Health and Social Care

Philippa Whitford Excerpts

Monday 27th February 2017 Commons Chamber

[Meg Hillier]

It may well be, as my hon. Friend says, a false economy.

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

The early figures that have come out from NHS England suggest a 23% drop in applications. Obviously, that is a significant change.

[Meg Hillier]

The key thing, of course, is how that figure comes through the pipeline and how we fill the gap. While the Minister is on his feet at the end of the debate, it would be helpful if he said what analysis the Department of Health has done of the impact of Brexit and any changes it may herald for our NHS workforce, because a high percentage of them are from Europe. We are hearing the right sounds from the Government, but we have not yet had any action on securing the future of those European citizens currently resident in the UK. If the Minister is able to give us any comfort on that, it would be very welcome.

I am heartened that so many Members are in the Chamber to discuss this important issue. I should mention that the Public Accounts Committee has also been working with the Procedure Committee to try to ensure that the House can discuss the financial details of estimates rather than just the general principles, although I have obviously strayed into those, too. Hopefully, we can base these debates on the figures we have spent so much time looking at in the Public Accounts Committee. It is unedifying for the public to hear anonymous briefings and public argument; that does not wash with them. We need to be on top of this issue so that we hold the Government’s feet to the fire and make sure that, every step of the way, they know we are watching the budget. We will not let you get away, Minister, with raiding the capital budget to fund the accounts this year.

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

I certainly welcome the fact that, in recent months, since the hearing of the Health Committee, the Secretary of State for Health has stopped using the £10 billion figure and has recognised the £4.5 billion figure, which is much closer to reality. Spending is normally allocated on the basis of health spending, not just NHS England spending. The increase in NHS England spending was at the cost of significant cuts to public health, even though we all recognise the need for prevention, and cuts to Health Education England, despite the attempt to have 1,500 extra doctors every year, extra nurses and 5,000 extra GPs, which is therefore rather a challenge.

As has been said, last year was the good year before we come to the lean years. I am not going to go into details of the pockling that was required to get anywhere close to the required outturn, which was missed by £207 million, as that has been so clearly explained by those on the Public Accounts Committee. That results in what the Auditor General has described as short-termism—people simply working to meet the bottom line instead of lifting their chins up and looking at what the real challenges are.

There are three big challenges. We have talked about the ageing population, we recognise that we have significant workforce challenges, and we all know that money is tight and does not grow on trees. Those three things create a conflict. People are sometimes putting in a short-term patch that will actually cost more money in the end. Providers across England can be recognised for getting their agency costs down, although they are still more than twice what they are in Scotland, but what is lying ahead? How will we meet the challenge of providing the workforce after Brexit—not just the challenge of people leaving, but of how we recruit in future? The turnover at the level of nurse and social care worker is about 25%, and we need a constant stream. A Government Member mentioned the tiny proportion of population below the age of 65—of working age. That is exactly why we needed immigration in the first place. Are we going to end up with more agency workers, or will the Government take action to make sure that we can attract nurses, doctors and social care workers from Europe?

A lot of these problems are blamed on an ageing population. In fact, Scotland’s demographics are worse than England’s, and going through the hard winter that we have all faced, we did not meet our A&E target either. However, in Scotland the A&E department four-hour achievement level was 92.6%, while in England it was 79.3%—the worst level since records began. That shows that there is a real crisis. This is not meant to be a measure for us to attack each other with. In general, this has been a great debate compared with what some of our debates are like. Rather, it is meant to be a thermometer to take the temperature of the whole system—not just the whole hospital system from A&E to discharge, but from home to GP, to A&E, to hospital, to getting back home again. The problem lies in the significant cuts made outside the Department of Health but within social care. Obviously patients require the support to be able to get back into the community, and preferably even back to their own homes.

Why are we are managing, despite our demographics, to keep our nostrils above water when NHS England is not? It is partly because in Scotland we have focused absolutely on integration rather than financial competition. The convoluted system that now exists between CCGs and outsourcing contracts, bidding and tendering is estimated to take £5 billion to £10 billion out of NHS England’s budget. That would be enough to cover the deficits—to plug the social care hole—and yet the Department of Health does not even keep data on it, so it is not keeping track of how these administration costs are growing. There is no possibility of a cost-benefit analysis of bringing in outside providers and causing this fragmentation instead of people being able to work together.

In Scotland, as I have said before, we have gone down the route of integrated joint boards between health and social care, taking money from both sides so that we do not have the argument over whose purse is funding a patient. We have used other innovative approaches such as community pharmacies, which we have debated here previously, and minor ailments units within community pharmacies. As a result, in the past five years attendance at A&E in Scotland has increased by 3.4%, while in England the figure is 11.8%—three times our attendance rate.

The situation with admissions is similar. Our emergency admissions have increased by 4.6%, while those in England have increased by 14%. That is all because the effort is not being made in the community.

There is a lot of talk, all the time, about the five year forward view. Frankly, we are halfway through the five years, so we are left with a two-and-a-half year forward view. That does not look far enough ahead. Scotland did “2020 Vision” back in 2011, and we are now working on 2030, by which time the number of people aged 85 and over will have doubled. That is what we need to think about: how do we design not only our social care services, but out health services around the ageing population?

Our Cabinet Secretary is focused on what keeps people independent. Members may think that that is because I represent the Scottish National party, but I am talking about people being independent and living high-quality lives. What is it about? It is about hip replacements, knee replacements and eye surgery. If someone cannot see or walk and they are stuck in their house and lonely, we are going to have to look after them. Therefore, we have invested in—this is often laughed at here—free prescriptions so that people take medication to control chronic illnesses. We have also invested in giving free personal care to people in their own homes so that they do not land in hospital and get stuck there. That is why last year our delayed discharges went down by 9%, while here they went up by between 25% and 30%.

People also laugh at free bus passes. The hon. Member for South West Bedfordshire (Andrew Selous) mentioned loneliness, an issue that was championed by Jo Cox. It is as big a killer as diabetes. Older people in our community are out and about. They are taking day trips and going shopping, and they love it. They are not stuck in their houses. This is about starting with looking at that population.

STPs are the best change going forward, but at the moment they are being handed a bottom line and told to work back from it. It cannot be budget-centred care; it must be patient-centred care. All of us across the House can recognise that place-based planning for a community will provide the best service to those patients and our constituents. That is what we should be doing. We need to get real about public health and preventing chronic ill health in later life, and that means addressing health in all policies. It is really bad that, day by day, this House considers individual decisions that completely contradict each other. We should always ask of every decision, “Will this make the health and wellbeing of our citizens better or worse?” If it makes it better, in the end it will save money. That includes poverty—the biggest cause of ill health.

I call on Members to consider the systems and how we do things, but we need to provide the care in the community before we take it from the hospital. Let us also think a little more broadly in some of the other decisions that we make.

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[David Mowat]

I will come on to social care. We have covered the NHS, which this Parliament will get a real-terms increase of 8% or 9%. Let us accept that and move on. On social care, a 5% or 6% real-terms increase has already been made available—that is not the Budget; I do not know what is in the Budget. Again, we can argue about whether that is enough, given the demographics, but we cannot argue whether it is true.

I want to spend a little time on the international comparisons, about which we heard some discussion earlier. According to the OECD, in 2014 this country spent 9.9% of its GDP on health. The OECD average is 9%, so that is 1% more, but it is true that the OECD average includes countries such as Mexico with which we would not necessarily wish to compare ourselves. The average for the EU15, which by and large does not include the newer states in the east, is 9.8%. So in 2014 we spent more than the EU average. It is true that we spend less than some of our comparator countries—we spend less than France and Germany—but it is completely wrong to say that there is a massive gap between us and the EU.

[Dr Philippa Whitford]

I thank the Minister for giving way, but 2014 was three years ago, and are we not heading towards a figure of less than 7%, which will put us 13th out of 15 among the EU15?

[David Mowat]

No. The 2014 figures are the most recent available—and they do not include the comparatively large settlement on healthcare and the front-loaded money in the spending review.

The Government spend 1.2% of GDP on social care—we spend another 0.6% privately. That is more than countries such as Germany—the Chair of the Communities and Local Government Committee talked about Germany—which spends 1.1%, and more than Canada and Italy. Again, it is less than some countries—Holland, an exemplar country in this respect, spends considerably more; I accept that there are choices to be made—but it is wrong to pretend that we are massively out of kilter with the sorts of countries we would regard ourselves as equivalent to.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 7th February 2017 Commons Chamber

[Mr Dunne]

I urge the right hon. Gentleman not to indulge in scaremongering about the number of people applying to become nurses. There are more than two applications for each of the nursing places on offer to start next August. He needs to be careful about interpreting this early the figure for applications from EU nationals, which has gone down significantly, because it coincided with the introduction of the language test for EU nationals.

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

With the reduction of 23% in applications to English nursing schools, the Minister might want to re-look at the policy. There has been a significant drop—a 90% drop—in EU nationals applying. With one in 10 nursing posts in NHS England vacant and a cap on agency spend, who exactly does the Minister think should staff the NHS?

[Mr Dunne]

I say gently to the hon. Lady that there are 51,000 nurses in training at present. The number of applications through the UCAS system thus far suggests that there will be more than two applicants for each place. As I have just said to the right hon. Member for Leigh (Andy Burnham), the reduction in application forms requested by EU nationals has coincided with the introduction of a language test.

[Dr Whitford]

Language test applications were more than 3,500 last January, so the reduction after the language test was from that to 1,300. In December, there were only 101 applications. This cannot all be blamed on the language test, so what is the Minister going to do to protect nursing numbers?

