End of Life Care

Philippa Whitford Excerpts

Wednesday 2nd March 2016 Commons Chamber

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

As has been mentioned by several Members, we all share one thing in common: we are all mortal. Although some people think they are not, we will all die. In this House, we make decisions about provision for things that might happen, but this is something that absolutely will happen to all of us and so we all have a vested interest in making sure those services are as good as possible. Three quarters of people who die do so expectedly, which means they die of an ongoing illness they already have. About a third of those are cancer patients, and the palliative care system has focused on them since its inception in the 1960s. As has been said, we should rightly be proud of the fact that the UK is listed as No. 1, but that is largely to do with inputs and resources; it is not always to do with outcomes, because we cannot always measure those. A lot of that top position we owe to the hospice movement. We owe it to people such as Dame Cicely Saunders at St Christopher’s hospice. Everyone here knows my background, but even when I was a medical student this was my interest. My fourth year dissertation, “On Death and Dying—Home, Hospice, Hospital”, was written at a time when we had hardly any hospices and this was a new-fangled specialty.

The problem is that that is not the choice people are getting, as we have heard from Members from across the House. In Scotland, we did an audit in 2010 and again in 2013 which involved every single person in hospital on one day and following them up for a year. That showed that a third of people in hospital—it was exactly the same both years—will die within a year. That backs up a well-known fact that the majority of healthcare is spent on people in the last year of their lives. Some 10% of those people actually died on that admission, and the average stay of someone who dies in hospital is about two weeks. Some of those will be deaths we did not expect—they will be things that went wrong. However, a lot of them—three quarters—will be people with an expected illness. It is not just wasteful and it is not just futile, but for the family and the patient it is distressing.

We have heard about how people get stuck in hospital when they would like to be somewhere else. The question is: why? The No. 1 reason is that we do not talk about it; the family have not talked to the patient and the patient has not talked to the doctor—nobody has broached the subject. As someone who has been a cancer surgeon for 30 years, I know that it is difficult. I have often had to help families and patients open that conversation. There are people who say, “I won’t tell my mother”, or, “I won’t tell the children.” The family needs to be front and centre with this. One of the advantages of being at home is that people are in their own intimate space together. They have one luxury: the opportunity to say goodbye. People may have a row, go out the door, slam it and never come back. That is the worst loss. People need a chance to prepare. They need to make sure that they are at peace, that everything is organised, that they are not worrying and fretting, and that their families have the chance to say that they love each other. There is also the need to reconcile. Perhaps that person who went off in a huff 20 years ago comes back. That last bit of time is very precious.

In 2010, Scotland conducted a review of the “do not resuscitate” policy. We moved to what was described as best practice. That answers some of the issues raised by the hon. Member for Faversham and Mid Kent (Helen Whately)—people being scooped up by the ambulance and taken somewhere else. This was not just a tick box that the nurse or the doctor went through; it was a discussion that was shared with everyone.

The core person in all this is the GP. The GP provides the continuity. In Scotland, the summary care record is used for out-of-hours care. The GP must register a patient on the palliative care register, and that is automatically shared. If, at the weekend, someone is called in, they know what the aim is, which is that that person wants to die at home. If someone has been kept at home for months with lots of support, there is then nothing worse than if, in the last 24 hours, the family panics—“Mum’s got worse. What do I do? Dial 999”—and the person ends up in an ambulance and then in hospital. That is just a disaster.

As the hon. Member for Totnes (Dr Wollaston) said, we need to tackle training. We need to train our students, our doctors, our nurses and our carers in all the settings, because people will die in all the settings. People will still die in hospital. That is unavoidable, as was said by the hon. Member for Strangford (Jim Shannon), who is no longer in his place, but it is not an excuse for poor care or poor communication.

Ayr hospice in my constituency provides the liaison services to the hospital in which I worked, so we had palliative care consultants, liaison nurses and training for other staff. We also have a beautiful hospice that provides outreach and home care, and is trying to educate the whole community.

In Scotland, the funding of hospices is 50:50, whereas here, as we have heard, the average is a third, so it is very variable. Hospices now talk about the increased complexity of commissioning. Many of them deal with multiple clinical commissioning groups—the average is four—and they feel that they are having to jump through many hoops in exchange for whatever bit of finance they get. Hospices need to be put on a safe financial basis, and they also need to be able to plan their funding for the future.

We must not forget the care home. By 2030, a quarter of us will die in a care home, and that is the thing that many of us are most frightened of. That is because we have a sense of it as a place that we are tidied away to, and we fear that. We need to improve the quality of care homes and to individualise the care. We also need to introduce this end of life and palliative care philosophy to those homes.

Of course, the prize is dying at home. That is what 80% of people choose. In Scotland, we are lucky because we already have free personal care. Patients who are under 65 and have had a DS1500, which defines them as within six months of death, get free social care. We do not have the barrier that there is in England of either the difficulty of paying or the sheer time it takes to go through means-testing to get care organised. None the less, we have our challenges. The social care has to be in place. We know that all local authorities are struggling to balance their budgets. As has been mentioned by Macmillan, Marie Curie, Nuffield and the palliative care review five years ago, this would save money in the long term. However, the money cannot just be taken from the hospital and given to social care or to palliative care, because the hospital would fall over. We have to double-invest initially because, as with a Rubik’s cube, we need that little bit of space to move the first piece before anything else will happen.

This has been going around since 2011, and we are calling on the Minister to grasp the nettle and rise to the challenge. We need to follow the patient and support them through the whole journey and, as was mentioned, to support people after that journey through bereavement, to ensure that they have access to support and are not left struggling after the loss of a loved one.

It is well known that people will cope with bereavement better if their loved one has had a good journey. As was mentioned, in the assisted dying debate we threw down the challenge that if we voted against that, we had to provide high quality palliative care, to allow people to end their journey not in fear, not in pain and not feeling a burden. I call on the Minister and the Government to rise to that challenge.

Crohn’s and Colitis Treatment: England

Philippa Whitford Excerpts

Wednesday 24th February 2016 Westminster Hall

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

It is an honour to serve under your chairmanship, Sir Roger.

I, too, pay tribute to the hon. Member for St Albans (Mrs Main) for securing this debate, because, as we have heard in some of the contributions, there is a lack of awareness of the difference between irritable bowel syndrome and inflammatory bowel disease. Having been a doctor myself for more than 30 years, and a general surgeon for 20 of those before specialising purely in breast cancer, I know well what the outcome can be for people with IBD.

As the hon. Lady said, the rate of surgery is such that between 50% and 70% of Crohn’s patients and almost a third of those with ulcerative colitis will end up having an operation. The conditions are not trivial or embarrassing; they are life-threatening. It is therefore absolutely important that we try to get the research funding so that we can understand the cause, because that then gives us a chance of finding the cure. As my hon. Friend the Member for Ayr, Carrick and Cumnock (Corri Wilson) mentioned, for some reason Scotland has a very high incidence of such conditions. Is that genetic, or is it environmental? Looking at what is going on in different parts of the UK may help us get a handle on what is going on. Those are the things that we need to look for in the long term.

Normally when we are in the Chamber talking about a disease, we are talking about access to medicines in the major sense of not being allowed a new drug that would make a difference. Unusually, that is not the case here. The anti-tumour necrosis factor drugs can make a huge difference and have been passed by all the nations of the UK, but there is an issue with patients getting all the medicines that they require. If patients are on biologics, they will not pay prescription charges, but most of them are on a panoply of drugs, and for those they do have to pay. England needs to consider that Wales, Northern Ireland and Scotland have got rid of prescription charges. That move was led by Wales in 2007.

Plenty of research shows that, in general, less than 10% of the population pays for prescriptions, with half as pre-payment and half as pay-as-you-go. However, whenever surveys are done of people with chronic diseases, we find that some 75% to 85% are paying. That is because many of those diseases do not hit people once they have conveniently retired and qualify for free prescriptions. We have talked about how Crohn’s may hit people in their teens and how ulcerative colitis may hit people in their 20s and 30s, and they will have those conditions for life. They will be on different medications: methotrexate, steroids, enemas—the whole works—and they will be paying £8 an item. We talk about pre-payment, but many of these people will be in poorer jobs, because there will be times when they are not so well and when they are in and out of work as they have a waxing and waning condition. Because of that, they have to try to work out whether it will benefit them to pay £100-odd to have a pre-payment certificate. Perhaps they have a good year, perhaps they do not.

What has been shown in all the research is that approximately 35% of people report having not picked up a prescription because of charges, and approximately 30% have done that repeatedly. With all conditions we know that if someone is not taking their medication, they will get worse, but that is particularly the case with Crohn’s and colitis, which have such complications as strictures and toxic megacolon.

Working in breast cancer, we talk about “the big C”, but when I was doing general and emergency surgery I used to think of Crohn’s as “the wee C”, because it affects virtually all of someone’s life. It is debilitating and will affect everything that they do. These people are in and out of hospital, developing strictures, perforations and ischemic bowels and undergoing ileostomies, reversals and so on. It goes on and on. The hon. Member for Islwyn (Chris Evans) mentioned his member of staff, and I suggest he proofreads his speeches. She may write them, but it is his job to check them. People with Crohn’s often end up in hospital having expensive and incredibly difficult surgery. To go back into the abdomen of someone who has Crohn’s is a surgical nightmare. I have been there with the sweat pouring off me, trying to do those operations. Using the anti-TNF drugs earlier and ensuring that patients take all the medication required will make a difference in reducing surgery and, in the end, that is more cost-effective.

