would provide tools for employers that would enable them to help such staff members?

[Mr Jones]

As I have said on other occasions, I think that mental health in the workplace is one of the big issues that we do not talk about. I think the hon. Gentleman’s suggestion should be considered, but what struck me about this case was that it involved not a small employer but a huge multinational company, which should have had the capacity within its organisation to provide assistance.

[Liz Twist (Blaydon) (Lab)]

Does my hon. Friend agree that all employers could benefit from having policies to support staff when they are at work, and when, sadly, an employee dies by suicide? Should not employers be encouraged to take up programmes such as those developed by the Samaritans, Business in the Community and Public Health England for the benefit of staff?

[Mr Jones]

I agree with my hon. Friend. I know that she is involved with the Samaritans, and I congratulate her on the work that she does. Yes, there are a lot of tools out there for companies to use, but they must take them seriously rather than treating them as a tick-box exercise. Policies of this kind must actually be used in the workplace, and people must be trained so that if they encounter a case like Alison’s, they do take it seriously. That is what I would have expected from a large company such as Boots.

Anyone who has looked at the details of this case cannot but be moved by its tragic nature, and by the failure of Boots to exercise its duty of care at a national level. Mr and Mrs Stamps are certain that the long hours and the workload that Alison faced were a contributory factor in her death. I have spoken to representatives of the pharmacists’ trade union, the Pharmacy Defence Association. They made it clear that there are increasing demands on pharmacists, not only in terms of workload but as a result of staff cuts. Last year an article in The Guardian highlighted the situation at Boots, including many emails from Boots’ pharmacists claiming that profit was being put in the place of pharmacists’ health, and that they were increasingly being asked to hit targets for medicines use reviews—the company is paid £28 per review by the NHS—rather than concentrating on dispensing and the care of patients.

Those pressures are putting an increasing strain on pharmacists who work for companies such as Boots, but, like Alison, many choose not to complain, because they fear that if they do so they will lose their jobs or their professional qualifications will be withdrawn. That is a particular issue in the context of mental health, and in professions such as pharmacy. People remain silent for fear of the consequences of speaking up. I think that pharmacists need a system like the one that has been introduced for GPs. Many GPs also do not want to talk about their mental health problems because they fear that they will be disciplined. I think that that was Alison’s fear: she feared that if she raised issues relating to her mental health, she would be taken down the disciplinary route and lose her job.

I suggest to the Minister that that needs to be looked at. Pharmacists should have a system similar to that for GPs. I have done some work on this with GPs. The NHS has the GP health service, which is a confidential service for both GPs and trainees. I have met some of its staff, and it works very well in allowing GPs to self-refer confidentially. The GP health service can help doctors with anything to do with mental health, including stress and depression. The effort that has been made to ensure that there is GP support needs to be replicated for pharmacists, because I can say from a personal point of view that, with the best will in the world, giving someone with depression a helpline to ring is not the answer. People do not ring them; I can say from personal experience that I would not have done so when I suffered from depression. The work done for GPs offers a way forward that I ask the Minister to explore.

I also have to raise questions with the Minister about the role of the General Pharmaceutical Council. Following Alison’s death and Mr and Mrs Stamps coming to see me, I wrote to the GPC asking for its opinion of the case. It wrote back saying that its role was to protect patients by

“setting and upholding standards for individual pharmacists and pharmacy technicians.”

I understand that the GPC has been aware of complaints concerning Boots’ working practices for pharmacists, but has taken no action against that company or—so far as I can see—any other company about how pharmacists were being employed. That raises the question of what this regulator is actually doing.

It is also disappointing that the regulator sees itself as a peripheral player on the issue of workplace pressure and stress, and the pressures put on pharmacists. This stance by the regulator allows employers such as Boots to preside over poor working conditions without any threat of sanction. It says that its job is to protect patients, but if a pharmacist has a severe mental health problem that is being created by workplace pressures and stress, that must be putting patients at risk. The potential danger of mistakes being made will be heightened if pharmacists are under such pressure.

In response to Alison’s death it seems as though Boots was most concerned about its own reputation. At the time, its main concern appeared to be whether any controlled drugs were missing from the pharmacy where she worked. It would appear that the drugs that Alison took to end her life came from the unused drugs that were returned to the pharmacy by patients. Although there is a register of these drugs, I wonder whether there should be tighter regulation because it is up to individual pharmacies whether the drugs are recorded. There should be a process of monitoring how the drugs are collected, registered and ultimately destroyed.

While doing the research for this debate I tried to find statistics on mental health problems and suicide among pharmacists. I am not aware of any statistics being held centrally that show this information. We might look into collating such figures to inform this debate, which is clearly ongoing.

Alison Stamps’ death is a tragedy, not only for her family but for us all as citizens, as we have lost a bright, conscientious young lady with much to offer. Her life was, sadly, cut short by circumstances she thought she could not face. It is quite clear that lessons need to be learned and that changes need to be made, not just in the way we regulate pharmacists but in the way we employ them and treat them in the workplace. Alison’s employer, Boots, should take stock not only of how it is dealing with her case but of how it employs other people within its organisation. It would be right to finish with something that Mr and Mrs Stamps said in a letter to me when they first raised the case with me. They said:

“It is clear that Alison was a victim of corporate greed and collateral damage by an uncaring company intent only on its own agenda.”

Oral Answers to Questions

Kevan Jones Excerpts

Tuesday 10th October 2017 Commons Chamber

[Mr Hunt]

Our plans envisage treating another 70,000 children every year by 2020-21, but that is still not enough. It will take us from one in four children needing help to one in three. That is why we are publishing a Green Paper on child and adolescent mental health.

[Mr Kevan Jones (North Durham) (Lab)]

One of the staffing shortages is actually in children and young people’s services. In County Durham in my constituency, the waiting time for autism diagnosis is two years. I have raised this with the mental health trust and NHS England, but the problem seems to be with the clinical commissioning group. What can the Secretary of State do to ensure that the extra money that he has pledged to put into the service actually gets to the service?

[Mr Hunt]

I would like to thank the hon. Gentleman for speaking out about mental health, like so many colleagues in this House, which makes a massive difference to the Time2Change campaign. It is unacceptable for someone to be waiting that long, and I do not want to stand here and defend it. I will certainly look into the individual case that the hon. Gentleman raises, but the fact is that many Members will know of similar cases. The money is starting to get through to the frontline. It is not just money, though; it is also capacity, and having trained mental health therapists—nurses; psychiatrists—and that is why we are boosting their training, too.

Clinical Commissioning: North Durham

Kevan Jones Excerpts

Wednesday 23rd November 2016 Westminster Hall

[Mr Kevan Jones (North Durham) (Lab)]

I congratulate my hon. Friend the Member for City of Durham (Dr Blackman-Woods) on securing the debate.

The decision of the North Durham CCG raises some fundamental questions about how the NHS is run in North Durham, and our constituents’ relationship with the NHS. As my hon. Friend described, there was no consultation of my constituents about the decision, which was taken in secret. There was no transparency at all, nor any consultation with Members of Parliament in the CCG area or any local elected officials. The decision changes the fundamental relationship of trust between a patient and their GP. My constituents have never been asked for permission for our private medical information to be passed to a private company—and neither have I or my hon. Friend. We have not been asked whether the company has our individual permissions. In many cases I do not think constituents have even been told by their GPs that the information is being passed to a private company.

What is the legal position on the giving of my private medical information, and that of my constituents, to a third party? Who is responsible for ensuring that it is secure? Do I have a right, given that it is my personal medical information, to withhold permission for it to be passed to a private third sector organisation? I certainly do not think that patients in North Durham are being told that that is happening. As my hon. Friend the Member for City of Durham said, the website does not give the impression that the information is being given to a third party.

The way the decision was taken was shameless. As my hon. Friend has already said, we met the CCG in September and there was no mention of the contract at all. I want to ask why. One of my constituents, Keith Johnson, raised concerns and the CCG responded:

“GPs have responsibility to make best use of NHS resources and need up to date evidence and advice to be able to treat patients in practice or to refer on appropriately. Unnecessary outpatient appointments are a large cost to the NHS.”

I do not think anyone would disagree, but that is the job of GPs; it is not up to a private sector organisation, or anyone else who has never seen the patient, to decide whether they should be referred to a specialist.

My concern is not just the way the decision is being implemented, but the fact that it fundamentally breaks down the trust that we all value, and the confidentiality between us and our GP. I am also concerned that the more articulate constituents and patients will insist on getting care; some others will not. There will be rationing of care, depending on people’s ability to make their case. That goes to the principle at the heart of the NHS—care being free at the point of need.

I have questions about the way the contract was let. We have had no information about how that happened. Was it by competitive tender? Did any individuals employed by the CCG have any pecuniary interest in awarding the contract? How will it be evaluated? What ability will patients have to say whether they agree with the outcomes? I challenge the North Durham CCG to publish the contract and all information and decision making about how it was awarded, because the cloak of secrecy around it is a disgrace. I also challenge it to scrap the contract and answer a basic question: why is it treating its patients with such contempt?

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[David Mowat]

I was explaining the purpose of the policy and the fact that this referral mechanism was used widely in 2007. A King’s Fund report from 2010 sets out the pros and cons of using referral management—I suggest the hon. Lady reads it.

These things are not new. They are a mechanism by which a consultant, or a GP with a specialist interest in the area of what is being referred—there are six areas of referral in this CCG, as the hon. Lady said—has two to three days to either accept that the referral goes on to the secondary system, or to contact the GP and have a discussion about what the best alternative pathway might be. There is an appeals process if the GP does not agree with that decision.

The hon. Lady asked where else such referral management was being done across the NHS in England. It was introduced in 2007, as I said, and it is being done very commonly. It is being done in Bromley, Cambridge, Peterborough, Imperial in London, and Southampton. I saw a similar system in Tower Hamlets to the one working in her area—indeed, the GP was very proud of the way they reacted, with an email referral system, when there was every possibility of things not going ahead.

This is not rationing. It is completely wrong to say that. It was brought in by the CCG, which is GP-led. If the GPs in the CCG do not agree with it, they have the mechanism to replace the chairman of the CCG.

[Mr Kevan Jones]

I understand what the Minister is saying, but what about the patient? Where does the patient come into this? If I go to my GP and he says I need a referral, that is between me and my GP. If it was not for my hon. Friend the Member for City of Durham (Dr Blackman-Woods) or the BBC raising this, none of my constituents—or myself and my hon. Friend, who are patients of the CCG—would have known about it. Will the Minister please answer the point about the patients?

[David Mowat]

The point I was in the middle of making—which I will finish making—is that if the GPs in the CCG have difficulty with the scheme, they have the mechanism to replace the CCG chairman and therefore to not go ahead with the scheme, so the GPs in his area are presumably content with it.

[Mr Jones]

The patients are not being consulted.

[David Mowat]

The fact is that the GPs vote for the head of the CCG who has put the scheme into place. On the patient issue, which is a fair one, if the patient expresses a preference to go to a secondary or an acute hospital and have an appointment, which could typically be six to eight weeks away, of course that is part of the process, and of course the referral management schemes will take that into account.

[Mr Jones]

I am sorry, that is not the case. In North Durham, patients have not been told about it. If I went to a GP who said I needed a referral, I would not be told that. What the Minister is saying is in complete contrast to what he told me during a debate on coeliac disease a few weeks ago, in which he condemned CCGs for not consulting people before awarding contracts.

[David Mowat]

We are moving around a little bit here, but I will come to the point about consultation. The GP that the hon. Gentleman refers to is a part of a CCG that has made the decision to extend the North Tyneside pilot to North Durham. All I am saying is that those GPs are part of the CCG and that presumably the CCG is doing this because it believes the clinical out-turns are right. We have a locally driven system. I will make some progress on the benefits of this for patients.

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[David Mowat]

I am going to talk about the About Health situation and the people who have been awarded the contract in North Durham. It is a one-year pilot that builds on the one-year scheme in North Tyneside. I think it started last month; it covers six disciplines and it does not cover urgent referrals, in particular cancer. All the national requirements for referral-to-treatment times still count in exactly the same way. The local CCG performed a risk analysis before it decided to take the scheme forward and build on what happened in North Tyneside, and the scheme is monitored.

I have been told that a very important feature is that there is a clear GP appeals process. If they are not happy with a decision that has been taken, that process can happen very quickly.

[Mr Kevan Jones]

What about the patients?

[David Mowat]

The GP represents the patients in the health system; that is the fact of the matter. If there are out-turns that are detrimental to patients, as the hon. Member for City of Durham implied, that is a serious situation and should be investigated.

About Health is CQC-regulated—with all that goes with that—in exactly the same way as a GP practice. It is staffed by NHS consultants and GPs with a particular interest. As I said, there is a two or three-day turnaround, and they have to have the same indemnity cover as everybody else. Part of what the CCG is doing is to save money—that is true. Inappropriate outpatient appointments mean that more people than necessary are working. If that can be reduced, there is a cost saving to the national health service. It is about optimising pathways.

[Mr Jones]

Will the Minister give way?

[David Mowat]

I will make a little bit more progress and let the hon. Gentleman in later.

This is about stopping inappropriate treatment; it is absolutely not about rationing. If it was about rationing, the whole referral management system would not have been first introduced by the last Labour Government. I think it is incredible that that point has not come across more strongly.

One of the concerns is that About Health is a private company. It is a private organisation that has won the contract, and the local CCG made that decision. Fair questions were asked about the confidentiality of patient records, in terms of them going across a boundary to a private company. My first point, which is an obvious one, is that GP practices are all private companies. Every partner that works in a GP practice works in a private company, in the same way that the GPs who work for About Health are working for a private company. However, all the requirements around patient confidentiality that About Health needs to make sure are in place apply in exactly the same way as they do in every other part of the national health service.

[Mr Jones]

The point about that is that I, as a patient, have not given permission for that. The way this has been done—with no consultation, which the Minister says is wrong—means that no one knows what is actually happening.

[David Mowat]

I was going to come to the point about consultation—I do not have a great deal of time left now. It is right to say there was no consultation on this, and that is because this is an administrative process change. There is no service change—

[Mr Jones]

That is absolute nonsense.

[Geraint Davies (in the Chair)]

Order.

Coeliac Disease and Prescriptions

Kevan Jones Excerpts

Tuesday 1st November 2016 Westminster Hall

[Mr Kevan Jones (North Durham) (Lab)]

I beg to move,

That this House has considered coeliac disease and prescriptions.

It is a pleasure to serve under your chairmanship, Mr Bailey. I am grateful for the opportunity to hold a debate that raises awareness of the problems facing those who suffer from coeliac disease and of access to gluten-free food prescriptions. It would be remiss of me not to thank the work of Coeliac UK, the national charity that represents people with coeliac disease, for not only supporting the campaign around the prescription of gluten-free food, but for its work to support sufferers.

Coeliac disease affects one in every 100 people in the UK. I declare an unwelcome interest: I actually suffer from coeliac disease, although I do not get prescriptions for gluten-free food. It is also worth noting that there are some half a million people in the UK who are completely undiagnosed, according to Coeliac UK.

Coeliac disease is a serious medical condition in which the body’s immune system attacks its own tissue when gluten is eaten. The only medical treatment currently available for sufferers is a strict adherence to a gluten-free diet for the rest of their lives. In the late 1960s, gluten-free food was first prescribed to prevent long-term health complications. However, that rationale has now been challenged by some clinical commissioning groups, despite the fact that their position lacks supporting evidence for withdrawing such prescriptions.