[Mr Dunne]

There are over 13,000 more nurses working in the NHS today than there were in May 2010. As I have just said to the hon. Lady, the language test came into effect from July last year, since when the number of applicants has been somewhat steady. It is down very significantly, but that is because, frankly, we have had applications from nurses from EU countries who have not been able to pass the language test.

Agenda for Change: NHS Pay Restraint

Philippa Whitford Excerpts

Monday 30th January 2017 Westminster Hall

[Mr Nigel Evans (in the Chair)]

I call Dr Philippa Whitford.

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

I thought I would be called to speak at the end.

[Mr Nigel Evans (in the Chair)]

No Members indicated that they wished to speak by standing in their place, but I can be flexible, with your permission.

[Dr Whitford]

Yes; I would expect to speak at the end, if other Members wish to speak.

[Andy Burnham (Leigh) (Lab)]

rose—

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

It is an honour to serve under you, Mr Evans.

We seem to have been in this place before. We had a lot of debate about the nursing bursary, and these things are connected, because it comes down to how we are treating people and valuing them, as has been said. In Scotland, we also have a pay cap of 1%, but one difference is that that is being paid each year, whereas for three of the last six years, nurses in England have faced a freeze—an award of 0%. What they are told is, “Well, your increment gives you a rise.” The increment is how people move through the Agenda for Change structure, so if they are not getting any cost of living rise, the increment structure of Agenda for Change is being undermined.

The Scottish Government are a real living-wage employer and are recognised and registered as such, so people earning less than £22,000 get £400 to keep them above the real living wage. Starting in the next financial year, 2018-19, those in the lower bands in England will fall below the national minimum wage; they do not come anywhere close to a proper living wage. We know the Government’s living wage as “the pretendy living wage”, because people cannot actually live on it. That term should not be used because it is confusing. The result is that at band 1 or 2, a nurse or healthcare assistant in Scotland will earn £881 more than their equivalent in England. The common band for a nurse graduate is band 5, and at the top of that band, the nurse in Scotland will earn £284 more than the nurse in England.

Scotland has had no compulsory redundancies since the crash. In England, there have been 20,000. That seems bizarre when we are short of nurses. The vacancy rate in England is 9.5%; in Scotland it is 3.5%. We get what we pay for. If we treat people badly, eventually they go away, or, if they are approaching retiral, they do not go on working; they finish, because frankly they are burnt out. Nursing is a hard, heavy and stressful job. Nurses in Scotland feel stressed because of the gap caused by vacancies, the increased demand, the ageing population and the complexity of the cases they look after, so we can only imagine what it must be like in hospitals in England, with almost 10% of places not being filled and having to be covered by agency staff, which, as we have heard, is just a circular, self-defeating argument.

[Lady Hermon]

On the hon. Lady’s point about how difficult and wearisome the work of a nurse is—it is hard work—those nurses born in the 1950s who are affected negatively by the Government’s pension policy cannot now retire until they are 65, 66 or, indeed, 67. Has there not been a double whammy for those nurses who want, for the love of the job, for the love of the patients and for the love of service of the community, to stay in post? The Government have an opportunity to recognise that contribution. If they will not do something on pensions—I hope that they will change their mind on that—they could at least remove the pay freeze.

[Dr Whitford]

The whole message that is sent by nurses, particularly those who are in their late 50s and approaching 60, is that they are burnt out; they do not feel valued. When they have to work hours and hours beyond their shifts, doing what is frankly heavy labour—coming from that background, I can vouch for its being heavy physical work—they will of course leave as soon as they can manage to do so. The problem is that that exacerbates the pressure on all their colleagues, and that is what we are seeing with the huge shortage of thousands of nursing posts across England.

We have to recognise that we will face more increased demand and more complexity as our population ages. When patients in their early 70s were coming to me with breast cancer, they had multiple morbidities. By that stage, they had had a heart attack, were type 2 diabetic, had a bit of kidney failure and were severely immobile from arthritis, obesity or one of the many other conditions that people are getting. The nurses were trying to deal with all those things. Going forward, we will face more cases of dementia and Alzheimer’s, which is a particularly challenging morbidity for patients and the staff looking after them. Working in that environment, where everyone around them is having a bad day at the same time that they are having a bad day, means that people do not enjoy going to work. If there is any chance to get out, they are going to take it.

We need to attract more nurses to deal with demand. As was mentioned earlier, approximately a third of nurses are due to retire within the next 10 years, and we need to prepare for that. Some of that relates to the expansion that we had under Labour; when there is a big expansion in a profession, a whole lot will tend to retire at the same time. Unless succession planning is ongoing and established, we will reach an absolute crisis.

That brings us to the other difference: the nursing bursary. In Scotland, we still pay a nursing bursary of more than £6,500. We also have free tuition, which is equivalent to £27,000. We have additional funding for nurse trainees with additional support needs. They tend to be older—they are around their late 20s and early 30s —so they get more than £2,000 for childcare, a dependency allowance if they have either an adult or children dependent on them and a single-parent allowance.

The Scottish Government know that we have a challenge to recruit and retain nurses to grow the nursing profession, and they are putting that money in. They are not putting it in by giving high pay awards each year, but they are the only Government that actually accepted the independent review body’s recommendation of 1% on top of any steps within Agenda for Change. What is the point in doing all the work around a review body, if the Government do not bother listening to it?

I suggest that the Government need to show nurses that they are valued. They need to look at the decision to get rid of the nursing bursary, because we already know from NHS England that there has been a decrease of 20% to 25% in applications, so it is having exactly the opposite effect than the Government talked about. We know from the Nursing & Midwifery Council that registrations from the EU have dropped by 90% since last July. That means that whole source is drying up, regardless of rules, because people do not want to take the risk of moving here. We cannot shut down every possible source for having enough nurses. A lot of this is about calling on the Government to change their attitude and realise that this is a difficult job. We need to attract people into it and we need to retain people for as long as we can. Nurses are worth every penny they are not being paid.

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[Mr Dunne]

I can say to the hon. Lady that there are 51,000 nurses in training today—I cannot tell her whether that is a record number, but it is a very significant number. There are 1,600 paramedics in training, which I believe is a record number. She and one or two other hon. Members have given anecdotes today about applications for new courses starting in the autumn, but I cannot tell her what the figures will be, because I have not yet seen any numbers published by UCAS. I think that they are due in the coming days, so we will have to see.

[Dr Whitford]

Will the right hon. Gentleman give way?

[Mr Dunne]

I will, although I am not actually right honourable.

[Dr Whitford]

Honourable but not right—I accept that. The figures from NHS England itself suggest a drop in nursing applications of at least 20% to 25%.

[Mr Dunne]

The hon. Lady must have access to figures that my Department and I do not have. My information is that we have yet to receive any formal numbers from UCAS; there may be some early indications, but they do not represent the actual numbers. We will just have to wait for them. There is no point in speculating any further.

A number of hon. Members mentioned the potential impact of Brexit on EU staff, who currently represent a significant number of the professionals working in the NHS. Some 43,000 non-UK-born nationals work in the NHS—about 15% of the workforce—and about half of them come from the EU. It is very important that none of those staff are unnecessarily concerned about their future. The Prime Minister has sought to make it clear on several occasions that she wants to protect the status of EU nationals who are already living here and that the only circumstances in which that would not be possible would be those in which the rights of British citizens living in EU member states were not protected in return. We wish to provide as much reassurance as we can, both to NHS workers and to their employers, that they have a constructive future here in the UK.

However, it is important that we move towards a self-sustaining workforce. Frankly, that is at the heart of the reason behind the change in funding for nursing places, which is to bring nurses in line with doctors and those doing other degrees in England, so that from this autumn onwards they receive funding through student loans rather than bursaries.

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[Mr Dunne]

The hon. Gentleman will not be surprised to hear that I cannot give him any reassurances on that. We will have to see what the recommendations are and then take a view. However, we are not very far away from that point now.

The hon. Member for Foyle (Mark Durkan) referred to the national living wage. I got the impression from him that some NHS staff members in Northern Ireland are earning only the national living wage; I can reassure him that no NHS staff in England are earning only at that level.

[Dr Whitford]

Looking at the graph going forward, however, those on bands 1 and 2 of Agenda for Change will fall not only below the real living wage, which they are already below, but below the national living wage, which is the minimum wage, in the coming years—2018-19 and 2019-20.

[Mr Dunne]

Once again, the hon. Lady is speculating about what might happen in future, and I am afraid that not only can I not comment on that, but I am not sure whether she is correct or not. There are some assumptions in what she said about what will happen to the national living wage. The Government are making some assumptions, but what the Government choose to do about the matter we will have to see. At present, the policy is certainly that nobody will be paid less than the national living wage. I can reassure her about that.

[Mark Durkan]

Just to clarify, like the hon. Member for Central Ayrshire (Dr Whitford), I was referring to the living wage and not to the national living wage, which is a figment of Government policy.

[Dr Whitford]

rose—

[Sir Roger Gale (in the Chair)]

Order. You cannot take one intervention following another intervention. I call the Minister to speak.

[Mr Dunne]

I am very happy to give way to the hon. Lady.

[Dr Whitford]

I was basing my assumptions and suppositions on what the Government themselves announced when they said that the pay freeze would continue in the next four years. That was announced in the comprehensive spending review, so I am not just making it up, and if pay goes on the trajectory that was announced last year, it will fall below the national living wage, which is obviously due to rise towards 2020.

