Cancer Targets

Philippa Whitford Excerpts

Tuesday 1st May 2018 Westminster Hall

[Mr Baron]

I completely agree. My worry about targets is that they focus on a very small, specific part of the journey when we should be talking about the journey as a whole. What I have not mentioned so far is that it was not just the one-year figures but the five-year figures that we were arguing for. We have to take a longer view of the journey in order to ensure that we take into account all aspects of it, including the support, the surround sound—the way of living—and so on. We have to ensure that those who survive receive enough support, but my central point is that if we really are intent on encouraging earlier diagnosis, the process targets have been too blunt a weapon. We all love them. Politicians love them. Both sides love them, and the Opposition can hit the Government with them if they are missed. It is a short-term approach. In reality, they have not improved survival rates to the point where we are catching up with international averages, and that is the key problem.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I echo the hon. Gentleman’s concern about process targets being just waiting times, particularly when we know that the wait for a patient to get up the courage even to go to see their GP will often be much longer than the wait on the pathway. Does he share my concern about not having a focus on the clinical evidence of what treatment should be? My concern about leaving everything to CCGs to decide is that we are not then sharing what we know to be the best way to treat any particular cancer. We need clinical standards that are also measured.

[Mr Baron]

I have a lot of sympathy for what the hon. Lady says, and that is why I think that cancer alliances have a decent role to play. They can take more of an overview and more responsibility for ensuring that best practice spreads and is learned from, but they can also take more of a role when it comes to clinical evidence in relation to treating cancer. My suggestion to the hon. Lady is this: if we get the NHS properly focused on improving its one-year figures and, therefore, its five-year figures, it will come closer to embracing the journey as a whole and coming up with initiatives, particularly at primary care level, that are designed to encourage earlier diagnosis. I fully accept that that is not the only answer—it is about supporting people and so on—but at the end of the day we are using blunt weapons to try to improve cancer survival rates, and the evidence clearly shows that we are not succeeding.

I will make some progress, but I will be happy to take more interventions later. In recent decades, the NHS has been beset by numerous process targets, as we have just discussed. Those have a role to play. It would be too revolutionary for me to stand here and say that we should discard them all and just bring in the one-year figures. I think that that would be too much for the NHS to grasp, but I do believe that process targets are too blunt a weapon. They offer information without context and, in my view, can hinder rather than help access to good treatment, especially when financial flows are linked to process targets, which has been the hallmark of our NHS since 1997. What is more, those targets, being very ambitious, have a tendency not to be met—a point made by the hon. Member for Strangford (Jim Shannon)—except in the very best of circumstances. They can easily become, as I have suggested, a political football between parties eager to score short-term points when in reality a longer-term approach is required. All sides are guilty of that.

Cancer has been no stranger to process targets. As I have mentioned, the House of Commons Library suggests that no fewer than nine process targets currently apply to cancer, most notably the two-week wait to see a specialist after a referral and the 62-day wait from urgent referral to first definitive treatment. Process targets, as I have suggested, can pose a particular problem when the NHS’s performance against them is used as a metric to control financial flows, which tends to skew medical priorities. Such targets are only part of the journey when trying to improve one-year survival rates, yet CCGs, although held accountable for outcome measures, in practice follow process targets, because they are the key to unlocking extra funds. That is one of the key issues that we need to explore further in the months and years ahead. I am talking about the fact that process targets account for only part of the journey when we need a longer-term view.

I also suggest that process targets are not the best means of helping when it comes to rarer and less survivable cancers, which for too long have been the poor cousins in the cancer community. Rarer and less survivable cancers often fall between the cracks of process targets. Data on those cancers is not used routinely in much of the NHS. That encourages the NHS to go for the low-hanging fruit of the major cancers. That has to change. Given that rarer cancers account for more than half of cancer cases, serious improvements in cancer survival will not be possible unless rarer and less survivable cancers are included. Outcome measures have the advantage of encouraging their inclusion when seeking to catch up with average international survival rates.

The all-party group’s most recent report, launched at the Britain Against Cancer conference in December, highlighted an example of how process targets can act against patients. In 2016, as I think all hon. Members in the Chamber will be aware, NHS England announced £200 million of transformation funding, intended to help the newly formed cancer alliances to achieve the standards set out in the five-year cancer strategy to 2020, and bids were invited. This should be straightforward. An extra £200 million is coming in and is being handed over by the Government to NHS England. The money should be going where it is most needed—to help cancer services at the front-line to deliver on the cancer strategy.

However, after the bidding process closed, a requirement for good performance against the 62-day target was introduced retrospectively. That was after the deadline—by some weeks, if not months. It resulted in multiple alliances whose performance was not deemed good enough not receiving their expected funding allocation. Oral and written evidence was taken by and submitted to the all-party group last autumn. I see members of the group in the Chamber. For those who arrived late, I point out that I have thanked the members for their help and stalwart support over the years. The oral and written evidence given to the group when we were conducting our inquiry suggested that the retrospective application of the 62-day condition was causing real problems at the frontline. We heard in effect a cry for help from those at the frontline of our cancer services. Our December report, as the Minister will be fully aware, called for a breaking of the link between the 62-day target and access to the transformation funds. Let us break that link and get the transformation funding down to the frontline, where it is needed to help to implement the cancer strategy.

It is an iniquitous situation, as the conditionality on process targets prior to funding release means that high-performing alliances receive even more money, while those that are struggling and could therefore most benefit from the extra investment do not receive the extra support. That is against the whole spirit of transformation funding.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I declare an interest; I was for 30 years a breast cancer surgeon, and I am co-chair of the all-party parliamentary group on breast cancer. Cancer affects one in three people in the United Kingdom at this point, but that is expected to rise to one in two for the population born after 1960. Part of the reason for that is that we live longer, and unfortunately still have not improved our lifestyles to a significant degree. In particular, we all know about smoking and cancer, but we should also be aware that obesity is the second most common driver of cancer, and is increasing.

The hon. Member for Basildon and Billericay (Mr Baron) spoke about process targets—particularly on waiting times. I remember when the cancer-specific waiting times came in, in Scotland, and I welcomed them. Before that, there was only the standard waiting time of 18 weeks. If a manager was told, “We are struggling to keep up with breast cancer,” but the 18 weeks had not been exceeded, there was no interest. That is the problem with any target; once a target is set, anything that is not subject to a target starts to be neglected. We welcomed targets at first. As the hon. Gentleman mentioned, the 31-day target is either being met, or is close to being met, because once people are diagnosed, all four NHSs switch into high gear and manage to treat people within the 31 days.

The problem is that that is only a little bit of the journey. The 62 days are meant to cover the time from seeing the GP to the referral to the clinic, from the clinic to the diagnosis, from the diagnosis to discussion and planning and a multidisciplinary team meeting, and from that point to the first treatment. If we look into it, the delay is often between being seen in the clinic and the diagnosis. With breast cancer we luckily tend to meet the 62-day target at around 95%, because our clinics are largely one stop. The patient usually gets all the tests on one day. However, in England the 62-day figure is below 83%, even though the 31-day figure is over 97%, and we can see how big the fall is, in trying to get people diagnosed. There is a huge workforce challenge in radiology, and in breast cancer a cliff edge is coming, because the generation who were appointed when screening started in 1991 are all retiring right now, and that is a real issue.

As I said earlier, in an intervention, it is not just a question of the time on the pathway; the biggest delay is getting people to go to see their GP. We need to get rid of the fear, embarrassment and stigma, particularly when a more embarrassing part of the body is involved.

We all run projects such as, in Scotland, Detect Cancer Early, and in England, Be Clear on Cancer, but it is important that such campaigns bubble along, rather than become intense. People need to see those adverts when it is in the back of their head that, yes, perhaps their bowel habits have changed, there is blood in their urine, or they find a lump. If that happened six months ago, it is no use. When we ran our first Detect Cancer Early campaign in Scotland with the comedian Elaine C. Smith, it was very humorous and well picked up. We got a 50% increase in people referred to breast clinics, but there was no significant difference in the diagnosis of cancer. It meant that the clinics were completely overwhelmed. We were doing clinics at night and at weekends to try to catch up, but the people who had cancer actually ended up waiting longer for their diagnosis. It is important that we generate not fear but education, and that first experience was taken into account in future campaigns.

Early detection has been mentioned, and screening is the best way of doing that if the cancer is screenable. Such screening will result in an increased incidence of cancer. People often do not think about the fact that if screening is introduced or expanded, or the technique is improved, more cancers will be diagnosed. The system must be ready to deal with that, and we need not to see it as a negative.

Since bowel screening was introduced in Scotland, there has been an 18% drop in colon cancer in men. Bowel screening, which was debated in this Chamber this morning, is not just a screening technique; it is actually preventive. When we test for blood in the stool, we can also diagnose polyps, which can then be treated to avoid them developing into cancer. That is a drop of almost one fifth over 10 years in our incidence of colon cancer. Bowel screening in Scotland starts from the age of 50 and runs to 75. Those over the age of 75 can request a kit, but they will not be sent it automatically. We have now moved to the faecal immunochemical test, which requires only one sample. It is also more sensitive, and there seems to be an almost 10% increase in uptake. Again, that will mean more colonoscopies and more diagnoses, and people must be prepared for that.

Process and outcome targets have been mentioned, but an important group of targets in between is those on quality of treatment. It is not good enough just to leave things to clinical commissioning groups or cancer alliances to work out the best way to treat various types of cancer. The data are international and national, and we need a group of experts to pool them together and come up with something that no one will quibble about, and that everyone agrees is what we should be aiming to achieve for various cancers, in people’s surgeries, after their diagnoses, and with their radiation or chemo.

In 2000, what is now called Healthcare Improvement Scotland developed clinical cancer standards for the four common cancers. I had the honour to lead on the development of breast cancer standards, and I led that project until 2011. We are now on the fifth iteration of our standards, and they have been slimmed down. We have moved from looking at four cancers in 2002, to 11 cancers in 2012, and now 18 cancers have detailed clinical targets for which they are audited, and for which peer review takes place. We do not set league tables, but we set standards that every unit can aim to pass. There is no point in being told, “The best unit is 500 miles away”; people want their local unit to be good.

The first two standards in our quality performance indicators state that every patient with breast cancer must be discussed at a multidisciplinary team meeting, and that patients must be diagnosed non-operatively by needle biopsy. When I started in my unit in the mid-1990s, our pre-op diagnosis rate was about 40%; it is now about 98%. If those two standards had been in place in England, the rogue surgeon Ian Paterson might have been picked up earlier. We now know that he tended to make his own treatment decisions, and he operated on women without proof of cancer. Obviously, the standards cover all sorts of things, including surgery, diagnosis, chemo and radiotherapy. Data are collected at the MDT meeting with a member of audit staff present. That means that they can capture evidence of recurrence and patients who develop metastatic disease, and everyone on the team is aware that that has happened.

To respond to the point raised by the hon. Member for Lincoln (Karen Lee), my unit discussed whether we would have separate cancer nurse specialists for those with recurrent or secondary disease, or whether it would be better if the original nurse followed the patient through, and that is what we went for—our nurses work between the surgical clinic and oncology, so that people see a face they already know. Having done it for years, I know that breaking bad news a second time is infinitely worse than breaking it the first time.

In England there are screening data from breast cancer and guidelines from the National Institute for Health and Care Excellence. There are, however, no audit data that are peer-reviewed and compared. We get no financial reward for improvement in our targets. Money is not part of it; it is simple clinical pride, and a wee touch of competitiveness. In Scotland we meet every year in the breast cancer service, and our data are put up. That is open and public; people can look for any of our reports on the internet, and they will see all the details about the numbers of patients treated and what has been achieved. Peer review and peer pressure is a great way to drive up quality.

The hon. Member for Basildon and Billericay mentioned early diagnosis and the need for one-year outcome figures, but spending all the money to gain another couple of per cent in a waiting time is not necessarily the best way to go. A comparison was made between breast cancer treatment in the UK and in Denmark, and because of screening—the UK was one of the earliest nations to pick up breast screening as a population screening—we have a higher percentage of patients diagnosed at stage 1 than Denmark. We do not, however, have a better survival rate because we have very slow access to new drugs. It takes new, expensive cancer drugs three or five years to get into common use. Yes, if someone is diagnosed early they might not need those drugs, but if they are unlucky enough to have a really nasty, aggressive cancer, they may end up fighting to get them.

[Mr Baron]

For a whole host of reasons mentioned by the hon. Lady, one area that perhaps shows promise in improving early diagnosis is breast cancer. In general, however, we fall behind international averages at that one-year point. The whole point of focusing the NHS on one-year survival rates, and encouraging it to improve those rates, is to send a message down the line and encourage early diagnosis across the whole panoply of primary care services, including improving screening rates and participation.

[Dr Whitford]

I totally agree. People who have died before one year—that is, in essence, what is being measured by our one-year survival rate—are largely those who presented with an advanced or incredibly aggressive disease. We are measuring people for whom we did not have a treatment, rather than just early diagnosis, and we will see that much more in the five-year figures. I am not saying that we should not have those measurements, but if a clinician is just being told, “You have to get better one-year figures,” should they take a bigger margin? Do they use this chemo or that one? They need guidance on what evidence shows will provide better one-year figures.

On prevention, there has been a drop of more than 17% in men with lung cancer, because of the fall in smoking in men. Unfortunately, there has been a rise in lung cancer in women. There has also been a rise in malignant melanoma in men, because they are catching up with women in the use of sunbeds and overseas holidays. We still have a long way to go simply to try to prevent cancer, because the gold standard is not getting it in the first place. As I have said, obesity is the second most common cause of cancer. We do not need strategies that are just for cancer. We need health in all policies to try to make people healthier, and that way we will reduce the number of people who are suffering from cancer.

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

Thank you very much, Mr Streeter, and it is a pleasure to see you in the Chair. As always, it was a pleasure to hear the debate.

I, too, congratulate my hon. Friend the Member for Basildon and Billericay (Mr Baron) on securing yet another debate on cancer in this place. I do not know how he does it; he must have a special line to Mr Speaker.

My hon. Friend and I worked very closely together in my previous iterations on the Back Benches. I am hugely appreciative of all his work as chair of the all-party parliamentary group on cancer. I did not know until today that he is coming towards the end of his tenure, but my goodness—he has certainly done his bit. He will be a hard act to follow, and I do not know who will succeed him. Who knows? Maybe that next person is with us today, Mr Streeter; you never know.

We have had some excellent contributions today. I do not know why the hon. Member for Scunthorpe (Nic Dakin) is looking at me that way; he is welcome to intervene on me.

May I just say that the hon. Member for Central Ayrshire (Dr Whitford) made a speech that was, as always, very sensible, balanced and packed with experience, which most of us can only hope to get near to. It is very welcome and very important in these debates that she speaks about her long time working in the breast unit in Edinburgh—

[Dr Whitford]

In Ayrshire.

[Steve Brine]

In Ayrshire—sorry. The hon. Lady is one of my successors as the chair of the all-party parliamentary group on breast cancer and she was so right in what she said about prevention; she was right in a lot of things she said, but she was so right about prevention. As we meet here in Westminster Hall, a certain well-known TV chef is giving evidence to the Health Committee upstairs; I am sure that can be seen on all good news channels this evening. One of the things the Committee is considering as part of its inquiry is child obesity, and one of the first things that I did in this job was to publish the tobacco control plan. I am passionate about that and I am also passionate about our alcohol challenge.

Plenty of people in this country—the majority—have a very healthy relationship with alcohol, but there are some people for whom that is not the case. As the hon. Lady knows, alcohol is also a big cancer risk factor. She was spot on in saying that this debate is not just about a cancer plan; it is about a health plan. I see the obesity challenge, the smoking challenge and the alcohol challenge as a holy trinity, if you like, in the task of tackling cancer.

[Dr Whitford]

I would just like to mark the fact that Scotland starts its minimum unit pricing on alcohol today. That will not be a panacea, but we hope that it will at least help to make the dirt-cheap white ciders no longer dirt cheap and keep them away from our teenagers.

The obesity strategy introduced by the previous Prime Minister appeared to be quite comprehensive, yet the final version published by the current Government—or the Government before; it is always hard to keep track—was only about a third of the original strategy. Is a much more ambitious plan likely to be issued and will it include attempts to tackle things such as advertising, which make our living space so obesogenic?