[Jack Dromey (Birmingham, Erdington) (Lab)]

I am grateful to my hon. Friend for bringing such an important debate on an issue that affects so many people. Does he agree that it is absolutely wrong that David Lissaman, a pensioner in my constituency, who thus far has been able to get gluten-free food on prescription, now faces the prospect of losing that as a consequence of the clinical commissioning group’s review? He is a good man who served his country well. In his own words, he will “have to find ways” of significantly reducing the amount of food that he eats, which, because of his other health problems, could put him at risk.

[Mr Jones]

I agree, and I shall refer to certain demographics—pensioners being one—that are particularly affected by these proposals.

Some 40% of CCGs in England are now choosing to restrict or remove support for patients with coeliac disease, which is leading to increasing health inequalities and, basically, a postcode lottery for NHS care, depending on where someone is diagnosed. The CCG’s rationale for going down that route seems to be justified on cost grounds alone. Indeed, Coeliac UK has made a number of freedom of information requests to try to get more details on why CCGs are changing their policies.

I will take a moment to read an example of a response to Coeliac UK’s FOI request, which came from North East Essex CCG, where sweeping assumptions have been made that are completely devoid of any systematic research. That CCG stated:

“We appreciate that there is a large cost-differential between supermarket value brands and GF [gluten-free], but many people within the CCG buy their bread from bakers or do not buy the supermarket value brands and the cost differential is therefore much reduced.”

That type of anecdotal evidence, used by CCGs to justify their decisions about patient care, is in direct conflict with a paper produced in September last year entitled “Cost and availability of gluten-free food in the UK: in store and online”. It said:

“There is good availability of gluten-free food in regular and quality supermarkets as well as online, but it remains significantly more expensive. Budget supermarkets which tend to be frequented by patients from lower socioeconomic classes stocked no GF foods. This poor availability and added cost is likely to impact on adherence in deprived groups.”

[Mr Jim Cunningham (Coventry South) (Lab)]

I congratulate my hon. Friend on securing this debate. The issue does not apply only to elderly people. I have had a number of young people write to me about this, who are very concerned that they may not be able to get gluten-free foods on prescription any more. Has he looked at the possible costs for people who are at the lower end of the earnings scale?

[Mr Jones]

My hon. Friend raises an interesting point. There is evidence—including from my own family—that gluten intolerance and coeliac disease run in families. If a young family includes several children with this condition, the cost could be significant.

[Sir Gerald Howarth (Aldershot) (Con)]

To reinforce the point, my constituent Sheryl Rees has drawn my attention to the fact that her son was diagnosed with coeliac disease when he was two. He is now 11. She pointed out the cost of gluten-free items. For example, a small loaf is £3. A pizza is £4. Pasta is £2 a pack. Basically, she is paying double. She has a family of six. This is really impacting on her family’s budget.

[Mr Jones]

The hon. Gentleman raises an interesting point, especially in terms of families with children. There is also a question of availability in some rural areas. Larger supermarkets stock some of these products at the prices he mentioned and higher, but in other areas the products are not available.

[Kevin Foster (Torbay) (Con)]

Will the hon. Gentleman give way?

[Mr Jones]

I will make a bit more progress.

We have a situation where, in places such as east Essex, the needs of patients are being discounted despite a complete lack of any type of research. I am concerned that more CCGs across the country will begin to use inadequate justifications as a precedent and follow a similar path. That leads me back to my earlier point about the big problem of under-diagnosis. I am afraid we will see a bigger problem if gluten-free prescriptions are not made available to those on low incomes.

[Dr Julian Lewis (New Forest East) (Con)]

On the specific point of failure to diagnose, until 20 years ago I had never heard of coeliac disease, and then I went out with a young lady who, as a teenager, had repeatedly gone to her GP knowing something was wrong. Coeliac disease was never diagnosed until she suffered something analogous to a stroke, which left her permanently all but unable to read. Although she has bravely developed coping strategies over the years, there is no doubt that her life and career have suffered, and she should never have been put in that situation.

[Mr Jones]

The right hon. Gentleman raises a serious point about the life-changing effects that coeliac disease can have. I was only diagnosed by accident, in my 30s; my mother was not diagnosed until she was over 70. Early diagnosis is important, but it is not uncommon for people to live a long time without one being made.

The Health and Social Care Act 2012 included a duty on CCGs to have regard for National Institute for Health and Care Excellence quality standards, but NICE guidance on prescribing gluten-free food for the management of coeliac disease has only recently been published. It says:

“Gluten-free products are more expensive and are usually only available from larger retailers, making access more difficult for people on low incomes or with limited mobility. As coeliac disease can affect more than one member of a family it can also be an additional burden on the family budget”—

as the hon. Member for Aldershot (Sir Gerald Howarth) said.

“To address this, healthcare professionals should help people who may need support to find suitable gluten-free food products on prescription to enable them to maintain a gluten-free diet.”

[Mims Davies (Eastleigh) (Con)]

I declare an interest, having been diagnosed in my late 20s. My cousin and all my second cousins are exactly the same. In fact, at university I was diagnosed with ME because I was so unwell and unable to work at various points.

This debate is an opportunity also to talk about the low incomes and limited mobility that can affect people’s access to these basic items. We must also make a plea through Coeliac UK to supermarkets to ensure that what they provide, which is very expensive, is of better nutritional quality, with lower levels of salt and fat. Although these foods are gluten-free, they might be full of some awful stuff as well.

[Mr Jones]

The hon. Lady raises an interesting point, but I assure her that the products available today are completely different from when I was first diagnosed. The bread then was like cardboard, and today it is very much different.

There is a general duty for GPs to prescribe treatments for health conditions via the FP10 prescribing system where treatment is available, and in the case of coeliac disease that is a gluten-free diet. There is also a duty in legislation for CCGs to reduce inequalities with respect to patient access to services and outcomes, but because of the lack of explicit recommendations on prescribing from NICE, CCGs are being given a fairly free hand to make decisions that run contrary to reducing health inequalities.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on securing this debate. Prescription of gluten-free food as medication clearly needs to be regulated by the NHS across the United Kingdom. One of my constituents said to me this week:

“The disease is antisocial and can lead to isolation.”

Does the hon. Gentleman agree that the supply of food on prescription can have social benefits, as well as mental, physical and emotional benefits?

--- Later in debate ---

[Mr Jones]

It can. There is some anecdotal evidence about the connection between coeliac disease and mental health. The hon. Gentleman raises an interesting point.

This situation is creating considerable uncertainty for those who rely on access to gluten-free staples on prescription, and it is the vulnerable who are most adversely affected. Individuals with the disease are not eating gluten-free food out of choice or because it is some type of fad or Hollywood diet. They do so because they have to. It is people on fixed incomes or on benefits who receive free prescriptions and those whose households rely on deliveries from community pharmacies who will suffer most if prescriptions are withdrawn.

A number of people have written to me ahead of this debate, and I would like to draw Members’ attention to their cases. Patricia said:

“The diet I and many others follow is not a fad. It is necessary as it will affect my health and wellbeing if not followed, and might actually result in my admission to hospital—an extra strain on the NHS.”

[Rebecca Pow (Taunton Deane) (Con)]

Will the hon. Gentleman consider students in this category? Many of them are on low budgets. They might be tempted not to buy the right food and then end up being sick and in the NHS, costing the state more money.

[Mr Jones]

That is the main point. What some CCGs are doing is a false economy, because one hospital admission will cost more than the annual cost of prescriptions for an individual who adheres to a gluten-free diet.

Another person living with coeliac disease, Janice, who is a constituent of mine, wrote to me saying:

“I strongly believe that these plans will cause more expense to the government when coeliac patients can’t afford shop priced gluten-free foods and don’t stick to their diet and end up with cancer of the bowels”,

as well as other conditions. She went on:

“I am a pensioner and find it increasingly hard to afford luxuries like biscuits and cakes. If I have to add gluten free bread, pasta and cereals to my shopping list this will cause more stress. I cannot have any form of gluten, even in small doses, as I am violently ill.”

As well as a failure to consider the evidence before making decisions to withdraw gluten-free prescriptions, there is also evidence of a lack of public consultation by CCGs. Coeliac UK has been doing a good job of holding CCGs to account. One example it provided is of Trevor, who told Coeliac UK that he has never received confirmation in writing that the policy had changed; he was informed only when Coeliac UK told him. He was diagnosed 10 years ago and has only ever had bread on prescription. He is unable to work and has ongoing medical problems. His nearest shop is a Co-op, which does not stock gluten-free products, and the nearest shop that does is some six miles away. That creates problems for people such as him.

The CCGs that have already removed access to prescriptions for gluten-free products have not outlined or implemented policies that offer alternatives to safeguard patients, such as access to specialist dietary or nutritional advice. When a coeliac patient is taken out of a CCG’s responsibility because their gluten-free food prescription has been withdrawn, that CCG can no longer monitor them or determine the changed policy’s impact on that patient’s health. This is an important factor, and I am concerned that it has not been taken into account by a number of CCGs.

In areas where gluten-free products are not prescribed, there is now no opportunity to encourage dietary adherence nor a prevention strategy for long-term management of people with coeliac disease. Effectively, patients who suffer the condition in these areas will be offered no support by the NHS. Although CCGs are engaged with local authorities and wellbeing boards to explore alternatives, none has yet been put in place.

The NHS has a good track record of involving the public in consultation, but the lack of consultation on the decision to withdraw prescriptions for gluten-free products is a disgrace, added to the fact that charities such as Coeliac UK are not consulted before such decisions are made.

[Nic Dakin (Scunthorpe) (Lab)]

I congratulate my hon. Friend on securing this debate. The point he is making is direct and correct. The nine-year-old daughter of my constituent, Helen Frost, has coeliac disease and Helen is worried that prescriptions for gluten-free products may be taken away. The uncertainty is adding stress to a situation that is already difficult to manage.

[Mr Jones]

That is not even taken into consideration, as my hon. Friend says.

My concern is that cutting prescriptions for gluten-free products is a simple and easy target for CCGs under financial pressure. The entire prescription cost to the NHS in 2014 was £26.8 million or 0.27% of the total prescription budget—£194 per patient. The procurement system that the NHS has in place is not working. The market for gluten-free products in the UK in 2014 was some £211 million, but the annual NHS budget was around £27 million or 13% of that total market. I do not know why the NHS cannot negotiate contracts with some commercial companies. Failure in procurement will clearly have an impact.

I turn to the issue of pharmacists. Back when we had primary care trusts, some pharmacy-led supply pilot schemes were set up in a handful of regions in England. When a patient was diagnosed with coeliac disease, the pharmacy-led scheme allowed patients to access gluten-free food and to manage their coeliac disease. However, with the establishment of CCGs, that seems to have gone out of the window—except in Scotland, which has a national gluten-free food service: a pharmacy-led scheme based on pilots in the UK.

Will the Minister seriously consider introducing such a scheme in England? It would save time and money and be a better way of managing people with coeliac disease. It is worth noting that the annual cost of gluten-free food is lower than the annual cost of items that the NHS provides that cost less over the counter—for example, paracetamol and so on. I beg the Minister to consider that, if properly done, what I suggest would save money.

I know the Minister has been in post for only a few months and I am sure he receives many demands for things to be provided by the NHS, but I am also sure his officials have briefed him on the principles of the NHS: that it is a comprehensive service available to all with access to NHS services based on clinical need, not individual ability to pay, and that it aspires to put patients at the heart of everything it does. This issue is about limiting choice because of cost.

In conclusion, the issue needs urgent intervention. It is not fair to individuals and there is a postcode lottery. A pharmacy-led system could be delivered better and more effectively. At the of the day, the people affected have no choice but to have a gluten-free diet. We should not ration care for some of the most vulnerable in our society.

Young People’s Mental Health

Kevan Jones Excerpts

Thursday 27th October 2016 Commons Chamber

[Helen Hayes (Dulwich and West Norwood) (Lab)]

I beg to move,

That this House notes the recommendations of the Youth Select Committee report of November 2015 on Young People’s Mental Health; endorses the findings of that report on the need for more support from the Government for mental health services for young people; acknowledges steps taken by the Government, since its response of January 2016 to that report, with regard to some of its recommendations; and calls on the Government to set out what further progress has been made since its response and what its plans are further to improve mental health services for young people.

The motion concerns the report of the Youth Select Committee on young people’s mental health and the Government’s response to that report. I am grateful to the Backbench Business Committee for allocating time for the debate, the application for which was supported by more than 50 members from across the House, and to the hon. Member for South Cambridgeshire (Heidi Allen) for co-sponsoring the debate.

I start by paying tribute to the many health professionals and voluntary sector organisations working in mental health services for young people, the teachers and teaching assistants who support young people with mental health difficulties in classrooms every day of the week and the youth workers seeking to support our young people in many different ways. This debate is not about the commitment of those who work tirelessly to support our young people but about the resources and the framework within which they are working, which affect our collective ability to deliver the outcomes we need.

The Youth Select Committee report on young people’s mental health was published in 2015, as a consequence of more than 90,000 young people voting for the subject of mental health in the 2014 Make Your Mark ballot. It is an exceptionally important piece of work because it is a report on mental health by young people, about young people. Since I was elected last year, I have been struck by how often young people’s mental health issues have been raised with me; whether by individual constituents struggling to access the support that they or their children need, doctors in my local accident and emergency department or teachers in our local schools. The issue is raised very frequently, and no one thinks the current situation is even close to being acceptable.

I pay tribute to the Youth Select Committee for its excellent, rigorous report and clear recommendations, which fall into three areas: funding and the state of services; a role for education; and awareness, stigma and digital culture. The report concludes that mental health services are significantly underfunded, and young people’s mental health services even more so, and that the challenge posed today by young people’s mental health is unprecedented. It highlights significant problems in accessing services, particularly in relation to first contact through GPs, and raises the urgent need for every young person in the UK to leave school with a good understanding and awareness of mental health, empowered and equipped to look after their own mental health.

[Mr Kevan Jones (North Durham) (Lab)]

Does my hon. Friend agree that some of the issues on access that are raised by this very good report could apply equally to adult services, so there is clearly a read-across between the two?

[Helen Hayes]

My hon. Friend is absolutely right to say that, although today we are debating young people’s mental health, many of the same issues apply to mental health services across the board for all members of our communities.

The Government published a response to the Youth Select Committee report in January 2016. That response was, on the whole, disappointing. It referred mainly to work that the Government were already doing rather than the additional work that they and other agencies clearly need to do. Most disappointing of all, the response rejected the key recommendation that statutory levels of attainment in mental health education should be introduced for all young people. I welcome the fact that the Government have subsequently announced some additional funding for young people’s mental health, but I remain very concerned about the current state of mental health services for our young people and the resourcing of those services.

I will focus, therefore, on the current state of services, and what I believe to be evidence of a crisis that is growing, not diminishing, and demands a response far bolder and more comprehensive than that which the Government are currently offering. I will also return to the conclusions of the Youth Select Committee report.

One in four of us will experience mental ill health in any given year. That means that mental health is something that affects every one of us. All of us have a friend or family member who has mental ill health, and many of us will experience mental ill health ourselves. I have known close friends and family members who have suffered from severe anxiety that impacted on their daily lives, clinical depression and eating disorders. There are few worse feelings than the worry for a loved one who seems unreachable in the pit of depression, except perhaps the worry when that loved one is a child. All any of us wants for our own children and the young people we represent is that they grow up happy, healthy and resilient to the stresses and strains of our world. Watching a precious child struggle with clinical depression, severe anxiety or an eating disorder is absolutely devastating.