[Mr Dunne]

I have made the Government’s current position clear and we will have to see what emerges from the NHS Pay Review Body’s recommendations, and then how those are implemented over the coming years. I think it is fruitless to speculate on what might happen in future years, based on the suppositions that the hon. Lady made—

[Dr Whitford]

Why?

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[Mr Dunne]

No. The hon. Lady has had a fair crack. I will make a bit more progress.

I was challenged in this debate to refer to what the Government are investing in the NHS and I obviously take some relish in responding to that challenge. We are investing an additional £21.9 billion in nominal terms, which is equivalent to £10 billion in real terms, to fund the NHS’s own plan for the future. By doing so, we believe that we are playing our part, through the measures announced over the last 12 months or so, to help the NHS achieve its five year forward view. It needs to do that not only by realising benefits from the Carter review to improve productivity, but by clamping down on rip-off staffing agencies and encouraging employers to use their own staff banks for temporary staffing needs, so that they can invest in their permanent workforce. That has been referred to by a number of right hon. and hon. Members.

Agency and bank working provide an opportunity for NHS staff to engage in more flexible working to suit their own circumstances, so I would not want to characterise all agency working as bad. What is challenging is when NHS organisations need, in some cases, to go out to external agencies beyond their immediate bank and pay significantly higher rates. That is why the Department introduced, a year ago, a number of measures to start to limit the ability of agencies to charge the NHS such high fees, and we have had some success in that. In the period for which I have figures—roughly the middle of last year—the agency costs to the NHS had been reduced by 19% over the equivalent period the year before, so we are doing something about those fees. We are apprised of the problem and are bringing down the cost to the NHS of employing agency staff.

This issue is not just about pay. NHS staff, like many people, work hard to improve our public services. They have families and commitments, and they deserve to be rewarded fairly for what they do. However, as has been said, pay alone will not necessarily persuade the skilled and compassionate people that we need to choose a career in the NHS. It would be wrong to see the NHS employment package as just about headline pay. NHS terms and conditions have been developed over many years, in partnership with trade unions, and they recognise that it is a combination of pay and non-pay benefits, which need to keep pace with a modern, changing NHS, that help to recruit, retain and motivate the workforce.

[Dr Whitford]

Certainly the nurses I met during the lobby here, who had come from all over England, but particularly from London, described literally struggling and facing great financial hardship. That is very difficult for them. They work so hard for the benefit of all of us, yet feel that they cannot go on in their profession because they simply cannot keep their families here in London.

[Mr Dunne]

I have already explained to the hon. Lady that we have a London weighting, which reflects the increased costs of living in London. I have also explained to her that average pay for nurses is significantly above the national average pay. She herself referred to average nursing pay of some £31,000—

[Dr Whitford]

indicated dissent.

[Mr Dunne]

If not her, then another hon. Member referred to it, and that is from the latest available workforce statistics.

Picking up on the hon. Lady’s point, it is important that NHS staff are confident that their employment package is competitive. We want employers to make better use of the full package in their recruitment and retention strategies. NHS Agenda for Change staff have access to an excellent pension scheme, far in excess of arrangements in the wider economy, which includes life assurance worth twice the annual salary, and spouse, partner and child benefits. They have annual leave of up to 33 days—six and a half weeks—plus the eight bank holidays, which is far better than that which is available in the private sector, and in many other elements of the public sector. They have sickness and maternity arrangements that go well beyond the statutory minimum and, as I have touched on, there are flexible working, training and development opportunities for staff at all grades. For too long, the NHS employment package has been a well-kept secret and we want leaders to make the very best use of the overall NHS employment offer to help recruit and retain the staff they need.

Defibrillators in Public Areas

Philippa Whitford Excerpts

Monday 16th January 2017 Commons Chamber

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

I am not sure whether the hon. Lady is aware of the impact that these defibrillators have in cardiac ambulances. When I qualified, an ambulance just picked someone up and took them to a hospital, but the big, boxy ambulances have more equipment in them than was in a casualty unit in those days. Even in professional hands, this technology has transformed out-of-hospital cardiac arrest.

[Maria Eagle]

I thank the hon. Lady for that very useful information, from her own experience as a doctor. It is important that the availability of this kit is widened across our society in order to save lives.

Current legislation surrounding public access to defibrillators is practically non-existent. Last year, the Government produced a guide for schools recommending the purchase of AEDs. While I welcome that move to highlight the issue, the Government should do more. Will the Minister undertake to meet Mark and Joanne and the OK Foundation to discuss a realistic programme of providing AEDs in public places and training for people such that they feel confident to use them? Will he facilitate a meeting with the Prime Minister? I know that the OK Foundation would welcome an opportunity to argue its case at the highest possible level of Government.

NHS and Social Care Funding

Philippa Whitford Excerpts

Wednesday 11th January 2017 Commons Chamber

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

Here we are again debating the NHS. [Interruption.] I am all on my own because obviously this is predominantly a crisis in NHS England, not a crisis in NHS Scotland, as I will discuss as we go on.

The problem is that we are talking about patients who are suffering—who may suffer from more infections, as we have heard. We are talking about staff who are in tears and who are desperate, and who feel that they cannot deliver the care they would expect to deliver. This is not just a matter of isolated stories of “Joe from Wiltshire” and “Mike from Leeds”: it is happening on a major scale. We hear from NHS Improvement that only one trust out of 152 met the four-hour target in December, and only nine made it to over 90%. Fifty out of 152 trusts declared a black or red situation over December, and there were 158 diversions of ambulances over that time. This is not just about normal winter pressures. It is not what the hon. Member for Lewes (Maria Caulfield), who is an A&E nurse, and people like me and other medics in the Chamber have seen in our careers—it is a really bad winter. Yet we have not had bitter weather and we have not had a flu epidemic.

The most recent four-hour data were published in October, when NHS England managed to achieve the four-hour target for 83.7% of the time. That is 5% down on the same time in the previous year, and it compares with 93.9% in Scotland. Scotland managed 93.5% in Christmas week. We have our challenges in Scotland, but the crisis is not the same as what is being discussed here.

[Sir Simon Burns (Chelmsford) (Con)]

Will the hon. Lady confirm, though, that throughout the whole of 2016, which includes winter, summer, autumn and spring, the Scottish Government’s A&E target was met in only seven out of the 52 weeks?

[Dr Whitford]

I would be delighted to agree with that, but NHS England did not make it over 90% at any point in 2016, so perhaps the right hon. Gentleman might want to check the NHS England figures before having a punt at me.

NHS England is performing 8% to 10% lower than NHS Scotland, which has been the top performing of the nations for the past 19 months. We have not done that by magic. We face exactly the same ageing population, exactly the same increased demand and complexity, and exactly the same—indeed, often worse—shortages of doctors as NHS England does, because of our rurality. We are not using a different measure—we use exactly the same measure—but the data show that there is a significant difference, and it is being maintained.

The Secretary of State is right: winter is always challenging. Summer is often busier for attendances at A&E, because the kids are on the trampolines and people go out and do silly things, but hospitals are under pressure in winter because of the nature of admissions—the people who go to A&E are sicker, older and more complicated. However, we have not seen any summer respite in NHS England. The worst performance in the summer was 80.8%; the best was 86.4%. NHS England is under pressure in the summer, and when winter is added on top of that, it is no wonder that we are talking about the situations that doctors, nurses, patients and relatives are describing to us.

My first health debate after my maiden speech in this House was an Opposition day debate on the four-hour target. At the time, I commented, and still maintain, that this target is not a stick for each party to hit each other over the head with, but it is a thermometer to take the temperature of the acute service, and it does that really well, because it measures not just people coming in through the front door but how they are moving through the hospital and out the other end. At the moment, the system is completely overheated. The comments about this not being anything unusual but just a normal winter, and everyone whingeing, show that the Government are not recognising the problem. The first step to dealing with any problem is to recognise it, because then we can look at how we want to tackle it.

[Victoria Atkins]

I remind the hon. Lady of the point the Prime Minister made in Prime Minister’s questions, which is that on the Tuesday after Christmas, A&E received the highest number of visitors it has ever received in its history. Does that not show the challenges facing the NHS both nationally and locally? These are extraordinary figures, and the Secretary of State is very much doing his best to help the NHS, with the professionals, to deal with them.

[Dr Whitford]

I totally accept that the NHS has been under inordinate pressure with, absolutely, the busiest day in its history, but given an ageing population that has been discussed for years, we should have been able to see this coming.

If, in the next couple of months, we get a massive flu epidemic, we are going to see things keel over. We have already had debates in this Chamber about STPs taking more beds away. I totally agree with the Secretary of State that part of the issue is that patients could be seen somewhere else. However, it is not a matter of changing the four-hour target and saying to someone who turns up, “You’re not going to count;” it is simply a matter of providing better alternatives. If we provide better alternatives, people will go to them. The House has discussed community pharmacy use, and it has been recognised that the minor ailments services we have in Scotland can deal with 5% to 10% of those patients. We have co-located out-of-hours GP units beside our A&Es, so someone is very easily sent along the corridor or into the next-door building if they need a GP and not A&E. We do need to educate the public, but the public will use an alternative service if it is there. If it is not, they know that if they turn up at A&E and just keep sitting there, eventually someone will see them, and we should not blame them for that.

[Toby Perkins]

The hon. Lady is right to say that we have an ageing population but that is predictable. Does she think it is also significant that in 2008 the UK was spending about the same as all the major EU nations, whereas the OECD now says that we are spending considerably less than most of the other major nations? Is that not actually causing this problem?