The other thing is access to care and trying to make it easier for people to get on with normal life. Along with Crohn’s and Colitis UK, the Scottish Government funded a two-year pilot that was looking at allowing patients to be much more linked to the clinician using e-health technology. That was carried out in the highlands to look at people living in rural areas, and in Greater Glasgow and Clyde to look at people living in a large city. The pilot developed information and support for patients and redesigned the services around the patients. Using the technology, the patient has an app that gives them information. They can have a two-way conversation with a clinician and they can register their symptoms. The clinician has a dashboard on their patients, and they can see whether someone is getting worse. That allows them to say, “Increase that”, or “Decrease this.” It means that patients do not always have to go and sit in the hospital if they are trying to hold down a job. If someone lives in the highlands and has to travel four hours to get to Inverness, that is a major pain when they are trying to maintain a normal life.

A new strategy is being launched in Scotland in June, and its aim is to meet the UK national Crohn’s and colitis standards. It will be the first comprehensive integrated strategy in the United Kingdom. It will create a patient portal where people can access their clinic letters and blood results so that they learn that they can manage their own disease. When we talk about the five year forward vision, or the 2020 vision in Scotland, the aim is to enable and empower patients to manage their chronic diseases as far as possible.

The last thing that was mentioned by the hon. Member for Islwyn was changing attitudes in society. Not everyone with a condition is on crutches or in a wheelchair, and we need to get past the embarrassment of talking about bottoms or going to the toilet. We need to realise that these are serious conditions that are debilitating. We simply need to make access to toilets available for everyone, whether they are elderly, incontinent or have inflammatory bowel disease. It is about trying to get past that access just being for certain people, because it is important for a lot of people.

Mental Health Taskforce

Philippa Whitford Excerpts

Tuesday 23rd February 2016 Commons Chamber

[Alistair Burt]

I thank my right hon. Friend for the question and his own personal interest and work in this area. He, like me, has come across this conundrum: we talk from the Dispatch Box about more money going into mental health and then we go to areas and they say, “Well, it’s not happening here.” That has been a genuine reality that we need to do something about. We are being more hands-on towards clinical commissioning groups and having a more transparent system of examining their finances. In addition, guidance from the NHS says that it expects the increase in finance to the NHS to go proportionately to mental health services and we have now given specific commitments to the series of services announced by the Prime Minister and contained in these recommendations. In that way, we hope to make sure that the diversion of funds that has happened in the past will not happen in the future. Local areas will thus feel that they, too, must ensure that they have the share of the resource.

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

All of us in the House welcome the strides made in changing the stigma around mental health, and people have been brave enough to speak out. In Scotland, we had the “See me” campaign, which was about seeing the person, not the condition.

Despite all the great talk, the money has often not gone to the services. Mental health trusts suffered a 2% cut in their budget between 2013 and 2015, and the number of psychiatric nurses decreased by 1.4%. The right hon. Member for North Somerset (Dr Fox) talked about money often ending up somewhere else, and we must avoid that. We need also to focus on children, because one in 10 of our children suffer from mental health problems between the ages of five and 16, and they are waiting a very long time to get help. We face the same challenge in Scotland. We measure it, we know how difficult it is to deal with, and we have managed to improve things by increasing staff and funding, but we also have a long road to walk.

One thing we are not doing enough is thinking about the whole spread of mental health support out into the community and about the way people work: people having insecure jobs; and people struggling to keep a roof over their head. Later, we are going to debate welfare reforms, and mental health issues arise from that. Three times as many poor children will have a mental health issue as children who are in a stable and well-financed family. Are we not going to try to join up our decisions and look at our other policy areas, in terms of how people work, how people are supported, and the mental health suffering that comes from the lack of that?

[Alistair Burt]

I thank the hon. Lady for her usual well-informed contribution to the debate on these issues, and for what she says about stigma and the general approach the Government have been taking. She is absolutely right about that. We have supported the Time to Change anti-stigma campaign, which has had some success, although we have to do more.

The hon. Lady is also right about children and wider cross-government work. On children and young people, for the first time we have a Minister in the Department for Education in England who has responsibilities for mental health, and the Under-Secretary of State for the Home Department, my hon. Friend the Member for Staffordshire Moorlands (Karen Bradley) is here to demonstrate that we take those cross-government responsibilities very seriously. One way in which we are going to manage the response to the taskforce is by having a cross-governmental team to make sure that Departments are joined up. Housing has something to do with this, as do education and work and pensions, as the hon. Lady said. We will make sure that that is done.

I should have said, but did not do so for reasons of time, that what has been said by the taskforce and what the Prime Minister has said is in addition to the £1.25 billion announced in March for the development of the child and adolescent mental health services in England and the £30 million a year eating disorder work, in order to recognise the increased pressures on children. As the hon. Lady rightly says, the more prevention work that can be done earlier, the better.

Junior Doctors Contracts

Philippa Whitford Excerpts

Thursday 11th February 2016 Commons Chamber

[Mr Hunt]

My right hon. and learned Friend speaks with great wisdom and also great experience. Many Members will remember how, when he was Health Secretary, the BMA put posters of him up all over the country saying “What do you call a man who ignores medical advice?”, and there he was, smoking his cigar. I am sure that there have been Labour Health Secretaries who have had similar treatment. He makes an important point, however. Under the new Labour Administration of Tony Blair, huge amounts of extra resources were put into the NHS but, unfortunately, because of the impact of contract changes in 1999, 2003 and 2004, weekend care actually became less effective, not more effective. Now, thanks to the tough decisions we have taken on public spending and turning the economy around, we have been able to give the NHS a funding settlement next year that is the sixth biggest in its entire nearly 70-year history. We are absolutely determined that, if we are putting that extra money into the NHS, it should come with reform that leads to better care for patients. That is the Conservative way, and we will not be deflected from it.

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

I should like to pick the Secretary of State up on some aspects of his statement. On Monday, I challenged the Under-Secretary of State for Health, the hon. Member for Ipswich (Ben Gummer) to step away from the term “weekend deaths”. The Freemantle paper does not show that; it shows increased 30-day mortality in people admitted at the weekend, and there is actually a lower mortality rate at weekends. The junior Minister said that the Secretary of State was really careful, but he has made that suggestion twice in his statement today, and I think that that is very misleading.

What should have come from the Freemantle paper and others is an attempt to understand why these things happen. The only study that gives a clear answer and backs up the Francis report is the Bray paper on 103 stroke units, which showed that the single most important factor was the ratio of registered nurses. We should know what the problem is before we try to fix it. The one group of staff that is there, along with the nurses, is the junior doctors. They are not the barrier to achieving the 10 standards.

I welcome the progress that has been made since last November. In a debate in this Chamber in October, the Secretary of State seemed relatively unwilling to go to ACAS, but progress has been made since the negotiations started, and particularly since Sir David Dalton became involved in the past month. I therefore found it incredible to see on the BBC this morning that, having achieved 90% agreement and following a tweet at 4 minutes past 8 saying that we should now get both sides back to the table, the Secretary of State was going to impose the contract.

The problem with the recognition of unsocial hours might increase the difficulty that we already have in recruiting people to the acute specialties: A&E, maternity and acute medicine. They are already struggling, and this might well make things worse. I also still have concerns about the role of the guardian. The problem is that a junior doctor at the bottom of a hierarchy will have to go and complain, and we can imagine how difficult that might be in a hierarchical system and how easily that doctor could be labelled a troublemaker. So there are still things to be dealt with. I welcome the progress that has been made in the last month, but this is absolutely not the time to pour petrol on the fire and then throw in the towel.

[Mr Hunt]

I welcome the tone of the hon. Lady’s comments. I do not agree with everything that she has said, and I shall explain why, but they were immensely more constructive than the comments that we have heard from other Opposition spokesmen. She is right to say that the studies talk about mortality rates for people admitted at weekends. There have been eight studies in the past five years, or 15 since 2010 if we include international studies. She is right to say that we need to look at why we have these problems.

The clinical standards state that when someone is admitted, they should be seen by a senior decision-maker within 14 hours of admission. They will be seen by a doctor before then, but they should be seen by someone senior within 14 hours. The standards also state that vulnerable people should be checked twice a day by a senior doctor. Now, across the seven days of the week, the first of those standards is being met in only one in eight of our hospitals and the second in only one in 20. That is why it is important that junior doctors should be part of the group of people who constitute those senior decision-makers—consultants are also part of it—and that is why contract reform is essential.

The hon. Lady is right to say that this is also about nurse presence, and the terms that we are offering today for junior doctors are better on average than those for the nurses working in the very same hospitals, and better than those for the midwives and the paramedics. That is why Sir David Dalton and many others say that this is a fair and reasonable offer.