According to NHS statistics, around one in 10 children and young people has a diagnosable mental health condition; that is around three students in a typical classroom. Many more young people do not have a diagnosable condition but experience a period of mental ill health or emotional distress during their childhood or adolescence. The Government’s own measures of children’s wellbeing found that almost one in four children showed some evidence of mental ill health. Half of mental health problems are established by the age of 14 and three quarters by the age of 24.

Shockingly, suicide is the most common cause of death for boys aged between five and 19, and the second-most common for girls of that age, after traffic accidents. A recent survey by Girlguiding found that 69% of girls aged seven to 21 feel that they are not good enough. It is thought that around one in eight young people self-harm between the ages of 11 and 16.

--- Later in debate ---

[Helen Hayes]

I agree with the hon. Lady completely. As we focus on prevention and early intervention, we need to think about early intervention in terms of age, as well as the stage of mental ill health.

As a consequence of the lack of early intervention support, the number of young people attending A&E because of a psychiatric condition has more than doubled since 2010. I have spoken to many doctors who tell me that when this happens and a seriously unwell young person presents at A&E needing a CAMHS in-patient bed, they frequently wait a very long time—sometimes days—for a bed to be identified. Often that bed is hundreds of miles away from home. One south London hospital has provided me with data that show a 37% year-on-year increase in the number of under-16s being seen in A&E with a mental health condition, and a 193% year-on-year increase in the number of those children being admitted to an in-patient bed.

[Mr Kevan Jones]

Does my hon. Friend agree that while there is a shortage of beds, another issue, particularly in cities such as London, is poor quality housing? In cases where individuals could perhaps have been treated at home and in the community, that treatment cannot be delivered because of the lack of proper housing.

[Helen Hayes]

My hon. Friend is right. There are multiple causes and contributory factors to mental ill health, and multiple contributory factors that present obstacles to addressing that and providing the treatment people need, where they need it. Housing is certainly one of them.

In London, 69 young people from Lambeth, Lewisham, Southwark and Croydon were unable to receive in-patient care in the South London and Maudsley Trust. Of those, 45 were sent out of London for their care. This issue, of seriously unwell young people being sent a long distance away from home to access in-patient care, needs to stop. It is distressing for families, it stops young people receiving the maximum possible support from family and friends to help them recover, and it makes them more vulnerable. When young people are admitted to a CAMHS in-patient unit, very often the service is not what it should be. The Care Quality Commission found that 62% of CAMHS in-patient wards and units were inadequate or required improvement.

The goal of parity of esteem for mental and physical health was introduced into the Health and Social Care Act 2012 via an amendment by Labour peers, and was a landmark in the way that mental health services are considered. However, we only need to think for a moment about what our response would be if some of the statistics on young people’s mental health related to a physical condition to realise just how far away we are from the stated objective of parity of esteem being realised. Just imagine if 75% of people with a bacterial infection struggled to get access to treatment; if almost a quarter of referrals for cataracts were turned away; if people with a chest infection were routinely forced to wait until they had pneumonia before any help was provided; or those with a broken leg were forced to wait for days in A&E only to be sent to a hospital hundreds of miles away to be treated. It would be a national scandal. The state of our mental health services, particularly those for young people, is a national scandal: it just is not being recognised as such. Words alone cannot achieve parity of esteem; the Government must start to act differently.

What action, then, is necessary to transform mental health services for our young people? I want to return now to the conclusions of the Youth Select Committee report. The Royal College of Psychiatrists highlights three recommendations in the report, which it believes are key. First, the Government must increase funding for young people’s mental health services and ensure that this funding is ring-fenced to guarantee that the money “reaches the ground” to CAMHS. There is particular concern at the moment about the introduction of sustainability and transformation plans across the NHS, and the resourcing implications of those plans. The Royal College of Psychiatrists recommends that the Government introduce ring-fenced funding for CAMHS and rejects any sustainability and transformation plans that do not clearly set out a plan to improve children’s mental health services in their area. I hope the Minister will commit to that today.

Secondly, health services must pursue co-production, in which young people themselves are involved in the process of formulating policy to improve CAMHS. Research shows that where young people have a clear voice in service design, the end result much better reflects the real needs of the patients.

Thirdly, the Government must focus on improving mental health education in schools, with the aim of ensuring that young people leave school with not only an understanding of mental health, but an understanding of how to help their own mental wellbeing. This recommendation was made by the Youth Select Committee and it is supported by the Education Committee, the National Association of Head Teachers and other teaching unions, the United Nations and many others. The Government have introduced new lesson plans for the personal, social, health and economic curriculum, but there is a broad consensus across the health and education sectors that the role of mental health education in developing resilience, preventing mental ill health and safeguarding young people is so important that it should not be left to chance, and that along with sex and relationships education it should be a compulsory part of the curriculum. I hope the Government will reflect on the urgency of the situation and the consensus around the need for compulsory education, and will make a commitment to introduce it.

The Youth Select Committee report made many other practical recommendations, including the introduction of regional commissioning, the development of an app to provide mental health advice and support, and the introduction of plans to support students through periods of exam stress. I would welcome an update from the Minister on the progress that is being made to deliver these excellent ideas.

Finally, we know that one of the greatest barriers to delivering the mental health support and services that our young people need has always been the stigma that surrounds mental health. I want to pay tribute to a brilliant piece of work that was recently published by the YMCA in partnership with the NHS. Called “I Am Whole”, the research sought to identify the extent and impact of mental health stigma and included the finding that three quarters of the young people spoken to believe that people experiencing difficulties with their mental health are treated negatively as a result of stigma. The project also sought to address stigma directly by publishing a series of stories from young people about their experiences of mental health difficulties. These make for very challenging and moving reading.

Before I close, I want to read a quotation from the foreword to “I Am Whole”, from Connie, aged 22:

“Having mental health difficulties is like being trapped inside a thousand invisible prisons. There are a thousand reasons that as a young person you are driven deeper into that colossal void. Not only isolated by the struggles you’re facing mentally, but further enveloped in a thick, suffocating darkness. The darkness descends, comprised of a tangled web of myths, harmful language, misconceptions and misunderstandings. This is stigma. It is time for these myths to be dispelled, the web broken and the isolation to end. It is time for us to be free to talk about our mental health difficulties openly, so that we can access the services we need. Once the conversation begins, you promote understanding for others and break down misconceptions people hold…It is like being stood in the dark, untangling parts of that web until the sun’s warmth breaks through…the light reaches your eyes, and you look around to see you are not alone.”

When we talk about young people’s mental health, we are talking about the wellbeing of our precious children, about their health and happiness, about the resilience of the next generation and about the ability of young people to fulfil their potential and be everything they can be. We are talking about the ways to stop more families living with the heartbreak of a young person with mental ill health and about ways to stop more families suffering the devastation of a loss to suicide. There are few things more important than this and it is time the Government got it right.

--- Later in debate ---

[Tim Loughton (East Worthing and Shoreham) (Con)]

I declare my entry in the Register of Members’ Financial Interests. I apologise for missing the opening couple of minutes of the speech made by the hon. Member for Dulwich and West Norwood (Helen Hayes).

I am delighted that we are having this debate, and to be participating in it, for two main reasons, which I am sure you will share, Madam Deputy Speaker, because I know your interest in this matter. First, this is an important subject. It is something that we are failing on, so it is right, proper and beneficial that hon. Members talk about it openly, especially because, as we heard from my hon. Friend the Member for High Peak (Andrew Bingham), young people are much more prepared than ever to come forward with their own stories of their problems and issues, hopefully so that solutions can be found through them.

Secondly, I am delighted to participate in this debate because it is part of the UK Youth Parliament’s work. It is significant that we are giving up mainstream parliamentary time in the main Chamber of the House of Commons to discuss a report by the Youth Select Committee, an offshoot of the UK Youth Parliament. It is a shame that we have to do it in Backbench Business Committee time rather than Government time, but I pay tribute to the hon. Member for Dulwich and West Norwood for securing the debate and giving it such an excellent start—this will clearly be a high-quality debate. I take the view—I think that you share this view, Madam Deputy Speaker—that the Youth Select Committee has now taken on such status and stature, with its production of reports of such high quality involving such good research, that not only should the Government produce a formal response to the reports, as they have, but they should give up Government time in this Chamber on an annual basis—just once a year—so that we can formally debate the work of the Youth Select Committee. I have put that idea forward for some time, so I hope that the Whips and Government business managers are listening.

I am a big supporter of the UK Youth Parliament. It was founded during my time in Parliament, and I always try to attend its annual parliamentary sittings, which are a great spectacle. It is always exceedingly frustrating for Members when we return on the Monday and the Speaker inevitably says, “Why don’t you lot behave as well as the UK Youth Parliament members who were here on Friday; they are very smart, very concise, very well behaved, don’t heckle and set an example?” It is a shame that the media coverage of the Youth Parliament sitting is not more extensive because it is a great event for a great organisation, and it is great that we are discussing its work today.

When I was the Minister for children and young people, we produced the “Positive for Youth” document, which was all about promoting that sort of youth engagement. One of the things I most treasure having done is helping the transition of the UK Youth Parliament across to the British Youth Council to secure its future. I pay tribute to all its work over the past few years. It is a mainstream part of the youth voice in this country and in this Chamber.

I was the first witness ever to be called before the Youth Select Committee. It was an awesome and intimidating experience. I was called for its first inquiry back in 2012 along with the then Transport Minister, Norman Baker. We rather too nonchalantly rocked up before this group of young people in the Boothroyd Room. They were exceedingly well-rehearsed and well-researched, and were certainly not taking any BS from anybody. I have appeared in front of Select Committees—mostly the Education Committee—on many occasions, but I have to say that this was the most intimidating experience I ever had as a Minister in front of a Select Committee, and it was fantastic. That shows why the work of this Committee, and this, its fourth report, need to be taken seriously.

This Youth Select Committee report is difficult to distinguish, other than by its cover, from a House of Commons Select Committee report, and I congratulate Rhys Hart and his team on their work on it. They did all the things they should have done: they visited experts and sufferers of mental illness, and took no fewer than 148 submissions from expert witnesses and others—if only all the other Select Committees had as many well-informed and well-researched submissions as it did.

The Youth Parliament also has a substantial democratic endorsement. In 2014, when its priorities and the subject of the Youth Select Committee report were decided upon in the “Make Your Mark” ballot—which includes a debate in this House in the Youth Parliament’s annual sitting—no fewer than 875,000 young people from up and down the country bothered to turn out and vote. Of them, more than 90,000 voted specifically for the subject of mental health services, which is why we are debating this report in the Chamber today. That is a huge democratic mandate.

Every year I hold an event in the House of Commons to present democracy awards to schools in West Sussex, including my constituency, that have achieved a high turnout in the elections that are held every February. Each year the turnout gets higher, so more and more trophies have to be given out, and an ever bigger room has to be booked to accommodate everybody. Last year, one school had a 100% turnout—all its pupils turned out to vote for its UKYP members, which is absolutely fantastic.

This report is a chunky piece of evidence that needs to be appreciated, looked at and, importantly, acted upon. I am delighted that we are giving time to it today, and I am also pleased that the Government produced a formal response to it, whatever we may think about the shortcomings of what they said. That was produced jointly by the then Health Minister, my right hon. Friend the Member for North East Bedfordshire (Alistair Burt), and the then Education Minister, my hon. Friend the Member for East Surrey (Mr Gyimah). Neither of them are still in those ministerial posts, but I welcome the Under-Secretary of State for Health, my hon. Friend the Member for Oxford West and Abingdon (Nicola Blackwood), to her new position. I am sure she has learned the ropes quickly and that she will continue to do so. We need consistency in our approach to mental health, however, and a much more joined-up approach—and not just between education and health, because there are many other aspects as well.

This subject is clearly important to young people, as is this report, so it should be important to the House and the Government. There are many useful lessons that we can learn.

I am also very frustrated, however. I have been in the House for almost 20 years. I have been shadow Minister for mental health, and I was shadow Minister for children and young people for some nine years, as well as Minister for children and young people. I currently chair the all-party group on children and the 1001 group, which is all about perinatal mental health. I have seen mental health Bills come and go, too, and have been involved in them. I saw the 2011 mental health strategy “No health without mental health”, which was a very important statement about the parity of esteem we need to achieve, although we still have not. In 2014, I saw “Closing the gap: priorities for essential change in mental health”, with specific commitments to improve mental healthcare for children and young people. I saw the rolling out of talking therapies and the improving access to psychological therapies programme. In March 2015, as has been mentioned, we had the mental health taskforce, which produced “Future in mind”. I have seen lots of good work in the Department of Health, in particular, such as that done by my right hon. Friend the Member for North East Bedfordshire, and in February this year the mental health taskforce produced the “Five Year Forward View for Mental Health”. There has been a lot of talk about the importance of mental health and the necessity of achieving parity of esteem but, as the hon. Member for West Ham (Lyn Brown) rightly said, there is still a very big disparity. And here we are again: we are still here talking about this, and record numbers of children and young people still have mental health problems.

[Mr Kevan Jones]

Does the hon. Gentleman agree that we can have reports, taskforces and recommendations, but the real problem is that mental health is seen as a Department of Health issue, whereas what we actually need is a completely cross-Government approach so that mental health and wellbeing can be part of every single piece of policy development?

[Tim Loughton]

The hon. Gentleman is right; he pre-empts a couple of my comments. From my experience as a former Minister—and, I am sure, from his—the term “joined-up government” is a complete illusion. Joined-up government does not happen in practice. On becoming a Minister, one is cocooned in a Department, and instead of having a dialogue with colleagues in the Division Lobby or wherever, a huge wall suddenly comes between you. Trying to get interdepartmental action becomes really frustrating.

I remember setting up something called the youth action group, which consisted of Ministers from nine or 10 Departments and representatives of six major children’s charities. It was co-chaired by the Prince’s Trust and Barnardo’s. The charities came to us with problems—often complex ones—affecting young people. One example related to housing benefit and accommodation for children in care. I cannot remember what the specific problem was, but it involved housing, which was the remit of the Department for Communities and Local Government, and benefits, which were the remit of the Department for Work and Pensions, as well as children in care, who came under the remit of the Department for Education. Normally there was a vicious circle that involved people being pushed from pillar to post. Alas, that committee has not met for the past 15 months or so, but our meetings used to consist of at least six actual Ministers—not just civil servants—from the relevant Departments as well as their officials. We would get Ministers together and ask them to go away and solve the problem.

Mental illness falls into that category, in that it is not simply the remit of the Department of Health or the Department for Education. There are many other implications and knock-on effects that can relate to the underlying cause of somebody’s mental illness problems. The hon. Gentleman is absolutely right that the structure of government needs to be much better. We need taskforces that genuinely cut across Government Departments, but in my experience they will flourish only if they have the buy-in and direct engagement of Ministers at the top. One welcome initiative from the hon. Gentleman’s party was the appointment of a Cabinet-level Minister for mental health. I think that that appointment has slightly gone by the wayside now, but the principle behind it was absolutely right, in that it tried to join up all the relevant Departments at the top table.

--- Later in debate ---

[Mr Kevan Jones (North Durham) (Lab)]

I congratulate my hon. Friend the Member for Dulwich and West Norwood (Helen Hayes) on securing this debate and thank her for it. I also thank the Backbench Business Committee for allowing time for the House to discuss this issue. May I also put on record my thanks to the British Youth Council, the UK Youth Parliament and the Youth Select Committee for this excellent report? May I also give them another big thank you for allowing us again to talk about mental health on the Floor of the House? People perhaps get a bit sick of me saying this, but I say it again: the way to address some of the stigma is by talking about this more. Talking about this report as we have done today will mean that young people know we are taking this subject seriously.