[Dr Whitford]

Money is not the only problem. I accept that part of it is about how things are done. The Secretary of State talks about variations and many hospitals performing well, but, as I said, only one trust is meeting the target and only nine are at over 90%, so it is not that the majority are doing well and a few are failing.

The ability to look at how we deliver the NHS is crucial, but change costs money. We must therefore invest in our alternatives so that our community services and primary care services can step up and step down to take the pressure off. One of the concerns about the STPs is that because people do not have enough money, a lot of them start by thinking that they will shut an A&E, shut a couple of wards, or shut community beds—even though those are what we need more of—to fund change in primary and social care. Then the system will fall over. We need to have double running and develop our alternatives and then we will gradually be able to send the patients there.

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

I always enjoy listening to the hon. Lady’s well-informed remarks. I agree that most people do not want to go to A&E if they can avoid it. Does she agree that part of the problem is that when people phone general practices, they tend not to be offered an appointment that they regard as being within a reasonable timeframe, or they cannot get to see the doctor with whom they are closely associated, which particularly applies to people with chronic and long-term conditions? As today’s National Audit Office report makes clear, we need to address that as a matter of urgency. Paradoxically, seven-day-a-week general practice may militate against being able to provide people with such continuity of care during core hours.

[Dr Whitford]

Many doctors in general practice would accept the argument for having access to a GP on Saturday morning, particularly for people who are otherwise at work. However, someone who cannot see their favourite doctor is very unlikely to go to A&E and wait eight hours to see a doctor they have never seen before in their life. This is not about that; this is about the fact that people feel they cannot find an alternative. If it takes three or four weeks to get any appointment with their GP and they do not yet have a community pharmacy offering such a service, they will eventually end up at A&E. It is therefore the service of last resort for people who go there and just stay there. We have to develop alternatives first, but as the hon. Gentleman says, no one in their right mind would choose to go and wait four hours in A&E if they could be seen in half an hour in a community pharmacy.

[Dr Murrison]

The hon. Lady is being very generous in giving way. I have to disagree with her, because winter pressures and the pressures we are seeing at the moment tend to involve not people with short-term, self-limiting conditions, but the chronically sick. Those people in particular, and with good reason, want to have a relationship with a particular practitioner who understands their needs and their family context. That is surely the essence of general practice.

[Dr Whitford]

I totally agree, but in fact the chance that their doctor will be on duty would actually be lower on a Saturday morning or a Sunday afternoon. One of the things we have done in Scotland with SPARRA—Scottish patients at risk of readmission and admission—data is to identify that 40% of admissions involve 5% of the patients. Those patients are all automatically flagged and will get a double appointment no matter what they ring up about, because it will not just be a case of a chest infection or a urine infection, but of having to look at all their other comorbidities.

That is the challenge we face; it is not a catastrophe of people living longer. All of us in the House with a medical background will remember that that was definitely the point of why we went into medicine, and it is the point of the NHS. However, we are not ageing very well. From about 40 or 50 onwards, people start to accumulate conditions that they may not have survived in the past, so that by the time they are 70 they have four or five comorbidities that make it a challenge to treat even something quite simple. My colleagues and friends who are still working on the frontline say that it is a question not just of numbers, but of complexity. Someone may come in with what sounds like an easy issue, but given their diabetes, renal failure and previous heart attack, it is in fact a complex issue.

That is part of the problem we face, and we need to look forward to prepare for it. We need to think about designing STPs around older people, not around young people who can come in and have an operation as a day case and then go away, because that is not what we are facing. Older people need longer in hospital, even medically, before they reach the point of being able to go home. It takes them a couple of days longer to be strong enough to do so. They probably live alone and do not have family near them, so they will need a degree of convalescent support and they may need social care. That is really where the nub of the problem lies. Social care funding has gone down, and therefore more people are stuck in hospital or more people end up in hospital who did not actually need to be there in the first place.

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

On the frailties of older people, does the hon. Lady think that just as Scotland led the way with St Ninian’s primary school in Stirling introducing the daily mile, there is something we could learn from countries, such an Andorra, that have a real focus on exercise for older people, so that they are a lot less frail in their 70s and 80s?

[Dr Whitford]

The whole prevention and public health message is crucial, and that is one of our other challenges. I am very grateful to the Secretary of State for no longer talking about a figure of £10 billion, because the increase in the Department of Health’s budget is actually £4.5 billion. Part of that relates to the reduction in public health funding, just at a time when we need to move it on to a totally different scale. Whether that is children or, indeed, adults doing the daily mile—perhaps we should run up to Trafalgar Square and back every lunchtime, which I am sure would do us all a power of good—we need to invest in such preventive measures. One of my points is that when we end up desperate—patching up how the NHS runs, or dealing with illnesses we did not bother to prevent—we always end up spending more money.

[Graham Evans]

The hon. Lady knows how much I respect her and what she says. As the chairman of the all-party group on running, I endorse the daily mile and encourage all adults to do it. Park runs, which happen across the nation, are a good example. There is huge expertise in Scotland, so can NHS England learn from Scotland? What is best practice, and will she give us some examples of it in hospitals and hospital trusts in Scotland that we can take away and learn from?

[Dr Whitford]

The whole issue comes down to sustainability, which is obviously the idea behind the sustainability and transformation plans. As those who have heard me speak about STPs will know, I support the idea in principle. The idea is to go back to place-based planning on an integrated basis for a community. The difference in Scotland is that we have focused on integration. We got rid of hospital trusts in 2004, and we got rid of primary care trusts in the late 2000s—in 2009 or 2010. Since April 2014, we have set up integration joint boards, where a bag of money from the NHS and a bag of money from the local authority are put on the table and a group sit around it and work out the best way to deal with the interface and to support social care. Anyone in the Chamber or elsewhere with family members who have been stuck in hospital will know that people get into a bickering situation: Mrs Bloggs is in a bed so the local authority is not interested, because she is safe there, and the local authority is instead busy with Mrs Smith, who has fallen off a ladder trying to put up her curtains and who is not considered safe because she is leaving the gas on. Such boards get rid of all that perverse obstruction.

[David Rutley (Macclesfield) (Con)]

The hon. Lady is making an important point, and I welcome the tone that she, unlike the shadow Secretary of State, has brought to this debate. She makes the point that the integration of care—social and health—is important, but does she agree that, with further devolution to the sub-regions and major cities in England, there is a huge opportunity to move forward that agenda south of the border?

[Dr Whitford]

The whole idea of STPs is to go back to areas. We simply have geographical health boards—the only layer we have—so we are not wasting huge amounts of money on having layers and layers, which could be integrated. For an STP to work it must make sense geographically, which might be a county or something bigger or smaller. I think that they should be put on a statutory footing. We have 211 CCGs. There will be an average of six CCGs for every STP, so that is a waste of layers, and it will be very difficult to integrate.

One of the biggest differences is that, in 2004, we got rid of the purchaser-provider split. In the past 25 years, there has been no evidence of any clinical benefit from the purchaser-provider split, the internal market or, as it now is, the external market. It is estimated that the costs of running that market are between £5 billion and £10 billion a year. That money does not actually go to healthcare, but on bidding, tendering, administration or profits. We cannot have an overnight change, but if we simply made a principled decision to work our way back to having the NHS as the main provider of public health treatment and to integrate care through the STPs, we could reach a point of sustainability.

As I said earlier, we must protect things such as community hospitals and community services and, indeed, invest in them. Our health board has rebuilt three cottage hospitals as modern hospitals, because that is where we should put an older person who is on their own and has a chest infection, who just needs a few days of antibiotics, TLC and decent feeding. We do not want them in big acute hospitals; we want them to be close to home. The danger is that under the STPs people will see community hospitals as easy to get rid of, but that is an efficiency saving only if it gets rid of inefficiency. If we slash and burn, we will end up spending more money in the end.

[Victoria Prentis (Banbury) (Con)]

Much of what the hon. Lady says is music to my ears as somebody who is campaigning to save their local general hospital. May we have the benefit of her views on the role of consultation with patients and the wider community when sustainability and transformation plans are being considered?

[Dr Whitford]

Public consultation is important, and not just in the way it has often been done in the past—“We’ve made a decision, it’s a fait accompli, and we’re coming and telling you about it.” Unfortunately, that is very much what we have heard about the STP process, partly because it has been so short and partly, I am afraid, because it is about budget-centred care, not patient-centred care. Areas have been given a number and told, “If you’re not reaching this number, don’t bother submitting your plan,” and they are working back from that. That will not achieve an efficient, integrated service, so the public must be involved.

Frontline clinicians must also be involved. They work in a service and know exactly what the bottlenecks are and exactly what horseshoe nail is missing and holding a service back. If we have clinician-led redesign, such as I was involved in for breast cancer in my health board 17 years ago, we can track a patient’s path. We can quickly imagine ourselves as a patient, see the bottlenecks and focus investment on them.

I read an article yesterday stating that three hospitals in Manchester have spent £6 million on management consultants to say, “Shut a ward, sack hundreds of people and jack up the parking charges.” I am sorry, but that was not good value for £2 million each.

[Jo Churchill (Bury St Edmunds) (Con)]

I thank the hon. Lady for, as ever, eloquently expressing issues that face us all, no matter where we come from and who we are. Does she agree that having good healthcare data for clinicians enables patients to be put through the system seamlessly? Many individuals do not realise that their data do not go from their GP into acute care and then back into social care. If we could improve that—I make a plug for my private Member’s Bill on Friday—it would help patients.