With respect to A&E recruitment, the impact of the contract change we are proposing is that people who regularly work nights and weekends will actually see their pay go up, relatively, compared to the current contract. These are the people who are delivering a seven-day NHS and we must support them every step of the way.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 9th February 2016 Commons Chamber

[Alistair Burt]

The issue with ambulances and with quality of care elsewhere is the variation in quality. It is so important to ensure that local leadership addresses those local problems, because they are handled very differently in different places. It is right for my hon. Friend to raise this matter, and I am sure he has raised it with his local ambulance trust, as well as the hospital, to see how there can be better facilitation of patients going in and being discharged so that ambulances need not queue.

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

The Health and Social Care Information Centre has shown that last year 124,000 patients waited more than 12 hours after arrival at accident and emergency, which compares with a figure of 1,700 in Scotland, and the number has doubled since 2013. The Royal College of Emergency Medicine has explained that these tend to be the sickest patients and that this delay is associated with increased mortality, so how do the Minister and the Secretary of State plan to improve that performance?

[Alistair Burt]

I have to tell the hon. Lady that patient satisfaction with A&E was rather lower in Scotland than it is in England, which indicates that we all have problems to deal with in this area. It is correct that we continue our progress both to increase resources throughout the health service and to A&E, and to improve transparency and people’s ability to see what is going on. Unacceptable waits are not part of what we all want to see from the NHS, which is why we are determined to drive them down. Patients in England will have the best information anywhere in the world about what is happening in their NHS, as we continue to drive efficiency and improvement.

[Dr Whitford]

Patients will not have the information about the four-hour waits, as that has not been published since November. The doctors required to look after these people are A&E specialists. There is already a major problem in retaining A&E trainees because they work a higher proportion of unsocial hours. These are exactly the hours that will be less rewarded in the new contract, so how does the Secretary of State plan to recruit and retain doctors in emergency medicine in the future?

[Alistair Burt]

There have been 500 more consultants in A&E medicine since 2010. The new contract is under negotiation at the moment and the majority of it has been agreed with junior doctors. It is designed to replace the failures in the old contract, which everyone knew needed to be corrected, and it provides the basis for the profession for the future to deal with some of the issues the hon. Lady mentions. All of us are concerned to ensure that the negotiations continue and that there should be no strike tomorrow, so that this pattern for the future, which is wanted by doctors and patients alike, as well as by the Government, gets a chance to work.

Junior Doctors’ Contract Negotiations

Philippa Whitford Excerpts

Monday 8th February 2016 Commons Chamber

[Ben Gummer]

My hon. Friend is right that new measures have been introduced in the proposed contract. A new guardian role, which was proposed by NHS Employers, will help to protect the hours of junior doctors in individual trusts. That has been a point of success in the negotiation between the BMA and NHS Employers. A new fines system, which is not currently in place, will penalise trusts and ensure that the moneys that are generated by the fines go towards enhancing the general wellbeing and training of doctors within those trusts.

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

Obviously, I am disappointed that it is not the Secretary of State we are speaking to today. The Minister referred again to weekend deaths. I gently point out that if one studies the evidence from Freemantle, one sees that there is a lower level of deaths at weekends. Perhaps we might be a bit more precise and say that we are talking about people admitted at weekends who die within the next 30 days.

I welcome the commitment to increase diagnostics and social care, as I think will everyone in the NHS, but junior doctors already work seven days and seven nights a week, so I really do not see how they can be the barrier to the safety of patients.

I do think that, on looking back, the Secretary of State and the Minister may regret how this matter has been handled. Right from last summer, it has been so combative. In October, when we debated the junior doctors, the Secretary of State was still refusing to go to ACAS, so this cannot all be put on the BMA. Doctors are not stupid; they are capable of reading what has been offered. Many of the junior doctors who have written to me have talked about the fear of hours getting out of control. When I was a junior doctor, the hours were ridiculous and it was the automatic financial penalty on trusts that changed things. It is important that their concerns are listened to and that they are not patronised, as they were on the Marr show yesterday. That has aggravated things further, and the way in which this process has been dealt with from beginning to end has been really disappointing.

We are facing the second day of strike for the first time in 40 years—that is my entire career. What does the Minister feel will be brought to the table by the Department of Health in the next few days to try to get out of this and to try a different approach? We do not have junior doctors on the streets in Scotland. He has to ask himself why we have them on the streets here.

[Ben Gummer]

The hon. Lady speaks from experience, and rightly points to the fact that avoidable mortality that is attributable to weekends is different from mortality at weekends—the Secretary of State has been clear about that in his public statements. However that gap does exist, as the hon. Lady knows, and Professor Sir Bruce Keogh was clear in his statements that there is an avoidable rate of mortality. He stated:

“There is an avoidable ‘weekend effect’ which if addressed could save lives. This is something that we as clinicians should collectively seek to solve. It also strengthens the moral and professional case for concerted action.”

The way in which the hon. Lady characterised the discussions in September, October and November is not quite right. We implored the BMA to come and talk; I personally had those discussions with leaders of the BMA, and they refused to do so. It was only when they came and talked to us that we made substantive progress.

The hon. Lady is right to raise these issues, and we wanted to discuss such matters with the BMA. One issue was protection against excess hours, but we had no counterparty with whom to negotiate. Since we have had that counterparty, we have made good moments of progress, and the result is the guardian position, which she welcomed in another place. The guardian will be able to levy fines, and those fines will be remitted to the guardian. I hope—and indeed expect—that process to reduce the excess hours that we still see in a small minority of positions. We must get away from the perverse incentives for trusts and a small minority of doctors that mean that unsafe working hours are perpetuated.

Of course we all regret the course that this dispute has taken, but it would not have done so had the BMA taken a responsible position from the beginning. If people lie to their members and say that they will have their pay cut and their hours raised, of course doctors will be angry—all of us would be. The fact is that that was never true, but it has inflamed the situation. We could have had the kind of productive talks that we have had over the past three or four weeks back in August, September and October had we not had all the mess beforehand because of untruthful statements issued by the BMA.

NHS Trusts: Finances

Philippa Whitford Excerpts

Monday 1st February 2016 Commons Chamber

[Ben Gummer]

My hon. Friend will be aware of the increase in the better care fund that this Government have introduced and the 2% precept on council tax bills that will deliver increases for social care. She will also be aware that “Five Year Forward View” is a holistic understanding of the healthcare system that includes transformation of the NHS and social care towards that point. That is why we are proud to fund “Five Year Forward View” in the manner that Simon Stevens requested —front-loaded, with £3.8 billion in the next year. The manner of that bottom-up integration over the next few years will ensure that the challenge around social care that my hon. Friend identifies will be addressed in years to come.

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

With almost 80% of trusts running a deficit, I am not sure that we can say that it is just failing hospitals that are having problems. The Government talk about giving £10 billion upfront, but £2.2 billion of that is already written off in the deficit, and usually budgets are ascribed across the Department of Health, whereas Public Health England and Health Education England are losing money. With the £3 billion that is being clawed back from the areas that are not specifically under NHS England, it is actually £4.5 billion, not £8 billion, that is being put in. “Five Year Forward View” identified public health and prevention as crucial. The Government have a plan to recruit 5,000 extra GPs, but I am not sure how that can be done without Health Education England. The one thing that has so far been shown in evidence to impact on unnecessary deaths is a good, strong ratio of registered nurses to patients, so it is important that we look at how that will be funded. If trusts are not allowed agency or immigrant nurses, how are they going to do this? Why do we not get the National Institute for Health and Care Excellence to finish the piece of work on safe nursing levels throughout hospitals?

[Ben Gummer]

I thank the hon. Lady, who asked some salient questions that I will address. She asked about the deficits across the system. It is true that there are some particularly challenged providers where the heaviest deficits fall, and they account for the larger part of the accumulated deficit, but it has been a very challenging time across the system, not only because of the demographic challenges facing the NHS that have got worse in every year of this and the previous Parliaments, but because of the effect of the excessive charges of agencies levied after the increase in staffing levels in the wake of Mid Staffs. To seek to address that area, which makes up the majority of the cost of the deficit, we have brought in the controls not only on agency spend—on locums—but on very high salaries and on consultancy spend. Taken together, that will make a significant difference to hospital trust finances.

The hon. Lady talked about public health. We accept that that is a very important part of achieving “Five Year Forward View”. That is why, over the course of this Parliament, we will invest £16 billion in public health across England, to ensure that we can achieve the kind of transformation that she wishes to see.

On GP recruitment, we intend to have 5,000 additional GPs by the end of this Parliament. I am glad to say that Health Education England is so far meeting its targets in filling those training places. I congratulate its chief executive, Professor Ian Cumming, on the work he has done in that regard.

The hon. Lady mentioned safe staffing and the NICE guidelines. During the process of NICE looking at safe staffing levels, it became clear, as the chief nurse identified, that we need to look more broadly at team staffing levels, not just at individual positions on wards. I think that the hon. Lady in particular will understand that. That is why the chief nurse and Dr Mike Durkin were commissioned together to look at and build on the advice of NICE. The safe staffing guidance, which will be released in the next few months, will show a broader and more complex understanding of staffing levels, which I know the hon. Lady will appreciate from her time on the wards.