As I said in an intervention, the report raises issues that cross over into those relating to adult mental health services. As the hon. Member for High Peak (Andrew Bingham) said, the unique thing about the report is that it gives those of us more advanced in years an insight into pressures on young people today that were not there when we were younger and into the challenges for parents and schools in dealing with them. The core of the report is very important, because it deals with a lot of issues that also affect adult mental health services.

I wish to concentrate on two aspects of the report: how young people get access to mental health services; and the vital issue of prevention and being able to address not just mental health, but mental health well-being. As has been said, how people access these services is important. The report talks about mental health services to young people being:

“The Cinderella of Cinderella services”.

Is this about money? Yes, it is, in some cases. My hon. Friend the Member for West Ham (Lyn Brown) eloquently mentioned that we can have all the aspirations in the world, but if the funding is not there locally to provide services, the services will not be there and people will not access them. I agree with the report that this is therefore about more cash, but it is also about how we structure our mental health services in this country.

Page 5 of the report sums it up well. It contains a diagram of a pyramid showing a list of organisations that commission mental health services—schools, local authorities, clinical commissioning groups and NHS England—and calls for a lead commissioner. I totally agree with that, but I would go one step further. When we talk about commissioning services, we need to talk about the treatment pathways and how people get into those systems. Adults trying to navigate the mental health system find that it is like a maze. Not only do they have to find their way through it, but when they get into it they on many occasions find that, as my hon. Friend said, they can wait weeks, months or years to get help—this help is available in some areas but it should be provided more quickly. Early intervention, especially for young people, can prevent problems further down the line.

I sympathise with parents today, because how do they know who to go to if their child has mental health problems? What do they need to ask for? We assume that, somehow, people are well versed not only in issues around mental health, but in how to access help—that is also true for families of adult sufferers. We do need that pathway.

The report quite rightly highlights the issue around GPs and GP training, but, as I have said many times, therein lies the problem. I am not criticising GPs, because there are some very good ones who do help, who are sympathetic and who can access services. I support the recommendation in the report for more training for GPs, but we need a more open system—a system of self-referral—which does not necessarily mean going through a GP.

That brings us to the issue around commissioning and how we provide mental health services in this country. Mental health services very much follow the medical model, but I am not sure whether that needs to be the case. What we need in this country is an open system, which involves the community and voluntary sector. I am suggesting this not because it is a cheap option, but because it is perhaps a better way of providing mental health services. However, those voluntary groups need to be funded, as my hon. Friend the Member for West Ham said. It is no good saying that we are going to pass this work over to some very good voluntary sector organisations and expect them to do it without the funding. Therein lies the problem. I give credit to the former Minister, the right hon. Member for North East Bedfordshire (Alistair Burt), who was a great champion of parity of esteem and of concentrating on how to make the system better. As I said in an intervention on the hon. Member for East Worthing and Shoreham (Tim Loughton), it is no good just looking at mental health in terms of the Department of Health, because the cuts that have taken place in local government are having a direct impact on the provision of mental health services—I am talking about the closure of youth services and voluntary sector organisations that provide mental health services locally. This is a false economy. If we are putting more money into health and taking it out from elsewhere in the system, we will create an ongoing problem.

We also need a fundamental review of CAMHS, as it is a complete failure. I am not for one minute criticising the dedicated individuals who work in that service, because I have met them and know that they work very hard. Given their workload and the way that they get their referrals, they are doing a fantastic job, but the system is broken. We cannot have this situation in which young people are waiting possibly six months for an assessment, and in which families and the individual young person are somehow expected to cope.

[Mark Tami (Alyn and Deeside) (Lab)]

Does my hon. Friend agree that, in some cases, children have to become badly ill before the problem is addressed? The problem should be addressed in the first place so that they do not get into that state.

[Mr Jones]

That is the case, yes. I can say from personal experience that the longer a person leaves the problem undiagnosed or untreated, the worse it gets.

I wish to touch on this idea that parents are, somehow, geniuses and know how to deal with children with mental illness. They do not. I work with Kinship Carers in Durham, which is run by Lyn Boyd, a friend of mine. It deals with grandparents, uncles, aunts and others who often find themselves, later on in life, looking after young people and children. Many of them have quite horrifying stories to tell. They often end up with the children, because of abuse, because the parents cannot cope, or because they want to save them from the care system.

I had a case earlier this year in which a six-year-old was self-harming. When I looked at his background and talked to his grandparents who were looking after him, I could understand why, but the issue is how does he access CAMHS. They were told that he had to wait six months. There we have a couple, who are not the biological parents, looking after a six-year-old. All they can say is, “What do we do?” The child is also disruptive at school. That leads to pressure on the school, which then seeks to exclude him. What happens to the child then? We are talking about not just the trauma, torment and heartache of a six-year-old self-harming, but the knock-on effect on the family and the school.

We do need a new system. It may be a community-based provision. I would certainly like to see open access services—they could be run by well-funded voluntary sector organisations or by the local authorities and councils—where people can go for help or even on occasion just information. Those grandparents, for example, did not have a clue what to do. What does a person do in that situation? The system is certainly failing those individuals. It should not be up to me as a Member of Parliament to contact a mental health trust to enable those people to gain access to services. That is where we are failing.

The problem is not just about ensuring that we have joined-up local services—I have already said that local authority budget cuts are having a direct impact on the working of such services—but the changes in the national health service and GP commissioning, which has made things worse for many voluntary organisations. Contracts are being let for a whole host of services, many of which are too large and too complex. The idea that local community groups can bid for such services does not work because those services are just too big, which means that those groups are being excluded from the money that is available. I am not for one minute saying that anyone who works in the voluntary community sector providing mental health services wants a free ride. Those groups are quite happy to be evaluated. My hon. Friend the Member for West Ham mentioned a project in her constituency that secured lottery funding. That project will certainly have had to ensure that the outcomes were there and that it was accountable. There is no way that many of those small organisations, which in many cases would provide a cheaper and better option for delivering the service, can manage those contracts that are currently being let by the NHS.

The way in which the Government should look at this matter—it is perhaps very difficult in this age of austerity—is that if they deal with it properly, they could save taxpayers’ money. It would save not just the heartache of the individuals who are going through the system, but, if done properly, money as well. On page 9 of the report, the chief medical officer said:

“Early intervention services that provide intensive support for young people experiencing a first psychotic episode can help avoid substantial health and social care costs over 10 years perhaps £15 in costs can be avoided for every £1 invested.”

If the Government really want value for money, this is a way to do it. However, there is a problem, which is that, in this country it is said that we know the cost of everything, but the value of nothing. The investment now in young people will possibly not pay for itself for another 10 or 20 years, but when it does, the payback to society will be quite large, and not just in terms of our having a healthier and happier society.

Another area I would like to touch on, which is covered in the report, is prevention—through the work done in schools and by making sure that we mainstream wellbeing. The hon. Member for East Worthing and Shoreham mentioned the difficulties of Whitehall Government and the silos people are in. We have enough reports on some of these areas now, and we do not need any more; what we need to do now is to hardwire mental wellbeing into all public policy across Whitehall. Can it be done? Yes, it can. I was involved when the last Labour Government mainstreamed veterans policy. Bob Ainsworth, who was the Minister at the time, commissioned a report on veterans. He made sure that the issue was taken forward and that each Department, when it was coming up with public policy, took veterans into account. We need a similar approach to mental health and mental wellbeing. The only way to do that is to have a Cabinet Sub-Committee so that this is dealt with at Cabinet level and the main Departments make sure, when they are coming up with a policy, that they take into account mental health and mental wellbeing.

As I said, early investment saves money, but it also makes for a better society. Another issue where I totally agree with the report is supporting school counsellors. Counsellors could be something of a pressure valve in the system. If they are properly trained, and there is a proper network of them across schools, they could intervene early on and prevent some of these issues. The hon. Gentleman said he was reluctant to make it mandatory for schools to carry out this work, but, as the report says, we have national standards and curricula for physical education, so we should have them for mental health as well.

Again, it is a patchy picture. There is some good work going on in schools across the country, with teachers taking the initiative. In my constituency, Simon Westrip, a lecturer at Northumbria University, has done some work around mindfulness with local community groups, and he is now taking that into secondary schools. If we look at some of the feedback on and evaluation of mindfulness in schools, it is clear that this is not just about the effect on individuals; it actually raises standards in many cases. However, the approach to these issues is patchy, and unless they have dedicated time in the curriculum, or they are something governing bodies need to take into account, people will not do that. Done properly, such work will not only address the pressures that a lot of our young people face now, so that they are happier going through school, but it will save lives and, in some cases, save money in the long term. Is this rocket science? I am not sure it is. We in this country have to change our attitude to mental wellbeing. If we get it right in children, as the report highlights, the payback for this country and its economy in the long term will be tremendous.

Let me finish where I started, by thanking the British Youth Council for its work. I also thank it for giving us another opportunity today to talk about mental health on the Floor of the House.

--- Later in debate ---

[Nicola Blackwood]

It is not fair to say that CCGs are ignoring the funding that is coming through. Moreover, it will not be possible for them to ignore what is going on when transparency and accountability is put in place with data sets that clearly show not only performance down to CCG level but the amount of funding that CCGs are given and the amount they are spending. These data will be much more detailed than before. In January, we introduced the first ever provider-level data set on children’s mental health services, and that will provide data on outcomes, length of treatment, source of referral, and location of appointment.

[Mr Kevan Jones]

The Health and Social Care Act 2012 contained one provision that I welcomed—allowing CCGs and others to commission services in the third sector, for example. A lot of the good work in this area is done in the third sector, but the problem lies in how the contracts are drawn up, because they are either too big or too complex for smaller organisations to bid for. Will the Minister look at that?

[Nicola Blackwood]

I am happy to look at it. We are very clear that there is a vital role for the voluntary sector to play in delivering some of these services. We hope that local transformation plans will be part of the way in which this is clarified. The programme to deliver transparency and accountability will be essential if local areas are not only to design effective services that match the needs of their local populations, but to be held to account for delivering them. I will not beat about the bush. We recognise that a complex and severe set of challenges faces children and young people’s mental health services. This area has been undervalued and underfunded for far too long.

While I am happy to investigate funding formulas such as those mentioned by the hon. Member for Ilford North in relation to Redbridge, I agree with him that leadership and accountability are also key to making the changes that we need. That is why we are committed to delivering real changes across the whole system, not just in funding, and to building on the ambitious vision set out in “Future in mind”. I pay tribute to my predecessors for the work they have done to bring those forward. As the hon. Member for Dulwich and West Norwood has said, we need to go further to drive through these changes, which young people have told us they want to see.

Children want to grow up to be confident and resilient, and they want to be supported to fulfil their goals and ambitions. We are placing an emphasis on building in that resilience, on promoting good mental health and wellbeing, on prevention—it is so important, as the shadow Minister has said—and on early intervention, as a number of the recommendations propose. We are looking, in particular, at how we can do more upstream to prevent mental health problems before they arise.

Baby Loss

Kevan Jones Excerpts

Thursday 13th October 2016 Commons Chamber

[Patricia Gibson (North Ayrshire and Arran) (SNP)]

I am deeply honoured to participate in this debate on an issue that could not be closer to my heart, and I am grateful to the cross-party group on baby loss for bringing this forward.

As we have heard, the loss of a baby is what every parent dreads. Those to whom it occurs are irrevocably changed for ever—their lives scarred by unspeakable tragedy. A year before I was elected, I had no notion that I would ever have the honour of being elected to represent the good people of North Ayrshire and Arran, but here I am, and because of my own horrific experience of stillbirth I feel profoundly that I should use that experience to help shine a light on this issue, which truly is the last taboo.

For too long, too many of those to whom this has happened understandably did not feel equal to the task of speaking out about this issue, and in turn those who have no direct experience of this issue simply do not know how to broach it and are often surprised to find out how prevalent stillbirth is across the UK. Around 3,500 babies each year across the UK are stillborn and another 3,000 die shortly after birth. To put this into context, that is around one baby every hour and a half, the equivalent of 16 jumbo jets crashing every year. It is inconceivable that this should continue. But it will, unless we remove the taboo and shine a light on this awful, awful phenomenon and do all we can for all the mums and dads of the future and all the babies yet to be born. It is sobering to think that in the course of this debate, somewhere in the UK two more little babies will have died, and two families will have been destroyed. It does not bear thinking about, but think about it we must. Yes, it is extremely difficult to talk about this, but we have a duty to all the babies who have been lost and a duty to all the bereaved parents who are struggling to put the pieces of their lives back together.

The fact is that, in Scotland, 34% of stillbirths are babies at the full term of pregnancy, and in England the figure is 33%. This is shocking, since medics at all levels will say that, barring some terrible freak accident, no baby who has survived a full pregnancy need die—not if proper monitoring and procedures are in place—yet such babies do die. In Scotland, some progress has been made in recent years to reduce the incidence of stillbirth, but we still do not compare favourably with our European neighbours. Across the UK, we still have a long way to go.

I know, as many others do, the horror of losing a baby. My baby, Kenneth, would have been seven years old this Saturday, the very day when we reach the culmination of Baby Loss Awareness Week—international pregnancy and infant loss awareness day—when we will see a wave of light for all our babies.

When children lose their parents, they are called orphans. When a husband loses his wife, he is called a widower. When a wife loses her husband, she is called a widow. When parents lose their child, there is no name for that. The reason that there is no name for it is that there are no words. It goes against nature. And in other loss of loved ones, all those who knew and loved them can share memories such as the last holiday, the last Christmas or the last important family milestone, but it is not like that with a stillbirth, so people understandably do not know what to say. How on earth could they? Sometimes, people are so keen to avoid saying the wrong thing that they say nothing at all. I have heard reports of women after a stillbirth seeing their neighbours cross the road to avoid speaking to them, such is the discomfort and anxiety about saying the wrong thing, because there is no right thing to say. There simply are no words; just a deafening silence and a terrible sense of being utterly isolated in consuming grief.

Like so many parents who have lost their babies, my husband and I are haunted by the loss of how we expected our lives to be after five years of fertility treatment. We are haunted by the potential wiped away so cruelly, so suddenly and so unexpectedly; haunted by the fact that it was completely avoidable; haunted by the fact that all this grief and sense of waste was because the Southern general hospital in Glasgow, now called the Queen Elizabeth university hospital, made a series of basic errors; haunted by the fact that that same hospital pulled the shutters down and for six and a half years refused to recognise that any mistakes were made at all and to this day has still not done so; and haunted by the fact that that same hospital, despite independent experts flatly contradicting it, insists that it did nothing wrong.

And this matters. It matters because this is an all too common story and demonstrates an unwillingness openly to engage in a learning process when mistakes are made. That shows the real culture—a fear even—of improvement if people cannot accept it when mistakes are made. How many parents must go through this horrific ordeal only to feel swept aside, ignored, dismissed and told, “It’s just one of those things,” as they try somehow to cope with the crushing weight of grief?

As we have heard already, bereavement care for parents is simply not good enough. Sands has done very important work in this field, and I want today to pay tribute to it. It understands the importance of listening to mothers’ concerns. It found that 45% of the mothers it surveyed who had undergone a stillbirth felt something was wrong before any problems were diagnosed, yet too many of those women were told that their concerns were unfounded and sent home, only for their babies to die shortly afterwards. Antenatal care must be a collaborative process. Mothers’ concerns must be paid attention to. Women know their own bodies.