--- Later in debate ---

[Dr Whitford]

I would not say that we are super IT wizards in Scotland, but we did not get involved in care.data, which unfortunately is a black shadow over the whole issue of NHS data in England, and now all our referrals are electronic, so nothing goes in the post. All our letters back are also electronic—I dock my dictation machine during a clinic, and when I finish I sit and check it, and the letters go off. After a Friday morning bad news clinic, the letters are on their way by 2 o’clock. A GP can email my colleagues and say, “I don’t know whether you need to see this person.” I have heard clinicians here in England say, “No, we can’t email about a patient.” Unfortunately, the wrong move that was made on care.data has ended up holding people back.

Our GPs in Scotland use a care summary. If they have a palliative care patient who has been accepted as being in terminal care, that patient’s care summary will be put on the out-of-hours system. If there is a call about the person, the doctor who goes to see them knows that they will not be throwing them in an ambulance but will be keeping them comfortable. The discussion has already been had, and the aim is for them to be at home. England has to gain the ability not just to analyse data at a later point but to share information as a first step.

In finishing off my speech—[Interruption.] I am sorry if I was taking too long for an hon. Lady at the back of the Opposition Benches. Integration is the key, and it is possible to get it through the STPs—but only if they are designed around patients, safety and services, rather than just starting with the bottom line and working backwards.

[Several hon. Members rose—]

--- Later in debate ---

[Sir Simon Burns]

I certainly agree that, under the leadership of the Department of Health, we should work with anyone and everyone to come up with a solution.

I was the Social Care Minister in the late 1990s, before we left office. Integrating health and social care was then at a very early, formative stage, and the ambitions were immense and tremendous. I am afraid that the reality has not matched the ambitious nature of what was being said in the 1990s, which is why I was particularly interested by the comments of my hon. Friend the Member for Totnes. Yes, we must think about that, but what we must also think about—let me push the funding element to one side for the moment—is building on the work of my right hon. Friend the Secretary of State for Health, particularly his investment in patient safety, the raising of standards, dignity for patients in our hospitals and throughout the health system, and the cutting out of waste and inefficiencies.

In 2010, when I was at the Department of Health for the second time, we had the Nicholson challenge, which was to save £20 billion over three or four years by cutting out waste and sharing best practice to improve the quality of care. I know from a debate that we had just before Christmas that the NHS achieved £19.4 billion of those savings. The beauty of that was not just that it created greater effectiveness and efficiency in the delivery of healthcare and the sharing of best practice, but that the Treasury did not receive £19.4 billion with which it could do as it wished. The £19.4 billion was reinvested in patient care.

[Dr Whitford]

Was not a significant proportion of that saving due to wage freezes for NHS medical and nursing staff? That is not something that can easily be repeated.

[Sir Simon Burns]

The hon. Lady is absolutely right. There was a wage freeze for those who were earning more than £20,000 a year, but that was in keeping with the policy throughout the public sector, which included Ministers and other Members of Parliament.

The important point is that it was possible to achieve that saving by a variety of means. One of them was a pay freeze, but others were improving the delivery of service, cutting out inefficiencies and ineffective ways of operating and getting rid of nearly 20,000 surplus managers, so that the NHS could concentrate on enabling clinicians, nurses, ancillary workers and everyone else to work on patient care. That is the right way forward, and we cannot give up on it. We must continue to think about where we can make savings.

Mental Health and NHS Performance

Philippa Whitford Excerpts

Monday 9th January 2017 Commons Chamber

[Mr Hunt]

Yes, I can do that. It is a very important point. We have had a patchy record in the NHS of ensuring that money promised for mental health actually reaches the frontline. The way that we intend to address this is by creating independently compiled Ofsted-style ratings for every CCG in the country that highlight where mental health provision is inadequate. Those ratings are decided by an independent committee chaired by Paul Farmer, who is responsible for the independent taskforce report, so he is able to check up on progress towards his recommendations. I am confident that, by doing that, we will be able to shine a light on those areas that are not delivering on the promises that this Government have made to the country.

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

After the Health Committee’s recent inquiry into suicide, I absolutely welcome the extra funding for mental health. I am sure that the Secretary of State remembers some of the discussions that we had in that room.

I also pay tribute to the staff. Obviously, with my background, I know exactly what it is like when A&E is swamped and there is nowhere to put people. The staff across NHS England are not afraid of us discussing this topic and weaponising it. They are in tears; they are exhausted; and they are demoralised. They have never experienced a winter like this. Perhaps the Secretary of State will explain why his figures suggest 19 diverts and only two trusts in serious problems, whereas we are hearing from the Nuffield Trust that that 42 or 50 trusts are diverting, which is a third. That means that the problem is widespread.

I totally agree with the point about people going to A&E when they do not need to be there, but they are not the people who are three-deep on trolleys waiting for a bed for 36 hours—those are people who need a bed and who are there because they are ill. We have discussed sustainability and transformation plans and NHS sustainability on several occasions. The concern that people have is that, because there is not the money for a redesign, there will be A&E closures and bed cuts. I hope that this incident will show that that is simply not possible. It is not possible for the UK, particularly NHS England, to lose any more beds. In Scotland, we face the same problem of increased demand and shortage of doctors, yet 93.5% of our patients were seen within four hours in Christmas week. The president of the Royal College of Emergency Medicine estimates that in areas of England the figure is between 50% and 60%. That difference is down to how it is organised. It is the fragmentation and the lack of integration. There are things that can be done. We can use community pharmacies and GPs, and try to bring the NHS back together.

[Mr Speaker]

I hope that the hon. Lady will not take offence—she has vast experience in this field—if I say that her questions must be judged to be rhetorical, because I did not observe any question marks, although I am sure we will in future.

CQC: NHS Deaths Review

Philippa Whitford Excerpts

Tuesday 13th December 2016 Commons Chamber

[Mr Hunt]

I thank my hon. Friend, who does a huge amount of work on patient safety, not least because of sadness in her own family’s experiences that gives her particular passion in this respect. This is absolutely about creating a just culture. Inspiring people like James Titcombe, who lost his own son at Morecambe Bay, talk far more eloquently than I can about the need to get this right. Part of that just culture is about justice for people who use the NHS in future, to whom we have a responsibility to learn the lessons and make sure that mistakes are not repeated. One of the really important things we need to get right is to make sure that when something goes wrong in one place, there is a national way in which the lessons can be conveyed right across the NHS as quickly as possible.

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

I welcome this statement and remember the discussion of this tragic case. Obviously the majority of people who go into hospital and die in hospital will be people who are simply too ill for us to save, but we must not be nihilistic in imagining that that applies to everybody. The particular failure here was that people with learning difficulties or mental health needs were somehow just set aside and not looked at.

I welcome the idea of a safety board; there will be lots of things that can be learned and shared in that. I slightly pick up the Secretary of State on what he said about the Scottish patient safety programme, which is a national programme that has been running since the beginning of 2008. Part of that was about breaking down all the barriers, very much like in the airline business—being on first-name terms and making it everybody’s business so that even the cleaner in the theatre feels they can point out that they think a mistake is going to be made, but then when something happens having these adverse case reviews. In my hospital, we also reviewed near misses, and I commend that. It means that there is a review when what might have happened would have been serious. Certainly in the cases that I have been involved in, the family have been involved repeatedly. That is really important.

I also welcome the idea of a safe place for whistleblowers. People who have raised issues in the past and have been appallingly treated by the NHS still stand there as a terrible example to those who currently work in the NHS, so there needs to be some ability to go back to these old cases and provide justice for people who have ended up losing their careers by trying to raise patient safety issues.

[Mr Hunt]

I thank the hon. Lady for her contribution. I recognise the progress made in the Scottish patient programme, and particularly the inspirational leadership of Jason Leitch, who has done a fantastic job in Scotland and some very pioneering work.

The hon. Lady made some good points that I will take in reverse order. On whistleblowers, I asked Sir Robert Francis to look at this in his second report. He concluded that it would be very difficult, if not impossible, to go back over historical cases, because the courts have pronounced and it is very difficult to create a fair process where legal judgments have already been made. However, I take on board what she says, and I do not think that that means that we cannot learn from what has happened in previous cases; they are very powerful voices.

The hon. Lady is absolutely right about near misses, and we will include that issue in the “learning from mistakes” ambition.

The hon. Lady is most right of all about people with learning disabilities. The heart of the problem is deciding when a death was expected and when it was unexpected. About half of us die in hospitals. As she rightly says, the vast majority of those deaths are expected, but when a person has a learning difficulty it is very easy for a wrong assumption to be made that they would have died anyway. That is a prejudice that we have to tackle, and one that Connor Sparrowhawk’s mother talks about extremely powerfully. We have to make sure that this is not just about lessons for the whole NHS, but particularly about ensuring that we do better for people who have learning disabilities.

Accelerated Access Review

Philippa Whitford Excerpts

Tuesday 13th December 2016 Westminster Hall

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

Access to new drugs seems to be almost the commonest theme of debates in Westminster Hall. Having spent years as a breast cancer specialist involved in trials, I can say that it is really frustrating to have access to drugs within a trial and then lose that access when the drug is passed. The United Kingdom can be up to five years behind Europe or America in accessing such drugs. We talk all the time about having more research on brain tumours and other diseases, but that does not help us if, at the end of the research, our patients cannot get the drugs.