I want to be clear that that staffing guidance will be signed off only once it has the approval of NICE, Professor Sir Mike Richards, the Care Quality Commission and Dr Mike Durkin, the head of safety and quality at NHS England. It will require their imprimatur.

Access To Medical Treatments (Innovation) Bill

Philippa Whitford Excerpts

Friday 29th January 2016 Commons Chamber

What we are discussing could be a new system. Finally, it speaks about, “Delivering change”. I look to the Minister to make those five commitments work with off-patent, repurposed drugs for everyone in the UK.

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

I rise to support new clauses 1 to 3, 5 and 6 and amendments 10 and 13. The only reason new clause 4 does not stand in my name is that it relates to NHS England, which is outwith my purview.

People are well aware of my objections to clauses 3 and 4. Many Members in this House and medical voices outside the House have real concerns about the danger to patients of doctors having to convince only one colleague before trying a completely unproven approach. As well as the danger to patients, I feel that there is a danger to our clinical trials system. Why would someone go through applications, a year of paperwork and phases 1, 2 and 3, when they could just cut to the chase?

I pay tribute to the hon. Member for Daventry (Chris Heaton-Harris) for being willing to sit around a table with the Members who were named by the hon. Member for Torfaen (Nick Thomas-Symonds) and the Minister, and to start with a blank sheet of paper and work out how we could do something useful. It has been a great procedure. I welcome the fact that later in the day the hon. Member for Daventry will propose the removal of the clauses on innovative practice and litigation.

Turning to the off-patent drugs proposals, 6 November was a very frustrating day in this House. Every single Member who spoke from the Back Benches spoke in favour of the Off-patent Drugs Bill, but the time ran away during the Minister’s response—not the Minister who is here today. That debate showed the appetite across the House to get something done on off-patent drugs.

The hon. Member for Bury St Edmunds (Jo Churchill) has explained most of what I was going to explain. There is still the issue that while specialists are steeped in the evidence and used to using drugs off label, those who are not are less sure. There is no automatic place where they can check a dose or an indication. Sometimes, it is the general practitioner who does not carry it through. We have had lots of discussions in this House about the changes in the NHS and the evolution to multidisciplinary teams out in the community. That means that there are far more non-medical prescribers. The further someone is from the expert prescriber, the less comfortable they are. They do not have easy access to somewhere they can check when they think, “Is that just my bad handwriting or is that really what I mean?” That is what new clause 6 on the BNF could achieve.

The BNF is used by everyone and is on every desk in the NHS. As the hon. Member for Bury St Edmunds said, people can either check a drug that they have had a letter about from the hospital or look something up when they think, “I don’t have anything for this. What exists?” We will also discuss that when we come to the database proposals. I welcome the fact that the database has been changed from being a registry of people doing their own thing to a place where information is shared.

On new clause 5, which I tabled, although the inclusion of off-patent drugs in the BNF will achieve the sharing of information and will, in a sense, give them a slightly informal kite mark, I feel that it is important to look eventually at providing a licence. The reason for my concern relates to the drug simvastatin, which is used all over the place to control people’s cholesterol and has been found to be useful in multiple sclerosis—a disease that plagues many people and causes a lot of suffering, and for which, frankly, we do not have a lot to offer. That drug is incredibly cheap, but if a company decides to tweak a little molecule of it, call it something else and put it out as a new wonder-drug for multiple sclerosis, we will be having debates in Westminster Hall about a drug that costs fifty grand and that the NHS cannot afford. Under General Medical Council rules, the cascade is still that a doctor must prescribe a licensed drug over an unlicensed or off-label one, regardless of cost. If a doctor was faced with fifty grand for simvastatin-new versus sixpence for the simvastatin we all know, they would have no choice, and we would be right back in the same position—relentlessly discussing the NHS’s access to drugs.

The drugs we are talking about are already safe. They have had a patent and been used for so long that they are now off patent, which means that they have been around for a decade. We know their side effects, the common dosages and what to look out for. They should not have to start at point zero of the licensing process. We need a short licensing system, so that patient groups, academics, charities and the British Generic Manufacturers Association can say, “We think there is something useful here.” We have put provisions in new clauses 2 and 3 for the NIHR and NICE to have capacity in their systems to provide a funnel for evidence on such drugs.

These drugs are not developed by big pharma, so there are not huge costs that have to be recouped. The purposes of them are usually found by academics and clinicians, so pharmaceutical companies should not make a massive profit out of them. The benefit should be that the NHS can afford them and patients can access them. We have many debates about access to medical treatments in the House, usually in Westminster Hall and usually about drugs that are eye-wateringly expensive. In this case we are talking about drugs that are proven and cheap. We need to come up with a system that makes them accessible to patients.

I commend the Minister for the time, that, as others have said, he has given the four of us around a few tables, hammering these provisions together. I hope that we will be supported in working them through and actually doing some good for the NHS and our patients.

[Anne Marie Morris (Newton Abbot) (Con)]

It is with great pleasure that I rise to speak in support of this important Bill, introduced by my hon. Friend the Member for Daventry (Chris Heaton-Harris), and the amendments he has tabled. Specifically, I rise to support amendment 13. I am sure that the hon. Member for Torfaen (Nick Thomas-Symonds) will be disappointed that his private Member’s Bill did not make it to Committee stage, but I hope that he is happy to see some of it included in this Bill.

I had my reservations about the Bill as it stood originally, and I have reservations about some of the amendments, but I believe that amendment 13 will increase the use of off-label drugs in a safe and secure way. Those drugs can often be a cheaper and quicker way to tackle a disease, as they do not have to go through the rigmarole of being developed and licensed, which can take many years and many billions of pounds. NICE states that an unlicensed medicine is one that

“does not have a UK marketing authorisation and is not expected to do so in the next 2 years”,

whereas an off-label medicine is one

“with an existing UK marketing authorisation that is…used outside the terms of its marketing authorisation”,

and for which

“it is not expected that the existing UK marketing authorisation will be extended to cover this use in the next 2 years.”

The inclusion of off-label use classes in the database as innovative medical treatments will allow the medical profession to see where off-label use has been effective, even if it is at the other end of the country. However, we must be careful not to place off-label uses on a pedestal and allow people to cling on to false hope. They are the most vulnerable people in our society, often looking for any treatment that may help them, but we must ensure that any drug that is prescribed off label is used responsibly and ethically. I believe that the database will help by allowing doctors to see what is effectively a large sample trial that gives them more information on a particular treatment. I therefore support amendments 13 and 10.

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[George Freeman]

The hon. Gentleman makes two good points. This is, of course, UK-wide. One of the challenges, as a UK Minister, is to put in place a framework that will support this across the UK while respecting the different mechanisms in the devolved Administrations. I hope the Bill will provide a basis for a similar mechanism in areas where there are different formats. I believe that in Scotland, Northern Ireland and Wales, but particularly in Scotland and Northern Ireland, there is a hunger to do that. I believe the Bill will support those existing mechanisms.

[Dr Philippa Whitford]

We have moved on from talking about the BNF. I accept the comments about listing groups that would be considered in new clause 5. Does the Minister accept, however, that we still need to deal with the cascade of prescribing to ensure doctors are not forced to prescribe a licensed medicine, which is actually just a minimal moderation of an off-patent drug at a vastly expensive cost? That means we still need some kind of change to the licensing or short licensing process in the future.

[George Freeman]

The hon. Lady makes an important point about the classification of different drugs available to clinicians. Without detaining the House with too long a peroration on that classification, it is worth setting out that there is a clear cascade.

Clinicians can use unlicensed medicines in situations where, in their clinical judgment, and with patient consent, they believe it is the right thing to do. They are subject to all their usual professional undertakings. There are then off-label uses of drugs: drugs that do not have a licence for a particular indication but which the clinician, on the basis of evidence, is able to prescribe when they feel that evidence is compelling. The Bill now goes to the heart of that and will help to provide reassurance. For many clinicians, being able to click on a mouse with their patient and say, “For your condition there are one, two, three or no off-label medicines available for which NICE has looked at the evidence,” would be a powerful catalyst in helping to promote off-label use. There are generic drugs, which have been patented and brought to market, that are available at a heavily discounted open price.

There are then on-patent drugs, which have been brought to market and are still subject to a patent. The manufacturer has an exclusivity, which is the period in which their sunk costs in bringing the medicine to the system, can be reimbursed. That is an important protection to make sure we continue to have a thriving life science sector that can take the risks of investing in new drugs. Typically, new drugs take 15 years and £2 billion to develop. If there were no patenting mechanism, there would simply be no enthusiasm to do that research, which has a very high failure rate. In law, there is a key point of principle, which is that a licensed drug should be used first and that an unlicensed drug cannot be used purely on the basis of cost. That is a really important principle. An unlicensed drug can, however, be used on the basis of evidence. That is why the mechanism will allow NICE to look at the evidence and to signal to clinicians that they have the evidence basis on which to use the drug in an off-label indication.

One of the issues we have dealt with in discussions is the whole question of the European licensing of medicines. If we were to go down that route—I know the hon. Member for Central Ayrshire understands this—I can assure the House we would be here not just for weeks and months, but years. I am leading for the Government on reforming the European landscape of 21st medical research. The central role of protecting innovators’ sunk costs is really important to our life sciences sector, and the new clauses and amendments create a mechanism by which we can accelerate off-label use without running a coach and horses through that.