[Steve Brine]

Nice try. We always said that addressing child obesity was chapter 1 and therefore the start of a conversation. There are a lot of things within that plan that we are still to do, or in the middle of doing. For instance, Public Health England will shortly publish the initial results of the sugar tax on soft drinks—the industry levy—and we said that we would watch that tax very closely, to see whether we needed to continue the conversation. The hon. Lady will also know that there have been lots of discussions in this Chamber and in the main Chamber about advertising, “buy one, get one free”, labelling and reformulation. As she knows, I am very interested in said agenda and I watch these things like the proverbial hawk. So I thank her for raising that issue.

I always enjoy listening to the hon. Member for Scunthorpe; he speaks so well and I see him at so many different events in this House. He mentioned the cancer dashboard and blood—or non-solid—cancers. He knows that I agree with him; it is something that I am looking at very closely with officials and with NHS England. I also pay tribute to the work that he does on pancreatic cancer. I met one of the pancreatic cancer charities with my right hon. Friend the Secretary of State for Health last week—or was it the week before last? Time flies.

The hon. Gentleman talked about the survival figures for pancreatic cancer, and they are terrible in comparison with those for other cancers. However, sometimes we have to recognise that there is an enormous challenge with pancreatic cancer, in that it is very hard to diagnose because often it is not symptomatic until its latter stages. That is one of the reasons why I was very interested in the 16-day referral to surgery pathway that he talked about and the challenge that he identified within his cancer alliance. My officials will have heard what he said, and I will take it away and consider it, because it is a really important point.

The hon. Member for Ellesmere Port and Neston (Justin Madders), who is the shadow Minister, asked about the cancer strategy and the next update to it. It is not a “three year on” update, but the next update will be in the autumn of this year. I was glad to hear his welcome for the first ever cancer workforce plan, which Health Education England published in December. It sets out how we will expand the workforce numbers. Just last week, I was with Harpal Kumar of Cancer Research UK before he steps down, and we were talking about the critical importance of that plan. I, too, would have liked to have seen it sooner, but we are committed to training 746 more cancer consultants and 1,890 more diagnostic and therapeutic radiographers by 2021.

I was at the Royal College of Radiographers annual dinner last week in London, and its members did not miss an opportunity to make the case to me about the workforce. The cancer workforce plan is a really positive innovation, and I look forward to working with HEE and my colleagues as we take it forward.

I said in this place this morning that cancer is a huge priority for this Government, and I think that everyone in here knows it is a priority for me. Yes, survival rates have never been higher. Our latest figures showed an estimated 7,000 more people surviving cancer after successful NHS treatment than three years earlier, and our aim is to save 30,000 more lives by 2020. However, we know that there is a huge amount still to do, and that is why we accepted the 96 recommendations in the cancer strategy and have backed that up with the £600 million of additional funding up to 2021.

Two years into the implementation of the strategy, we are making progress, as I said in the Backbench Business debate that my hon. Friend the Member for Basildon and Billericay secured in February. I hear what he says about standards and targets, and in some part I agree, but they are only part of the story. The alliances are not targets; they are about pathways and best practice—not just learning best practice but implementing it. The NHS is very good at sharing best practice, but perhaps not always brilliant at implementing it. The example given by the hon. Member for Scunthorpe about the pancreatic pathway—

[Dr Whitford]

rose—

[Steve Brine]

I will not give way. I remember Mr Streeter’s ruling.

There are eight cancer waiting time standards and, since one in two of us born since 1960 will be diagnosed with cancer in our lifetime, they are an important indicator—to patients, clinicians and politicians and the public—of the quality of cancer diagnosis, treatment and care that NHS organisations provide to millions of our constituents every year. They are a component of the success we have had with survival rates, so it is good that we are discussing them here today. I use the word “target” cautiously, because I have always been clear that standards should not necessarily be targets. If someone has a suspected cancer, 28 days is 28 lifetimes too long—I will talk about the urgent diagnostic centres in a moment. Sometimes we are not trying to get to the maximum, so “target” can be a misleading term.

As has been said, we are currently meeting six of the eight standards. One of those we are not meeting is the 62 days from urgent GP referral for suspected cancer to first treatment, which is important because we want to ensure that patients receive the right treatment quickly, without any unnecessary delays. The standards contribute to cancers being diagnosed earlier—only “contribute to”—and that is crucial to improving our survival rates. However, our rates have historically lagged behind those of some of the best-performing countries in Europe and around the world. That is why we have the cancer strategy; we want to do better. The primary reason for those rates is late diagnosis. Early diagnosis is, indeed, the magic key. My hon. Friend the Member for Basildon and Billericay has used that term many times—I have heard him use it at the Britain Against Cancer conference—and he is absolutely spot on.

Going back to the 62-day standard and the recovery thereof, my hon. Friend the Member for Basildon and Billericay will know that due to factors such as an ageing population and the increase in obesity, which we have touched on, the incidence of cancer is increasing. The NHS is treating more patients for cancer than ever before. It is testament to the hard work of NHS staff across all four nations of our United Kingdom that we are treating more people, and do so with the care and compassion for which we know the NHS is world-renowned. However, those numbers are making the achievement of the 62-day standard challenging. To be perfectly honest, the standard has not been met since December 2015 and, although we do not yet have the figures for March 2018, it is unlikely to have been met in 2017-18 either. However, we remain committed to the standard and want to see it recovered. That is why, through this year’s mandate from the Secretary of State to NHS England, we have agreed that the standard will be achieved in 2018-19, while we maintain performance against other waiting time standards.

Social Care

Philippa Whitford Excerpts

Wednesday 25th April 2018 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It seems no time since we were discussing this topic in the autumn. There are three groups of people who require social care. The first and the one commonly thought about are the frail elderly. There is expected to be a rise of 25% in those aged 85 and above between 2015 and 2025. By 2030, that proportion will have gone up 63%. Therefore, this requires us to make urgent preparations. Elderly people requiring social care need support and comfort.

The next group comprises those who are facing the end of life. They want dignity and, if possible, to be at home. If their family is looking after them, they want their family to have respite. The third group, as has already been mentioned in the debate, are younger people with disability. For them, it is the quality of their whole life, their mobility and their ability to participate in society. This last group is expected to rise by 9.2% between 2010 and 2020.

The five year forward view for the NHS and the amount of money requested were based on a game-changing approach to public health and a strong increase in social care funding. In actual fact, the opposite has happened and social care has lost almost £5 billion. Age UK says that 1.2 million elderly people have a social care need that is not being met—up 48% since 2010. In England, there has been a 26% drop in local authority-funded patients getting social care—that is 400,000 people —despite an increase in the ageing population.

One third of the elderly population are looked after by their family. Those carers have been paid tributes here, but they need a bit more than tributes; they need support and, in particular, they need respite, because many of them are literally working all the hours of the week. There will be 2 million carers who are themselves over 65. At the moment, carers’ allowance is only £60 a week; it is not even the same as the jobseeker’s allowance. In Scotland, this is one of the benefits that we now have control over, and it is rising to meet the level of the jobseeker’s allowance. That is little enough tribute to these people who, frankly, are saving the state millions.

Some 700,000 people were identified by Age UK as getting no help whatsoever. The Green Paper is looking at options in the long term, but the problem is that social care needs funding now, and it is estimated that the gap will be £2 billion by 2020. The social care precept has been identified, allowing local authorities to raise council tax by 2% to 3% over the next few years. That will bring in £1.8 billion, but it will be the richer areas that will be able to raise more money.

The better care fund has been put forward for the integration of health and social care, which we should all welcome. It is estimated to raise £1.5 billion by 2019-20. The problem is that some of it—£800 million—has been raided from the new homes bonus, and when we are not here talking about social care, people are at the Dispatch Box talking about the lack of housing and the lack of affordable housing. The problem is that if we do not get away from silo thinking, we will never reach a point of health in all policies.

At the same time, the local authority funding grant will be cut by £6.1 billion by 2019-20, so we are talking about giving with one hand and taking away with the other. As has been touched on, the cuts to local authority funding of social care are causing providers to close. In the first half of 2016, one third of local authorities had at least one home care provider—and half had a care home or nursing home—that closed due to becoming bankrupt. Anyone who has had a relative supported by these services will know how traumatic it is, particularly if it is a residential care home, for someone who may have lived somewhere for years suddenly to be moved to a strange place.

Perhaps some consideration should be given in the Green Paper to combining health and social care, and to looking at some of the different approaches in order to consider whether it is actually safer to provide social care publicly. In Scotland, we have been increasing the funding into the community in primary care, which will rise to 11% of the health budget, and in mental health, community care and social care. The aim is to rebalance the budget over the coming years to 2021 until half the health budget is going to the community. We have been funding integration joint boards since 2014, and the care, design and planning is by health and social care partnerships. This is already joining up health and social care, so that we do not have the situation that I experienced when I worked in a hospital, with the social care side and the health side bickering over where Mrs Jones would be best served. With integration, we should just be able to work out what is best for Mrs Jones.

[Norman Lamb]

From what the hon. Lady is saying, I get the impression that she rather agrees with me that the Government will never come up with a solution by focusing in their Green Paper on one part of one part of the problem—in other words, older adult social care. We need to look at the whole system across the NHS and social care.

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[Dr Whitford]

I utterly agree. Obviously, we recognise the change in title of the Secretary of State. I am sure that many of us across the House hope that that would mean a move towards a more joined-up approach to health and social care. The pressure on the NHS is absolutely exacerbated by problems in social care.

[Kate Green]

There is an inconsistency between funding through continuing healthcare as part of NHS provision and the funding that is available to support people through social care. Does the hon. Lady intend to suggest that that discrepancy should in some way be rectified so that there is not a difference between the routes through which someone comes into the care system?

[Dr Whitford]

Many relatives and patients complain about the fact that, depending on which illness people have towards the end of their life, they will either be supported in an NHS or hospice system or they will pay for it in the social care system. A fragmentation has resulted from the Health and Social Care Act 2012 and the change in structure. Someone’s treatment may be delivered under NHS England as a specialist service for so many days, but then they go back to the clinical commissioning group and the ongoing care is suddenly not there. It is all very disjointed. In actual fact, we require an entire approach that joins up health and social care for the entire patient pathway. We should not expect patients to navigate from one pothole to the next.

We have exactly the same challenges with an ageing population. Indeed, the Scottish population is older and ageing more quickly than the English population. In all these debates, I always say that we must not look on this as a catastrophe. Having spent over 30 years of my life trying to get people to live longer, I ask Members to remember the alternative—living shorter. However, without public health changes and a game-changing approach, we are not ageing well; and we need to age well. But that will take a long time to turn around. We need to look after the people who require care right now.

Having failures in social care traps people in hospital. In Scotland, although we have a long way to go as well, delayed discharges from hospital have dropped in every year since 2014, when the integration started. Between 2010 and 2017, the average hours delivered through home care have doubled from six to 12 per week. In future, a quarter of us will die in a care home, so what kind of quality of care do we want to have, and what kinds of palliative care skills would we like our nursing homes and care homes to have? We need to create links between the hospice movement and care homes so that those skills and that supportive approach are shared.

[Mrs Madeleine Moon (Bridgend) (Lab)]

The hon. Lady’s dedication and work in the NHS knows no bounds. One of the things that no one has touched on is the absolutely vital importance of aids and adaptations that allow people to go home and have social care, or even have their family provide care. Often one of the major problems with delayed discharge is the lack of access to those adaptations—the commodes, the hoists, the hospital beds and the walk-in showers that people need in their home. Does she recognise that that is one of things that nobody is talking about that we must get right, and that money must be put in to make it possible?

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[Dr Whitford]

I thank the hon. Lady for her intervention. In my years of working particularly as a breast cancer surgeon, where I was involved in the palliative care of my own patients, we often met that as a barrier. We started to have the fast response teams who could get hold of hospital beds and commodes and get the changes done, particularly for somebody who actually might not have very long to live.

Since 2015, those who are defined by their medical care team as being in the terminal phase of an illness, whether it is cancer, motor neurone disease or another condition, have not been charged for personal care or nursing care at home. This means that they are not delayed by means-testing, which is another thing that can end up keeping a terminal patient stuck in hospital for weeks and weeks that frankly they just cannot spare.

Younger people with disability have been mentioned. In England, approximately half of local authority spend, and in Scotland approximately 40%, is for the working-age disabled. However, Scope, a charity involved with those with disability, says that two thirds of those who applied to local authorities for care were offered no help and were simply signposted to other charities. The 83% who were given some care felt that they did not get enough hours for it to support them sufficiently.

When we discussed social care in October, I mentioned that in Scotland we were hoping to pass Frank’s law, which is in honour of Frank Kopel—a footballer who played for Man Utd and Dundee Utd and who, possibly related to heading the ball, developed dementia at a very young age. I am glad to report that this law has now been passed. Starting from April next year, those under 65 with degenerative, chronic and eventually terminal illnesses will also be able to have personal care, and this will simply be needs-based, as it is for those over 65. I pay tribute to his widow, Amanda, who fought for a very long time to raise the issue of people who are being excluded from care based on precisely when their date of birth is. However, the Scottish Government are trying to clarify with the Department for Work and Pensions whether providing this additional free personal care to someone under 65 will not result in cuts to their disability benefits, because to give with one hand and have it taken away with the other would be tragic.

The UK Government’s Green Paper provides a chance to step back and rethink care. Obviously, the aim is to achieve sustainable care—as I say, perhaps to look at more radical considerations such as combining it with health and not having it as an utterly separate system.

On those who are younger with disability, the Minister talked about a parallel workstream for the under-65s. What are the terms of reference for that? What can people with disability expect?

After the complete shambles of the 2017 manifesto, it is crucial that there are no sudden changes or things that catch people out, with no notice to prepare for what they might have to pay for care. This is something that will affect people in the future. We have all debated the WASPI women in this place. Let us not create a new tragedy of people who are trapped by some sudden change in how social care works.

As the Minister said, the workforce are absolutely key to the care service. This is a service that is utterly delivered by people. It is not high-technology or machines, and by and large, it is not hospitals. In Scotland, the homecare workforce has risen by 11% over the last three years, but all care providers are reporting that they are struggling to recruit, and all of them see that Brexit will make that much worse, because colleagues who have come from Europe, and particularly eastern Europe, make up a significant proportion of our social care workforce.

We need to value carers. They have often been treated far too much as a cheap workforce, and that says to people, “This is not a profession or a job to stay in long term. This is until you get something better.”

[Mike Hill (Hartlepool) (Lab)]

There are of course also carers who are not employed. I came across kinship carers in Hartlepool. Does the hon. Lady agree that kinship carers, and in particular those who receive no benefits, should also feature in this debate?

[Dr Whitford]

I thank the hon. Gentleman for his intervention. There are all sorts of aspects to the provision of care, for whichever age group or needs, and the Green Paper will fail if it does not result in us stepping back and taking a wider view.

It is important to pay the real living wage, which the Scottish Government already support and fund, and not the national living wage. All hours should be paid—that commitment is being consulted on in Scotland at the moment—and that should include travel as well as overnight care.

For local authorities that have social care within their service, this is the biggest driver of the gender pay gap. Men who empty the bins are paid considerably more than the women who are caring for our grandparents. We should think of job satisfaction and give them the time to care, not 15 minutes. We should think of continuity for both the patient and the carer, but particularly we need to think of the career structure and the training. Caring needs to be a profession, and a profession that is respected.

Privatisation of NHS Services

Philippa Whitford Excerpts

Monday 23rd April 2018 Westminster Hall

[Gillian Keegan (Chichester) (Con)]

It is a pleasure to serve under your chairmanship, Sir Graham. I thank the hon. Member for Hartlepool (Mike Hill) for introducing the debate. It is important to get the facts out in the open and to ensure that erroneous arguments about the use of third-party companies in the NHS are put in context and understood. It is also important that the 1.3 million people who work in our NHS are assured that they will continue to do so and that they are not about to work for a private company.

We have all turned to the NHS for help at one time or another, and I think it is safe to say that we are all proud of our doctors, nurses and community carers. However, our healthcare system, which is regularly rated the best in the world, will have to adapt as we all demand more from its services. This change may include the use of third-party companies—they are already used to build our hospitals and sometimes to transport patients, or in key services such as dentistry and GP practices—all of which are private.

The NHS faces significant challenges. In tackling them, we must adopt a collaborative approach among all sectors to ensure that patient outcomes remain the driving force and that the health service remains a patient-first system. My right hon. Friend the Health Secretary recognises that better integration of health, social care and community care services is a big part of improving our health system. If we achieve more integration, we will improve services, save money and reduce some of the fragmentation that was referred to, which is a function not of who runs the service but of how the system is designed.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Does the hon. Lady not recognise that if parts of the service are in competition with one another for their financial survival, it is very difficult to integrate them and that that causes fragmentation?