Cystic fibrosis is one of the commonest of what we call the rare diseases. It involves a problem with transmission of salts through membranes, which results in incredibly thick mucus that clogs various organs, most commonly the lungs. As the right hon. Member for Leigh (Andy Burnham) mentioned, if it is diagnosed late, damage will already have been done. The earlier patients with cystic fibrosis are treated, the less damage is done and the healthier they are. The life expectancy has changed from childhood to middle age, due to a combination of approaches.

I am shocked to hear that people in England with cystic fibrosis have to pay for their prescriptions, because that would amount to quite a lot of money; they are on a lot of medication. We do not have prescription charges at all in Scotland, because you get an increased rate of people not collecting their prescription, or going to the chemist and saying, “Excuse me, dear, which are the two most important drugs for me to take?” and that ends up not being cost-effective. I would have thought that people with a chronic condition should at least have their names on a list as being exempt. I would have thought that that was the least the Government could do.

The right hon. Member for Leigh said that we have been through this with Kalydeco and many other drugs. Orkambi is a synergistic combination of Kalydeco, or ivacaftor, with lumacaftor, which makes it work much better. They are the first drugs that are not just antibiotics or mucolytics; they are trying to attack the disease itself. In that sense, they are transformative. The problem in the access review is that the definition of “transformative” going forward will not necessarily help those drugs. We do not suddenly find a drug that is a cure for any of these conditions; we move step by step, often adding drugs together or making new discoveries.

There is a real concern among those who develop drugs that in the consultation between NICE and NHS England, the levels considered acceptable for such highly specialised treatments are being changed. The problem is that if we send out the message to people with rare conditions, “I’m sorry; you’re just outside the pale,” we will be letting them down. We need a different approach. I think we need a different conversation for all drugs. The NHS in the United Kingdom brings a cohesive system that allows for follow-up data and allows a lot more information to be sent back to companies over time, which is not easily available in other countries. That should be on the table as part of the negotiations.

I have a real concern, going forward after Brexit, that in this country we will be further down the list for people to even apply for licences here. It may well be that the application to the Medicines and Healthcare Products Regulatory Agency for 60-odd million people in the United Kingdom may well cost an amount very similar to an application to the European Medicines Agency for a market of 450 million. That means we could end up in the same position as Canada, where it often takes about a year before a company decides to apply for a licence. The problem is that if, going forward, companies see that they must pay to apply to NICE, which will turn them down so they will have to pay to apply again, they may just decide that it is not worth the candle. That must be taken into consideration.

Obviously, England has the Cancer Drugs Fund, the idea of which is to allow a little bit of flexibility on access to new drugs, which are often expensive, but it does not help you if you do not have cancer. In Scotland, ours is a new medicines and rare diseases fund, which as a proportion of the population is three times the size of CDF, so it is more flexible. It cannot be a long-term solution for such drugs, or the funds would get sucked up, but it is important that when we are going through a phase of considering the real-life use of expensive drugs we have some flexibility for patients, and not just cancer patients.

We had a debate in the main Chamber last week about the Health Service Medical Supplies (Costs) Bill, and one discussion involved funding. In Scotland, the pharmaceutical rebate goes to fund the new medicines and rare diseases fund. In England, it goes back into core funding, which means that along the line, the beneficiary is the Treasury. If the NHS is managing attribution and access to new drugs in such a way that it gets a rebate, it should be able to use that to access more innovative medicines. That is why the pharmaceutical industry agreed to it. It also creates a better relationship with the pharmaceutical industry. We cannot have a situation where the industry just pulls a price out of the air and we must rise to it—of course we must get value for money—but it is really important that we do not leave people with certain conditions knowing that there is utterly no chance that they or their children will access treatment.

--- Later in debate ---

[Mrs Hodgson]

My hon. Friend is right to raise those concerns. We do not want to move into a new system that will create new unintended consequences. Perhaps the Minister will touch on that in his speech.

Although some are calling for interim solutions to help people who are stuck waiting for the accelerated access review’s recommendations to be implemented, it is also important that the Government get on with implementing those changes. The review was announced more than a year ago and was published two months ago now. It is important to remember that the transformation that we all want to see will not happen straight away, but it is still right that we keep up the pressure for the recommendations to be implemented. There are many such recommendations, and I hope that the Minister will be able to update us today on the progress on each of them. There are two in particular that illustrate what can be done to resolve the deadlock around Orkambi—the immediate establishment of an accelerated access partnership and the setting up of a new flexible strategic commercial unit.

The accelerated access partnership is one way in which, through co-ordination and collaboration across the system, we could see drugs brought on to the market more quickly to benefit patients who need access to them. I would be interested to hear from the Minister what progress has been made on its creation, especially in conjunction with the issues surrounding the deadlock on Orkambi.

It is clear that the strategic commercial unit could help to benefit those who wish to see Orkambi offered on the NHS. The unit could work with those involved in this dispute to end the current deadlock through facilitation of the flexibility and transformational change promised by the accelerated access review. That would go some way towards helping to access data on drugs such as Orkambi and getting them out to patients. There is a willingness out there for that flexibility to be brought into the system; for example, the Cystic Fibrosis Trust has offered to use the UK cystic fibrosis registry to help to provide essential data that can help to prove how effective drugs can be and what more needs to be done. We have already heard how substantial that registry is; it includes 99% of sufferers. I understand that the trust’s offer has been welcomed by all sides in the negotiations but is blocked due to the lack of progress in implementing the changes set out in the review. I hope that the Minister will give us some clarity on when the unit will be created and when we can see a culture shift within the system that will allow for flexibility to accept data and information that show how much effect these drugs have on people’s lives.

[Dr Philippa Whitford]

Does the hon. Lady share my concern about drugs for other conditions, such as sofosbuvir for hepatitis C? Even after they get NICE approval, those more expensive drugs are now being rationed at the NHS England stage. At the moment we are fighting to get through NICE, but it needs to be a smooth path all the way through.

[Mrs Hodgson]

The cost of drugs sometimes leads the NHS into the terrible and unfortunate situation in which rationing seems to become the norm. There can also be a postcode lottery, which is another element that we need to look at. The price of drugs really is the crux of the issue.

In conclusion, I hope that the Minister will offer some insight into the progress being made on the recommendations of the accelerated access review. The case of Orkambi can help to drive through these changes and to end this deadlock, which, as we have heard, is causing unnecessary suffering for those living with cystic fibrosis. The review has established a space for change and for patients to access new and innovative drugs and treatments. It is important that there is no stalling or delay in transforming the system, because people’s lives depend on the changes called for by the review. I am sure that the Minister will keep that in mind when he goes back to his officials.

Social Care Funding

Philippa Whitford Excerpts

Monday 12th December 2016 Commons Chamber

[David Mowat]

My hon. Friend is right. There is a raft of measures that need to be taken on informal carers and on the holy grail of better integration of health and social care funding, and we are pursuing that vigorously.

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

This was the substance of the letter from the Health Committee to the Chancellor, calling for extra money not for the NHS, but particularly for the capital budget and social care, because the back pressure from social care is what is causing the NHS to struggle. I totally agree with the Minister as regards integration. In Scotland, where we have the integrated joint boards, it has brought a change more quickly than we would have hoped. Our delayed discharges are down 9% in a year; in England they are up more than 30%. But this is not easy and it needs to be funded. We have debated the sustainability and transformation plans, which could be the basis for the future integration of the NHS, but all we hear within those plans is community hospitals being shut, losing the opportunity to have step-up and step-down beds, A & E departments being shut, and beds within hospitals being shut. This is the wrong way round. STPs could work, but they cannot start with the number they must reach—they have to design themselves around a service that keeps patients at home and keeps them well.

[David Mowat]

The hon. Lady made two points, both of which I agree with. The first was that in Scotland there has been a 9% reduction in delayed transfers of care. It is also true that in England many parts of our system, particularly those that have integrated most quickly, have achieved reductions of that size and more. She is right that the STPs are part of the process of re-engineering the system. Adult social care and the integration of adult social care are a big part of that and we need to ensure that we deliver.

Health Service Medical Supplies (Costs) Bill

Philippa Whitford Excerpts

3rd reading: House of Commons & Report stage: House of Commons
Tuesday 6th December 2016 Commons Chamber

[Keith Vaz]

In a little test tube! I carried my own blood to the laboratory, because it was the quickest way I could get a reading. Incidentally, from the look of him, my hon. Friend carries his blood very well. We want this innovation and research and development. The drugs companies should be able to plough back profits within the industry, and in the long run this innovation will make a great deal of difference.

When I went to New York for a meeting on Yemen, I stopped in at the diabetes centre of the Mount Sinai Hospital, and was told about the incredible innovation in diabetes in the US. I also went to see Mayor Bill de Blasio’s diabetes team. As Members will know, New York cut the level of sugar in soft drinks, as we are doing now, but the centre of its diabetes initiative is the lifestyle coach, not the GP.

As we look at these provisions, we see every opportunity for a cogent and coherent review that will particularly help—this is my main argument today—those with diabetes, but also others with similar problems connected with their illnesses. I urge the Minister, who I know has been extremely reasonable on this Bill, to look seriously at the new clause. If he cannot accept new clause 1 itself, will he at the very least give an undertaking from the Dispatch Box that the points embodied in it will be reported back to Parliament in a few months’ time?

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

Like the shadow Health Minister, we will not obstruct the Bill, because we support the basic aim to control prices in order to achieve a good return to the NHS from the drugs that it uses.