We must have better monitoring of pregnancies, particularly those of women at risk of experiencing a stillbirth or neonatal death. The truth is that we are failing to identify many babies at risk. In addition, we must have more knowledge, data and research to help us to tackle this issue. The more we know about why our babies are dying, the more measures we can take to militate against it happening. It is very important that if mistakes are made—and remember that one in three stillbirths are at full-term babies—health boards and trusts should not investigate themselves. For investigations to be credible, they must be independent and carried out by people outside the situation. That is the right and proper thing to do to challenge the culture of secrecy.

Where it is believed to be merited, we should allow coroners in England to investigate stillbirths, so that errors in care can be addressed, where they have occurred. In Scotland, the equivalent would be a fatal accident inquiry. These are not straightforward or easy asks, but such an investment now will increasingly mean that, as expertise grows and intelligence is gathered, the need for such measures will necessarily decrease over time.

[Mr Kevan Jones (North Durham) (Lab)]

Does the hon. Lady agree that local authorities need to take into account the registration of deaths? I have heard of cases where people have had to register deaths at the same place where people were registering births. That is most upsetting for those parents.

[Patricia Gibson]

Indeed. I take on board what the hon. Gentleman says. It is an extremely traumatic experience to register the death at the same place where people are registering births. That simply makes the experience much more traumatic.

In my own case, my notes recorded that I was asked if I wanted a post mortem performed on my son. My notes did not record who asked me this question, what information I was given, or when I was asked it. I was so drowsy on morphine in intensive care, since my liver had ruptured after my body tried for 48 hours to deliver my baby naturally and the hospital repeatedly refused to perform a caesarean section, that I have no idea if I was actually asked this question. Why was the conversation not properly recorded in my notes? It is all pretty suspicious and only feeds into the sense of cover up and evasion by hospitals in such circumstances.

I am delighted that we are finally putting this very important issue firmly on the political agenda, and that is where it must stay. For those of us inside the Chamber and those of us outside—all the grieving parents watching today—it is too late to save our little boys and girls. But there are other boys and girls—other people out there, thinking of starting their own families, for whom it is not too late. It is our duty to do all we can to ensure that those little boys and girls enter the world as safely as possible. It is our duty to commit ourselves to this cause for their sakes and for the sake of all the babies who have been lost but will never be forgotten.

--- Later in debate ---

[Will Quince]

Yes, of course I agree. I will come to that point later. After the debate in November on bereavement care in maternity units, my hon. Friend the Member for Eddisbury and I were taken aback by the number of people across the country who got in touch and shared their stories with us. We sat down—this was during proceedings on a Finance Bill, so it was about 1.30 am —with the then Minister with responsibility for care quality, my right hon. Friend the Member for Ipswich (Ben Gummer), my hon. Friend the Member for Banbury (Victoria Prentis), who is not quite in her place, and the hon. Member for Washington and Sunderland West (Mrs Hodgson). We thought, “This is a far bigger issue than just bereavement suites. The whole subject of baby loss needs addressing.” We were pretty surprised that there was not already a group looking at the issue.

The all-party parliamentary group was formed in February, and I am very proud of the work that we have done so far, working with amazing charities across this country. I cannot name some of them, because I would have to name them all. From large charities that do the most amazing work and fundraising, through to the groups made up of just a handful of people who get together in a local pub or village hall and knit really small pieces of clothing for babies who are premature and sadly stillborn, it means so much that so many people across this country want to play their part and make a difference.

I cannot let this speech go by without referring to the support of Mr Speaker, who is not in the Chamber at the moment, not just for this campaign, but in kindly allowing us to use his apartments for the reception yesterday, and during baby loss awareness week. Yesterday, which would and should have been my son’s second birthday, he called me to ask a Prime Minister’s question on this subject, and so raise the issue in front of millions of people and the country’s media.

[Mr Kevan Jones]

I know that the hon. Gentleman does not want to name individual charities, but Sands does a great job. The point raised with me by Ashleigh Corker, a north-east co-ordinator who lives in my constituency, is that one of the most powerful things that Sands can do is put parents in touch with other parents—people who have gone through the same thing—so that they can share experiences. Does he agree that that is a very powerful thing to do? A lot of people can empathise with what parents are going through, but unless a person has gone through this themselves, it is very difficult to understand.

[Will Quince]

The hon. Gentleman raises an incredibly good point. In the run-up to birth, people can go to groups such as NCT and prenatal classes, so I totally agree. We have made friends who have gone through similar experiences. You feel that you can talk openly with them, because they have gone through very similar experiences and are feeling the same things as you. That is very powerful. There may be a role that charities and the NHS can play in putting parents—where they feel able—in touch with other parents who may want to talk about their experience.

I shall speak briefly about Government targets. I know that the Government sometimes get a hard time on the NHS, but they have accepted the premise of our argument. I remember first meeting my right hon. Friend the Member for Ipswich as Minister responsible for care quality—it was like pushing at an open door. We now have firm commitments to a reduction of 20% by the end of this Parliament and 50% by 2030. It is our job as an all-party parliamentary group to hold the Government’s feet to the fire and to make sure that they are working towards those targets and that we start to see results.

I could not let this debate go by without talking about some of the issues that charities have raised with me. I shall touch on prevention and then talk about bereavement. Research in this area is vital. As my hon. Friend the Member for Eddisbury said, around 50%—in fact, the figure is 46%—of stillbirths and 5% of neonatal deaths are unexplained. We need to look, for example, at ethnicity and ask why south Asian women are 60% more likely to have a stillbirth, and why black women are twice as likely to do so. Why is there a geographical disparity across the UK? I know that part of the answer is social inequality, but why is the figure 4.9% in some parts of the UK and 7.1% in others? That is around a 25% variation. It is not acceptable and we need to understand why it exists.

We need to look at multiple pregnancies, as the hon. Member for Livingston (Hannah Bardell) mentioned from the Scottish National party Front Bench, and at lower income families. We need to study our European counterparts and see why they are getting it so right and whether we can implement similar measures in the UK.

Some right hon. and hon. Members have mentioned public health and they are right to do so. Maternal age, nutrition and diet, drugs, alcohol and smoking are all relevant. We could achieve a 7% reduction if no woman smoked during pregnancy. That is a huge target to achieve and we could do a lot of work on smoking cessation, especially during pregnancy. Studies show that we could achieve a 12% reduction if no mothers were overweight or obese.

There is a huge piece of work that we could do on empowering women and mothers-to-be. Initiatives such as Count the Kicks are important. Nobody knows their body as well as a mother. If she feels that there is something wrong, there is a good chance that something is wrong. When she picks up the phone to the hospital or to her GP and her concern is dismissed with the words, “Don’t worry, it’s not important,” she needs to get it checked out. If there is nothing to worry about, great, but on the occasions when we do not get a concern checked out and then something terrible happens, we have to hold ourselves responsible.

There are various initiatives to empower women. Teddy’s Wish is currently sponsoring fantastic folders—as anybody who has had a baby will know, mothers-to-be get purple maternity notes which they carry around religiously just in case the baby comes early. The wonderful plastic folders that the maternity notes go in inform mothers—and fathers—what to look out for, what are the signs if something is not right, when to pick up the phone, when to go and see their GP and when to go to the hospital. Such innovation is exactly what is needed.

Investigation and reporting are important so that we learn the lessons of every stillbirth and neonatal death. Covering things up and dismissing them with comments such as, “That’s unexplained. These things happen. I’m terribly sorry,” are unacceptable. We have to learn from every case. I am pleased that the Government have put a significant amount of money into setting up a system of reporting to enable us to investigate and learn from every stillbirth and neonatal death.

The hon. Member for North Ayrshire and Arran (Patricia Gibson) rightly mentioned post-mortems. So many parents are not offered a post-mortem. One might wonder what parent would want that opportunity, but parents who lose children often want to know why. They want to understand how and why it happened and how they can make sure that it does not happen again. Offered the opportunity, many parents opt for a post-mortem because they know that that research can help others, but clinicians may not be asking the question—often with good intentions, because it is not an easy question to ask. We must ask the question if we are to get post-mortem rates up, which will feed into the research that will allow us to cut our stillbirth rate.

An hon. Member—I apologise, I cannot remember who it was—mentioned late-stage pregnancy scanning. In this country we do not scan past 20 weeks. We scan at 12 weeks and we scan routinely at 20 weeks, but there is no routine scanning past that. I find it bizarre that the abnormality scan takes place halfway through the pregnancy, but after that the mother-to-be is not seen again for a scan until she arrives at the hospital when she is in labour. Other countries across the world and particularly our counterparts in Europe do scans at 36 weeks or Doppler scans. There are huge improvements that we could make in that area.

I want to clarify one point in relation to prevention. The NHS is brilliant, and where we get it right in this country, we really get it right. The problem is the inconsistency across the NHS. I know that the Secretary of State and the Minister of State will agree when I say that we have some of the best care in the world, but it is important that that is replicated in every hospital and every maternity unit in the country, so that whatever hospital a woman goes into and whatever GP she sees, she will get the same level of care and consistent advice.

Even if we manage to achieve our target, even if we match our European counterparts and reduce our stillbirth and neonatal death rates by 50%, that will still mean between 1,500 and 2,500 parents going through that personal tragedy every year. That is why it is important that the APPG puts an equal emphasis on bereavement. I have talked about consistency of care across the NHS, and there should also be consistency of bereavement pathway and bereavement care across the NHS. It is important that we consider aspects such as training for staff. I know that Ministers have put huge amounts of funding into training as part of the plan to achieve a significant reduction in the stillbirth rate.

North East Ambulance Service

Kevan Jones Excerpts

Wednesday 4th May 2016 Westminster Hall

[Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con)]

I represent a very rural seat in north Northumberland, where, in January 2015, we had the tragic case of the entirely avoidable death of a young man because an ambulance did not get there in time. The Secretary of State instituted a national review on the back of that to look at the issues that triggered that tragedy. I am grateful for that, and we have made progress.

Some issues have come out of that, and the North East Ambulance Service should be commended. In my area, ambulances go to Northumbria hospital—our new emergency-only hospital. Some colleagues have already mentioned that we have been seeing the queuing of ambulances as they arrive at the various hospitals. I am not familiar with the wider north-east hospital framework, but at Northumbria it was quickly evident that that was a problem. To its credit, the North East Ambulance Service sent a paramedic to help in the triaging process, along with a specialist nurse who was diverted from other duties, to improve the process when the ambulances arrive—the hospital knows when they are going to turn up because they phone ahead—and to do a better job in ensuring that patients were removed from said ambulance and that the kit was returned to paramedics so that they could crack on with the next case.

That has been working well. We have seen a much speedier process, so I would commend that to colleagues, who could encourage other hospitals in the region to look at doing that. That has been an investment, but without doubt the cost-benefit not directly to the hospital but to the overall health package for our constituents has been hugely improved, because ambulances are back in the system. We were also then able to ensure that Northumberland-based ambulances were coming back up into Northumberland and not being taken to 999 calls elsewhere in the region, leaving paramedics working 14 or 15-hour days to get the ambulance back to Berwick or Alnwick. I commend the ambulance service for listening on the challenging problems we had and trying to make improvements.

At Northumbria hospital, the figures for urgent and emergency attendances read like this for the past three months: January had 12,911, which was a 12% increase on 2015; February had 13,731, which was a 30% increase on 2015; and March had 15,146, which was a 24% increase on 2015. However, only 24% of those cases needed emergency hospital admission. Something is broken. We are overloading our ambulance service with calls that demand an emergency ambulance, but, once at the hospital, only 24% needed emergency care.

My concern is twofold, and I ask the Minister to look at how we can make progress on this. First, the algorithm that the 111 and 999 systems demand that staff in the call centres use is dramatically risk-averse. I do not want anyone who is having a cardiac arrest to be told they have heartburn and not be sent an ambulance; quite the opposite should happen. However, a few years ago, the North East Ambulance Service built the lower-level 111 system and tested it before it was rolled out around the country.

[Mr Kevan Jones (North Durham) (Lab)]

I hear what the hon. Lady says, but is not the real problem that 111 was rushed in and relied on technology? When it originally started, we had trained paramedics in the call centres who could categorise cases. There is clear evidence, which I will present, that, if something is not deemed life-threatening or someone is not having difficulty breathing, the case is categorised as green. The figures produced are meaningless.

[Mrs Trevelyan]

I thank the hon. Gentleman for his comment. Quite a few of my constituents were among those experienced staff. Some were retired midwives or had worked as nurses and then moved into the call centre framework. There was a big shift a few years ago to downgrade the medical qualifications required for those staff. We are starting to see a change in that, because the new chief executive is mindful that the huge increase in demand is partly down to staff’s inability to assess cases correctly. If they took another 30 seconds, they could assess properly the situation on the end of the phone.

Will the Minister work with the people who are writing the algorithm and building the system to get it right? The ambulance service personnel would then have a better tool to work with. That would also encourage ambulance services, and not just our own in the north-east, to go back to higher-value trained personnel who can ask the right questions and get the right answers, so that we do not end up with over 70% of emergency calls ending in someone getting to hospital and finding that urgent care was not needed.

The other side of this issue, which I have been campaigning on with St John Ambulance, is the need to help families to be better educated so that they can assess their own medical conditions. Other than for cardiac arrests, strokes and such evidently dramatic changes, it is often not emergency care but urgent care that is required. We need to encourage people and build their confidence in assessing for themselves whether they should go to the pharmacy or the doctor or call for an emergency service. We need to do that across the board, focus on it and drive it forward.

St John Ambulance wants to get into every single school, so that we are teaching young children the difference between what to do if they burn their finger on the kettle—put it under the tap, instead of dialling 999—and what to do in an emergency, such as if granny falls down the stairs. The next generation would then have confidence in knowing the difference between when emergency care is needed and when they can manage and find the right care over a longer period.

Our paramedics will not be able to continue meeting the demand, much of which is inappropriately placed on the ambulance service. We should make much better use of our amazing paramedics and ensure that retention is higher, because they are valuable members of our community.

[Mr Kevan Jones (North Durham) (Lab)]

I congratulate my hon. Friend the Member for Washington and Sunderland West (Mrs Hodgson) on securing this debate. In the past 18 months, I have heard about 12 quite serious cases. The ambulance service is in crisis, and that is not down to the men and women who work in it; it is down to the management. Urgent action is needed if we are to avoid people dying and prevent the suffering that my constituents are going through.

I will give a flavour of that suffering. In July 2014, in Chester-le-Street, a woman’s husband has severe angina. The first responder arrives and says he needs an ambulance. Three hours later, the ambulance arrives. A gentleman falls in Chester-le-Street from a six-foot fence and bangs his head. He is told to stay and wait for an ambulance. He waits two hours for an ambulance that does not arrive, so his neighbour takes him to hospital. A lady in Sacriston, which is about 10 minutes from the local hospital, has severe abdominal pains and is passed out, unconscious, waiting two hours for an ambulance to arrive. In Tanfield Lea, an 86-year-old lady has a fall at 9.30 pm on 13 February. Her partner is told by the ambulance crew not to move her. After several calls, the ambulance arrives on Saturday morning at quarter to 1. Apparently it had been diverted to Newcastle.

Patient transport is also an issue. One constituent, who had had a stroke and severe mobility problems, was waiting for patient transport to a medical appointment but was told that the ambulance would not attend. Another constituent from Stanley was transferred from his home to the Freeman hospital for regular dialysis. He had to wait two hours for transport back home, leaving him in severe discomfort. Another constituent who lives in Chester-le-Street found a young lady passed out outside her front door. She called an ambulance, and an hour and a half later, the ambulance arrived.