[Gillian Keegan]

I recognise that as a challenge. It is not just competition but organisational ownership—organisations sometimes want to control things themselves. We certainly saw that in West Sussex when we tried to put together two public sector pieces under an accountable care organisation. At the moment, we are going to have to find a different model to do that. That is not to do with finances or competition, although that can occur; it is to do with the will of the leadership to work in a more collaborative way. I accept that we face many challenges in the future that we must go towards.

Integration has a worthwhile prize: improved services that are delivered more effectively. When I served as a governor at my local hospital, St Richard’s, I saw at first hand acute beds being occupied by patients who, in medical terms, were perfectly fit for discharge but who still needed care. There were not sufficient community care services for patients to be discharged to. That situation would be exacerbated if private community bed options were removed as a result of petitions such as the one we are debating.

It has been the ambition of all major political parties to implement a modern health model that is fit for purpose and fully integrates community and acute care, but I think we can all agree that, despite our best intentions, that is easier said than done, for some of the reasons we have discussed. It is like someone trying to change the tyres on a car while they are driving—it is difficult because the system is operating.

In my constituency, we have capitalised on the support offered by this Government, such as the public health grant and the better care fund. West Sussex County Council is working on preventive action. Chichester is home to one of seven wellbeing hubs across the county. That hub, which is run by the district council, supports people one to one to reduce their risk of developing diseases such as heart disease, cancer and type 2 diabetes through sustained lifestyle changes. It helps people to lose weight, to be more active and to develop techniques to reduce their risk of falling, to name but a few things. Those services are provided in conjunction with local community and voluntary organisations, and with third-party companies, which provide a wealth of different expertise.

More than one quarter of my constituents are over 65, so adequate social care integration is vital. West Sussex County Council, in partnership with Coastal West Sussex CCG, has connected local authorities, GPs, voluntary and community sector partners, third-party companies, primary care services and our community foundation trust to form two local community networks. That list spells out some of the complexity there is even today, with many services delivered through the public sector. Those networks divide the more populated south, where there is a city, and the more rural areas in the north, recognising that needs are different in each locality. A social prescribing project has been formed as part of that work: a team of community referrers will be co-located in GP practices across the district to find community-based solutions to non-clinical issues.

The charitable sector is heavily involved in the delivery of many of our healthcare services. I recently visited the Sussex Snowdrop Trust, which works with children who have life-threatening illnesses and is funded in part by the NHS and in part by charitable donations. Its nurses give specialised care at home and teach parents how to care for their seriously ill children. The impact of its work is clear, and we should not underestimate the importance of working with such specialist community partners. The corporate structure of those partners is less relevant than the importance of the work they do. The Government have set out not only to better integrate the entire healthcare system but to allow local commissioners to dictate health provision to suit their populations. In cases such as the Sussex Snowdrop Trust, which provides specialist local services to a very small and specific portion of the population, the outsourcing funding model is effective and provides an invaluable service to families.

I fully support the work that is being done by local authorities in Chichester. They have already put plans in place to tailor services to different parts of the population—rural and urban—with different needs, and to focus on prevention and adult social care, in line with the Government’s five year forward view. Those changes are long overdue and will take time to bear fruit, but they are key to achieving a truly integrated health service. Being overly prescriptive about who can be involved in delivering services would limit options as we move towards integrating health and social care, using technology more widely and placing a bigger emphasis on preventive treatment, much of which will be new. It is important that the right level of patient care is delivered quickly and efficiently, and that it is free to all citizens who need to rely on our wonderful health service.

--- Later in debate ---

[Kevin Hollinrake]

I am grateful for the hon. Lady’s intervention. I absolutely think that funding needs to be fair. There are certain instances we can look at as to whether the funding for certain CCGs in York and north Yorkshire is unfair. We need to ensure that the funding is got right wherever people are. It is incredible that we have a postcode lottery for healthcare in this country; things differ in different parts of the country, based on many of those issues. They are issues that we absolutely need to resolve.

[Dr Whitford]

Will the hon. Gentleman give way?

[Kevin Hollinrake]

May I make some progress? I have taken three or four interventions in a row.

[Dr Whitford]

It is on the point about a postcode lottery.

[Kevin Hollinrake]

Okay.

[Dr Whitford]

I thank the hon. Gentleman for giving way. During the 33 years that I spent working in the NHS, the main aim was to get rid of postcode prescribing. He must recognise that the CCG system enshrines postcode prescribing.

[Kevin Hollinrake]

As I said, there are concerns. I have concerns: some of my constituents have difficulties. The overall quantum of healthcare funding—I will return to this at the end of my remarks—is putting pressure particularly on rural areas that I represent. We need to tackle a number of different issues. With regard to the future of healthcare funding, my perspective is similar to that of my hon. Friend the Member for Gloucester (Richard Graham): we should be working on a cross-party basis to deliver the solutions.

In terms of private or public, the public are absolutely behind the point that they have no preference. A greater number of people express no preference, in terms of a private sector or public sector provider, as to who provides their healthcare. Yes, of course the public are massively in favour—89% are in favour—of a taxpayer-funded healthcare system, but on the question whether the care should be delivered by private or public providers, it is a very different picture.

--- Later in debate ---

[Martin Vickers]

I agree with the hon. Gentleman. I am not arguing for privatisation. I am arguing that privatising some services improves patient care, which is surely what we are all interested in.

[Dr Whitford]

Having graduated in 1982, I know that the first services that were outsourced were the cleaners. That has been blamed for contributing to later hospital-acquired infections such as MRSA.

[Martin Vickers]

The hon. Lady is obviously very knowledgeable, as we heard earlier. I cannot compete with 33 years’ experience, although I recognise those faults and I can recall the stories of dirty hospitals, which may have had something to do with poor procurement and bad management.

However, the reality is that the private sector has a role to play. Are we seriously suggesting that we should inconvenience people by forbidding Boots, Superdrug or a supermarket from administering prescriptions? Obviously not. Should we preclude social enterprise operations from taking part in NHS services? Surely not, because they can be extremely valuable and improve patient care.

[Martin Vickers]

I thank my hon. Friend for that timely and helpful intervention.

The King’s Fund report, “Is the NHS being privatised?”, determined that the gradual increase in the use of private providers has improved the choice and service for patients. That must be for the good of everyone. It is the patients who are important; scaremongering does not help them. A focus on process rather than patient outcomes is unwise and a distraction from the real issues. The best interests of the patient are what matters. We must ensure that as much as possible of the resources that are made available goes into patient care.

The Leader of the Opposition has made repeated pledges to “save the NHS”. Frequently, those on the left whip up hysteria about how the Government of the day are doing something that will fundamentally alter healthcare in this country and bring the NHS to an end, but when exactly have these warnings been accurate? Were they accurate in April 1997, when Tony Blair famously declared that we only had

“24 hours to save the NHS”,

or when union leaders have spoken out about the NHS? Such reports have always proved false. As was said earlier, the reality is that the Conservative party has led government for 43 of the 70 years that the NHS has been in existence, so if the aim was to destroy the NHS, we have done a pretty poor job. The reality is that the Conservative party is as committed as any other party in this House to the continuation of the NHS.

What we see is outrageous hyperbole that is designed to prey on the worries of those who rely on the NHS, which—let us face it—is virtually all of us. That is irresponsible and in some cases cruel. Furthermore, it adds to a climate in which we cannot have a sensible discussion about the future of healthcare in this country. Within our politics, there is a paranoid conspiracy theory surrounding the motives of the Conservatives in relation to the NHS. It goes something like this: “Conservatives hate the NHS for ideological reasons, but given the toxicity of the subject and the reverence with which the public quite rightly regard the NHS, they realise the only way to implement privatisation is by stealth.” That is absolute and complete nonsense.

Let us face it, there have been changes to the NHS throughout its existence. We have had mention of fragmentation; I suggest that some of the fragmentation took place during the Blair and Brown Administrations. We spend around 8% of our GDP on healthcare, which is in line with countries such as Belgium and more than is spent by the likes of Australia and Canada, which have large private sector involvement. If, as we are told, we are underfunding healthcare to undermine support for the public system, what would be the motive for the apparent underfunding of healthcare systems elsewhere? The NHS turns 70 this year and, as I have said, the Conservatives have been in power for the majority of that time. There is no masterplan to replace the NHS with a privatised alternative.

There is also the question of what we mean by “privatisation”, which I mentioned earlier. “Privatisation” is a buzzword for ideologues to spread fear and embed an inefficient system that fails patients. Is Germany a private system, or is Switzerland? The answer is no. However, Germany and Switzerland embrace the market, while ensuring that no one slips through the net.

The German system shows that a healthcare system can be fully funded in the style of a pension system. The situation in Switzerland proves that even considerable levels of out-of-pocket patient charges need not be regressive. We can trust people to choose from a range of health insurance plans and identify the best option for them. Throughout Europe, healthcare systems offer universal high-quality care that is free at the point of use. In many cases, they make use of a greater number of private providers than our own NHS.

Social health insurance does not have to clash with the principles of the NHS that are so greatly entrenched in our society. We can still have a universal system of healthcare that is free at the point of use. We may have been the first country to establish a healthcare system based on those principles, but we are no longer unique in that respect. Virtually every developed country has some form of coverage.

The United States is an outlier in this regard. Canada offers universal healthcare that is free at the point of use. Germany offers universal healthcare, and while patients there may have to pay a small amount to see a doctor—around £10—the poorest in society are often reimbursed.

[Dr Whitford]

My husband is German and we lost his sister at this time last year, so I can point out that actually the German insurance system covers only 80% of costs and the bills continued to arrive for about six months after her death.

[Martin Vickers]

I thank the hon. Lady for that intervention. My understanding, and she will correct me if I am wrong, is that that 20% of costs could be reimbursed, depending on the individual’s circumstances.

[Dr Whitford]

rose—

[Martin Vickers]

The hon. Lady is probably going to tell me that I am wrong.

[Dr Whitford]

If a member of the public in Germany wants to cover that other 20%, they take out additional insurance to cover it.

[Martin Vickers]

I thank the hon. Lady for her intervention and for her correction, which I am very happy to acknowledge.

The debate over healthcare in this country is insular and inward-looking. It is ruined by a counterproductive tendency to pretend that the only imaginable alternative to the NHS is the American system. That is the go-to response for the vast majority of those who oppose reform. In reality, opposition to the US system is the one thing that unites us all. We can deliver meaningful NHS reform while maintaining the principle of universal coverage, as well as ensuring that the NHS remains free at the point of need.

Another area in which there has been considerable scaremongering relates to accountable care organisations. These organisations are hugely important in ensuring that patients have access to high-quality care that is orientated around their individual needs. While a different name for them would have been helpful, it is the substance that matters. Again, we are often told that ACOs are a move towards the US system of healthcare, but other than the name they have little in common with the US system.

ACOs will not alter the universality of healthcare in this country, nor will they prevent services from being free at the point of use. To suggest otherwise is dishonest and unfair on patients, and causes needless worry for those who are in difficulties and worried about their future healthcare needs. Claims that sustainability and transformation partnerships and ACOs are vehicles for NHS privatisation or the Americanisation of the health service have been refuted by all the key health organisations, including the King’s Fund and NHS England.

Only 10 days ago I visited the excellent St Hugh’s Hospital in Grimsby, which serves patients from my neighbouring constituency. It is a private hospital, but 83% of its patients are from the NHS. Ashley Brown, the hospital’s director, explained to me how private providers are held to at least the same standards as public providers, and often—as in his hospital’s case—to higher standards. Private providers are subject to the same rigorous inspections as public ones and they receive ratings from the Care Quality Commission, which holds all providers to the very highest standards. As a result, 70% of independent hospitals are rated by the CQC as “good” or “outstanding”. Furthermore, the punishments for failing to meet targets are far stronger in the private sector. I was told that if St Hugh’s Hospital missed its 18-week target for referral it would face a significant fine.

Another concern that is frequently raised regarding the NHS is about profit. We are told that no one should profit from someone being ill. However, if someone needs an urgent operation, do they actually care whether the person carrying out that operation, or indeed the hospital that it is being carried out in, might make a profit from it? They have provided the capital costs of the investment. What matters is the quality of care for the individual. As I have said three or four times, patient care is absolutely critical.

Across the UK, about 10 million NHS patients are treated by the private sector every year. If we were to remove the private sector from the NHS altogether, there would be an additional 10 million people on NHS waiting lists, which, as we know, are strained to the limit already.

People value the benefits that private provision can allow. The British social attitudes survey found that there were more people—43%—who did not have a preference between receiving care from the NHS or from a private company than people who would prefer NHS treatment. Furthermore, at a time when mental health has finally reached the top of the political agenda, it is worth noting that more than one third of acute in-patient psychiatric beds are provided by the private sector. There are calls to strip back the private sector, but that would have a detrimental effect on patients in that area.

Not enough is done to publicise the fact that patients now have a legal right to choose where they receive treatment. They can choose any NHS or private hospital in the country. If they opt for a private provider, they will not have to pay a penny. That places the power in patients’ hands, giving them the opportunity to make personal healthcare decisions, as well as helping to keep NHS waiting times down.

The NHS can benefit from working with the private sector. That should not be viewed as providers competing in a zero-sum game. If the two co-operate and realise how they can spread the burden of work, they can radically improve patient outcomes overall. Provided that the service delivered is of the highest quality and remains free at the point of use, who provides it is irrelevant to a patient in urgent need. We are rightly proud of the NHS and the excellent service it provides, but if it is to remain sustainable as a service that is free at the point of need for our children and grandchildren, we must acknowledge that we need a sensible debate about how we achieve that.

I suggest that with our electoral system there are only four possible outcomes of elections in the foreseeable future—a Conservative or a Labour Government, or one of them in coalition with the Lib Dems. I can guarantee that none of them would be elected if they included privatising the NHS in their manifesto. It may have escaped everyone’s notice, but Governments quite like to be re-elected, so if, during their administration, they had made moves towards privatising the NHS, they simply would not be re-elected. Those who signed the petition need have no fear of privatisation from this Government. As I said at the beginning of my contribution, privatisation is a myth peddled for party political advantage, and nothing more.

--- Later in debate ---

[Alex Chalk (Cheltenham) (Con)]

It is a pleasure to serve under your chairmanship, Mr Hosie, and to say a few words in this important debate about healthcare. Only this morning I had the pleasure of visiting Charlton Lane Hospital in my constituency. It treats people with functional mental health problems and dementia. It was striking to see so many dedicated nursing staff who work in such a challenging field, but show such consistent humanity and dedication.

NHS outsourcing to private providers is a sensitive topic, but that is essentially because it has been dressed up as a threat to the NHS’s guiding principle—namely that treatment should be provided free at the point of use and regardless of ability to pay. Nothing could be further from the truth, however. That principle is fundamental, inviolable and enduring. It is all those things because it reflects so much about the kind of country we are and want to continue to be.

This point has already been powerfully made by my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake), but it bears repetition. When a member of the public is rushed into hospital needing emergency care, we take pride in the fact that the ability to pay is irrelevant. NHS staff are interested in vital signs, not pound signs. That is why it was no accident that the NHS featured so heavily in the stunning opening ceremony for the London Olympics in 2012. It did so because it reflects our nation’s values. While it is perfectly legitimate to have a debate about the precise mechanics and arithmetic of how to deliver the principle of providing care free at the point of need, it would be wholly wrong to pretend that the principle itself is in play, because it is not. There is simply no appetite for the Americanisation of British healthcare. Even if there were, I could never support it, and I am entirely confident that my colleagues on the Government Benches could never support it either. It is vital that we do not conflate the word “privatisation” with Americanisation or fragmentation. It is neither of those things.

[Dr Whitford]

What is the hon. Gentleman’s view of patients who are being asked to provide co-payments of more than £800 to have a second eye cataract surgery or to pay for their second hearing aid? That has been creeping into NHS England. Patients are being asked to pay for more and more items.

[Alex Chalk]

I am grateful to the hon. Lady. I respect her past record and her contributions to the House. There is an ongoing debate among clinicians—no doubt colleagues of hers—about what the NHS should cover. Most of the clinicians I speak to would welcome a more open, non-partisan and grown-up debate about the full extent of the NHS, but the guiding principle should not be confused. Whatever it is that the NHS can provide, the core principle is that it will provide it to individuals in our country regardless of their personal circumstances. I am at pains to emphasise that, because from listening to some of the contributions of Opposition Members—no doubt made entirely sincerely, but made none the less—one could be confused into thinking that that principle was under attack. It is not, and it never will be.