We also support in principle new clause 1. Six months might be a little early technically to bring things together, and there should not be just a single report because we will only see change over time. To look at the success of these actions, we need to see a price being controlled, and to spot when prices are sliding out of control. I would therefore suggest looking at the data and information on an annual basis and perhaps laying it before Parliament to show that the Bill’s aim is being achieved and that the concerns of the official Opposition are being allayed.

We support amendment 8 because it advocates the same approach that we have in Scotland. While the Cancer Drugs Fund in England is welcome and has clearly helped many patients, it is limited in the sense that if people do not have cancer they cannot access the medicines fund. That means that people with rare diseases are left somewhat abandoned. Frankly, if it were left solely to NHS England, those people would be left in the desert. It is important that significant money will be released, and the provision could gain support from the pharmaceutical industry if it sees that the money it is returning is enabling innovative medicines to come to the NHS earlier. Sometimes when we compare certain illnesses such as cancer, we find that the gap is in relation to people with more advanced diseases struggling to access the newest medicines. If the amendment helps to address that, we would support it.

The Scottish Medicines Consortium was reformed in 2014, and Scotland has now moved up from passing 53% of all applications to 77%, with a further review going ahead at the moment to see how to improve this further. The aim is not to avoid using drugs; the aim is to access them at a decent price. If the pharmaceutical industry is returning money to the NHS, it should enable earlier access.

Amendment 9 was tabled by SNP Members and we put it before the Public Bill Committee. It deals with clause 5, which extends a power that in fact already existed but was never used—to control the price of medical services and medical supplies as well as drugs. I am slightly disappointed that we did not manage to get this amendment adopted, so I raise again the issue of quality control and ask the Government to consult on it.

I know I spoke extensively in Committee about surgical gloves, but they provide a good example in that the range of quality is vast, and if poor quality gloves are used, there is likely to be extra cost to the NHS either when gloves have to be changed two or three times within one operation or more subtly if a surgeon is exposed to blood at the end of an operation from a tiny pinhole that was not visible. The same point applies to gowns and drapes. Taking off a gown that is meant to be protective and discovering that you are soaked to the skin in blood is a pretty unpleasant experience, and it obviously increases the risk to staff. The idea that surgeons are not exposed to diseases such as HIV or hepatitis B and C is naive. I knew colleagues over my career who suffered from those conditions, which they caught from patients. There is clearly a responsibility to staff and to patients to avoid any possibility of cross-contamination. I mentioned in Committee, too, some fairly cheap items such as gauze swabs, because if they are shedding threads, it can lead to intra-abdominal infection—something that we do not want. This amendment is about consultation and looking further at the mechanism.

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[Rob Marris]

As hon. Members know, overall I welcome the Bill, which is broadly a socialist Bill. It reinforces price controls and profit controls on big pharma, when appropriate. I always like to encourage the Conservative party, sadly now in government, to come a little further down the socialist road. They claim to be the workers’ party, and that is good.

New clause 1, tabled and moved by my hon. Friend the Member for Ellesmere Port and Neston (Justin Madders), is central to what we should be talking about in many spheres of public life—namely, evidence-based policy. All too often in this House—this applies to Governments of both colours—policy appears to be made on a political whim.

I remember in, I think, 2008 the then Leader of the House, the right hon. Member for Blackburn, Jack Straw, writing certainly to Labour MPs asking what we wanted in the Queen’s Speech that year—[Interruption.] We were in government, but perhaps he should have written to the right hon. Member for Chelmsford (Sir Simon Burns). I replied, because I believe in evidence-based policy, that in that year’s Queen Speech I wanted not a single piece of legislation. I said that after 10 years of a Labour Government, I wanted Parliament to spend a year on scrutiny, looking at the legislation that we had introduced over that period to see what had worked and what had not worked.

To my astonishment, the Leader of the House did not accept that proposal, as those who were Members then will recall, and we had another full legislative programme. Let me add, as an aside—if you will grant me a small bit of latitude, Madam Deputy Speaker—that by the end of the Labour Government I had stopped voting on crime Bills because we had had so many. Some of them—this may have happened under the previous Conservative Government—repealed parts of earlier crime Bills introduced by a Labour Government which had never been brought into force. That was extraordinary.

I urge the Minister to recognise that evidence-based policy making is encouraged by new clause 1. I hope that, in the context of innovation, which was so eloquently addressed by my right hon. Friend the Member for Leicester East (Keith Vaz), he will say a little about the way in which the National Institute for Health and Care Excellence operates.

As the Minister may know, there is an issue involving cystic fibrosis and the drug Orkambi, which NICE turned down owing to a lack of sufficient data. I understand that, because it is NICE’s job to weigh the evidence, such as it may be. The drug is registered for use in this country, but it is not available on the NHS. Since NICE decided that the cost-benefit analysis did not stack up, some long-term data from the United States, which I understand to be robust, has been made available. I gather, although I may be wrong, that NICE has not yet reviewed its decision on Orkamb, although the evidence from the United States suggests that in certain cases it can be extremely effective in treating cystic fibrosis. I hope that when we are discussing processes, innovation, efficiency and policy-based decision making, the Minister will say a little, not necessarily about Orkambi itself, but about the process whereby NICE might, in the light of new evidence, promptly—I stress the word “promptly”—review its decisions.

[Dr Philippa Whitford]

There is an additional issue. Drugs or treatments are being passed by NICE but not actually introduced. Either they are rationed and limited to a certain number of patients a month, as is the case with hepatitis C drugs, or the decisions are being left to clinical commissioning groups, which means that we are enshrining postcode prescribing instead of getting rid of it.

[Rob Marris]

I entirely agree with the hon. Lady, who, as ever, speaks with authority on these issues. I am a bit of a centraliser, because I do not like postcode lotteries. We will already have that in a cross-border sense—between England and Wales, Scotland and Northern Ireland—but it is a great deal worse when just some CCGs in England are making a drug available when it has been signed off by NICE as safe for use but it is not mandatorily available, and not every patient for whom it is medically appropriate can obtain it from every CCG. That sort of postcode lottery undermines the “national” part of the national health service, which is regrettable.

Amendment 8, tabled by my hon. Friend the Member for Burnley (Julie Cooper), would ring-fence savings made through the provisions of this Bill and earlier legislation so that the money thereby saved, or paid into the pot by a pharmaceutical company, can be retained for expenditure on medicines and medical supplies. I hope the Government will support that. All too often we hear that Governments do not like ring-fencing, and I understand why: it fetters their discretion. Earlier this afternoon, however, I asked the Secretary of State for Justice whether the education budgets devolved to prison governors would be ring-fenced, because I feared that a prison governor who was under other budgetary pressures might not spend the money on education and prison education would not improve as it needs to. I was greeted with a very welcome one-word answer, which was “Yes.” I hope that, in a slightly different context, the Minister can give the same assurance this afternoon, because this is an excellent amendment which clarifies a slight gap in the Bill.

As for amendment 9, about which the hon. Member for Central Ayrshire (Dr Whitford) spoke so eloquently, efficiency is of course important, but so is quality. I do not know whether the old saying “Penny wise and pound foolish” is used in Scotland—she is nodding—but it certainly is in my part of the west midlands. We have seen that time and time again with privatisations. When services are privatised they go to the lowest bidder, and what do we find? Either the service is not up to scratch, or, all too often—I think this happened when Circle ran Hinchinbrooke hospital—the companies go bust because they find that it is not as easy as they thought it would be to make a profit out of, in this case, the health service. That may happen to other suppliers as well. Quality matters, and the national health service is not a commercial organisation.

--- Later in debate ---

The hon. Member for Central Ayrshire (Dr Whitford) has supported this amendment, and while it is not for me to comment on the policies of the Scottish Government, we know that the NHS in Scotland has raised concerns that the new medicines fund, to which she referred, only funds medicines at the end of life or for rare diseases, meaning that funding for other areas is not getting the same priority.

[Dr Philippa Whitford]

indicated dissent.

[Mr Dunne]

The hon. Lady is shaking her head. That is my information, but if that is not the case, perhaps she would like to enlighten me further.

[Dr Whitford]

It is a new medicines and rare diseases fund, and it includes orphan, ultra-orphan and end of life, but it is not only about end of life.

[Mr Dunne]

No, it is not only for end of life, but also for rare diseases. That was my understanding, but I stand corrected. However, my main point is that it should be for clinicians to decide what is spent across the range of activity. If money is ring-fenced into a specific fund for new medicines, that might not always be the right clinical decision.

[Dr Whitford]

Does the Minister accept that it is a slightly bizarre public relations thing to have a medicines fund that is only for cancer, ruling out people with other life-threatening illnesses? That is the case here in England.

[Mr Dunne]

The new cancer drugs fund was set up specifically to provide funds to deal with one of the most common causes of mortality in the country, and was a priority of the previous Government; I will not go into the reasons for that.

Returning to amendment 8, it was suggested that what happens to the receipts is not clear, but all income generated by the voluntary and statutory schemes is reinvested in the NHS. Estimates of income from the pharmaceutical payment regulation scheme are part of the baseline used in the Department’s spending review model. The model was used to calculate the funding increase that the NHS sought at the time of the 2015 spending review, and it helped to secure the £10 billion of real-terms funding over the course of this Parliament. The income from the voluntary and statutory schemes can and does fluctuate; that is the biggest problem with ring-fencing, which could bring risks in this area. For example, the annual income from the PPRS has varied between £310 million and £839 million in a full financial year in England, so there is the potential for the income that it generates to vary widely, which could disadvantage patients by making treatment dependent on income from a pricing scheme with unsteady income generation.