In New Kyo, a constituent complained that a young woman was having a fit in the local bus station. One hour and 10 minutes later, there was no response. She called the police, and they got the ambulance to arrive. Another constituent from Chester-le-Street needed to be transferred from Bishop Auckland hospital to the university hospital of North Durham. The request was made at 5 pm. She arrived in hospital at 1 am the following morning.

In Beamish, a lady fell down a flight of stairs and called an ambulance immediately. The first responder said she should not be moved. Two and a half hours later, an ambulance arrived. In March this year, an elderly lady in Sacriston—literally a 10-minute ride from the local hospital—waited an hour and 47 minutes in the cold north-east winter, being comforted by her neighbours with blankets, having broken her shoulder.

The last case I will touch on, which I have permission to mention, was raised with me by Mrs Irwin in east Stanley. Her 69-year-old mother-in-law, Joyce Irwin, had a fall on 14 March at 7.20 pm. Her son, who lives with her, came home and rang for an ambulance at 7.25 pm. He was advised by the controller that an ambulance would be there within the hour. Nothing happened. Her eldest son arrived and rang both 999 and 111. The first responder arrived at midnight, without any pain relief, and Joyce Irwin therefore had to wait until 1.10 am—four and a half hours later, having been on the floor in excruciating pain—for an ambulance to arrive. When she was finally delivered to the university hospital of North Durham, she found she had a broken hip. It is worth reading what Mrs Irwin says. She states clearly that her mother-in-law was in excruciating pain and was promised an ambulance that she did not receive. She says that Joyce has

“worked and paid her duties all of her life”.

Is that the way to treat our constituents in the 21st century? I suggest not.

There is something severely wrong with the North East Ambulance Service. I have a particular problem with the way in which it treats elderly people. My hon. Friend the Member for Washington and Sunderland West said that the service is missing its targets for red 1s and 2s, but fall cases such as those I mentioned are not even put down as red 1s and 2s; they are put down as greens. In many cases, these are elderly people who have broken bones and are in severe pain, but they are put down at the bottom of the queue. Will the Minister interrogate the hospital trust about the way it is prioritising cases?

I have been told anecdotally by a firefighter and a policeman that if someone wants an ambulance to arrive quickly, they should ring them up and say that a person either has chest pains or is unconscious. They will then get an ambulance straight away. In this day and age, it is not acceptable that our constituents—elderly, vulnerable people like Joyce Irwin, who have done the right thing all their lives—are treated like that. They have worked hard and paid into the system, and they expect in their old age that if they need the NHS in an emergency, it will deliver. It is not only the individual who is affected. The trauma also affects their families and loved ones, who, in Joyce Irwin’s case, saw her on the floor for four and a half hours in excruciating pain. That is simply not acceptable.

May I also ask the Minister to tackle the North East ambulance trust about its response to Members of Parliament, because it is absolutely diabolical at responding to Members’ complaints? I have had many complaints from people who have called an ambulance when they have seen an incident and they ask why the ambulance took so long. When I inquire, the ambulance trust responds, “We cannot discuss that case because of patient confidentiality,” because the complainant was not affected. That is complete rubbish. Those people do not want to know what happened to the individual; they just want to know why an ambulance did not turn up. It is interesting that we have got this debate today, because I recently had a flurry of answers to my questions, but I say to the Minister that there is a serious issue about how Members of Parliament can represent their constituents who complain to them.

I have a similar problem—if the Minister wants to intervene, that would be helpful—with the North Durham clinical commissioning group, which has failed to answer any complaints at all, so I have raised the matter with NHS England. There is something seriously wrong with the North East ambulance trust, although it is not down to the hard work of the individuals who work for it. They do a tremendous job in very difficult circumstances. There is also a question about the priority system that uses algorithms, as the hon. Member for Berwick-upon-Tweed (Mrs Trevelyan) suggested.

There is a question about rurality as ambulances are diverted to more urban areas rather than rural areas. I did not think I would say this, but it might be time to break up the North East Ambulance Service and put it into special measures. It covers a large area and is completely failing. Will the Minister look into whether it is fit for purpose in the long term? I do not think it is. Urgent action is needed. People are not only suffering, but they have lost faith in the service, which is a terrible thing. What should be a flagship service—North East Ambulance Service—that people call upon only in a time of need is clearly failing.

--- Later in debate ---

[Ian Lavery]

What I am saying is not meant to be any criticism of the people in the call centre, either—because if they veer from the crib sheet they have got, they are in trouble; but it shows how bad the whole situation is.

I want to mention Mr Taylor. I must say that he is a relative of my wife, who waited 11 and a half hours for an ambulance to arrive. He was really poorly. Plenty of people came from the NHS and said, “He needs an ambulance”—and then someone says “He doesn’t” and someone says “He does,” and someone else says “He doesn’t”. When he actually got the ambulance, at 1.45 in the morning, he was in a coma. That was seven months ago, and he is still lying in a coma as we speak. If that ambulance had turned up before, he might not be.

I will not dwell on that point other than to say that that brings me on to the complaints procedure, because MPs have complained, as well, about what happens to our constituents. We get a chronological list of what happened, and why the ambulances could not come, because they were diverted to other more serious incidents. That is not good enough. It is not good enough for me to say to one of my constituents, “Your mam couldn’t get an ambulance because somebody else was more important”—when she was lying suffering. Or if someone has a terminal disease and is desperate, or someone has a chest disease—it is not good enough; and the complaints procedure is not good enough. They are not treating people like human beings.

I have got lots to say and not a lot of time to say it, but I am going to reiterate the fact that these delays are utterly unacceptable and we cannot continue on this basis with the North East Ambulance Service operating as badly as it is. Someone mentioned that the service will be fully operational in 12 months. I have heard that before. It is not good enough for the people who will trip, fall and stumble. It is not good enough for elderly people, or young people playing football.

[Mr Kevan Jones]

My hon. Friend has obviously had the same letter from the North East trust that I have had; but does he agree, also, that it is not good enough because it is a question of our constituents’ confidence in the service? It should be a first world service, but it is more reminiscent of the third world.

[Ian Lavery]

I fully concur with my hon. Friend’s sentiments, and I am pleased about that intervention, because I think I might otherwise have needed an ambulance myself. I feel as if my blood pressure it is getting exceedingly high.

More seriously, we have to look at the North East Ambulance Service now. We cannot announce a review in weeks to come. We have got to get to the bottom of why the service is operating so badly. It is not meeting its major targets in almost every single category. It has been mentioned that it may perhaps be put in special measures, or that it should be broken up. To be honest, I do not have the answers, but one thing I will say is that the Government have to look at the North East Ambulance Service and improve it in the same way as in other areas of the country. There is no reason why people in my area, in the north-east, should be tret any differently from anywhere else in the country. We need to get hold of the situation immediately.

--- Later in debate ---

[Mr Kevan Jones]

I hear this from the Minister and I hear it from the trust, but could I ask her officials or NHS England to actually delve into the figures? The hon. Member for Berwick-upon-Tweed (Mrs Anne-Marie Trevelyan) raised an interesting issue. This is actually about the ways in which ambulance calls are classified. There are clearly reds that are not reds, but the other point that I would like the Minister to address, even if she cannot answer it today, is the way older people are being treated, because they are being put down as greens, whereby they get no priority at all, and they are some of the most vulnerable people in our community.

[Jane Ellison]

Indeed. I have very much taken that point on board and I will try to respond, but if I do not do so today, I will certainly write to the hon. Gentleman, because it is a fair point. The more general point is where the ambulance service sits in terms of our response and general position on urgent and emergency care. I will respond to some of the points made by my hon. Friend the Member for Berwick-upon-Tweed (Mrs Trevelyan), because I think that this sits within a wider, systemic challenge and I want to touch on that.

Every patient should expect to receive first-class care from the ambulance service, but the nature of emergency response work means that there will always be incidents in which unfortunate timing leads to a person assessed as being in a non-life threatening situation calling 999 at the same time as several other people who are in life-threatening situations. I am sure that hon. Members are realistic about that, but clearly we do not want to hear about such problems occurring on a very regular basis. Where that does occur, obviously the life-threatening situations must be prioritised and resources focused on those calls. Very rarely—unfortunately, we have heard about such cases this afternoon—waits may be unacceptably long. I do not shy away from that, but it is important to remember that the vast majority of people receive a timely response when they dial 999.

I have already said, echoing the words of the hon. Member for Washington and Sunderland West (Mrs Hodgson), who led the debate, that although the NEAS has not met the performance targets, that does not reflect on the hard work, dedication and skills of the local staff. A number of speeches brought that out. I am advised that although ambulance delays are the main reason for patient complaints, the number of complaints received in 2015-16 fell, but we do not want any complaints; that would be the situation in an ideal world. However, the fall is indicative of the fact that the efforts of the local ambulance staff are paying dividends. Although the performance target is effective in driving improvements and maintaining response times to the most critically ill and injured patients, it does not, inevitably, paint the complete picture of how a trust is doing.

I will talk about some things that the North East Ambulance Service, has put in place to bring about improvements to service, because that is the focus of the debate and people want to hear that the direction of travel is positive. The NEAS continues to expand the number of specialist clinicians working in its clinical hub who can provide telephone assessment and advice, and who can prevent the dispatch of an emergency response if it is not deemed necessary. That goes to one of the points made earlier. The trust expects that that will have a positive effect on response times.

Last winter, the NEAS piloted an end-of-life-care transport service, which provided three dedicated ambulances that were on call to respond to transport requests from healthcare professionals to take a person to their final place to die. The scheme has meant that emergency ambulances are not tied up in transporting patients when they are needed for more serious cases, and that terminally ill patients are not waiting a long time for transport to their preferred place of death. Although we do not often like to talk about end-of-life care, the preferred place of death is an important part of reducing stress at an inevitably very difficult time for an individual and their family. Results from the pilot were overwhelmingly positive and eased pressure on vital services.

Hon. Members have raised valid concerns about handover times between ambulance crews and emergency departments in the local area, and that is an issue across the country. Patient handover needs to be as efficient as possible to achieve the best possible outcome for the patients and to free up ambulance resource, but more can be done and is being done. Measures include hospital ambulance liaison officers, which are being put in place by the NEAS. HALOs are present in hospitals across the trust territory and I am advised that the trust has sought to make use of dedicated ambulance resource assistants as well.

The urgent and emergency care vanguard programme in the north-east will include the development of a standardised handover process for all acute providers, intended to minimise delays across the patch. That goes to the shadow Minister’s point about looking at the wider system. That will be to the benefit of crews and emergency departments. I understand that, as part of the vanguard, the NEAS also hopes to secure funding for a new “flight deck” information system that will enable diverts by ambulance crews to other hospitals to be proactively managed and will prevent ambulances from stacking up outside already full A&E departments. The trust believes that those initiatives will help to distribute A&E workload evenly and will be welcomed.

Several hon. Members have rightly commented on the recruitment challenge. It is very much recognised that there is currently a shortage of paramedics nationally and the NEAS trust is no different. We recognise that front-line staff are the vital component of a safe, effective and high-performing service, and work is being done by the NEAS to rise to the recruitment challenge. The hon. Member for Washington and Sunderland West mentioned some things that are being done. Efforts include developing new advanced technician roles to support front-line services, and the trust is running a substantive recruitment of paramedics nationally and internationally.

The trust expects 77 student paramedics to graduate by February 2017, in addition to recruiting an additional 36 qualified paramedics in 2016-17. The trust has also recruited a total of 56 emergency care clinical managers, and that represents a significant investment in front-line clinical leadership. It also advises me that it expects to be up to full paramedic establishment by April 2017. I know that that commitment will be keenly watched by hon. Members.

Mental Health Taskforce

Kevan Jones Excerpts

Tuesday 23rd February 2016 Commons Chamber

[Mr Speaker]

I know that the right hon. Gentleman will take it in the right spirit when I say that it is immensely encouraging that he notices his own answers.

[Mr Kevan Jones (North Durham) (Lab)]

Parity of esteem and extra resources are important, but one of the main messages from this report is that we need to hard-wire mental health and well-being into public policy. Twice as many people take their own lives as are killed on our roads each year. Does the Minister agree that it is now time for a national campaign to address this issue?

[Alistair Burt]

Yes, I do, and I thank the hon. Gentleman for his comments and for his work and interest in this area. Included in the taskforce’s recommendations is a national ambition to reduce by 10% the number of suicides—that would be a reduction of some 400 a year. Three areas are already piloting a “zero suicide ambition strategy”, and this probably needs to be given more prominence than it has been. A national suicide prevention strategy is in place, which I am reviewing to see how it can be better implemented locally, because not all local areas have a similar strategy. It is right that that gets extra prominence, and we had a debate on it not too long ago in Westminster Hall. We recognise that it is a significant issue for men in particular, because three times as many men as women take their own lives. The recent increase in the number of women doing so, which was noted just a few weeks ago, is also significant. It is important that we talk about this more, recognise that suicide is not inevitable, and have a national ambition to challenge it and do more. I am confident that the hon. Gentleman will be able to champion that work, just as he has championed other things.

Mental Health

Kevan Jones Excerpts

Wednesday 9th December 2015 Commons Chamber

[Mr Kevan Jones (North Durham) (Lab)]

I welcome today’s debate. We are doing a very simple thing today, but it is very effective: we are again talking about mental health in this Chamber. Both the Secretary of State and my hon. Friend the Member for Liverpool, Wavertree (Luciana Berger) talked about a change in attitudes and said that things are changing. I agree totally that things are changing for the better, not just in this place, but in the media and in society. Sadly, in my own party there are some parts that still need to go a bit further in understanding mental health, but we are making great strides and they should be recognised. That is down to the great work that is being done by Rethink, Time to Change and other charities, which are not only those individuals who work for those organisations, but the thousands of volunteers behind them.

[Chloe Smith]

I hope the hon. Gentleman will welcome this intervention, because I seek only to give him the due credit that he deserves for his place in that all-too-brief history of our actually talking about mental health.

[Mr Jones]

I thank the hon. Lady for her intervention. I have a simple view on mental health, which is that we need to talk about it more, because that will change attitudes.

What do we do next? Well, we need to hardwire mental health and mental wellbeing into public policy and society. To those who ask why that is important, I say that not only is it the right thing to do, but, even in these times of austerity, it makes economic sense. It saves money as well as lives. We need a system in which every single Government policy is road-tested against mental health and mental wellbeing.

The Secretary of State accused my hon. Friend the Member for Liverpool, Wavertree of being political on this matter. Well, I am sorry, but the Government cannot escape from some of the things that they are doing in this area. It is the Opposition’s job not only to question the statements they make, but to look at the facts. The Chancellor announced an investment of £600 million in talking therapies, which I welcome, but that is set against a cut of almost 8.5% in the previous Parliament. The money will do nothing to replace the beds that have been lost in psychiatric wards. As the right hon. Member for North Norfolk (Norman Lamb) has said, there are people who have to travel ridiculous distances around the country to access those beds. What is the root cause of that? Is it a shortage of beds? Yes, it is in some areas, but another root cause, particularly in London, is the shortage of available housing. Our housing policy has a direct effect on the problem.

Another area of concern relates to the back-to-work interviews and the work capability assessments. My hon. Friends and I have raised that matter on numerous occasions, but the Department for Work and Pensions is not listening. People are still being put through that tortuous process, which is neither good for the taxpayer nor good for the individuals concerned. A 56% cut in the local government budget will have a direct effect on the delivery of mental health and support services. At the moment, a consultation exercise is out on the formula for allocation of public health funding. On that basis, County Durham will lose £20 million a year.