The debate is about the delivery of a common goal. Many take the view, with some justification, that we should be open to solutions that deliver that goal most effectively for patients. Last year, the respected and politically independent King’s Fund wrote in its report:

“Provided that patients receive care that is timely and free at the point of use, our view is that the provider of a service is less important than the quality and efficiency of the care they deliver.”

When debating this important question, we should not rewrite history. As the hon. Member for Ealing North (Stephen Pound) has conceded, it is a fact that certain services have been provided independently since the NHS’s inception 70 years ago. Most GP practices are private partnerships; the GPs are not NHS employees. Equally, the NHS has long-established partnerships for the delivery of clinical services such as radiology and pathology, and non-clinical services such as car parking and the management of buildings and the estate. To give an everyday example, the NHS sources some of its bandages from Elastoplast. That is common sense. It would be daft if public money was diverted away from frontline patient care to research and reinvent something that was already widely available. It would be just as daft if the NHS had to do the same for its water coolers or hand sanitisers.

As the King’s Fund put it in its 2017 report:

“These are not new developments. Both the Blair and Brown governments used private providers to increase patient choice and competition as part of their reform programme, and additional capacity provided by the private sector played a role in improving patients’ access to hospital treatment.”

Throughout Europe there are healthcare systems that offer high-quality care, free at the point of use, and make use of far greater numbers of private providers than the UK.

I want to say a few words about the impact on my constituents in Cheltenham. I will give three brief examples. First, Cobalt is a Cheltenham-based medical charity that is leading the way in diagnostic imaging. It provides funding for research, including into cancer and dementia, which it does as part of a research partnership with the ²gether NHS Foundation Trust. It assists with training for healthcare professionals, and it even provided the UK’s first high-field open MRI scanner, which is designed for claustrophobic and larger patients. Are we seriously suggesting that is an affront to patient care in Cheltenham? Not a bit of it. Are we seriously suggesting that getting rid of it would be a good idea? Emphatically no.

Secondly, we have the Sue Ryder hospice at Leckhampton Court, which is a 16-bed hospice that delivers truly excellent care in the Gloucestershire countryside. It also provides hospice-at-home services. It also supports, as I know, family, carers and close friends. It is part-funded by the NHS and by charitable donations. It shows astonishing compassion, but also creativity and innovation in how it delivers care. The third example is Macmillan and its nurses. I need say no more about it—it is a fantastic organisation. To suggest that these independent providers and charities are somehow not good for patient care is to stretch a political principle beyond breaking point.

We also need to slay the myth—there was just a glimmer of it today, but it was not really developed—that somehow different types of providers are held to different standards. All providers are held to the same standards and given rigorous Ofsted-style inspections and ratings by the Care Quality Commission. For my constituents in Cheltenham, I want to see resources allocated as effectively as possible to free up resources for facilities such as A&E at Cheltenham General Hospital, which can only be delivered there. There is growing demand for A&E in Cheltenham, and the service needs to be 24/7.

It is right to say, however, that there are some legitimate concerns that can be properly addressed. The experience of Carillion has laid bare the chaos that can be caused when private providers take on significant contracts and then fail to deliver. We have to recognise that the consequences of failure in health services would not simply be an unfinished construction project, important though that is, but could be a decline in the quality of patient care. I mention that only because community services are disproportionately served by independent providers, but let us keep this in context. Based on a survey of 70% of CCGs in 2015, Monitor published analysis in its report, “Commissioning Better Community Services for NHS Patients”, showing that independent providers were responsible for just 7% of contracts. We should be vigilant, not dogmatic and quasi-religious in our approach. The NHS as a whole must ensure that no contract ever becomes too big to fail and that contingencies are always in place to cater for such an eventuality.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a delight to serve under your chairmanship, Mr Hosie. In the scope of the history of the NHS, I would like to make a little punt for the Highlands and Islands Medical Service—a forerunner of the NHS that was founded in 1913, a long time before the UK NHS.

To make a gentle point to the hon. Member for Gloucester (Richard Graham), I will read the World Health Organisation’s 1995 definition of privatisation. Privatisation means

“a process in which non-government actors…become increasingly involved in the financing and provision of health care, and/or a process in which market forces are introduced into the public sector.”

Patients who attend any of the four UK health services will receive amazing care, but that is predominantly due to the dedication of the people who work in them, some of whom are working against much harder pressures than others. Government Members talked about outsourced cleaning and car parking as a good thing. There was evidence that it was the outsourcing of cleaning, and poor-quality cleaning, that led to the rise of hospital-acquired infections.

[Kevin Hollinrake]

rose—

[Andrew Selous]

Will the hon. Lady give way on that point?

[Dr Whitford]

No, because there is very little time.

[Andrew Selous]

We have 35 minutes left.

[Stewart Hosie (in the Chair)]

Order. The hon. Lady will decide what interventions she wants to take.

[Dr Whitford]

I have only just started, and there is not much time left. It is repeatedly mentioned in this House that patients and carers in England have to pay significant car parking charges. That should not be seen as a benefit.

The Conservatives introduced the internal market in 1990. That introduced competition between NHS hospitals, and even at that point created an “us and them” mentality in my local area. It created divisions between the GPs and the hospital through the purchaser-provider split. Sometimes, if a patient was sent to me but had a problem that I diagnosed as pertaining to a different department, I could not refer them on, because the GP would not fund it. They had to go back to the GP and start again. That was both inefficient and, at times, dangerous.

Unfortunately, I have to criticise official Opposition Members, because I remember in 1997 when Labour got in and talked about going back to one NHS. Those of us who worked in the NHS were delighted. Sadly, we soon started to hear about foundation trusts and, in essence, we were back to the same policy. It was Labour that introduced independent treatment centres, initially with block contracts for common operations such as those on hips and knees. Most of those contracts were not met, and were therefore of incredibly poor value. GPs were being pushed to refer their patients to the ITCs. That was eventually recognised, and the move was made towards payment by results, which eventually led to the tariff. Capital funding was also kept off the books, leading to the private finance initiative, which we have discussed many times in this place. PFI has been shown to result in between £150 million and £200 million of profit per year for the companies that hold the contracts. That is putting a huge strain on many trusts.

In the 2010 election, the Conservatives promised no top-down reorganisation. Unfortunately, just a couple of years later, with the introduction of the Health and Social Care Act 2012, we saw that that was not true. The Act came into force in April 2013, and section 75 in particular pushed commissioning groups to put contracts out for tender. That has created relentless pressure to bring independent sector providers into the NHS. As the hon. Member for Thirsk and Malton (Kevin Hollinrake) mentioned, it has risen from £2.2 billion in 2006 to £9 billion in 2016-17, more than 10 years later. That is approximately the same cost as providing all GP services, so it is not a minor cost; it is significant. The independent treatment sector in 2015-16 won approximately 34% of contracts—a figure that rose to 43% in 2016-17. However, as the independent treatment sector has moved towards more community services, it is now winning approximately 60% of contracts. There is no question but that there is greater involvement of private companies in providing healthcare.

We hear all the time about waste in the NHS, but we have had circular reorganisation throughout my career—from 100 health authorities to 300 primary care trusts, to 150 primary care trusts and to a little more than 200 clinical commissioning groups. CCGs were described as putting power into GPs’ hands, but less than half of CCGs have a majority of clinicians on them, and less than 18% have a majority of GPs. We are now going to go through another change, with the introduction of 44 sustainability and transformation plans or accountable care organisations. The costs associated with the redesign, the redundancies, the new organisations, the external consultants and the change managers are all described as one-offs, but this has been repeated relentlessly over the past 30 years and has resulted in huge waste. Much smaller organisations, such as hospital trust and ambulance trusts, are now run by very senior managers with six-figure salaries—the same size as those received by the people who ran health authorities at the start of all this. That is a waste.

Then there are the running costs of the market itself—the contracting design, the tendering, the bid teams, the corporate lawyers, the billing and the profits. The costs of the system are utterly opaque. It is not possible to penetrate the veil of commercial sensitivity, and the Department of Health does absolutely nothing to show where public money is spent. It is estimated that the cost of the English healthcare market is between £5 billion and £20 billion—no one really knows. We have no evidence of precisely how high the costs are, and there is absolutely no evidence of a benefit, so it is not possible to do a cost-benefit analysis.

[Kevin Hollinrake]

The hon. Lady is talking about the efficiency of the system, but is she aware that the Commonwealth Fund report, which addresses some of the issues she is talking about, described the NHS as the most efficient healthcare system in the world?

[Dr Whitford]

The 2014 “Mirror, Mirror” report was actually based on the years before the Health and Social Care Act 2012 came into force—2010 to 2013—and at that time the NHS was No. 1 in eight out of 11 markers. That was due not to privatisation, but to easy accessibility. One of the key things is that patients can access the NHS quickly and easily. That ranking is not based on the system of reform that the Health and Social Care Act introduced.

[Kevin Hollinrake]

The hon. Lady seems to be implying that the internal market is a problem, but it has been in place since my right hon. and learned Friend the Member for Rushcliffe (Mr Clarke) was the Chancellor. Efficiencies have been driven, and she must take into account the internal market reforms that are in play.

[Dr Whitford]

The difference is that the original market was an internal market; what we have at the moment is an external market, which means that money is leaving the NHS and going to external companies. That is quite different from competition among hospitals.

To tackle waste, we should start with the cost of the market. Even if it is at the lowest end—£5 billion—it would help to clear the debt and pay for the hole in social care. It would make a significant difference.

In the five years leading up to 2013, the NHS always somehow managed to find money down the back of the sofa, and it scraped out with about £500 million at the end of each year. In 2013-14, it was overdrawn by £100 million. The next year, the figure was £800 million, and in 2015-16, it was £2.5 billion. People sometimes say, “There’s this little bit of efficiency, and this little bit has been saved”, but when I started the UK spent 4.5% of its GDP on health, and the highest it reached was 9%. Imagine if all that money had gone to frontline care, as the hon. Member for Thirsk and Malton talked about, and was used to pay nurses properly, get rid of bureaucracy and actually deliver care. We can do that only if we have a planned single system; we cannot do it if we create an entire bureaucracy.

Scotland diverged in 1999 when we got devolution. We abolished hospital trusts in 2004 and primary care trusts in 2008. We have place-based planning in the form of health boards, which have led to the integration of primary and secondary care. We now face the difficult challenge of the integrated joint boards for integrating health and social care. Look at our success: in-patient satisfaction is up to 90%, delayed discharges have been down every single year and Scotland has had the best accident and emergency performance since March 2015. In February, emergency department performance in Scotland was 90.3% in four hours; in England, it was 76.9%. Look at how the challenge evolved: it literally started in April 2013, when the NHS in England came under pressure.

I have frequently welcomed the plan to move to place-based planning. I agree that the term “accountable care organisations” is unfortunate, but the model contracts put out in August still make it clear that independent sector providers could bid to run an entire accountable care organisation. There is no statutory structure. The basis must be that there absolutely has to be accountability and a statutory responsibility. I believe there should be a presumption of a return to the NHS.

It is crucial that we reform the perverse incentives. Hon. Members have mentioned the tariff. Hospitals earn money only if people are admitted. They make money out of those who are not that sick and lose money on people who are incredibly sick. How will a hospital take part in this if keeping people in the community, which we all want, means that they lose money? That should be reformed in this place. Section 75 of the Health and Social Care Act caused the Nottingham University Hospitals NHS Trust to waste £500,000 preparing a bid for the Nottingham Treatment Centre against Circle, which then just pulled out. Hon. Members have mentioned that Virgin has sued six Surrey CCGs, one of which leaked that it is paying £328,000. Multiply that by six, and we are talking £2 million. The idea that outsourcing to private companies has brought benefits simply does not stack up. We are putting money into care. Get rid of outsourcing and fragmentation. I support the idea of place-based planning, but patients, not budgets, have got to be in the middle of it.

Surgical Mesh

Philippa Whitford Excerpts

Thursday 19th April 2018 Commons Chamber

[Paul Masterton (East Renfrewshire) (Con)]

I congratulate the hon. Member for Kingston upon Hull West and Hessle (Emma Hardy) on securing this debate. Although we went in front of the Backbench Business Committee together, the truth is that she did most of the work. I am hugely grateful for what she has done in this space. Having set herself a very high bar with the way in which she opened the Westminster Hall debate in October, I can safely say that mesh-injured women in Scotland will be incredibly grateful for the support that she has shown them through her remarks today.

In the six months since that debate, there have been a number of important developments both internationally and domestically. There have been landmark announcements in Australia and New Zealand, as other hon. Members have mentioned. While the UK Government have so far not chosen to take similar action here, I will certainly continue my efforts with the all-party group on surgical mesh implants to persuade them that banning mesh is the right thing to do, particularly now that the National Institute for Health and Care Excellence has issued guidance that favours an effective ban in practice.

There was a Public Petitions Committee debate in the Scottish Parliament just before Christmas—as I set out at our previous Westminster Hall debate, the Scottish Mesh Survivors group was left with very little option but to continue its fight through the Scottish Parliament Public Petitions Committee following a hugely disappointing report from an independent review group established by the Scottish Government. A further review exercise is currently progressing in Scotland. However, it will not re-evaluate the conclusions of the independent review—it will assess only the merits of the process by which those conclusions were reached, so it has the potential to undermine that flawed exercise even further.

At this stage, I pay tribute to the three amigos in the Scottish Parliament: my Conservative colleague Jackson Carlaw, Labour’s Neil Findlay, and the Scottish National party’s Alex Neil, the former Cabinet Secretary for Health and Wellbeing. All three immediately recognised that there was a serious issue to be investigated and continue to champion mesh-injured women across Scotland, such as my constituents Elaine Holmes and Lorna Farrell.

One of the big difficulties is that it has been very hard to get media uptake, particularly in Holyrood with the male-dominated press lobby. They found it a bit icky and did not want to write about it, so I pay tribute to Marion Scott, a journalist who has been absolutely dogged in her determination to highlight this issue, and to the hon. Member for Pontypridd (Owen Smith), who has gone out of his way to make sure that it gets pushed up in the media across the rest of the UK, giving it exposure that it would have otherwise been very difficult to achieve.

In February, the Secretary of State for Health and Social Care outlined a number of important measures to review mesh and investigate what had gone wrong. It is fair to say that a lot of the campaign groups found the overall package slightly underwhelming, but it is vital that their input into the process is given the utmost attention. Of course, this week the retrospective audit was published.

As has been said, it is right that the Health Minister, Lord O’Shaughnessy, has instructed the chief medical officer in England to respond to the findings with some urgency following engagement with the medical authorities and, importantly, with the patient groups representing women whose lives have been wrecked by mesh. Too often when there have been statements, guidance and responses, the views and experiences of these women have been completely ignored. They have been talked about as though they are not there. Their experiences have been undermined and dampened down, so if patient groups are to have any faith in the UK Government, it is important that patient voices are front and centre of the process.

I was particularly pleased when the Secretary of State announced to the House that £1.1 million would be provided for the establishment of a comprehensive mesh database. That is a positive development, and mesh-injured women in Scotland have reacted warmly to it, but they have also made it clear that, if the authorities are to gain a true picture of the suffering that mesh can cause, it must be accompanied by a requirement for mandatory reporting of all mesh procedures. Crucially, as a number of others have said, that must encompass not just NHS but private procedures, because many of the women concerned were treated privately. If mandatory reporting is not already envisaged, I urge the Department to explore that possibility.

The setting up of a database in Scotland was one of the six points included in the petition that Scottish Mesh Survivors brought to the Scottish Parliament in 2014 and 2017. It is fair to say that progress has been pitiful, and it was therefore welcome that the Secretary of State made clear that he was open to the idea of a UK-wide database and to working closely with the devolved Administrations with the aim of establishing a clear UK-wide picture. Along with my hon. Friend the Member for Angus (Kirstene Hair), I wrote to the Scottish Government Cabinet Secretary for Health and Sport about the database, and was pleased when she confirmed that her officials had been liaising with colleagues at Westminster and the other devolved Administrations. Perhaps the Minister will explain exactly how those communications will proceed.