[Dr Whitford]

I accept the Minister’s points, but my concern remains that if in 10 years we have simvastatin in its current form versus a new name that is just a tweaked simvastatin at a thousand times the price, doctors will, under GMC rules, have to go for the one with the licence, as opposed to the off-patent one, even if it is in the BNF. I accept that the BNF mechanism will absolutely increase usage, but we still need to consider the longer term, given that in the future we might have huge numbers of off-patent drugs with new purposes.

[George Freeman]

The hon. Lady makes an interesting, important and useful point that I undertake to pick up in our consultation in response to the accelerated access review. The landscape will continue to change fast over the next few years. The Bill, as amended, will promote the greater use of off-label medicines. Crucially, the database mechanism, which, I reassure everybody, is very different from the original registry proposed in a precursor Bill—it is to make clinicians aware of what drugs are available—will generate data that will be incredibly powerful in helping the system to adapt and use the freedoms I hope to give it through the accelerated access review. That will ensure we are better and faster at getting these repurposed medicines into use.

I am delighted to say that the Government are happy to support amendments 10 and 13. Amendment 10 would set out in the Bill that its purpose specifically includes promoting access to the innovative use of licensed medicines outside their licence indications. It puts four square at the heart of the Bill the aims of the Off-patent Drugs Bill, which was promoted by the hon. Member for Torfaen (Nick Thomas-Symonds), and which, as hon. Members across the House have commented, had a lot of in-principle support. I am pleased, therefore, that we have found a form of words that moves it forward. At the heart of it, there is a clever protection for clinical sovereignty. We are not telling clinicians what they have to prescribe or putting in law a requirement that they prescribe in a particular way. We are giving them information on evidence-based off-label drugs. The feedback from clinicians so far is that it genuinely will help them to understand, promote and prescribe off-label uses.

Amendment 13 seeks to clarify the definition in the Bill of innovative medical treatments to make it clear that it includes off-label and unlicensed medicines. I mentioned earlier the pace at which genomics and informatics were uncovering new uses for drugs—some have referred to it as finding diamonds in the dustbin. There are extraordinary applications among the existing pharmacopoeia of tens of thousands of drugs. We now realise that many of them have particular impacts and effects. That is all to the good. It is thanks to the power of our life sciences sector that we are beginning to uncover those, and the Bill will support that.

With those comments in support of amendments 10 and 13, I hope I have given hon. Members enough reassurance and that they feel able to withdraw or not press the probing new clauses. I will be happy, following Third Reading, to put in place, through the accelerated access programme, a clear plan for keeping on top of the system’s implementation and tracking the use of repurposed medicines. We will continue with the work we did with charities through the winter and with the very helpful discussions we had with the charitable sector, and the Department will look annually at the data and whether the landscape is changing, and if it is, we will keep that under review.

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[Chris Heaton-Harris]

I just thought I would check about amendment 13, Mr Deputy Speaker. This whole experience has been a steep learning curve when it comes to procedure in the House. Perhaps we have invented a few things on the side as well, given how we have gone about our business here. I do not want to speak too soon, but if we could conduct all our health debates in the positive and constructive tone that has characterised these debates and the process behind the Bill, we might improve our heath service in leaps and bounds, rather than getting caught up in unnecessary politics. But that is where we are.

My amendments 1, 2 and 3 would remove, among other provisions, two clauses on clinical negligence. I want to talk about the reasons for their removal and the original idea behind the clauses. As right. hon. and hon. Members who have been following the progress of my Bill will know, many of the ideas in it came from Lord Saatchi’s Medical Innovation Bill in another place. Those ideas have not had the smoothest of journeys in this place. I have been regularly reminded by hon. Members—I thank those here today—and others outside this place that these clauses have not enjoyed the support of stakeholders.

Such concerns have been around since before the Bill was even drafted. Unfortunately, the echoes of those concerns haunted the first mention of the word “innovation” in the clause, and I decided from conversations I have had that those concerns could not be quelled in time. Throughout the process, I was clear that I wanted to listen to everybody with something to say on this matter. I have met and read the briefings of everyone who has contacted me wishing to share their views, and I hope it has been evident that I have been up front, honest and very clear about my intentions. I tried to solve the concerns of Members and the medical community who believed the clause would have negative and unintended consequences. That is why I tabled these amendments.

I hope that this process reflects favourably on Parliament and shows how a piece of possible legislation can evolve with a huge amount of stakeholder engagement and with parliamentary opinion taken on board. Since the beginning, I have focused on the sharing of good practice and transparency—and, indeed, on the failures of treatments through a database. Those ideas are reflected in clause 2 and have received much support.

I wanted to maintain the camaraderie built up around the Bill and have been unable to find the support I needed for the more controversial clauses, 3 and 4. Clause 3 sets out the steps that a doctor would need to take to show that he or she had acted responsibly using the Bill. They were intended to reflect the steps that a responsible doctor could be expected to take under common law when innovating. In relation to a proposed treatment, clause 3 would require the innovating doctor to

“obtain the views of…appropriately qualified doctors”

with

“appropriate expertise and experience in dealing with patients with the condition in question.”

Clause 4 expressly preserves the common-law Bolam test, the key precedent for judging whether a doctor has acted negligently.

The two clauses received strong opposition, which I will not go into too much. However, I worked closely with many officials from the Department of Health, and I want to thank them, because I had read the briefings that were so adamant in saying how dangerous parts of the Bill would be, so it was nice to have some of the best and brightest legal and parliamentary counsel remind me again and again that they viewed them as perfectly safe and did not see them as a danger to patients.

[Dr Philippa Whitford]

Does the hon. Gentleman understand the danger of undermining our clinical trials systems, in that, using the Bill, a doctor would have to convince only one colleague before they could go ahead and try something completely new? The recent tragedy of the patient who died while taking part in a phase 1 trial shows the need for steps and procedures to reduce the risk.

[Chris Heaton-Harris]

The hon. Lady knows that I would obviously have preferred to retain clauses 3 and 4, but I have to agree with her: the body of opinion stands on her side of the argument, not mine, so the simple answer is yes.

I remind the House, though, that there was a decent and honourable purpose behind clauses 3 and 4. Dr John Hickey, the former head of a primary care trust, contacted me to say that,

“as a registered medical practitioner, a former NHS Trust Chairman and with 30 years’ experience in the field of legal medicine with the Medical Protection Society (last five years as Chief Executive), I believe I am adequately qualified to comment on your Bill.”

He went on to say:

“Over the last 30 years I have seen how doctors have increasingly practised defensive medicine…because of the fear of litigation and disciplinary action by their regulators; this defensiveness is not in patients’ best interests.”

In fact, it may interest Members to hear that, in reading the debates on the Bill introduced by the hon. Member for Torfaen (Nick Thomas-Symonds) and the recent debate on the Mesothelioma (Amendment) Bill, I have seen much stated that supports the action I wanted to take in clauses 3 and 4 to reassure doctors who fear litigation. For example, the British Medical Association’s parliamentary brief for the Second Reading of the Off-patent Drugs Bill stated that there were

“two barriers to the use of off-patent drugs in a new indication: 1) Clinicians’ confidence in prescribing: clinicians take on a personal and professional liability if they prescribe an off-patent drug in a new indication”,

and therefore they require reassurance. The brief goes on:

“GMC guidance also indicated a greater level of responsibility for the doctor prescribing off-label and therefore potential greater risk of liability which would be a disincentive for a doctor prescribing off-label drugs”.

That is a simple statement of the purpose of clauses 3 and 4: to give doctors a supplementary way to assure themselves that they are doing the right thing where they might want to do something they believe to be in their patients’ best interests, in a fully evidenced, responsible and honest way.

Similarly, the Multiple Sclerosis Society’s brief on the same subject states:

“Guidance from the General Medical Council is clear that a doctor takes on an extra level of personal liability when prescribing off-label, which would be a significant disincentive to prescribing”.

Breast Cancer Now says that, because of personal liability,

“doctors can be unwilling to prescribe drugs for new purposes, even where…clinical evidence is strong”.

As Lord Freyberg stated in the mesothelioma debate in the other place,

“The fastest way to save lives is to see if the drugs for common cancers work on the rarer ones as well, given the shared mechanism of disease across cancer. This is off-label research and until we fix the issue of liability, as advocated by the noble Lord, Lord Saatchi, we will continue to send thousands, like my sister, to an early grave.”—[Official Report, House of Lords, 20 November 2015; Vol. 767, c. 407.]

There was therefore plenty of reason and evidence to support clauses 3 and 4, but I guess politics is all about being pragmatic, and I believe that the provisions that we have already discussed are worthy in themselves of inclusion in a sensible Bill, because they will do some positive things. It is therefore with some reluctance, as I am sure the House will understand, that I have decided to table these amendments, which strike the elements relating to clinical negligence from my Bill.