People might say that all those policies have nothing to do with mental health, but they do have a direct impact on the services that we deliver. We need to hardwire mental health and mental wellbeing into all those areas, whether it be schools, society, the family or the criminal justice system.

Many issues face people with mental illness. Personally, I have been to some very dark places, but the most tragic and darkest place is faced by those who commit suicide. We are talking about not just a life being cut short, and the opportunities that are missed in terms of the fulfilment that that person could give both to society and to their families, but families being left bereft and in a very emotional state. In this country, three times more people commit suicide every year than are killed on the roads. We had a great road safety campaign, which addressed the problem of people being killed on our roads. We need the same campaigning zeal to attack the suicide rates in this country.

My own region in the north-east has an unenviable suicide record. We have the highest rate of suicides in the country, with 13.8% per 100,000 individuals taking their lives. Such rates are related to the economic situation. People may try to gloss over that fact, but economic situations do affect people’s lives. We must also address the fact that 78% of that figure are men. Men are terrible at talking about mental health. So, yes, progress is being made, but we do need to have mental health and mental wellbeing running through all Government policies.

I welcome the debate today, because it provides us with another opportunity to talk about mental health on the Floor of the House, which must be a good thing. Now is the time to change those words into action.

[Several hon. Members rose—]

--- Later in debate ---

[Mr Kevan Jones]

I commend the right hon. Gentleman for his work. Does he agree that those leaders now need to translate that action into policy, both at a national and a local level?

[Norman Lamb]

I totally agree. We have to set the framework, put the funding in place and deliver services on a local basis. How can anyone in this Chamber possibly justify this: if someone has suspected cancer, they have a right to an appointment with a specialist within two weeks of referral by their GP, but a youngster with an eating disorder has no such right, yet we know that their condition can kill? That is a scandal and an outrage and it must change. There must be equality of access.

When someone does get access to treatment, too often it is a lottery. As we discussed last Friday, we have the continuing scandal—the hon. Member for North Durham (Mr Jones) referred to this earlier—of people being shunted around the country in search of a bed. That would never happen to someone suffering from a stroke or a heart condition. It is inequality of access to treatment, and it is a complete scandal.

[Mr Jones]

There is an issue with the number of beds, but does the right hon. Gentleman also accept that one of the problems is that people are in those beds for far too long? One of the crisis points in London is access to adequate housing so that people can be discharged into the community.

[Norman Lamb]

I was so pleased that the hon. Gentleman made that point in his speech, and I pay tribute to him for the work he has done. The answer is not simply to have more beds; we should also be reducing the length of stay, which often is not therapeutic for the individual. Getting them into secure housing is central to their health and wellbeing.

Cities and Local Government Devolution [Lords] Bill

Kevan Jones Excerpts

Wednesday 21st October 2015 Commons Chamber

[James Wharton]

I have had discussions with my hon. Friend the Member for Altrincham and Sale West, I recognise the comments that he makes and I will of course listen carefully to the further discussion today. I will set out the Government’s position on the issue in due course, but I wish to make it clear that the intention is to be consensual. We intend to listen to concerns that hon. Members might raise and try to find a way whereby we can agree across this House on what we want to deliver. I recognise the important point being made and I am sure we will discuss it further.

Amendment 4 is about mayors being a condition of devolution. We are seeking to remove the requirement that a mayor cannot be a precondition of transferring local authority or public authority functions to a combined authority, because it is wrong in principle, and it is at odds with our manifesto policy and manifesto commitment. In addition, if the requirement remained, it would mean that the deals we have made already with Greater Manchester and with Sheffield could be in jeopardy. The requirement is wrong in principle.

[Mr Kevan Jones (North Durham) (Lab)]

I welcome this movement, but can the Minister explain why the Secretary of State has always insisted in his discussions with the combined authority and the north-east council leaders that a prerequisite for any devolution is having a mayor?

[James Wharton]

I think the hon. Gentleman may have misunderstood the direction of travel that I am setting out, but I am happy to clarify it and I hope to go on now to address his concerns.

--- Later in debate ---

[James Wharton]

It is important to be clear about what the devolution we are talking about does. It takes powers that exist in Whitehall—powers that rest with public bodies—and transfers them to local decision makers. It does not affect the arrangements that are already in place for local government, which recognise differences and the communities within them. We will allow them, of course, to pool areas of policy if they wish to do so, but nothing in this legislation would allow us to compel them to do so.

In his Budget speech in July, the Chancellor was clear:

“The historic devolution that we have agreed with Greater Manchester in return for a directly elected Mayor is available to other cities that want to go down a similar path.”—[Official Report, 8 July 2015; Vol. 598, c. 329.]

All of that is reflected in our manifesto commitments to

“legislate to deliver the historic deal for Greater Manchester”

and to

“devolve far-reaching powers over economic development, transport and social care to large cities which choose to have elected mayors.”

[Mr Kevan Jones]

I would like the Minister to clarify something. As he knows, the north-east combined authority area is not a metro area, because it covers a large rural area. He said that the agreement is between the combined authority and the relevant Minister, but the insistence so far from the Secretary of State has been that the only way the north-east combined authority will get devolution is if it has an elected mayor. Is the Minister now saying that there is an option for devolution without an elected mayor for the north-east?

[James Wharton]

The hon. Gentleman will recognise from the quote by the Chancellor that I just read out that where areas want significant devolution on the scale that Greater Manchester has and where they have metropolitan areas at their heart, the Government will ask for that requirement to be part of that deal process. However, nothing in this Bill will allow the Government to compel any area to have a mayor or to have devolution. This is an enabling piece of legislation. The hon. Gentleman is absolutely right that in the deal that we are discussing with the leadership in the north-east area—all of it from his party—there is that expectation and requirement, and it is a deal on which great progress is being made.

--- Later in debate ---

[Mr Betts]

The right hon. Gentleman is absolutely right. Of course, the whole principle of the devolution that the Government propose, which I support, is that areas should come forward with their own ideas about what they want to see devolved. Why should they not also come forward with their own ideas about how that devolution should be exercised and about the governance arrangements for it?

[Mr Kevan Jones]

I agree with my hon. Friend, but it is obvious why the Government want mayors. In certain areas—in his area and in others—they are hoping to break up the powers of locally elected Labour local authorities in the hope that if they have an elected mayor, they will either get an independent or someone who claims to be independent but is actually a member of the Conservative party.

[Mr Betts]

I would not want to second guess the motives of the Secretary of State, so I will use my own arguments to resist what the Government are trying to do.

Apart from the inconsistency of approach, the proposals are confusing. That takes me back to the point I made in my intervention on the Minister. In the Sheffield city region the economic powers, which are important and cover skills, economic development and the infrastructure associated with it, are to be devolved to the combined authority, which will cover nine districts—four metropolitan and five non-metropolitan districts. But as I understand it from the deal, the mayor will have responsibility for just transport. So the mayor is to run transport, and the combined authority is to run economic development. The public want some consistency of approach on these matters. I do not believe that the combined authority, the district, would naturally have come forward with a proposal that broke up the responsibilities in this way.

--- Later in debate ---

[Mr Kevan Jones]

My hon. Friend talks about the principles of devolution, but one of the key factors as to whether it will work will be the proper and fair allocation of resources. This Government have a track record of devolving responsibility to local authorities while at the same time top-slicing their budgets. Is not my hon. Friend concerned that this Government, who are committed to a small state, will devolve not only responsibility without resources, but blame for cuts?

[Mr Allen]

My hon. Friend makes a very sound point, of which we should all be wary. We need to break that system so that we are able to go with the begging bowl and say, “We can prove we need a little bit more than anyone else,” and take as much control as possible of our own areas and resources. The amendments I have tabled seek to achieve that. The localities need their own tax base and powers. Those powers also need to be entrenched so that they cannot be sucked back by any Government—by that black hole of magnetic force we call Whitehall—unless they are able to demonstrate that their stance can be defended constitutionally, as explained in a couple of my amendments.

We need not be afraid. As well as the tremendous example of what has happened in Scotland, we have the example of what happens in every other western democracy. People in western Europe and north America take as given the independence of their locality, state, region or länder from the centre. They cannot be told what to do. The idea that the President of the United States could tell the states of New York and Georgia how they should spend their money is laughable, as is the idea that all the money in individual areas in Germany, Italy and Scandinavia should go to the centre and then be redistributed. They would think we were crazy if we proposed that system for them, yet that is the system we operate for ourselves. We are the oddities—we are the odd ones out.

We need to mature as a democracy. Sometimes I think our democracy is a bit frail and feeble, but actually it is underpowered: we do not have enough of what other nations in the western world have and we are unable to take steps forward. That is why I welcome the Bill in general, but I want to propose a number of other steps for the Minister to take either now or, perhaps more realistically, in the next devolution Bill.

--- Later in debate ---

[Mr Rees-Mogg]

I am very grateful for the hon. Lady’s intervention, because it brilliantly encapsulates what I want to say, which is that Bristol is a fantastic city, a noble city, a city of fine history, but it is not Somerset. What I want to do is to protect Somerset from encroachment by Bristol. I want Her Majesty’s Government to ensure that the people of Somerset are not subjected to any pressure, any force or any arm twisting to be ruled from Bristol or to subsidise Bristol. I would rather, and I know the people of Somerset would rather, see our money spent through decisions made in Whitehall than decisions made in Bristol. We see the unity of the nation and we see the history of our county; what we do not see is a random administrative area.

I hope that the Minister can give me one commitment, which is that if we do not sign up to these things and if we retain our independence and freedom of manoeuvre, the Government institutions that spend money, such as Highways England, will continue to spend money—that it will not mean any loss of money, but will merely be about who decides how it is spent. For once, I am trusting the man in Whitehall against the man in red trousers in Bristol.

[Mr Kevan Jones]

The Minister made three startling claims in his opening remarks. He said that mayors will not be imposed, that devolution settlements will not be imposed and that the Government will seek consensus on such settlements. That is just not what the Government are doing.

The hon. Member for North East Somerset (Mr Rees-Mogg) talked of an iron fist in a velvet glove. What we have here is complete doublespeak. The portrayal of the situation by the Minister and others is that these decisions will somehow be taken in local areas. At the same time, the North East combined authority is being told that it will get devolution, but that a non-negotiable condition of that is to have a mayor. When councillors meet the Secretary of State and ask him why they need a mayor, he says that it is because the Chancellor of the Exchequer requires it as a prerequisite of devolution. The Conservative party and its friends in the north-east state that when the North East combined authority’s leaders ask sensible questions about why other areas have devolution without a mayor, or legitimate questions about how the mayor will work in practice, they are somehow being difficult, and that is why amendment 51 is so important. Throughout this entire exercise we are forgetting one important group of people—those who elect us and who are served by local councils and local areas.

Last week on Second Reading the hon. Member for Bromley and Chislehurst (Robert Neill) claimed that the Secretary of State was being a Chamberlain-style reformer. No, he is not, and I agree with my hon. Friend the Member for Sheffield South East (Mr Betts) when he says that we will end up with a complete dog’s breakfast.

There has been no great commission. When the Conservative party restyled local government in the 1970s we had the Redcliffe-Maud report, and in the ’60s—I think it went over into the Heath Government—the Crowther commission considered devolution. At least we are considering the issue and have some consistency to our approach, but that is because this Bill has nothing to do with real devolution and is about the Chancellor’s political control. He is seeking to ensure that the cuts required by his ideal of a small-state Britain can be devolved to local authorities or mayors, so that when people ask, “Why do you have to make these cuts?”, he will stand back and say, “It is nothing to do with me. It is down to your local mayor, and you decide.”

[Ian Mearns (Gateshead) (Lab)]

The North East LEP does not really hang together cohesively in its geography. It extends from south of Barnard Castle that borders North Yorkshire, right up to the Scottish border at Berwick-upon-Tweed—a considerable distance. This is not some sort of city region; it is an urban heart with a considerable rural hinterland. It does not hang together well from a business perspective.

[Mr Jones]

My hon. Friend makes a good point. In 2010 the Government were completely against regions, but now they have recreated a region in the northern LEP area. What he says is right—the area is very diverse and has some difficult issues regarding population, services, and other things that are delivered.

This is slightly different from when we had mayors for local authority areas. The Minister said that we need elected mayors because this is about devolving power from Whitehall to the regions, and that is why the approach needs to be different. I am sorry but—I make no bones about this—in 2004 I remember the Labour Government’s proposals for regional government in the north-east. Was it right for local people to have a say in whether the north-east had an extra tier of regional government? Yes, I think it was, and people overwhelmingly rejected it. I am not sure whether the Minister was around then, but many Conservatives in the north-east who now support him argued vigorously for the idea that it was right for people to have a say in the future governance of their region. Indeed, I think that some of the people who funded his election campaign also funded the no campaign in the north-east.

If it was good enough then, and the Conservative party and its backers in the north-east argued vigorously for why we should allow people to have a say, why now will they not allow people to have a say over a new tier of regional government? That is inconsistent, and it is interesting that the same voices that once argued vociferously against regional government in the north-east have remained completely quiet now that a Conservative Government are preparing to impose a system on the north-east without giving local people a say.

I congratulate the hon. Member for Hazel Grove (William Wragg) on his amendment, and I hear what people are saying about Manchester. I will not get into Manchester politics, but council leaders should be careful. If we have learned one thing in the past few years, it is that people cannot be taken for granted. If we are to listen to and represent people, it is important at least to give them a say in what we do. This is a major issue, given the change to how the country will be governed, and excluding people in the north-east and not giving them a voice in their future is completely wrong. The Government need to explain why they are afraid to allow people in the north-east to have a say in the future governance of their region.

[Several hon. Members rose—]

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[James Wharton]

My hon. Friend is of course right about the importance of sharp accountability with respect to the ability of a metro mayor to drive the change that devolution presents an opportunity to deliver. This direct approach from the elected metro mayor should help to ensure that we get the maximum benefit from a process of devolution. That has been shown the world over, when many big cities with mayors deliver real improvement and success for the areas they represent. It is a proven model, one that we want to see delivered through this devolution agenda. It is also one, importantly, that will not be imposed on any area.

[Mr Kevan Jones]

Will the Minister just be honest? He says that he is not going to impose a system, but he well knows the alternative. Unless the north-east accepts an elected mayor, no devolution will take place. That is a take-it-or-leave-it provision; it is an imposition by any other name. The Minister should admit that he wants to impose an elected mayor on the north-east irrespective of what local people or local politicians want.

[James Wharton]

I listened carefully to hon. Gentleman’s contribution, and I know that he is exercised by this issue. I do not recognise the narrative that he put forward as entirely fulsome in its representation of the processes that are under way. [Interruption.] I will explain my comments thus. The Bill does not allow the Government to impose devolution or a model of devolution on any area. It allows areas to reach agreement with the Government about devolution when they see the benefits to their areas from it.

In the north-east—an area represented by the hon. Member for North Durham (Mr Jones) and one close to my heart and interests—we have had productive discussions with local authority leaders. Those leaders are not exclusively Conservative or even Liberal Democrat, as we are talking to Labour local authority leaders, too, and they are working with us to find the right package to deliver devolution. The Bill gives no power to impose devolution on the north-east and we would not attempt to impose a model of that devolution without the two going in tandem. The opportunity is there in the legislation for areas to ask for devolution; we can enter into discussions and deals can be made in a bespoke and bottom-up way to ensure that every area gets the right deal.