In view of the failure in Scotland to proceed with a database in the four years since the survivors’ petition was first brought to Holyrood, Scottish involvement in the issue of a UK-wide database—

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Is the hon. Gentleman aware that the discussion in Scotland was about the need for the database to be UK-wide? We have talked about EU registration. The bigger a population, the sooner a problem is noticed. The Medicines and Healthcare Products Regulatory Agency is UK-wide. It is not a question of small databases. The Scottish Government were not obstructing the proposal. The profession felt that the database needed to be UK-wide, and needed to feed into the MHRA.

[Paul Masterton]

I certainly agree that a UK-wide database will be far more effective and beneficial in providing a true representation of the story of the mesh-injured women, but the hon. Lady must accept that the women in Scotland have found the response of the Scottish Government—and, in particular, that of the current Cabinet Secretary—fairly poor.

A lot has happened in the past six months, both at home and abroad. Some progress has been made, and important steps have been taken, but we have much further to go. Members of Parliament are often asked, “What do you want to achieve in this place? What tangible thing do you want to walk away from here and say that you have done?” Securing justice for mesh-injured women is right up there at the top of the list. Let me simply say to those watching at home and those in the Public Gallery that the fight goes on.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, pay tribute to the APPG and to the hon. Member for Kingston upon Hull West and Hessle (Emma Hardy). I also pay tribute to the women who have campaigned. If they had not campaigned, the issue would not be at this point today.

As a surgeon for more than 30 years, I have to start by pointing out that there is no such thing as risk-free surgery. There will never be an operation about which it could be said there is not a 1% complication rate. When I looked at complications and talked about risks, I used to write them down on the consent form so that I went through every single one with patients. We talk about the complications that are minor and common, and we warn patients, “This will probably happen, but it’s minor.” The complications that are life threatening or quality of life threatening, even if they are rare, should be up there in block capitals so that women know.

We, as surgeons, have a duty to minimise risk and to inform the patient so that, as has been discussed, decent and informed consent can be given. The problem of this saga is that a lot of the surgeons were not informed. If a surgeon is doing 30, 20 or 15 mesh implants a year and they become aware of a problem only in two or three years’ time, it does not register in their brain as being common. We also know that many of these cases really presented only years later, so that feedback loop—“Oh my God, we have a problem!”—was not there. That is why so much of this is to do with regulation, reporting and, inevitably, the yellow card.

[Gordon Marsden]

Obviously, the hon. Lady has enormous personal experience of surgery and of this area. Does she agree that one of the other possible problems for some surgeons, although I hope not many, is that in this country we have historically been very bad at explaining risk-benefit analysis to patients? If people are being offered an operation for a condition that is not necessarily life threatening, the judgment in a risk-benefit analysis is very different from that for something far more serious.

[Dr Whitford]

I thank the hon. Gentleman for his intervention. In fact, there are studies showing how difficult it is even to explain risk, let alone risk-benefit, to patients. Certainly in the cancer field, in which I spent so much time, patients will go through really appalling treatments even if there is only a relatively small chance of cure. As a clinician, it is difficult to explain a lot of this.

Sufficient information has not been given to the medics, and therefore clearly not to the patients. We have heard this described as a “minor, straightforward procedure”.

[Owen Smith]

Does the hon. Lady agree that part of the problem is that mesh was marketed so widely as being a quick fix? Previously, far more expert urogynaecological surgeons would have undertaken what was far more difficult and invasive surgery—colposuspension or autologous sling. When it went to day-case surgery and, effectively, keyhole surgery, a much wider range of less expert surgeons was suddenly involved.

[Dr Whitford]

I would echo that. We should always be a little suspicious whenever an impression is given that an operation is easy and quick. We hear talk within the medical system of the problems of specialisation and how, actually, we need to go back to having more generalists. The depth of knowledge on breast cancer now would make it impossible for a general surgeon, who might also be doing upper gastrointestinal and lower gastrointestinal surgery, to keep up with that knowledge. That is why we will always need specialists. The danger is when something is thought to be trivial and straightforward.

Although it has been mentioned that the two problems—pelvic organ prolapse and stress incontinence, and particularly the latter—are very minor, there is a broad range. There will be patients for whom the condition is incredibly distressing and who simply cannot leave the house because of their incontinence. We should not put everyone in the same basket.

As has been mentioned, the traditional repair for prolapse would have been colposuspension, which lifts the womb and then buttresses the muscular tissues of the pelvis. The surgeons thought that by adding mesh to muscle that is clearly weakened—that is why prolapse happens in the first place—they would make the muscle stronger.

There was a perception that the results of colposuspension were poor, and a big American paper in 1997 suggested that prolapse recurred in 29% of women. As a surgeon, that seems like catastrophic failure, but, reading the small print of that paper, two thirds of those women were hugely obese and one third had bronchitis and were coughing all the time. There was also a high rate of smoking. It was not the average range of women with prolapse; it was actually a particularly high-risk group. Unfortunately, the paper seems to have dominated the profession’s perception for years.

The problem right across this is that not enough trial work and research were done at the beginning and that the follow-up was far too short. What we have seen is that the mesh problems emerge only after time goes on. There was a Cochrane review in 2007 looking at multiple smaller studies, and it showed no benefit from the use of mesh in prolapse. Since then, we have seen a slow decrease in the use of mesh, but the recent review shows that 2,500 women with prolapse in England had mesh put in last year. That means the issue is still happening.

A 2011 EU study showed no benefit from mesh in prolapse even for recurrence, and one of the few prospective studies, in which the data is collected as time goes on, also shows no benefit. That prospective study was published in 2016, so the information has not been available for decades, and it found that the mesh complication rate at two years is 12%. That is at two years, so the rate can only go up. The Scottish review of 20 years of data from 1997 to 2016 shows only a 4% recurrence of prolapse after the traditional repair. Mesh is no better at avoiding recurrence.

Colposuspension has surgical complications: a surgeon might damage something; a surgeon might injure the bowel or bladder, which is much more common; or a patient might get a wound infection. Those complications fade as time goes by whereas, as has been reported in the Chamber today, the mesh complications do not occur early, but occur as time goes on. In Scotland, after the review, the advice is absolutely clear: mesh should not be used in cases of prolapse as a routine first procedure.

We have heard about stress incontinence and the option of physiotherapy has been talked about. That option should have been used much earlier; there should have been trials of it. As has been said, this is about getting to women in the post-childbirth period so that we have the chance of strengthening their pelvic muscles. The initial repair for stress incontinence was the tension-free vaginal tape, which developed in the late 1990s. A randomised controlled trial was carried out in 2002, with the one-year follow-up report finding only a 1% complication rate and finding that the patients had less pain, and that they recovered more quickly and went home more quickly. This seemed like a great solution, which is part of why the surgeons were so convinced by it; it seemed quick and easy. They were talking about a keyhole approach and the way we deal with gallbladder and other procedures.

The problem that has gone on since has been talked about. We have had the morphing of one tape into another, and one material and so on changing, with little other research having been done and little follow-up. When that trial did follow up its patients, it found that at 10 years the mesh complication rate was 5%. Because the focus was on not injuring the bladder, we find in clinical terms that that has been the focus of the clinicians, because that is what they knew from colposuspension. The idea that two, three, four or five years later people would develop mesh complications was something the clinicians were not expecting and certainly not looking out for.

The incidence of bladder injury for the retropubic tension-free tape was about 10%, which is why the transobturator developed. Someone who has seen an X-ray or a pelvis skeleton will know that the front of the pelvis is made of two struts, so that we are not so heavy that we cannot actually stand up, and the obturator is that hole. The idea was to keep away from the bladder and therefore reduce bladder injuries, and indeed this did that.

Bladder injuries were reduced from 10% to 1%, so, again, everybody was patting themselves on the back. But what happens is the spikes—the trocars—used to put these things in are going through muscle and close to nerves, and are coming out in the groin; they are coming near the muscles that allow people to pull their thighs together. That is where a lot of the side effects and complications have come, and there was definitely a huge upswing and surge in these complications after the obturator tape became the common approach. We also had such slow recognition of what was happening. Many of us women in here, particularly us women of a certain age, will recognise that old story of women simply being dismissed, patted on the head and patronised.

An odd quirk of regulation is that the Federal Drug Administration’s regulation 510(k) allows any similar devices to pass through in a very simple fashion and they are not re-examined. Class I is low risk, and initially these tapes were all classed as class I, which means no research had to be done. They are now class III, which means a randomised controlled trial is required, and we see that Johnson & Johnson, and others, are withdrawing; they are stopping making these things because they would have to go back to carry out trials. The problem is that the tape and the trocars might have looked similar, but when the move was made from tension-free retropubic to a transobturator tape, we were talking about a totally different operation, and there was simply no evidence to show that this was either similar or better.

If something has been passed by the FDA, it tends to get passed in Europe, and the Medicines and Healthcare Products Regulatory Agency tends also to accept it without doing anything else. The European CE mark is only a mark of the quality of production; it does not imply anything about research. As my hon. Friend the Member for Glasgow North (Patrick Grady) mentioned, there is a plan to develop the EU medical devices regulation system from 2020, but, unfortunately, the UK will not be part of that, unless there is a specific negotiation.

The problems began to be recognised in 2012, because of the campaigners, their persistence and their speaking out. In 2014, the then Cabinet Secretary for Health and Wellbeing, Alex Neil, advised all health boards in Scotland to suspend meshes until there was some degree of clarity. It might have been stimulated by that, but certainly at the same time the Australian Therapeutic Goods Administration started to look at its products, immediately de-licensing a third, reviewing a third and, initially, keeping a third as standard. But last November it de-registered all prolapse meshes, so these materials are simply not available in Australia.

The Scottish independent review was set up from 2014 to 2017, and its advice was unequivocal: there should be no routine use of mesh for prolapse, and as regards incontinence, if mesh was being used, registration was made mandatory. There has been discussion about where this registration will occur. Obviously, the colleges have been developing a registration, but we need to know about everyone who had a mesh in. This could be done through scanning the barcode off the mesh and registering it in the notes—that is the obvious way to do it. Having had to review all the case sheets of breast reconstructions after the PIP— Poly Implant Prothèse—silicone implants scandal, I know that it is really important that if something is being left permanently in a patient, we know how to recall it and who had that done.

As has been mentioned, we had the NHS England review and a paper was produced last year, using hospital episode statistics, that showed a 9.8% complication rate at five years. Again, we can expect that to climb. The review published on Tuesday showed that about a third of the 72,000 patients who were treated for prolapse were treated by mesh; that is between 2008 and 2017, and we see a fall over time, so the rate might be higher during the earlier period between 2000 and 2008.

We have seen a 13% drop over that time in prolapse meshes, but, as I say, in prolapse they have utterly no benefit and therefore there can be only loss, so it is hard to justify why so many patients in England are still having prolapse meshes. Some 100,000 women have had mesh incontinence tapes, and this has decreased by 48%, meaning that the overall decrease in the use of mesh over that period is about 32% in England. Since the Scottish inquiry, the reduction in the use of mesh has been 94%—and that is continuing.

The hon. Member for Kingston upon Hull West and Hessle mentioned Dr Wael Agur, whom I am lucky enough to have as our local gynaecologist. I have been able to meet him and get information with him. The only places that are using incontinence meshes are the two specialist units in Glasgow and Edinburgh. In Scotland, a consent process has been developed, which is now being looked at by the colleges so that it can be rolled out, and, obviously, we are talking about usage in tiny numbers here.

Even though registration is mandatory, none of the other health boards is doing this, so it is not expected that Scotland will have many patients registered. What Dr Wael Agur and other colleagues are using is a small piece of rectus sheath, which is the tough tissue we have in front of our muscles. Those who are lucky enough to have a six pack—I do not see many in here— will find that that is very strong tissue. [Interruption.] We do not ask anyone to show them, please. Only about 6 cm of this is required. So we are using the patient’s own tissue and we will be back to an autologous repair, where there might be complications, wound infections and failures, but we would not see this progressive problem.

So what went wrong? Not enough research was carried out and, categorically, there was not enough follow-up. The survey that was reported on Tuesday now gives NHS England a denominator of how many patients have had mesh, but I am sorry to say that just using hospital episode statistics does not give a numerator as to how many women have problems, so I suggest a survey of all those patients or a review is necessary, in order to know how many, even within the NHS, have got these problems.

In addition, as we have heard, there was poor information on which people could base their consent; as I say, the clinicians did not know, because no detailed trials were being done of these new techniques and certainly there was no decent audit. Women were being dismissed and patronised. The regulatory system was far too complacent, simply taking things from the FDA all the way to the MHRA and not looking at changes in technique. The audit was very poor, with a recent survey showing that only 27% of patients who had had meshes were registered.

Finally, the yellow card system failed, yet again. The hon. Member for Congleton (Fiona Bruce) mentioned the other scandals associated with sodium valproate and Primodos. Unless patients are aware of the yellow card system and unless GPs and doctors have it literally in the front of their brains, people will not send a yellow card until they are sure that the drug or the mesh caused the problem. For any new drug, for any new technology that is being implanted, and for any baby born to a mother on medication, there should be a yellow card, because the whole point of the yellow card system is that someone centrally is able to notice. That is why we need more of these yellow cards. There is clearly a problem, so we need better registration and reporting, so that we do not have to have another similar debate in future.

Austerity: Life Expectancy

Philippa Whitford Excerpts

Wednesday 18th April 2018 Westminster Hall

[Andrew Selous (South West Bedfordshire) (Con)]

I pay tribute to the hon. Member for Sheffield, Heeley (Louise Haigh) for bringing this important matter before the House.

I will start with the economics, because the debate relates to austerity and life expectancy. Government Members would probably talk about living within our means and would put to the hon. Lady the argument that the consequences for the poor and the vulnerable of a country continuing to live beyond its means are very grave. Economic history tells us that when countries lose control of their finances, it is not the well-to-do or the comfortable who suffer, but the poor and the vulnerable. That needs to be put very firmly on the record.

It is also worth noting that the Commonwealth Fund, which is an independent body, last year pointed out that our NHS was the best health system of the 11 different health systems it looked at. If we look at our outcomes on strokes, heart attacks and cancer, we see that they are getting better—there are 7,000 people alive today who would not be alive had we not seen that improvement in cancer outcomes.

Looking at the data across Europe, we see that what is happening in the UK is part of a trend, because life expectancy is also falling in Italy, Spain, France and Germany. Some of those countries spend quite a lot more on health than we do. France and Germany spend one percentage point of GDP more on health than we do, yet they have also seen that downward trend.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Will the hon. Gentleman give way?

[Andrew Selous]

I will in a moment. There has been no austerity in Germany, because the Germans live within their means and run a big budget surplus. They have a trade surplus with China. However, life expectancy is falling in Germany as well. We need to look at these wider factors and at the European context. I will now of course give way, with great pleasure, to my former colleague on the Health Committee.

[Dr Whitford]

Does the hon. Gentleman also recognise from the data that there is not a similar fall in life expectancy in the Scandinavian countries and that it is wrong to look narrowly at health services, because the biggest driver in relation to life expectancy is poverty?

[Andrew Selous]

I will come on to those very important public health issues and what we need to do about them, because I care passionately about them, as probably everyone in the Chamber does. As the hon. Lady is from Scotland, it is also worth looking at what is happening there, because Scotland offers free adult social care and spends a higher amount on healthcare per head than England, yet still has a lower life expectancy than England. We need to get those issues firmly—

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The hon. Member for Sheffield, Heeley (Louise Haigh), whom I commend for securing the debate, spoke a lot about the impact of austerity on health and social care. To pick up on that, I should say that austerity has a triple impact. Spending on health and social care ends up being strangled, as we have seen: the reduction of the annual climb in expenditure from 3.5% to approximately 1%.

Of the two other impacts, one is the economic impact that we have faced ever since the crash at the end of the 2000s and which has been felt throughout Europe—I have a German husband, and I can tell you that while Germany itself may have a surplus, there are people there who are struggling and have not seen the wage rises that they would have liked. Also, in this country especially, we have seen welfare cuts, which have removed social security from people, creating particular areas and populations of poverty. That has particularly hit the disabled, children and pensioners.

There has been a lot of talk about healthcare. After 33 years as a doctor, I have to say that we can have far too much faith in what medicine can do to change overall life expectancy. We have some impact, but the biggest driver of ill health and the biggest impact on life expectancy is poverty and deprivation. That is something we have seen increasing in this country.