Access to Medical Treatments (Innovation) Bill

Philippa Whitford Excerpts

Friday 29th January 2016 Commons Chamber

[Dr Philippa Whitford]

I wonder whether the hon. Lady will clarify what she is saying. The database that is referred to in the Bill will share information on drugs and trials that ought to be available to anyone, whether a pharmacist, a GP or a doctor. It is simply about information sharing. Is she referring more to a database of patient information from which we can learn in the future? Obviously, that is outwith the scope of the Bill, but it has been held back by the various data challenges that have been faced.

[Jo Churchill]

I apologise. Yes, I have confused the two, because I really believe that if we are not careful, what we do today will have an effect on our ability to bring that second broader database to fruition, which would give us the information we need to drive the trials, the life science industry and so on. Databases need to be fit for purpose. I could not have put it better than the hon. Lady did. We want the database that we are talking about today to be fit for purpose, but we do not want to put too many constraints or too much rope around it if that will stop us moving forward with clinical trials and with the whole area of genomics and patients.

I want every life to mean or have meant something. A patient should be able to choose to give knowledge as their legacy. Data hold the answers—the answer for my constituent whose two-year-old had a brain tumour; the answer for a family I know who have diabetes in several generations; the answer for a family member whose humour is tested by Parkinson’s that attacks his body. Personalised medicine should be a reality. As was pointed out in a paper yesterday, we are doing great things with CRISPR—clustered regularly interspaced short palindromic repeats—and across the piece.

Like me, every patient is somebody’s parent, partner, child or friend. That must not be forgotten. If the database we are discussing allows for information to be given that is appropriate to the individual, with care taken by the clinician right through the pipeline, it has to become a force for good. We should not wrap it up in too many constraints, but should allow it to develop. We must allow the Under-Secretary of State for Life Sciences to give us a lead in how to proceed in this field in the most effective manner.

The use of data offers the possibility to accelerate medical trialling from seven to two years and to link research together to find new insights. My glasses are not rose-tinted. I would want assurances about the use of my data, as any sensible person would. I want the recommendations of the accelerated access review to be implemented. The use of health data will be central to solving this country’s health challenges, not least in terms of cost, and its economic challenges. Our medical future will be uncertain unless we unleash the potential of information about patients for patients. I therefore support the Minister’s proposal.

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[Chris Heaton-Harris]

Yes, but in responding to amendments 8 and 9, which were tabled by Her Majesty’s loyal Opposition, I know that, when the Secretary of State and the Minister choose to use the power conferred on them in the Bill, they will confer far and wide on how the database is set up and used. Perhaps my hon. Friend will have an opportunity at that time to put her point in the consultation on how wide and extensive the database should be.

I mentioned Emma’s story because it was about evidence sharing within our existing system, which every single Member would like. Of Emma’s treatment, the NHS stated that it could not find evidence to approve the effectiveness of the operation that saved Emma’s life, and then withdrew funding for it. However, in its consultation on the matter, the NHS did not talk to the surgeons at the hospital where Emma was treated. There is a general point. I could tell hundreds if not thousands of stories in which a simple flow of information and data, or innovation or other things in our NHS, could improve the quality and type of care that is given to patients.

Amendment 15—the Minister’s amendment—states:

“References in section 2 to medical treatment include references to treatment carried out for the purposes of medical research (but nothing in section 2 is to be read as affecting the regulation of medical research)”.

That is an important amendment because it signals the Government’s intention to use the database wisely when it comes to dealing with research. Research has come on in leaps and bounds, meaning that a huge number of new treatments are coming into our NHS through clinical trials and innovative ideas everywhere in the system.

[Dr Philippa Whitford]

Although people who work in an academic unit will be very aware of trials—a lot of trials are UK-wide, but European Organisation for Research and Treatment of Cancer trials are Europe-wide and occasionally there are worldwide trials—people who work in district general hospitals, where there might be greater numbers of certain types of patients, are often less aware. Adding a listing of trials under any disease topic or area of clinical practice could be helpful in attracting clinicians to say, “I am aware that you can access a trial in Birmingham or Manchester.” The measure might promote trials to the busy clinician who is not directly involved in academic research.

[Chris Heaton-Harris]

I thank the hon. Lady, and I completely concur. I can foresee great benefits for those in the outer reaches of the NHS who do not necessarily come across information about many of the trials that are taking place. One of the biggest criticisms of the original formulation of my Bill was the fear in connection with getting people on to clinical trials. I would like to think that we have not just overcome that issue, with the amendments we are discussing and the latest version of the Bill, but have gone some way along the line to help improve the ability of registered medical practitioners to have knowledge of such trials. I completely concur with the hon. Lady’s point. We have innovation everywhere, so there is a real purpose behind having a database, regardless of whether the Minister has had the ability to set one up before now.

On research, Lord Winston made a very important point particularly well in the other place on Second Reading of the Mesothelioma Bill. He stated:

“There is no question that in the field of treatment there is a great deal of research.”

He had a list of a number of chemotherapeutic agents that were being looked at, saying:

“In recent years I can count at least 10 or 11”.

He then went on to name them. They are impossible for me to pronounce, so I will not do so here today. He said that,

“there are various combinations of those therapies with other well-known mitotoxic agents. These have included trials”.

He went on to say:

“Other treatments have been researched: of course there is surgery…and there are now attempts to try to reduce the tumour inside the lung membranes.”

He spoke about three trials that Cancer Research UK is conducting to emphasise the wide range of “stuff”, as he put it, that is going on.

“One is some work with HSV1716, which is a virus that acts against dividing cancer cells. It comes from the herpes virus…a very good example of where we might make a breakthrough in treatment. Then there is a different strand of research with ADI-PEG 20, which in combination with other drugs such as cisplatin affects a particular amino acid in the chain of cell division”—

which could prevent cancer cells from multiplying.

“That has been specifically targeted for the treatment of mesothelioma. A compound, GSK3052230, developed by GSK, is I think about to enter phase 3 trials very shortly. That attacks the FGFR1 gene, and therefore stops cancer cells growing.”

This is where he makes the point exactly:

“There is now an increasing emphasis on understanding that, if we are going to improve outcomes for patients with a variety of different cancers, and other chronic long-term conditions, we need to move away from a generalised approach to managing disease towards personalised, precision medicine”.—[Official Report, House of Lords, 20 November 2015; Vol. 767, c. 395-7.]

Medicine is going to change. Research is going to change. Spreading the information about that across our NHS, and how quickly we can do that and learn from success and failure in our NHS, is a very, very important matter.

[Chris Heaton-Harris]

I truly believe that personalised medicine will become a reality. I would like to think that a database would aid the spread of knowledge about how individual medicines are being used and who they might affect in different ways, so yes, I nearly completely agree with my hon. Friend.

[Dr Whitford]

I have two small points. First, personalised medicine, particularly for breast cancer, has been evolving for years. Right from when we could tell whether a cancer fed on the female hormone oestrogen or not, we were targeting the treatments towards patients. We have been moving that way and it will accelerate.

I know it is not the subject of the Bill, but I hope that the accelerated access review will consider in general how we get drugs to patients—a subject that we debate relentlessly in Westminster Hall. I see a negative feedback loop coming from among colleagues who used to be trialists, such as myself. We registered patients and did all the work to take part in research, but when the drugs were finally made available, the NHS could not afford them. We need a totally different way of accessing those drugs. The companies want to sell them, and we and patients want them.

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[Chris Heaton-Harris]

I will give way to the hon. Member for Central Ayrshire, who will give a much more informed answer.

[Dr Philippa Whitford]

I think the hon. Member for Beckenham (Bob Stewart) has a much greater admiration for what a computer on a desk can access at that moment when a GP has a 10-minute appointment. What they are actually looking at is the patient’s records. They also have the ability to prescribe, but to track something down they would have to shut those systems down and go into something else, as with searching the internet. They cannot do that live, in front of a patient, and that brings up an important point. If the new system is meant to be used live, in front of patients, it will have to interact with the NHS computer systems, which someone can literally click on and use to look things up relatively easily, in the way we look things up in the BNF at the moment.

[Chris Heaton-Harris]

I thank the hon. Lady for her explanation to my hon. and gallant Friend the Member for Beckenham (Bob Stewart).

It is important that doctors are aware of the changing methods by which care is being delivered. Innovation in the delivery of care must be recognised in the tapestry that is our wonderful national health service. I fully welcome the Minister’s amendment to my Bill. It makes it more worth while. The improvements we are making to the Bill today are dramatic, but they have not come out of thin air; they have come from a great deal of work. A great deal of thought has gone into them, which I very much appreciate.

Finally, and briefly, let me turn to amendments 8 and 9, in the name of the right hon. Member for Lewisham East (Heidi Alexander).

NHS and Social Care Commission

Philippa Whitford Excerpts

Thursday 28th January 2016 Commons Chamber

[Norman Lamb]

I said at the start that I am primarily focused on England because health is a devolved responsibility, but I also said that the same pressures apply everywhere, and so the case for a process of this sort in Wales, in Scotland and in Northern Ireland is just as strong as it is England. I would encourage this debate to take place in Wales as well. We must overcome the clashes between the parties to recognise that something bigger is going on and we need to work together.