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[Mr Dunne]

I am grateful to the hon. Gentleman for his advice, but I am afraid that I do not think it is relevant to my point about the fluctuation in income coming from the scheme. It is relevant in relation to whether NICE or politicians make such decisions. They need to be made by clinicians.

[Dr Philippa Whitford]

rose—

[Mr Dunne]

I will give way, but then I will make some progress.

[Dr Whitford]

I thank the Minister for kindly giving way. The cancer drugs fund has a budget of some £350 million, so if he is saying that the money that can be retrieved varies from £300 million to over £800 million, that would allow for the expansion of a new medicines fund.

[Mr Dunne]

It might if the move was always in the same direction. My concern is that the amount could decline between one year and the next; it may not always go up—certainly not up in a straight line.

Separately from the Bill, the Government are taking action to secure the UK’s future as an attractive place for the life sciences sector and to support faster patient access to medical innovations. I have already touched on the recently published accelerated access review, which sets out ways to increase the speed at which 21st-century innovations in medicines, medical technologies and digital products get to NHS patients and their families. The review’s recommendations included bringing together organisations from across the system in an accelerated access partnership, and creating a strategic commercial unit within NHS England that can work with industry to develop commercial access arrangements. We are considering those recommendations with partners and will respond in due course.

NHS England and NICE are jointly consulting on several proposed changes to NICE standard technology appraisals and highly specialised technology appraisals, including around speeding up the appraisal process. The Department of Health continues to work closely with NHS England and other stakeholders to improve uptake of new medicines. A key element of that is the innovation scorecard that I have already referenced. With those comments about our concerns about what is proposed in amendment 8, I ask the hon. Member for Burnley (Julie Cooper) not to press her amendment.

Turning to amendment 9, tabled by the hon. Member for Central Ayrshire, the Government recognise that section 260 of the National Health Service Act 2006 does not explicitly state that the Government are obliged to consult industry. However, I am aware that the Act does explicitly state that there is an obligation on the Government to consult when it comes to controlling the cost of medicines. A similar amendment was tabled by the hon. Lady in Committee. I want to reiterate that I am happy to consider with her how we could best introduce a general requirement to consult industry in section 260. Indeed, my officials have been in discussions with her, and I am grateful for her time and constructive comments.

I note the hon. Lady’s reference to the effect of any pricing controls for medical supplies on maintaining the quality of those supplies. I assure her that the Government would take into account all relevant factors, including any concerns raised by industry about the quality of medical supplies, when making and consulting on any price controls for medical supplies. The Government would not however be in favour of putting one of those many factors in the Bill.

The Medicines and Healthcare Products Regulatory Agency is responsible for the safety, efficacy and quality of medical supplies, and the Bill will not change that. The MHRA has assured me that any use of the price control powers in the Bill would not affect any of the quality or safety requirements that must be met before medical supplies can be placed on the market.

The hon. Lady referred to the procurement system in Scotland; I assure her that the Government are committed to improving procurement across the NHS. She will be well aware of the Carter report, which concluded that there is considerable variation in the value that trusts extract from their expenditure on goods and medical supplies. NHS Supply Chain is working hard to deliver procurement efficiencies, to meet recommendations to increase price transparency, to lower costs, and to reduce the number of products and suppliers used across the NHS to deliver economies of scale. The hon. Lady referred to 600,000 products, but it has had success in reducing the range in the catalogue down to 315,000 to help NHS organisations purchase products more efficiently. It continues to work to reduce that number. I am aware of similar work in Scotland. In England, we are using the Carter review to deliver that.

While I understand the intent behind the hon. Lady’s amendment, I am not fully convinced that, as drafted, it would have the desired effect. If she will continue to work with me and my officials, the Government would be happy to consider, while the Bill is in the other place, how we could best introduce the requirement to consult into section 260. On that basis, I invite her not to press her amendment for now.

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I have a couple of remarks about amendment 10, which was tabled by the hon. Member for Central Ayrshire. New section 264B in clause 6 enables the Secretary of State to disclose the information that is collected to a range of bodies, including NHS England, special health authorities, NHS Digital, other Government Departments and the devolved Administrations. The Government have concerns about this amendment, as we are dealing with confidential and commercially sensitive information that can be used only for specific purposes. We are therefore reluctant to introduce a requirement to disclose information to, for example, any Government Department or NHS England. It is important that the Government can be trusted with the information that they collect, and that there are sufficient safeguards to ensure that it is treated as confidential or commercially sensitive.

[Dr Philippa Whitford]

rose—

[Mr Dunne]

I would like to conclude this point for the hon. Lady, as I hope it will satisfy her. Her concern is about how the Government will behave in response to requests from devolved Administrations; we recognise that we need to give reassurance to the devolved Administrations that, in the light of the constructive conversations we have already had with them, they will have full access to all relevant data that the Government collect. We are quite happy to do that. We have indicated that we will enter into a memorandum of understanding, which will be discussed and agreed with the devolved Administrations. Those discussions will cover whether they have automatic access to this information—in real time, or in some other format—and whether that is done through giving them direct access to the systems, or by forwarding the data that we collect, immediately on request. We need to get into the detail of that in discussion on the memorandum of understanding, rather than committing that to the Bill at this stage. On that basis, I hope that the hon. Lady will not press her amendment to a vote.

[Dr Whitford]

I welcome the Minister’s comments, and I am happy not to press the amendment if we can reach the point of a clear memorandum of understanding. I just point out that all my amendment does is to say that the groups listed by the Bill should be able to ask for data on request; it does not add anyone else. I understand that my attempt at the amendment in Committee included groups that it should not have, but that has been corrected. This amendment does not spread confidential information any more widely.

[Mr Dunne]

I am grateful to the hon. Lady for that clarification. I think this is best addressed through a memorandum of understanding, rather than in primary legislation, in case we need to adjust the memorandum in subsequent years.

Finally, I wish to address Government amendment 7, which provides a definition of “equipment”. The hon. Member for Wolverhampton South West took us through the drafting on the definition of “medical supplies”. The amendment gives a definition of “equipment” in the National Health Service (Wales) Act 2006 to ensure consistency with the National Health Service Act 2006. “Equipment” is defined as including

“any machinery, apparatus or appliance, whether fixed or not, and any vehicle”.

When taken in tandem with the common definition of “medical supplies”, the definition is broad enough to capture any medical supplies on the market, from bandages to MRI scanners. The point of distinction was not so much the definition of “medical supplies” as the definition of “equipment”, which is a subset of the medical supplies definition. I hope, therefore, that hon. Members will accept the amendment.

I have spoken at length on these amendments. I hope I have made my position clear, that Opposition Members will not press their amendments to a vote, and that the House will accept the Government amendments.

--- Later in debate ---

[Dr Philippa Whitford]

I will open my remarks with thanks, because this is the first Bill that I have helped to take through the House, and I am therefore very grateful to you, Madam Deputy Speaker, the Chairs of the Public Bill Committee and all the staff who have worked on this, particularly those in the procedural hub; as a newbie, being able to go and ask them what happens next has been immensely helpful.

Obviously, we welcome the basic premise of the Bill, particularly clauses 1 to 4, which give the Secretary of State the power to control the price of drugs and avoid the excesses we have seen recently, as was highlighted in the article in The Times, particularly by those companies that are in the voluntary scheme but also produce generics, and therefore the price of those generics is not controlled. There are also those companies that have picked up drugs that have orphan status—they are no longer produced by anyone else—and basically robbed the NHS by increasing the price by many thousand per cent. That is just unacceptable.

When we accept relatively high prices for new drugs, we often excuse that on the basis of research and development. We need to realise that not all research and development is done by big pharmaceutical companies; they often collect drugs by buying small, spin-out companies from universities. With regard to generic or repurposed off-patent drugs, the R and D is usually done by clinicians within the NHS, or by academics in university departments. Companies have admitted in the past that they do not always price drugs in relation to their R and D costs; they sometimes do so simply by what they think the market will bear. We must not always allow them the excuse that they are spending huge amounts on R and D, because that is simply not always the case.

I tabled two new clauses in Committee. Now that the Secretary of State will have this power, I hope that the two issues raised by my new clauses will be dealt with. One is the issue of specials, which are simply hand-made preparations, usually an ointment for dermatological use. I arranged for the briefing from the British Association of Dermatologists, which highlighted companies that had a Scottish price list and an English price list, to be sent to the Minister. I therefore hope that those powers will be used. In Scotland it is done by using an NHS producer who makes the drug and therefore keeps the price down, rather than simply paying a pharmaceutical company or a pharmacy company, because the pharmacy with which the patient is dealing might have a mother or sister company and they are simply taking a very high price from them.

The other issue, which was raised last November, is that of repurposed off-patent drugs. As the shadow Minister explained at the time, an off-patent drug may be picked up by a new company and used for its new purpose, such as simvastatin for multiple sclerosis, but with the merest tweak it could be put out as if it is a new drug, and suddenly at a price that people cannot access. That also touches on the hierarchy whereby doctors must prescribe a licensed version before an unlicensed one. If a licensed drug came on the market that was actually just a version of an off-patent drug, doctors would be under pressure to prescribe it.

I understand that work has gone ahead since last year’s Bill, but I exhort the Minister, and through him the Secretary of State, to ensure that the powers given by this Bill are used in all these circumstances to ensure that prices are controlled. Otherwise, what happens is not a matter of expenditure to the NHS on its own, but usually that CCGs will not allow these drugs to be accessed, which is what is happening in the case of specials. We now have the powers. We welcome that, but hope that they will be used.