For example, over the past 20 years the rate of pensioner poverty dropped 28% to 13% by 2011-12, but it has now come back up to 16%. Twenty years ago in England, child poverty started out at 33%, got down at best to 27% in 2011-12, and is now back up at 30%. In fact, Scotland has the lowest rate in the UK: we started at a similar level, got down to 21% in 2011-12, and are still the lowest, at 24%. However, we have seen the same uplift, and that is because of aspects of social security and the impact of things such as the removal of child tax credits or the cuts to all the various social security supports. Over the past few years, similarly, poverty in general has risen slightly in England, Wales and Scotland, although Scotland has the lowest poverty rate, at 19%.

Important impacts of poverty on health include housing and fuel. People in the lowest 20th will be spending a third of their income on housing and, in the north of Scotland, another third on fuel. People are literally being squeezed and are struggling to eat well, which of course impacts on their health. We can see big differences in wealth across the UK. There is approximately twice the wealth in Kensington and Chelsea as in Glasgow—as well as more than 10 years’ difference in life expectancy.

As has been mentioned, the improvement in life expectancy has halved, from three months to approximately six weeks, although in Scandinavian countries the improvement continues, because social support and the social fabric is something they invest in. In Scotland the life expectancy deprivation gap has narrowed from 13.5 years to nine. That gap can, in the raw sense, be influenced by healthcare—we manage to keep people alive—but we are not keeping people healthy. They are surviving but accruing more and more diseases. In Scotland, therefore, the healthy life expectancy gap has increased from 22.5 years to 26 years. People are struggling with all of that, and it results in a much higher health spend and much more pressure on the NHS. That is exactly what Members have been saying: there is no sensible saving of money if it ends up being spent somewhere else.

Infant mortality is a measure of the impact of poverty on health that is used right across the world. For three decades, infant mortality had been dropping; it has now taken a small uptick. In Scotland, again, we have the lowest infant mortality rate—0.5 per 1,000 live births lower than in England—but it too has gone back up. Look at the contrast between the wealthiest and poorest areas: in the wealthiest areas, just over 2.5 babies per 1,000 live births will die within a year; and in the poorest areas the rate is more than double that, at 5.9 per 1,000 live births. Read Professor Marmot, and we cannot escape what we have known for 20 years: that the biggest impact on survival, quality of life and outcomes is poverty—and the biggest driver of poverty is austerity.

--- Later in debate ---

[Jackie Doyle-Price]

The right hon. Gentleman knows that we have made tackling that a priority. It is too early to draw any conclusions. It is the case that poverty is a big source of inequality, but we need to do more work before drawing conclusions. Having developed the evidence, we will act. There is a reason that we have developed a national maternity safety strategy. There is a reason we are focusing resource on the perinatal phase, because we recognise it is critical. We will also continue to spend money on the healthy living supplements to give children a better start in life and to tackle some of those inequalities.

[Dr Whitford]

The Minister accepts in her speech that poverty is a big driver of these changes and talks about doing more, but we expect that over the next few years another quarter of a million children will be driven into child poverty. It is not a matter of doing more. In fact, the policies at the moment are making the situation worse.

[Jackie Doyle-Price]

I do not accept that. The real issue for us as a Government is being able to make those interventions that address the sources of inequality. It is about giving practical steps, which I will come to in more detail.

The hon. Member for Sheffield, Heeley referred to the article in The BMJ by Hiam and Dorling about the spike in mortality and winter deaths. She was absolutely right to highlight that. We must pay attention to emerging studies. However, using the total number of deaths can be misleading and needs to be put in the broader context. It does not take account of the ageing population and the fluctuations in population numbers. We use the age-standardised mortality rate as the accepted measure, which looks broadly stable. Clearly this is not something we should be complacent about, and we should continue to keep a very close eye on trends in those numbers.

I mentioned people with learning disabilities living for 20 years less than the rest of us. It is good that that figure has come down since 2000. Their life expectancy has risen by seven years since the millennium. We must encourage that direction of travel by supporting them to live full, healthy and independent lives. That goes to show that having better health is not just an issue for the NHS and health services, but is about having more support to get people into work and to help them to live in the community. We need to use every interface with the state to achieve that.

If we take a lifestyle approach to securing the best possible health outcomes and tackling inequalities, an individual’s start in life is the beginning of that. We are focusing on pregnancy through early years and into old age to ensure that every child gets the best start and journey through the rest of their life. Public Health England is leading programmes to ensure that women are fit during pregnancy. It is leading programmes to ensure that children are ready to learn at two and ready for school at five. We want to continue to support smoke-free pregnancy, which leads to better health for children. Central to that is local commissioning driving best-quality service and interventions as appropriate.

We are obviously very concerned about childhood obesity. If we do not tackle it, it will set people up for poor life expectancy in the longer term. It is worrying to see the number of children entering school at the age of five who are already obese. We need to leave no stone unturned to achieve early intervention. Broader public education about the impact of sugar is helping, but there is much more we can do to encourage people to adopt healthier lifestyles.

--- Later in debate ---

[Jackie Doyle-Price]

I cannot give the hon. Lady that information now, but I will write to her.

Alcohol is a source of poor health outcomes, so we are also doing much to tackle that. I am in dialogue with Members on both sides of the House about supporting the children of alcoholic parents, recognising that they are a particular need group. I thank those hon. Members who have been associated with that.

[Dr Whitford]

With Scotland having been the first place to ban smoking in public places, and now moving forward with minimum unit pricing for alcohol, will this Government consider following that lead for England to tackle alcohol?

[Jackie Doyle-Price]

I am grateful for that point, which consideration is being given to in the Department. There are any number of tools that we could use to tackle alcohol. Probably the most important thing is to give the message that unsafe drinking is bad for the health. It is always interesting to learn from Scotland’s experience, and we will keep an eye on that.

Tobacco is a major cause of poor health. It is worth noting how much progress we have made over decades to reduce the prevalence of smoking. That should lead to better health outcomes, but that has yet to be seen.

GP Recruitment and Retention

Philippa Whitford Excerpts

Wednesday 28th March 2018 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under your chairmanship for the first time, Mrs Moon.

I declare an interest, in that my other half is a GP. He is German and has been here in our service for 32 years. That highlights a particular problem that we shall face in the next few years because of Brexit. As the hon. Member for Houghton and Sunderland South (Bridget Phillipson) mentioned, GPs are not just gatekeepers, but are the core and heart of general practice, which is where most interactions occur. They specialise in teamwork and continuity. They may know their patients for years and over generations. All UK health services face three key problems. We all face tight budgets and increasing demand because of an ageing population, and the workforce is bringing those things to a head in relatively short order.

There is a drive in Scotland and England to rebalance the proportion of funding that goes towards primary care, to approximately 11% of the budget. With the climbing complexity of cancer care, emergency care, A&E and targets, more money has been moving into secondary and, indeed, tertiary care. The demand is still there. Having worked as a breast cancer surgeon for more than 30 years I can tell the House that we also face shortage and increased demand, so there is no easy solution—but if primary care fails, the entire system fails.

In Scotland the new GP contract was designed by working with the British Medical Association, and at the moment it is in phase 1, which is trying to stabilise the system. Two thirds of practices will have a significant increase in income, and the others will be protected so that no one experiences a fall. Phase 2, which will start next year, is an attempt to consider something a bit more radical. It touches on issues that have been raised by some Members, to do with changing the shape of primary care, and the system. The income of GPs varies hugely. Some practices are immensely profit-making and have a good income. In other areas the GP, despite perhaps working longer hours, may earn £20,000 or £30,000 a year less. That means that the area in question becomes relentlessly harder to recruit to. Consideration is being given to whether there should be a range of income, perhaps similar to what consultants have—an NHS salary.

That is obviously a huge change from the situation at the moment—the independent contractor status. Older GPs who have lived with independent contractor status certainly do not want it to go. They welcome the independence and the ability to design and run their practice as they see fit. However, it is important to recognise that the younger generation feel utterly differently. As has been mentioned, they are not interested in buying into a practice or even, necessarily, in being partners. They are not attracted to the businessman side of being a GP. Therefore we need contracts that do not destroy independent contractor status for those who already have it, or those who want it, but that enable people to work in practices where perhaps the building is provided by the health board, and where they are salaried and can create a more predictable work-life balance.

One of the small-print issues that is arising in England is the fact that no new general medical services contracts have been awarded since 2013; everything has been done on the basis of alternative provider contracts, which means that they are only for five years. It might be attractive to a big multinational to take on a franchise and hope that it gets the contract again; but there is no possibility that a family doctor would be interested in setting up or taking on a practice for a mere five years.

[Jamie Stone]

I am greatly interested in what the hon. Lady is saying, which is very constructive, good stuff. Would she, at this stage in her planning, factor in the extreme rural issue that I mentioned, in any way?

[Dr Whitford]

If the hon. Gentleman will bear with me, I shall come to that naturally later.

The issue of indemnity has been touched on. I am not sure whether it is realised how extreme the position is. GPs in England are paying three to four times the indemnity that GPs in Scotland are paying. The range in Scotland would be £1,500 to £2,300 on a range of half a dozen to 14 sessions, but in England that would be £5,500 to £9,500. That is a considerable chunk of money to ask of someone, and it is very significant when it comes to taking on the extra weekend surgeries of seven-day working, or out-of-hours work.

[Alex Chalk]

That is an acute point. Does the hon. Lady share my consternation, particularly with respect to out-of-hours work, that in the past few years the premiums have been rising stratospherically? I think they went up by close to 10% last year.

[Dr Whitford]

I absolutely agree. As I have said, it is not particularly an issue in Scotland, but it is very much one in England. I know that it is being looked at under the new contract. Hon. Members may remember the Prime Minister’s challenge fund: extra surgeries at the weekend are better paid and do not involve the same indemnity issues as going to do a stint at the local out-of-hours. Unconsidered consequences of that kind must be looked at.

There is obviously increasing demand. We talk negatively about the ageing population, but living longer is a good thing, and I would like to recommend it. I spent 30 years trying to achieve it. In Scotland the number of GPs increased by 9% between 2005 and 2015, but the number of patients over 65 increased by 18%. Obviously, much innovation across the UK is to do with trying to reduce workload. Scotland was first to get rid of the quality and outcomes framework, which had encouraged significant quality improvements but grew into a huge bureaucratic machine. We are working on developing the multi- disciplinary team, with physios, access to counsellors, and pharmacists. That is happening in England as well. One innovation in England is known as “time for care” and concerns extra training at the frontline—reception—to encourage triage of patients to the right member of the team. However, my attention has been caught by the development of a new app that allows patients to book appointments directly; that would remove the option for triage. It is important for innovations to be joined up.

We need to innovate and to use all community resources. Scotland has for 10 years had community pharmacies providing minor ailment services. Our optometrists are allowed to make direct referrals to hospital for cataracts, and now they treat 90% of all acute eye problems. Those are things that may at the moment be referred to general practice simply to ask for a letter to be passed on. That is a waste.

There has, obviously, been a climb in the number of practice vacancies, including in Scotland. Our whole-time equivalent has fallen, in the past three years, by 1.9%—in England the figure is 2.8%. There has been a 50% increase in the number of GPs taking early retirement, at the age of about 57. Some of that is because of the change in pension tax rules. The problem of having too big a pension is a nice one to have; however, if people who invested 40 years ago in very expensive added years are finding suddenly, as they approach retirement age, that that means they are accruing no further pension, we have a problem.

Brexit is definitely a threat. In Scotland, 3.5% of the health and social care workforce—and 5.8% of doctors—are from the EU. In London the figure is 14%. We know that 14% of EU doctors in Scotland, and 19% in England, are already in the process of leaving and, as has been said, that is simply because they feel unwelcome. As we have seen with the difficulty of getting tier 2 visas over the past four months, recruiting from outside the EU is a real issue. Businesses in London can increase someone’s salary to get past the limitations, but the NHS is not able to be so flexible.

[Michelle Donelan]

Does the hon. Lady agree that we also need to tackle social injustices to ensure that the most disadvantaged in our society have the confidence and know-how to pursue a medical career? Does she welcome Government programmes to tackle that?

[Dr Whitford]

I absolutely welcome them. Similarly, in Scotland the new graduate medical programme will take on people who have done other degrees, and that is particularly aimed at encouraging those people to go into general practice and rural practice.

[Jim Shannon]

May I gently ask the hon. Lady whether Scotland has a bursary scheme? Both I and the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) referred to that, as we feel that such a scheme might help.

[Dr Whitford]

Obviously, in Scotland we do not have tuition fees, so that is a considerable difference in student debt, particularly for a five-year medical course. We do not, as yet, have a system of bonding or tying students down. The worry is that that would create a feeling of being trapped, and that as soon as the bond finishes, the person runs away. I am sure that all Governments in the UK are thinking about such things, but it is about working out whether such a scheme is beneficial or negative in the long term. We do have a GP bursary scheme for those entering a traineeship, so that when someone moves from a hospital where they work on-call, and becomes a GP trainee, the drop in salary is compensated.

As the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone) said, in Scotland we have a particular issue with the provision of rural services. We have a much higher ratio of GP per head of population, with 91 GPs per 100,000 people, as opposed to 71 in England, 73 in Wales and 70 in Northern Ireland. What often gets forgotten when people look at the weirdly angled weather map, is that although Scotland is one third of Great Britain’s landmass, it has 8.3% of the population. Anything that involves providing services across an enormous area is a challenge. We also have 70 inhabited islands that require services. Our recruitment and retention fund is putting additional money into this issue. The Scottish Rural Medicine Collaborative involves 10 health board areas, and relocation money—the golden hello for trainees or indeed any GP moving into practice—has been increased from £2,000 to £5,000. Any GP moving into rural practice will have a golden hello of £10,000, and trainees will have £20,000. That has been rolled out from the 44 island practices to all 160 rural and remote practices.

One key issue driving this problem, which perhaps is not often recognised, is the change from full-time to part-time working. Headcount for GPs is up by 5% in Scotland, but down by 4% from 2013. The change seems to have been in the last five years—indeed, there is a real culture change as the next generation comes in. When my husband became a GP, he was the first part-timer in his practice. They interviewed all the women before him, because it seemed so weird to have a man who wanted to work part time—that is because I was always in the hospital. Now, out of eight GPs, only two are full time. The number of patients in the practice has not changed, but instead of six actual GPs, there are eight. Therefore, the average GP is working considerably less. In England, the change in headcount of those looking to work full time meant that numbers went from 39,000 to 27,000. That shows the dramatic difference between the full-time equivalent and headcount, and it means that the average GP is working about 70% of what a full-time GP worked. The problem for any Government is that they then need to train 30% more GPs to cover that.

The key, however, is satisfaction. At the deep end, the 100 most deprived GP practices in Scotland face the inverse care law: people do not demand, and therefore service is not delivered. Govan health centre is running the SHIP project—social care and health integrated partnerships, and that innovation is now being picked up elsewhere. It means that GPs have extra time, and a significant multidisciplinary team, but in those areas, 31% of patients will have four or more conditions.

We have an even deeper problem, however, which is the attitude to general practice. Other specialisms look down their nose at it, and therefore a student may not be encouraged to enter general practice. Students are not getting enough exposure to general practice, either as students or in their foundation years. We also have a particular problem with the two foundation years since “Modernising Medical Careers” came in. We pour all our young doctors into a hopper—a computer—and they get divvied out. They will struggle to be with their family or where they were living before. In 2011, 29% of young doctors left after the two foundation years. Last year it was 50%. They do not feel part of the team or have a sense of continuity—things that are utterly crucial to general practice. Therefore, although we may be putting in more money and coming up with schemes, we must also reform the foundation years so that we do not have an entire lost generation.

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[Bridget Phillipson]

I am grateful to all hon. Members who contributed to the debate. We have heard that the future of general practice faces a significant challenge the length and breadth of the country.

On the Minister’s point about funding, since 2010, the rate of increase in NHS spending has slowed considerably. It is well below the real-terms average increase of the 3.7% that the NHS has received since its inception in 1948.

For all that the Minister referred to the Prime Minister’s comments about a long-term and sustainable funding model for the NHS, we are nearly eight years on. We need that model, but we also need something to undo at least some of the damage that has taken place in that time.

On a more positive note, given the success that we achieved in the University of Sunderland bid, I hope the Minister will look carefully at regional variation in the fill rate for training places. We need to take more action to address it.

The scale of the challenge that we face with general practice is clear. It falls to the Minister and to NHS England to take action so that all our constituents, no matter where they live, get the access to world-class healthcare they need.

[Dr Whitford]

On a point of order, Mrs Moon. I have a factual correction to make. The hon. Member for Aberdeen South (Ross Thomson) stated that only 51% of students at Scottish universities were from Scotland. In fact, it is 70%.