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

I want to return to the right hon. Gentleman’s point about the data. Last June, we had a debate about moving from weekly to monthly data, and we were told that the NHS would still know what was going on. We now have a six-week delay in the publication of those monthly data, which results in a total of 10 weeks. Having asked about this at the most recent Health questions, I understand that people within the NHS can access the data, so why are they not being shared with this place? The last data we had was in November.

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[Dr Wollaston]

I thank my hon. Friend for mentioning the “Five Year Forward View”, but I would respond by saying that Simon Stevens has referred to prevention and social care as “unfinished business” from the spending review. If we are to deliver the plan, we need to listen to his views and be mindful of the fact that spending on social care actually saves the NHS money. We cannot separate social care from the NHS, and we should not ignore his wise words on the importance of prevention in delivering the “Five Year Forward View”.

[Dr Philippa Whitford]

Is it not the case that when Simon Stevens was before the Health Committee, he said that a quarter of the £22 billion of savings that were hoped for would have to come from prevention and public health, yet that is being cut?

[Dr Wollaston]

Indeed; I remember that too. I agree that unless we up our game and redouble our efforts on prevention, we will not achieve the savings that are required to close the gap in the “Five Year Forward View”. That is why I wanted to touch on prevention first.

There is another area that we need to do much more on here and now. We need to have a relentless focus on variation across the NHS. We hear examples of local systems that are making things work, but the NHS has a long history of failing to roll out best practice. The “Growing old together” report, which was published today by a commission set up by the NHS Confederation, gives examples of good practice across the NHS and social care in which integrated practice is not only delivering better care for individuals, but saving money. The only depressing aspect of that is that one has to ask why it is not happening everywhere. Rather than endlessly focusing on the negatives in the NHS, let us focus more on the positives and on facilitating their roll-out.

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[Dr Phillip Lee (Bracknell) (Con)]

It is a pleasure to follow the hon. Member for Leicester West (Liz Kendall) and other colleagues who have spoken. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing the debate.

I broadly support the call for some cross-party engagement to try to secure the future for the national health service, although I will come on to clarify that in my speech. The right hon. Gentleman may encounter some difficulties in seeking cross-party support for financing the NHS, not least because of some of the contributions so far. There are some profound challenges to financing health and social care, primarily because of the challenges that we, and all western societies, face with an ageing population. I remember the Intergenerational Foundation launch here in Parliament a few years ago. Only the former Member for Dulwich and I turned up. At the time, the subject was not much discussed, but I note that it is now increasingly being discussed. We are beginning to do the maths and realise that we cannot afford the current settlement for financing health and social care and that we will have to discuss it at some length. The problem is that one ends up talking about broadly different political philosophies and approaches. Some people, I suspect more on the Conservative Benches, will want to emphasise the need for personal responsibility; others, I suspect more on the Opposition Benches, will want to emphasise collectivisation and the like. That is why I suggest that discussing the financial settlement is possibly a road to nowhere.

I think there is scope, however, for discussion on the structural organisation of the health service: where our hospitals are located and what each individual hospital does. In a week when we have had yet another dreadful failure of the system with the 111 line and out-of-hours services, it is beholden on us to start to discuss what is offered in the out-of-hours arena: how the services are structured and where patients should go to seek the appropriate care for themselves or their children.

The context has been set out by other colleagues. We know that we have a problem of increasing demand, which is driven mainly by ageing, obesity and the welcome advances in surgical practice, technology and drugs. There is also a problem with the health-seeking behaviour of different generations. In my own clinical practice, I am seeing the passing of the stoic wartime generation. Their attitude towards health, and to symptoms of pain and suffering, is noticeably different from that of their children and that will bring increasing demand on healthcare services. If we consider that together with the large cohort who were born between 1945 and 1955, we have an equation that results in a significant deficit.

On the subject of deficits, since I have been here I have seen many faceless NHS bureaucrats come up with numbers relating to likely demand and shortfall. They are always wrong; the figures are usually underestimated. I said at the time that the £20 billion challenge in the previous Parliament was an underestimate of likely demand and here we are talking about £30 billion. What is next: £40 billion? I am glad that a shadow Minister for mental health has been appointed and that people are waking up to the importance of mental health because demands for mental health services in particular will increase the £30 billion figure.

On hospital structure, essentially we have 19th and 20th century buildings trying to deliver 21st century care. Medical and management staff are trying to do their best within this infrastructure, but to be blunt it is not possible to deliver the very best care in all hospitals and in all locations.

[Dr Philippa Whitford]

Is it not also, to some extent, a failure to engage with the public so that they understand how much 21st century medicine has changed? People who have a heart attack are not going to their local casualty department. They are being taken to a heart unit where they will have an angio and an angioplasty. People do not understand that the big boxy paramedic ambulance has everything that an old A&E used to have.

[Dr Lee]

The hon. Lady is right. Tomorrow I will be working as a doctor. I am very proud to be working as a doctor. I have been very public and open about it throughout my time here and I will continue to practise medicine for the foreseeable future. I encourage her to face down her internal critics, as well as those rather ill-informed external critics in the Scottish Daily Mail. I actually stood for election calling for the closure of my local hospital. I did not want my constituents going to an ill-equipped hospital, or thinking that it provided care that it did not. I have sought to educate my local electorate about the need for a 24-hour angio suite and for a 24-hour stroke unit.

We have made some progress on reconfiguration, particularly on stroke care. In London and in Greater Manchester, stroke services have been consolidated. That is why people are now surviving and survival rates for strokes are improving. Patients are taken to appropriate units and appropriately cared for. The appropriate intervention can be applied within the appropriate time. Sadly, that is not possible across the country. It is available only in areas where difficult decisions about reconfiguration have been taken. On oncology, there is a widespread belief that cancer outcomes are all to do with late diagnosis in primary care. Forgive me, but that is not necessarily the whole story. It is the quality of cancer care when patients reach the hospital—any delay in receiving radiotherapy and so on—that is having a profound impact on cancer outcomes. If we consolidated oncology services into fewer sites, we would get better clinical outcomes.

On out-of-hours care, when I turned up here I said that I would scrap out-of-hours care as it is currently constituted. Most people looked at me and thought, “Are you slightly nuts?” The answer is no. Having done many, many, many sessions in the primary care out-of-hours arena, I realised that there was the potential to delay the care of the acutely unwell in a way that could have an adverse impact and, in extremis, lead to someone’s death. I suspect, without knowing the details, that the case we heard about in the urgent question on Tuesday was such an example. I do not believe it is clinically possible to properly assess a sick child via a telephone. We can go some way towards doing it with an adult, because—guess what?—an adult can express themselves more accurately. With a child, we have to see them and touch them, and, in particular, we have to see the mother’s response towards the child, to assess how acutely unwell they are.

The problem, with all best intentions, is that with a telephone service these types of incidents are always going to happen. It was no different with NHS Direct; the medical profession used to get very frustrated with that, and 111 is the same. The symptoms of sepsis can be the symptoms of many things, so if we tighten the protocols we end up flooding the service with more and more people worried that their child has sepsis when, actually, it is not that common.

I would revisit the whole out-of-hours settlement. We could get away with having fewer doctors during antisocial hours primarily looking after the housebound and those who are terminally ill. The list of patients who could be visited by said doctor would be compiled by GP practices in that region. Patients would not get a visit unless the GP practice has said they are entitled to a visit because of a diagnosis of being either terminally ill or housebound. In future, I would put the resources into urgent care centres. For now, I would put one in each casualty to sift through. I would make sure it was a doctor. Forgive me, but doctors are taught to triage and to diagnose. No other healthcare professionals are taught in the same way. The best thing to do is to put one’s most experienced and qualified person at the front end, because then proper triage can take place.

[Dr Lee]

I thank my hon. Friend for her intervention because it allows me to elaborate. A couple of years ago, I had a meeting with the right hon. Member for Leigh (Andy Burnham)—all the polls were saying that the Opposition would win the election, so I thought I would have a meeting with him in advance. I said, “Look, Andy, you’re going to have a problem. We’ve got all these hospitals. We know some of them are not fit for purpose. We know we’ve probably got too many because of how healthcare has changed. Some 80% of care delivered in the NHS is for chronic conditions. Why don’t you have a cross-party commission so that all the parties can share the political pain of deciding which hospitals should be retained as acute hospitals, delivering the 24-hour stroke and angiography suites, the surgical interventions and the like, and then have more community hospitals, with urgent care centres attached”—the hub-and-spoke model. At the time, he looked at me and said, “Well, maybe”, and made no commitment.

My point was that it was extremely difficult for colleagues in marginal seats to come out and say what I said in my constituency, which was that the current local hospital settlement was not in the best interests of my constituents. It is very hard to do that in a marginal seat, be it Labour, Conservative or whatever, so, with a cross-party commission, we could all share the pain.

All the royal colleges, particularly the paediatricians and obstetricians, know that staffing in some district general hospitals is not ideal. It is extremely difficult to provide the level of care we know we can deliver. How do we get to that point? A couple of years ago, I thought that having all the parties and independent experts in a room would be one way of going from approximately 200 to 100 such hospitals in England and Wales. That is the sort of scale change I am talking about. I hope that that answers the question from my hon. Friend the Member for Twickenham (Dr Mathias).