We have been clear throughout this process—it was clear in the manifesto on which this party stood at the last election—that if areas with large metropolitan city centres want a devolution package similar to the one that Greater Manchester has agreed with the Government, we would expect a metro mayor to be part of the package.

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[James Wharton]

Of course. Areas that choose not to be part of devolution—and it is their choice; devolution will not be imposed on anyone—will suffer no disadvantage as a result of that choice. I shall be happy to meet my hon. Friend and his colleagues to discuss any concerns that they may have about what may come to be proposed for the area that my hon. Friend represents, and also about the implications should an area choose not to be part of the process. This is not about imposition; it is about consensus, working together and co-operation.

[Mr Kevan Jones]

Will the Minister give way?

[James Wharton]

I will if the hon. Gentleman is very brief. I know that he is enthusiastic to have his say.

[Mr Jones]

I am, because what the Minister has just said is not true. What has been said to the seven local authority leaders in the north-east is they must either accept the mayor and the devolution settlement or not receive the extra money that has been trumpeted by the Tory party in the north-east and by the Minister’s friends. The only way to get extra resources for the north-east is to accept an elected mayor and the system to which the Minister is agreeing.

[James Wharton]

I am not sure how much more clearly I can express myself. We will not impose devolution on any area, but any area is free to come forward and negotiate with the Government to make a deal for the delivery of devolution if it wishes. Areas that do not choose to be part of devolution will not have anything taken away from them as a consequence, and when devolution is delivered, it will be about powers coming down. Local authorities will only see powers transferred up to a metro mayor when they opt for that to happen. I think I have made myself very clear on that important point.

There is one more important point that I want to make to Opposition Front Benchers, about amendment 4. It is imperative that when the conditionality amendment that was made in the other place is put forward, we are able to deliver on our manifesto commitments, and so that we can do that, the changes that the Government have proposed today need to be made.

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[Mr Allen]

Our London colleagues have done some fantastic work on how to localise taxation that is currently held by the centre. That has to be done sensitively and carefully, but as I said earlier—I do not think my hon. Friend was present then—every other western democracy manages that difficulty without a problem. In Sweden, America, Canada, Italy, Germany and Holland, it is second nature to retain money locally from business rates, landfill taxes and land taxes such as stamp duty. They get by pretty well. In fact, because that system is institutionalised, their local government has immense power over and above what we have as vassals. In effect, we do what we are commanded to do according to the crumbs left in the begging bowl after the Chancellor has done his bit for the national economy.

It is absolutely open to us to do work similar to that done by my hon. Friend, Professor Tony Travers and consecutive London Mayors to liberate people. Nottingham gets a lot of tourists because of the Robin Hood tradition and the castle, so we could have a hotel tax or a bed tax of £1 a night. That happens in other western democratic countries and the people endorse it. There is a big caveat though: no council should do this unless the people have okayed it and bought into it. Councils should also be able to borrow on the open market on the basis of their credit rating, but they need to have the consent of the people. It is perfectly possible for us to do what my hon. Friend suggests.

[Mr Kevan Jones]

I have been listening carefully to my hon. Friend and, while I do not disagree with him, the proposal to retain 100% of business rates will be a disaster for some poorer areas. It is fine for areas of central London, such as Westminster, to argue for the ability to retain 100% of their business rates. However, business rates in poorer areas of the north-east and elsewhere are never going to generate a great deal. In fact, one large closure can devastate the local income base. There has to be a redistribution mechanism.

[Mr Allen]

My hon. Friend is absolutely right. A proper redistribution mechanism—whether it is based on the amount received from income tax, business rates or any other taxation—must be in place; otherwise the system could be distorted and deeply unfair. That is why my amendments, which my hon. Friend will have read, suggest that equalisation should be central to the process; otherwise we will end up with the disjointedness he mentions.

[Mr Allen]

No, I do not believe that is the case. That happens everywhere. Although I am very much an ardent devolver, I believe there is always a place for the federal level. President Clinton was not denied his wish to introduce Head Start to every state in the union. He did not impose it, but he offered it as a federal programme and virtually every state picked it up. Devolution would not diminish our role in this place to do good things, and it certainly should not diminish our role in insisting on the sort of equalisation that my hon. Friend the Member for North Durham (Mr Jones) has in mind.

[Mr Kevan Jones]

Does my hon. Friend agree, though, that that is not what is being offered by this Government? They are offering retention of 100% of business rates without equalisation, which will have a dramatic effect on those areas with low business rate receipts. It will also be to the advantage of some areas that perhaps do not need extra resources.

[Mr Allen]

I again agree with my hon. Friend. We are not there yet and it is not a done deal yet. We need to make the points that he very ably makes about equalisation. I will say to him, however, that if it is a choice between being instructed by Whitehall how to spend not very much money and having not very much money to spend locally, I would go for spending it locally every time, because we will maximise value and spend the money sensitively. Whatever money is available, it is better spent by those who know what they are doing, rather than by the man in Whitehall. I totally accept my hon. Friend’s points.

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London is different from the rest of England. The scale of our economic and social challenges, our rapidly rising population and the fact that our competition is now far more about New York, Berlin and Tokyo than about other UK cities demand a much stronger devolution package for London. That does not by any means undermine the case for further devolution to other parts of England, as the Bill already suggests.

[Mr Kevan Jones]

Amendment 2, tabled by my hon. Friend the Member for Nottingham North (Mr Allen), calls for the creation of a constitutional convention, which I think is very important.

As we heard earlier from my hon. Friend the Member for Sheffield South East (Mr Betts), the Government’s proposals are likely to end up as a dog’s breakfast. The Bill does not represent a movement for devolution or an attempt to improve local government or governance; it represents a clear political agenda. It is about the Chancellor’s vision of a small state Britain that will make it easier for him to push through draconian cuts. Once he has pushed responsibilities down to local government or regional tiers, he will be able to top-slice the budgets, while the difficult decisions will have to be faced locally, by mayors and councils. Those individuals will get the blame for the tough decisions that will be taken. The Chancellor and this Government will step back and say, “I’m sorry, it’s not our fault; it’s your local decision-making process.”

This is a unique way of approaching the devolution debate in this country. There have been other approaches. There was the Crowther debate in the late 1960s and early 1970s, which stood back and looked at not only Scotland, Northern Ireland and Wales, but how to devolve power locally. The Redcliffe-Maud reorganisation of local government took time to look at future structures for local government. That was controversial at the time—some of the historical counties were abolished, for example— but at least there was an evidence base.

That is not what is on offer now, which is why amendment 2 is so important. We need a properly thought-out national debate on devolution and what the structures will be. What we have now in this so-called enabling legislation is legislation with a big stick attached to it. Local areas such as the north-east have been told they can have devolution but only if there is an elected mayor, even though the Minister keeps denying that. He said an interesting thing in response to the previous set of amendments; he said no area would be disadvantaged if it did not go down the devolution route. That is not what he has been saying in the region or what his supporters in the Conservative party have been arguing in the region. The argument there is that if these truculent local authorities do not agree to devolution, they will lose out on all this money. The Minister has changed his tune this afternoon and said that is not conditional. It will be welcome if there is still an option to get those extra resources without necessarily going down the route he wants.

This is about local decision making, but what is key in any organisation is who holds the purse-strings. The Chancellor still holds the purse-strings under what is being proposed, and when the tough decisions come down the line his fingerprints will not be on them.

My hon. Friend the Member for Harrow West (Mr Thomas) mentioned business rates. I take his point: allowing local councils and others to have the powers to regenerate areas and try to create extra revenue is welcome, but he will appreciate—as my hon. Friend the Member for Nottingham North noted earlier—that there is not a level playing field across the UK. Without any mechanism for redistribution in local business rates, areas such as the north-east—those that have already been hit disproportionately by this Government taking the need element out of grant formula, which rewards richer areas more than poorer areas—are going to lose out.

Westminster city council will benefit if it gets to retain 100% of its business rates and gains from any new development it can have. Its situation will be easy compared with that of the poor people of Redcar; Redcar council is going to find it very difficult to attract new development that plugs the hole left by the closure of the steelworks.

We need to ensure we put in place structures that not only will work and have the support of people, but are practical. If we have a Teesside mayor and a mayor for the north-east, both will have responsibility for transport in their area. Where that will leave the A19, the M1 or any of the other transport links that cross the area, no one seems to know. Will the mayor of Teesside be responsible for the section of the A19 as far as the border of the area? Will the mayor for the north-east assume responsibility for the road network beyond that point? Therein lies one of the issues.

The Government said that they were against regions, but they have now divided quite a small geographical area. Supporters of the proposals have not explained how all this will work in practice. They have been out there in the north-east vigorously putting forward their case. Many of them have been posing as business people while forgetting to tell everyone that they are actually Conservatives.

There is a similar problem with resource allocation. The Government are proposing to impose a new tier of regional government, but how will it relate to the existing local authority tiers? The Minister keeps saying that this will be different because it involves moving power down from Whitehall to the region, but I can envisage people starting to ask whether they really need the large numbers of councils that they have at the moment. That will certainly happen in Manchester, for example. I know that turkeys do not usually vote for Christmas, but some local authorities need to think about where the Government’s agenda will lead. The Conservative party has traditionally been quite passionate about local government—it has always been supportive of it—but I believe that the Bill represents a move to reduce those tiers of local representation.

We need to step back and look not only at how the new system will work in practice but at the levels of local support. The Government are refusing to allow the people of the north-east a say in whether they want an extra tier of local government. The Minister is adamant that he is not prepared to give those people a say over whether they want an elected mayor whose responsibilities would stretch from the Scottish border down to Barnard Castle. As I said earlier, when we proposed a regional assembly in 2004, we quite rightly put it to the people. The Conservatives and their supporters argued vigorously against the proposal, and I am sure that if the then Labour Government had imposed an assembly on the region without taking the proposal to the people, we would rightly have been criticised. There would have been an outcry. Those same advocates who argued against us then are keeping very quiet now, however.

I have some sympathy with the amendment tabled by the hon. Member for Carlisle (John Stevenson). He has raised various issues, and I agree that there is a problem. One question that some of the smaller district councils will face is whether they will have capacity as a result of the cuts that will be imposed in the autumn statement, on top of those that have already been imposed. The last Labour Government introduced unitary councils in the north-east, in Durham, and it was one of the best things that happened making decisions more straightforward. I hate to think what some of those smaller councils would do if they were still in existence now, given the cuts that this Government have imposed. I doubt that they would have the capacity to deliver their services.

I put it to the Minister that these larger areas will need an effective mechanism for ensuring that local people are engaged in the decision-making process. I used to work in Cumbria and I know it well. I understand some of the attitudes he has referred to. Having a veto over decisions on what is needed there could be a disadvantage for Cumbria rather than an advantage.

We need the measures that my hon. Friend the Member for Nottingham North is proposing. We should have had them in place before we embarked on this process, but the Government know exactly what they are doing. This is not about devolution. It is about the clear political agenda of the Conservatives and the Chancellor. They know what they are doing, and it has nothing at all to do with the proper devolution of decision making.

[John Mann (Bassetlaw) (Lab)]

I concur that a constitutional convention would be very sensible, as my hon. Friend the Member for Nottingham North (Mr Allen) said.

I hear the idea of a hotel tax in London—I hope it is not on my constituents coming down for a good overnight stay, but on those coming from abroad. I am not sure a hotel tax would work particularly well in Bassetlaw, although it is worth considering. I recall that until the last few years Welbeck Estates levied £3 on every tonne of coal produced for a century. If local government had been allowed to do that, Bassetlaw would be a very different place, because the infrastructure and so on would have been appropriately remunerated for the coal that we provided for the rest of the country in wartime and in peacetime, at great cost. That concept of local decision making is a very good one, so I would accord with the idea, but I hope there would be some exemptions to anything that is done in relation to the good people of Bassetlaw.

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[John Mann]

I suppose Bassetlaw would have the option of declaring itself a unitary authority, of getting approval for that and of joining Sheffield city region. There may be routes around it, but the principle is fundamental. We need to have the ability to choose. If those two choices were put to the electorate, I suspect that I know which they would choose, and probably decisively. They may have a different view to me, but that is their prerogative—we have a word for that: democracy. What we do not want is “undemocracy”. Some people are very hostile to what the Government are doing and some are much more sympathetic. Either way, will these two options—is it the D2N2 model—lead to more councillors?

[Mr Kevan Jones]

I am very interested in what my hon. Friend is saying. He knows that I am very familiar with his constituency, having grown up there. Does he think that the fundamental weakness of this Bill is that there is nowhere for the people to have a say in what actually happens?

[John Mann]

The Minister will clarify whether, legally, people can have a say, but I am sure that there are ways in which a say can be created to ensure that there is popular consent. There are ways in which we could choose to do that. I am not talking about my own informal consultations, which are pretty huge. It would be interesting to get the Minister’s take on that. Those are key points.

Can we have some assurance that, over time, these measures will not lead to more elected representatives? If people are honest, they understand that if we have a two-tier scenario linked in with unitaries, either the districts or the counties will inevitably go at some stage, and probably sooner rather than later. That is bound to happen. Some may say that that is a good thing. As I have said, I have argued for unitaries before, but it is important that councillors understand that that is what is happening. Similarly, it must be clear that we will be able to choose, and the Derbyshire districts will be able to choose, where we will go. I am sure that the Government want that. They say that it is a brilliant idea, so they must want us to be part of it. It is really how we do that with guarantees. It would be useful to have that on the record.

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[Alistair Burt]

I know the area well, and I know exactly what the hon. Gentleman is referring to. Yes, that is part of the consideration, but it is essentially part of the consideration of the combined authority. Not only will it have to devise the working of its services within the confines of what is commonly known as Greater Manchester, but it will have to recognise that some of the provision of those services is carried out by those with cross-border responsibilities, and work something out with the adjoining areas. Nothing in the Bill speaks to that, because it does not relate to what I am discussing—the control of standards and the like—but the hon. Gentleman is absolutely right. That is part of the process that people will be going through.

[Mr Kevan Jones]

The Minister has said that the Secretary of State will retain overall control.

[Alistair Burt]

Not overall control.

[Mr Jones]

If something goes wrong in the delivery of care, where does the buck stop? Does it stop with the Secretary of State, or at local level?

[Alistair Burt]

I have read the report of the debates in the House of Lords on exactly this topic, because there was a lot of confusion. My understanding is that it depends on precisely what the breakdown is. Let us suppose that the breakdown, or failure, is in the way in which services have been put together by the combined authority. This is purely off the top of my head, and does not refer to anything of which I have any current knowledge. Let us suppose that there was a dispute between two constituent areas of Greater Manchester, one of which claimed that there was some inequity between the service that it was receiving and the service being received by the other. It might be claimed, for instance, that the combined authority’s decision was somehow disadvantaging Ramsbottom in favour of Bramhall. In the event of such a dispute, the buck would stop with those who were making the decisions locally, and that is the combined authority. The matter would not go anywhere near the Secretary of State. What the Secretary of State retains responsibility for is the standards and whether or not there has been a breach of NHS duties in relation to anything that falls within his own overall responsibility. So the buck still stops with the constituent authority that is delivering the service. In relation to a CCG that is not performing properly, the buck will stop with the CCG, not the combined authority. If there is a lapse of standards in anything connected with the NHS, ultimately the regulators govern that and the Secretary of State would be responsible. But if it is a decision being taken by those who are responsible for the new combined authority to do with where services go and it is within their remit, it will be a matter for them—the buck will stop with them. The short answer, therefore, is that where ultimately responsibility lies depends on where the breakdown is, but it is clear in relation to each of the services and it does not mean anyone can evade their responsibilities.