[Mrs Madeleine Moon (in the Chair)]

I am sure that information will have been gratefully received.

Question put and agreed to.

Resolved,

That this House has considered recruitment and retention of GPs.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 20th March 2018 Commons Chamber

[Mr Hunt]

I will re-look at the issue and the response that the hon. Gentleman was given. The issue is that there is unevenness and unfairness in the rates charged to GPs whose surgeries belong to NHS Property Services. We are trying to make this fair across the country, but we also want to make sure that no GP surgeries close.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

With an ageing population, I, too, welcome the aim of integrating health and social care and developing population-based planning, as we have done in Scotland with health and social care partnerships, but the outsourcing of health service contracts to private providers in NHS England has led to more fragmentation rather than integration. Will the Secretary of State agree that we need to repeal section 75 of the Health and Social Care Act 2012 so that local commissioners can develop patient-centred services and not fear litigation if they do not put them out to tender?

[Mr Hunt]

We want to encourage the NHS to move towards more integrated services, and part of that is about contractual structures, but part of it is about funding, and I gently point out to the hon. Lady that 8% of the NHS budget in England goes to general practice and only 6.6% in Scotland, which is why there is an even bigger problem with GP surgeries closing in Scotland.

[Dr Whitford]

The many and varied new integrated care structures developing in NHS England have no statutory basis, yet in the future will control the entire health budget for a population. Does the Secretary of State accept that with another major NHS reorganisation we need debate and legislation in this place to get the structure and governance right?

Draft Human Fertilisation and Embryology (Amendment) Regulations 2018 Draft Human Tissue (Quality and Safety for Human Application) (Amendment) Regulations 2018

Philippa Whitford Excerpts

Wednesday 31st January 2018 General Committees

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, support the regulations. It will be important that the UK, as it becomes a third country, matches the regulations and is able to export human cells and tissues into the EEA, as well as being able to import them now.

Two matters have been referred to: the need to have a single code that is traceable right across Europe and to have clear standards for countries that are outside the EEA. All of us would welcome that. I have a little concern about what is referred to as the one-off exemptions. That implies that for certain patients there could be repeated one-off exemptions. I would urge the Government to look at that to ensure that it does not become a loophole that would allow repeated import of something substandard, even if it were designated for a single patient, which is how it is identified.

Although organs and blood are obviously outwith this measure, we are well aware of the CJD––Creutzfeldt-Jakob disease—and infected blood scandals. Those happened at the time when we imported blood products from America and people were not thinking about it. It is important to think ahead, so that if there is an issue, it is identified and traced quickly and the supplier shut down.

I welcome both the importing controls from third countries, particularly when we hear of some quite frightening trades in stem cells, organs and tissues in parts of Asia, and also the traceability of having a single code. I echo the point that that will obviously require a little bit of investment.

NHS Blood Cancer Care

Philippa Whitford Excerpts

Wednesday 17th January 2018 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Wilson. I, too, commend the hon. Member for Crawley (Henry Smith) on securing this debate.

As has been said by Members, blood cancers often represent a hidden cancer, but that applies to solid cancers as well, particularly ovarian and pancreatic, which also tend to present with vague abdominal symptoms that simply could be nothing. The general practitioner sits there seeing cases of back pain and tiredness one after the other, and the challenge is to spot the patient among hundreds who might have something else. Obviously, if someone talks about bruising and night sweats, we hope that a GP would do a simple blood test that might flag up that one patient—that canary among the swallows —who needs to be referred to hospital and diagnosed. At medical school, we medics were taught to have a high index of suspicion, to not just go around assuming everything is nothing, but to try to hold those other things in our heads.

The hon. Member for Crawley mentioned that there are more than 130 types of blood cancers, but there are three main groups: leukaemia, lymphoma and myeloma. As a breast cancer surgeon, I dealt with lymphoma patients because they present with a lump. Lymph glands are all over the body and commonly swell up, so they would present with a lump in their neck or under their arm. A woman would commonly be sent to me with a suspicion of breast cancer.

Blood cancers are grouped together because of the type of cells they come from, but they behave in different ways. As was said, the challenge is how to get them diagnosed: how to have that index of suspicion. When someone moves to treatment, we use radiotherapy in some patients, particularly in lymphomas if the disease is localised or regionalised. The downside is that they might have radiotherapy over a large area of the body. Most of us are aware that radiation is damaging. I had patients in my breast cancer clinic that were under follow-up because they had had radiotherapy to their chest when they were teenagers and now had an additional risk of breast cancer. As we get more people to survive cancer, the challenge is the risk that they have of other diseases or ongoing side effects.

Dependence on chemotherapy and drug treatment has been mentioned. Of course, the biggest breakthrough was bone marrow transplants to deliver healthy stem cells. Radiotherapy is also used as part of that. The dependence on drug treatment and chemotherapy means blood cancers are even more vulnerable than other cancer types to the difficulties of accessing new and expensive drugs. A new drug, daratumumab, was just passed in Scotland in October. The decision will be made by NICE next month. It is the first immune treatment for one of the diseases in question, and obviously we hope that it will be the first of many that could start to bring about change, but inevitably such drugs, based on monoclonal antibodies, will be expensive, and that raises the issue of drug access.

In Scotland, there is the new medicines fund and in England there is the cancer drugs fund, a slight downside to which is that it is only for cancer. That might not be a problem for the patients that we are concerned about in this debate, but it is for people with some other diseases. However, the fund plays a role for drugs that have not yet reached the point of being passed by NICE, but for which some hope is felt. There was obviously great anxiety when seven key treatments were removed from the cancer drugs fund a few years ago.

Something else that happened a few years ago was that a limit started to be put on the holy grail treatment of bone marrow and stem cell transplant, in that patients with a recurrence were not given the opportunity for a second transplant between the summer of 2016 and the spring of 2017, because that was no longer being commissioned. Politicians and those high up in organisations such as NHS England need to be conscious that trying to balance the books may pull the rug from underneath people. The gap of three quarters of a year will have been catastrophic for some people who might have benefited. That must be recognised when decisions are made.

In the Scottish NHS, we do not have mechanisms such as 100-days commissioning, and hearing about it highlights to me how time, energy and people are wasted in trying to knit together a system that has become fragmented. I hope that the husband of the hon. Member for Coventry North East (Colleen Fletcher) is doing well, and continues to do well; but for the cancer nurse specialists or doctors to have to try to plug a gap, or for patients to fall through the gap because, as was said in one briefing, there are CCGs and commissioning groups that do not even know they are responsible for commissioning that care after the 100 days, is a waste. I spent more than 30 years working as a breast cancer surgeon and I would not want to have to waste clinical time in trying to deal with the gaps between stools. I think that the friction between what NHS England commissions and what CCGs are responsible for must be looked at.

The hon. Member for Crawley highlighted, as did the charity briefings we received, the watch and wait approach taken with patients suffering from one of the more chronic types of blood cancer, such as chronic lymphocytic leukaemia and follicular lymphoma. I do not think that that should be seen as negative. We would not want to put people through tough chemotherapy if they were well; therefore we would not rush to do that. That is probably why many years ago those types were not labelled as cancer: what was referred to as “the C-word” was seen as a catastrophe. There was an attempt to give people the feeling that they were living with a disease; whereas we see cancer as meaning that the clock is running and we must rush to do everything. Therefore using the word “cancer” and then telling someone, “Actually we are not going to do anything about it,” is very challenging. That requires time for the clinician to have an open, honest and informed debate with the patient, so that they understand why they are not suddenly being put through chemotherapy.

Data and the auditing of performance are important for driving through the improvement of any service. I do not mean such things as waiting times, on which we all collect data, but actual clinical standards—how someone is treated and what we would expect. What would all the clinicians in the area think was good practice? I do not mean shutting things down, or units being threatened by the Care Quality Commission. Having developed the breast cancer standards in Scotland in 2000, I can say that sitting in a room with all the breast teams of Scotland and looking at the data in a big PowerPoint on the wall is a dynamic tool for getting people to change practice. No one goes to work wanting to be the worst team in their country, region or area. Having access to actual clinical data is a great driver of quality.

In England, work is being done on setting up cancer dashboards for the four commonest cancers. In Scotland, we have them for the 11 commonest cancers. We have had Scotland-wide breast cancer data since 2003. I have seen the quality go up simply from our all meeting every year, looking at the data and challenging each other and discussing the data—and sharing solutions. Whatever problem a unit faces—whatever the reason for their performance going down—someone else in the room will have had that problem before, and solved it. Such peer review and sharing of practice drives things forward. One of our big hopes for the cancer alliances is that they will redevelop what existed in cancer networks, which we still use in Scotland: people meet, support each other, and share practice.

The importance of research has been mentioned. As a great believer in the European Union and the things that we have gained from it, I am anxious about our leaving the European Medicines Agency, about the loss of its support mechanism on rare diseases, and about the possibility that we will be outside the clinical trials regulation system, which is designed vastly to reduce the paperwork involved in taking research forward in a clinical trial. In the end, what we want to come from research is new treatment—new drugs. The UK is dynamic in the life sciences and the development of new pharmaceuticals, but the rather bizarre thing is that often our doctors do not get to use them. For people working in hospitals, that is getting to be a negative feedback loop. We do not get paid extra if we put patients into trials. There is an enormous amount of paperwork, and people inevitably stay well after time to make sure that things function. If suddenly at the end of the trial period, when they might be getting the drug funded, they cannot get access to the drug for several years, until it gets through NICE in England or the Scottish Medicines Consortium, those people feel, “Who is gaining? It is not my patients.”

We require a different conversation with the pharmaceutical firms—some form of risk sharing by which perhaps a drug can be provided at a much lower price to the NHS. Instead of access simply ending and our going generic when the patent is finished, there could be a deal as to how many patients are treated with the drug before the NHS uses generic drugs. In that way the firms would know they would get a return on their money. The way things are at the moment, at the end of all the trials the price is worked out from how much time is left and how many patients are likely to be treated. If, as when Herceptin came in, it is a matter of thousands of pounds—Kadcyla was £90,000 per patient—it becomes almost impossible. While we tinker at the edges of the pharmaceutical price regulation scheme and what is done with the money we need a much deeper conversation.

Obviously we want to promote awareness of blood cancers. Public awareness of the blood rash was mentioned; but also doctors need to think about having a high index of suspicion, and doing a simple blood test. For legislators and those who oversee the NHS systems in which decisions are made, it must be important that when a patient goes to see the doctor they set off on a smooth pathway that does not involve negotiations, hassles and disruptions, and that we support them all the way through that journey.

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[The Parliamentary Under-Secretary of State for Health (Steve Brine)]

It is a pleasure to serve under your chairmanship, Mr Wilson—I believe it is the first time that we have danced in such a way. I congratulate my hon. Friend the Member for Crawley (Henry Smith) on securing this debate on an issue that I know he feels passionately about, and I commend him for his work chairing the all-party group. We all come to the House with our motivations and experiences, and we all gather more experiences in the House. One reason why this is the job that I always wanted to do in government is because I have fought many types of cancer in many different ways, and lost more than I have won. It is always moving to hear Members speak personally about their experiences and why they have promoted certain issues in their parliamentary career, and I thought my hon. Friend did that brilliantly. Such experiences make us the MPs that we are, and I hope only that the figures for the people watching this Westminster Hall debate match those for people watching daytime television shows instead, because I think they would have a great view of the way that Parliament operates.

Let me start by saying that the Government, and this Minister more than ever, are absolutely committed to transforming cancer services across England, and we take an all-cancer approach to doing so. It is true that cancer survival rates have never been higher, but we want cancer services in England to be the best in the world. We want to ensure that every patient, regardless of the type of cancer that they unfortunately get, has access to the treatment, the services and the support that give them the best possible chance of a successful clinical outcome and a successful recovery back into their lives, which are temporarily paused while they go through treatment.

Shortly after this debate, as my hon. Friend the Member for Crawley advertised very well, the all-party parliamentary group will publish its first report. Having chaired the all-party parliamentary group on breast cancer with the shadow Minister for many years—and for a bit with the hon. Member for Central Ayrshire (Dr Whitford)—and produced all-party parliamentary group reports, I know how much work goes into them and how important they are. My hon. Friend should know that they are noticed by Ministers—they are certainly noticed by this Minister. I have here the copy he kindly shared with me. I think it is an excellent and informed piece of work and I congratulate him and the charities that supported him through the secretariat. I assure him that the Government and NHS England will take careful notice of its findings and recommendations. As I always do when I speak in response to the launch of a report, I will see that he gets a response in writing to the recommendations that he has made, in addition to what I will say in today’s response.

The report highlights that someone is diagnosed with a blood cancer every 14 minutes. Nearly 250,000 people are living with blood cancer in the UK today, and it claims more lives than breast or prostate cancer. It is the third biggest cancer killer in our country, so this debate is as timely as it is important. I am pleased to say that many of the recommendations in this report mirror the strategic priorities set out in the cancer strategy for England, which outlines how we will implement all of the 96 recommendations of the independent cancer taskforce, chaired by Sir Harpal Kumar of Cancer Research UK, who will shortly step down from that role. What a loss that will be. I wish him well. I hope I can therefore assure my hon. Friend and other hon. Members that two years into the implementation of the strategy, we are already making significant progress in implementing the recommendations of the APPG report.

My hon. Friend the Member for Crawley stated where we must start—a point also made by my hon. Friend the Member for Henley (John Howell)—and that is early diagnosis. We all know that this is key for all cancers and it gives the best possible chance of successful treatment. To improve early diagnosis, the Government made £200 million available to cancer alliances in December 2016 to encourage new ways to diagnose cancer earlier, improve the care for those living with it and ensure that each cancer patient gets the right care for them. The APPG report highlights that early diagnosis of blood cancers is difficult—we have heard different contributions as to why that is—as symptoms such as tiredness or back pain, are often misdiagnosed. My hon. Friend the Member for Crawley mentioned that his mother presented with flu-like symptoms, which maybe threw them off the scent a bit in the early days. That is why, for suspected blood cancers, the National Institute for Health and Care Excellence published a revised guideline in 2015, which clearly sets out that GPs should consider a very urgent full blood count within 48 hours to assess for leukaemia, if adults present with suspicious symptoms. I am very sure that there is more that we can do around education in primary care, but I think that was a positive move from NICE.

Further, I must here mention the accelerate, coordinate and evaluate programme—ACE for short. It is a unique early diagnosis initiative, and a programme of 60 projects exploring innovative concepts across England. The programme is testing a new multidisciplinary diagnostic centre approach to diagnosing patients with vague or unclear but concerning symptoms, often characteristic of hard to diagnose cancers such as blood cancers. There are ten pilot MDCs across five areas of the country. They are one-stop shops that can ensure patients rapidly receive a suite of tests, reducing the risk that patients bounce around services receiving multiple different referrals for the same problem, having to start that explanation all over again—I know that is incredibly difficult—and do not get that all-important early diagnosis. We know that early analysis of these schemes is very positive and many patients can receive a diagnosis or the all-clear within just 24 hours. I look forward to seeing further analysis of these pilots when that is available and I very much hope that MDCs can become an important tool in helping us to identify blood cancers earlier. We have the new 28-day faster diagnosis standard coming down the track. I always say that 28 days is not a target, it is an end point. If we can beat it and do it in 28 hours, happy days.

Patient experience when it comes to cancer is clearly so important. The APPG’s report also rightly highlights the importance of that. Improving patient experience is one of the six strategic priorities set out in the cancer strategy, and cancer patients are receiving better and more effective care, we believe. We are committed to ensuring that this improvement continues. In 2016, NHS England surveyed just over 118,000 people through the national cancer patient experience survey, which I am committed to continuing in one form or another, because I know how important it is. Over 70,000 cancer patients took part in the latest survey. I am very grateful to all of them for giving us their feedback to help to improve the experiences of cancer patients in the future. This feedback is vital to inform and shape the way hospital trusts and clinical commissioning groups achieve further improvements for patients. The Cancer Vanguard has also developed an innovative cancer patient feedback system which is now being used by many organisations that provide cancer care in our country. This new system collects real-time patient feedback at key points in the patient care pathway, which we have heard mentioned today, so that it can be fed back and used by those redesigning services to put patient experience at the heart of improvements in service.

Linked to this point about patient experience is access to a cancer nurse specialist. My hon. Friend made the important point in his opening remarks that access to a CNS can make a hugely positive difference to the treatment experience of patients with blood cancer. Health Education England’s first ever cancer workforce plan clearly stated that we will ensure that every patient has access to a CNS or other support worker by 2021, and if we can do it sooner we will. We will do this by developing national competencies and a clear route into training.

I thank my hon. Friend and others for their tributes to Macmillan Cancer Support. I have been to Southampton General Hospital—my neighbour, the hon. Member for Southampton, Itchen (Royston Smith), was here earlier—to visit the acute oncology centre, which is a partnership between the University Hospital Southampton NHS Trust and Macmillan, and a brilliant centre it is too. I met patients undergoing treatment for blood cancers. It was not a planned visit, but it was timely, given this debate. Macmillan—a brilliant charity—is also currently carrying out a specialist audit to understand the current size and location of the specialist cancer nurse workforce. This will enable us in the Department and NHS England to develop a much more comprehensive picture of how many specialist nurses are working in cancer and what further action and investment might be required to ensure timely and good quality patient care and experience in line with the target that I have set out. Once we have this data, I hope in the spring, we will publish an additional chapter to the cancer workforce plan, and consider the actions needed to support and enhance the wider nursing contribution to cancer.

My hon. Friend the Member for Gordon (Colin Clark) spoke of workforce shortages north of the border. It is a familiar tale. We both face a cancer workforce challenge, which is why HEE produced our cancer workforce plan. It is a significant challenge to the NHS and cancer care, but one that we are absolutely determined to meet head-on and to beat.

My hon. Friend the Member for Crawley and other hon. Members made points about living with and living beyond cancer. I take the point made by the shadow Minister about that term. Obviously the cancer strategy is as published, but in time it will be refreshed, and I take on board the point, which she made well. More than ever, thanks to innovations in treatment there can be a full life beyond a cancer diagnosis. The hon. Member for Central Ayrshire reminded us really well about the C-word. It did used to be the big C. It used to be a terror, and still is for many, but so many people now have a full life beyond a cancer diagnosis.

[Dr Whitford]

While we are obviously talking in particular about the chronic types of blood cancer, there are also solid tumours. Indeed, hormone positive breast cancer is actually much more of a chronic disease. It carries the same risk into the future and people may be living with it for decades. We have to get round that curve of seeing cancer as something that is dealt with acutely and then is over. There will be many cancers that we control, and we therefore need to help people to accept them as a chronic disease and not torture themselves with the C-word.

[Steve Brine]

What a good point. I love the term “survivorship”, which we often hear. It is probably an Americanism, but it is one of ours now. It is a great term because it suggests a positive: we have survived and we will continue to survive and to fight. My officials do not like me using the term “to fight cancer”, but I do think that it is a battle, and a constant battle. Macmillan’s brilliantly moving PR campaign at the end of last year talked about life with cancer. There are lots of people living with chronic conditions. When I visit cancer patients, as I did on Friday in Southampton, I always make a point of asking them what they do when they are not in the cancer ward and what they are planning to do when they finish being in the cancer ward, because their lives are more than their cancer, and they are not their cancer.

From the moment that they are diagnosed, patients benefiting from the recovery package, which we have heard mention of, receive personalised care and support. Working with their care teams, patients develop a comprehensive plan that addresses their physical and mental health requirements, which we have also rightly heard mention of, as well as identifying any other support that they may require. We are working to ensure that every patient in England, including those with blood cancer, has access to the recovery package by 2020. I repeat: if we can do it sooner, we will.

Different cancers affect the body in different ways, and treatment and the recovery journey for someone with blood cancer can vary greatly to those for a patient with a solid tumour cancer. That is why every patient will receive a holistic needs assessment as part of their recovery package. For blood cancer patients, their recovery plan will be personalised to take account of the unique characteristics of blood cancer. My hon. Friend the Member for Crawley described the end of treatment as falling off the end of a conveyor belt, which is an expression that I have heard before. In my job I have seen research to the effect that the end of treatment can be more depressing than the moment of diagnosis. That is a really hard thing to say and to accept, but I can well believe, and know from personal experience, that it is true.

That moves us on to psychological support. My hon. Friend makes the point that many patients with a chronic blood cancer diagnosis will sadly never be cured. They will be on a regime of watch and wait, often over many years, to see if the cancer has progressed to a point where treatment needs to begin. That can, understandably, take a huge psychological toll on the patient and their families. That is why the point made by the hon. Member for Central Ayrshire is so true, and why the recovery package rightly takes a holistic approach and considers the patient’s mental health needs. The Prime Minister has made improving access to mental health services a priority for her Government. There has been a fivefold increase in the number of people accessing talking therapies since 2010, but we know there is much more to do, and I will be watching that like a hawk in my job.

We have heard today about the importance of research. If we are to continue to beat cancer and to better our figures, sustained investment in research is vital. The National Institute for Health Research spent £137 million on cancer research in 2016-17. That represents the largest investment in any disease area. It is thanks to advances in research that more than 90% of children diagnosed with the most common form of childhood leukaemia now survive. However, I recognise that progress in improving survival rates, including for some blood cancers, has been slow and that survival rates remain low. We have heard today that treatment of blood cancer is especially dependent on the development of new drugs and on being able to access them—an obvious truism—and that is why our focus is on not only research, but ensuring that proven innovations are adopted swiftly across the NHS in England. NICE’s fast-track appraisal process, or the FTA, which was introduced in April last year will, we hope, do just that. The FTA process will help to ensure that cancer patients have accelerated access to any clearly effective treatment that represents value for money for what is a publicly funded health service.

[Dr Whitford]

Will the Minister explain how that interacts with the budget impact assessment that allows drugs to be delayed by up to three years, even if they have been passed by NICE, if the overall cost of them might be more than £20 million? There are many concerns among groups that that might actually delay innovative drugs, which often tend to be expensive.

NHS Winter Crisis

Philippa Whitford Excerpts

Wednesday 10th January 2018 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Like others across the House, I thank all staff in all four UK systems, who, as the Secretary of State has said, have gone above and beyond the call of duty to focus on their patients, and I do not think any debate we have in here is intended to upset or insult any of them.

Before the hon. Member for Ludlow (Mr Dunne) perhaps leaves the Chamber, I want to thank him for his service as a Minister of State for Health, whom I often met across the Chamber, but I also want to correct a comment he made in answer to my question on Monday. He claimed that the number of patients waiting longer than 12 hours in A&E in England was half the level of that in Scotland.

Naturally, I would have expected the Minister to know all the stats and what they mean: in England data are only published for the percentage of patients who meet, or do not meet, the four-hour target. There is no publication of data on eight hours or 12 hours. The clock restarts for patients who require admissions, and that is defined as from the decision to admit until they get a bed and is known as trolley waits. So 48,000 patients waited over four hours on a trolley after their four-hour wait in A&E to get a bed, and the 109 he was referring to had waited over 12 hours on a trolley for a bed after the four or five hours they had waited in A&E. Therefore, it was utterly incorrect to compare that with the Scottish data, where we have a single clock from when the patient starts right through until they get to where they need to go. I simply want to clarify that while the hon. Gentleman is in the Chamber.

[Stephen Kerr (Stirling) (Con)]

I know that comparing England and Scotland is one of the pastimes that Scottish National party Members like to engage in—it is a fascination for them—but the reality is that in my constituency of Stirling, served by the excellent NHS Forth Valley in Larbert, only 57% of patients were seen within four hours in the last week of last year because we have a flu epidemic in Scotland, as they do in England, and that should be acknowledged.

[Dr Whitford]

If the hon. Gentleman gives me a little longer, he will find that I intend to talk about the flu epidemic, but before he gets too celebratory he might want to wait until tomorrow when we will have comparable data, because while in Scotland the data are published every week, in England they are published only every month. I am glad, however, that we no longer wait six weeks after the end of a month, which is 10 weeks after the start of it, but get it a fortnight later. So that will be available tomorrow, and then he can compare hospital trusts in England with hospitals in Scotland to his heart’s content. I would have thought that, as someone who celebrates the United Kingdom, he might want to praise the fact that Scotland has led the entire UK since March 2015 on emergency admissions and A&E.

Having corrected that, all of us recognise that this is a particularly tough winter because there has been an outbreak of flu on top of a bad freeze. I point out to those who think the worst is past that the flu season lasts until March and at the moment this is an outbreak, not an epidemic, but it comes on top of underlying pressures, and across the four nations this has involved staff having to go above and beyond the call of duty.

Whether it was how Public Health England said it or how the media reacted to it, this business of stating in public that the flu vaccination does not work is unfortunate and irresponsible. The flu vaccination recipe is planned by the World Health Organisation at the beginning of each year. It will already be working on next year’s flu. It does not have a crystal ball and people who have what we in the medical profession call a retrospectoscope should recognise that that tool was not available at the time when the decisions were made. Producing vaccine is a biological process that takes months, so the decision is made in March for the northern hemisphere, and all the companies produce to that recipe. Headlines in Scotland implying that the Scottish Government popped down to Boots and took the wrong vaccine off the shelf are therefore facile, and that also encourages people not to bother.

We already have falling vaccination rates in childhood vaccination and in flu. We should be pointing out that multiple flu viruses are circulating. While all the talk in the media is of Australian flu, in Scotland that is about a quarter of the strains that are circulating.

One of the issues with flu is that it happens in cold weather, and in Scotland we get the coldest weather in the United Kingdom, so we have double the rate of flu that there is down here in England. We also had a worse freeze, and are continuing to have a worse freeze. So when the data come out tomorrow, I think we will see that Scotland will still lead the UK. We will not be performing to the level we want. We have not met the 95% target for emergency departments since August, but England has not met them since 2015 and, sadly, Wales has not met them since 2008. So this is a challenge across the board, but Scotland has been more resilient. I call on all MPs to encourage staff and other people to get a flu vaccination, because this will continue until March and it is still absolutely worth doing.

The Secretary of State often talks as if the problems in A&E are due to people who should not be there. If we talk to anyone who works in A&E, they will say that, by and large, that is not the case. With people getting fractured ankles and fractured wrists on the ice, A&Es will have been very busy with having people carted in and X-rayed, and what we call in Scotland getting a stookie put on before they go home. That is all going to take time, but anyone who works in A&E would say that the key issue is frail, sick people, often with multiple conditions, and whether they fractured their hip falling on the ice or have a respiratory problem secondary to flu, they need a bed and the issue in England is that there are not enough beds.

[Dr Rosena Allin-Khan (Tooting) (Lab)]

I work in A&E and spent some shifts in recess working in A&E—on new year’s eve and just a few days ago, on Sunday. I agree that many of the people attending A&E, particularly at St George’s where I work, are there because they are frail, but they are also there because this Government have ensured they cannot get an appointment with their GP, our social care is in crisis and we do not have mental health budgets.

[Dr Whitford]

I thank the hon. Lady for her intervention.

Obviously, the shape of medicine has changed. More is delivered in primary care—as a surgeon, I well know that more surgeries are delivered in a day—but if we are doing a straightforward operation on an older patient, they will still always require longer rehabilitation; they are more likely to stay overnight or several days, and if they have fractured their hip, they will require full rehabilitation before they go home. The problem is that the number of beds in England has been halved since 1987—under successive Governments—and the NHS stats released for the end of the second quarter of 2017-18 show that almost 1,000 beds have been lost even since the winter of last year, when the situation was described as a humanitarian crisis. That was a mild winter that did not have a flu outbreak on top.

England has only 2.4 beds per 1,000 population, whereas the EU15 that the Secretary of State refers to has 3.7, and we in Scotland have more than four. If we are running constantly with bed occupancy rates of over 85% or 90%, that is where the issue lies.

[Paula Sherriff]

The hon. Lady refers to the decreasing number of available beds; does she agree that we have a bottleneck now in many hospitals due to the lack of social care? In one day over the festive period in my area, just over half of ambulance transfers were completed within the required period. The Secretary of State likes to quote statistics at me, but I would like to give him that one to think about.

[Dr Whitford]

There will obviously be lots of bandying around of figures, and talking about the four-hour target and the achievements and the numbers, and, as I have said, it serves as a thermometer to look at the entire system from the patient turning up at A&E to their going home. That is what this is a measure of, and it is there to flag up concern. While we will be getting that data, we do not need it; we have already seen ambulances 12-deep, and have already heard that 75,000 patients are stuck in ambulances for between half an hour and an hour, and 17,000 stuck for more than an hour. As was mentioned by the right hon. Member for North Norfolk (Norman Lamb), who is no longer in his place, this means that those ambulances are not available to respond to other 999 calls, which endangers patients.

[Huw Merriman (Bexhill and Battle) (Con)]

I think the hon. Lady for giving way, and I apologise if she was still answering the point made by the hon. Member for Dewsbury (Paula Sherriff). I accept her point that many of those who are in A&E need to be in A&E, but the reality is that admissions to A&E have gone up 20% over the past 10 years to 6 million per year. Does she agree that more interventions could be made by GPs to prevent some of those admissions from being made and to allow people to be looked after in their own homes?

[Dr Whitford]

I am not 100% sure whether the hon. Gentleman meant attendances at A&E or admissions, which is what he said—

[Huw Merriman]

Attendances.

[Dr Whitford]

Attendances at A&E tend to be higher in the summer, when kids are on bikes and trampolines, and up trees. It is admissions that are higher in winter, when A&E is dominated by people who are sick. Of course we want primary care and the 111 system to work, so that people do not use A&E as a first port of call, but the problem comes when that all gets too complicated and patients cannot work out where they should go. That is when they go to A&E. It is important to make it really clear where they should go to address which problems.

Having seen the crisis last year, when there was no flu, snow or ice to blame, I believe that there are underlying structural problems. The target was met comfortably until 2013, when the Health and Social Care Act 2012 changes kicked in and NHS England started to become fragmented and to be based on competition instead of co-operation. I would welcome the establishment of a cross-party group here to work on this, so that we did not always have to have these debates, but it would have to look at the structure and unpick what has been done to NHS England in the past four and a half years. Carrying on breaking it apart will not provide a solution.

[Clive Lewis (Norwich South) (Lab)]

Does the hon. Lady agree that the Government’s plans to establish accountable care organisations, which will exacerbate the fragmentation in the NHS, through secondary legislation are completely wrong and will make the NHS crisis even worse?

[Dr Whitford]

I completely agree that establishing accountable care organisations only through secondary legislation is utterly wrong. We have had multiple debates about STPs, and I have said that going back to place-based planning is the right way to integrate and develop a local service, but there should not be a private company at the top making the decisions. There needs to be a publicly accountable body. There is going to be yet another big reorganisation in NHS England, and the proposed structure needs to be debated in this place, not behind closed doors. Yes, money is tight, with the NHS seeing rises of just over 1% a year in the past seven years compared with almost 4% in the past, but it is estimated that between £5 billion and £10 billion is being wasted in the healthcare market itself, through bidding, tendering and profits, and now through this habit of companies suing if they do not win a contract.

It is crucial to move back to developing services for a community. It is also crucial that health and social care should be integrated, and I welcome the combination of both titles in the Secretary of State’s role, if that means that we are going to work towards meaningful integration, but it must be done in a structured, responsible and legalistic way.

[Chris Elmore]

The Government spend an awful lot of time attacking the Welsh NHS. In terms of the Secretary of State’s new cordial attitude in not attacking any NHS services, will the hon. Lady join me in condemning former Prime Minister David Cameron’s comment that Offa’s Dyke was the line between life and death, depending on which country one lived in? Wales has an integrated health and social care service, which is also integrated with local government, with a £60 million fund having been established over the past five years. She referred to the cross-party working that could happen, particularly if the Government were willing to engage properly in these services rather than attacking the Scottish and Welsh Governments on NHS care. Does she agree that we could use such working to learn good practice?

[Dr Whitford]

The four health services are very different. In essence, we have four laboratories. NHS England is by far the largest, but they all face different as well as similar challenges. I am sure that if there were more discussion of how things have been done, there could be more lesson-learning in different directions.

In 2010, we were promised that there would be no more reorganisation. The same promise was made in 2015, but NHS England is now facing another reorganisation, in the STP system and in accountable care. It is crucial that the focus should be not on bottom-line, budget-centred care but on patient-centred care. It is wrong that any such changes should be introduced through secondary legislation. They must be introduced in this place—either through debate, in Committee, through convention or in a royal commission—to enable us to come up with a structure that will function. Since 2013, the deficits have gone up, the waiting time failures have gone up and the stress on staff has gone up, making it even harder to keep hold of people. Let us put the patient in the middle, but let us also support the staff who look after the patient.

[Several hon. Members rose—]