[Dr Philippa Whitford]

In my constituency, we have hospitals that have grown organically and are not far apart, but we have also seen an increase in the number of modern community hospitals—what people would have called cottage hospitals. The hon. Gentleman says that many of our patients require the management of chronic diseases. We need to take that closer to the public. It is the highly specialised things that should be centralised. The public would accept that, provided they do not get the sense of their hospital disappearing and provided they are aware that other services are coming closer to them.

[Dr Lee]

Again, I agree with the hon. Lady—we are making a habit of this. I held a series of public meetings at which people were initially against my position, but when they understood that I was trying to provide more services closer to home, but that this might mean their having to travel a bit further for acute care, they accepted it and became broadly supportive.

I am under no illusions about the difficulty of all this, but if there is one goal we should all seek in the NHS, it is better clinical outcomes. At the moment, clinical outcomes are not as good as they should be. The much-trumpeted Commonwealth Fund report made that clear. Part of the problem—perhaps a significant part—is where the care is currently being delivered. The junior doctors strikes, which have just been paused; the consultant contracts; the nursing contracts to come—all these would be made easier with a structure in place that is more easily staffed. It would be easier to avoid husband-and-wife doctor teams being split if we had bigger hospitals with bigger staff pools to provide the cover.

We need to concentrate first on the structure of healthcare, and social care—I am conscious I have not spoken about social care, but of course it should be integrated; it is so obvious. But let us concentrate on the structure of healthcare first, as part of a cross-party approach, and then perhaps we can have a debate about finance. I suggest to the right hon. Member for North Norfolk, however, that finance might be a harder nut to crack than the hospitals, on which I think there is a broad consensus that we are all in it for the same outcomes: people recovering from their illnesses; people being treated appropriately when they have operations; and ultimately everybody, irrespective of means, leading long, health lives.

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[Mr Clegg]

I stand corrected. Anyway, it was not £250 million.

There may be perfectly explicable teething problems. The announcement was made in the spring of last year, and it will have been necessary for all the mental health trusts to shift gear. However, I hope that the Minister—or, if not him, the commission—will ensure that not only future mental health reforms but previous commitments are delivered and funded in full. The £250 million that has not been delivered over the last year needs to be made up for between now and the end of this Parliament.

My second point concerns the importance of prevention —in all areas of health, obviously, but perhaps especially in mental health. The need for better prevention measures was one of the key findings of the mental health taskforce’s public engagement exercise, yet there has been little if any mention of it in recent Government announcements. Mind, the mental health campaign and policy group, has established that local authorities spend just 1% of their public health budgets on the prevention of mental ill health. That is £40 million out of a total budget of £3.3 billion. Yet we all know—even if we are not clinical experts, we know as parents, and as human beings—that intervening early to improve child and adolescent mental health avoids so much illness, so much heartache, and, to be candid, so much cost to society thereafter. Half of those with lifetime mental health problems first experience symptoms by the age of 14, and 75% of children and young people who have a mental health problem do not get access to the treatment they need.

Waiting times are still far too long. Average waiting times for CAMHS is two months—and as yet there are no waiting time standards in children, adolescent and mental health services. I think we all know, and I certainly accept it, that as we try to revolutionise the approach to mental health, the waiting time standards that have already been announced need to be spread and extrapolated to other parts of the service. Members have talked about the need to reconcile and bring together social care and healthcare, and if we want to put the NHS on a financially sustainable footing, which is the purpose of the cross-party commission, we also need to understand that the lack of prevention and of early intervention on mental health problems is one of the biggest drivers for subsequent inflated costs on the NHS budget. It is therefore essential that the commission looks at this as well.

Thirdly—and arguably most importantly, and also perhaps most technocratically complex—is the issue about the formula or mechanism by which mental health is funded. The problem is that for as long as anyone can remember mental health trusts have been funded according to block grants, through a lump sum of money given to them by some varying formula, while other NHS trusts—acute trusts—are paid on a per patient, per outcome, per recovery basis. That of course is deeply unfair, because it means that any time any Secretary of State for Health, Chancellor or NHS boss needs to make savings, the easiest thing to do is quietly shave a little money off that block grant, as no one really notices it —it does not stick out like a sore thumb like other financial cuts do—and that is precisely what has been happening. That is one reason why—even in recent years, however much new and welcome emphasis there has been on the priority mental health should have in the NHS—the basic funding formula or mechanism constantly discriminates against mental health trusts.

[Dr Philippa Whitford]

If I understand the right hon. Gentleman correctly, he is suggesting a tariff system for mental health, rather than a block grant, but it has been obvious from evidence in the Health Committee that the tariff can also work against having more community care. I met a paediatrician who did outreach work and, having reduced admissions by 40%, the hospital pulled it because it was getting less money. So be careful what you wish for.

[Mr Clegg]

The issue here is about moving from a block or lump of money to an outcome-based formula. One can then decide from an infinite number of ways how to administer the outcome-based funding formula, but the principle that mental health trusts are rewarded and financed for the outcomes they produce, rather than having some random, and often arbitrary and unjust, lump of money, is the fundamental point.

What is happening at the moment is that mental health budgets are, whether we like it or not, at risk of being raided to pay for the unsustainable deficits in acute health. In 2014-15 London’s health commissioners spent 12% of health expenditure on mental health, and in 2015-16 that fell to 11%. In other words, there was a transfer of money from mental health to acute trusts. That is completely the wrong direction of travel.

In 2012, to address this problem, the then coalition Government announced that we would pilot a new approach to mental health funding via what were called care clusters. They work in the following way: adults receiving care are assigned to one of 21 mental health clusters based on their needs, and services are then tailored on the basis of the needs of the people in each cluster and the effectiveness of the interventions on offer. Each cluster is then given a local price, and commissioners work out payments to the mental health trust based on how many patients fall into each cluster.

It is fearfully complex yet there is evidence that transferring the funding of mental health trusts from a block grant system to this care-cluster, outcome-based system has already yielded results. Recent research by the Independent Mental Health Services Alliance has found that mental health trusts operating under block contracts had more delayed discharges and more emergency readmissions than trusts operating without a block contract. Geraldine Strathdee, national clinical director for mental health, has agreed. She says that block grants

“do not facilitate access to timely evidence based care such as those set out in the new mental health access standards”,

and Monitor itself has been very critical indeed of block contracts:

“Despite the introduction of the care clusters, most local agreements still rely on simple block contracts. We believe that block payments…do not work in the interests of commissioners, providers and, most importantly, patients.”

Frustratingly, notwithstanding the decision in principle to shift the whole system to an outcome-based, care-cluster system and away from the punitive effect of the block contracts, 35 out of 62 NHS trusts are still providing mental health services using those block contracts.

Forgive the technocratic detour, but the devil really is in the detail, particularly if we want to close the gap between the much more aggressive aspirational rhetoric that finally has occupied the public and the political debate around mental health and the pressing need to get on and push the system in a radically different direction, not only because it is the right thing to do to end the outrageous discrimination—and it is discrimination, although it might not have been felt or expressed like that—that has existed against patients with mental health issues who have suffered in silence, alone and untreated for generations, but also because if we do not do that and do not make some of these fundamental changes the spiralling costs then placed on to the shoulders of the NHS will merely continue. This is a vital element in meeting the cross-party commission’s mandate to arrive at a new Beveridge-style, cross-party consensus on how to place the NHS on a long-term and sustainable footing.

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[Jeremy Lefroy]

My hon. Friend is absolutely right. In fact, last year Staffordshire County Council raised its council tax by 1.9% but ring-fenced that part for social care, so it was ahead of the game. I believe that it is looking at doing the same this year, possibly taking advantage of the Government’s welcome proposal.

[Dr Philippa Whitford]

My concern about the 2% precept is that wealthy areas will obviously get a lot more money than poor areas, and that will increase health inequalities. Would the hon. Gentleman consider, for example, combining tax and national insurance? National insurance has become an anomaly in that people pay it even when they earn very little and stop paying it when they retire, even if they are very wealthy, so should something more radical be looked at?

[Jeremy Lefroy]

I do propose something radical, but in completely the opposite direction, because I believe that national insurance is an incredibly good thing. I always listen to the hon. Lady with great respect, but let me argue the case for national insurance, and she may disagree with me by way of intervention or otherwise.

We have allowed national insurance to become less relevant, with the exception of the various eligibilities I mentioned. As a result, it has come to be viewed by Her Majesty’s Treasury as just another form of raising funds. There was a proposal for a consultation on merging income tax and national insurance. I would vehemently oppose that, because my perception is that our constituents still, understandably, see national insurance as something different from income tax in being their contribution to the NHS, pensions, and welfare. Indeed, about £60 billion a year of the national insurance money that is raised, although this is a bit of a fiscal fiction, still goes towards the NHS. That is far less than we spend on the NHS, but it is still there.

The notion that, as I contend, our constituents see national insurance differently from income tax was particularly evident when Gordon Brown raised national insurance in order to put additional money into the NHS. He rightly viewed that as the best way of raising additional money for the NHS because it was more acceptable than putting a couple of pence on income tax. The best way—I think the only way, but a commission would need to be very broad-minded in its views—to ensure that we can finance the NHS and social care properly in the long term is through progressive, income-based national insurance with a wider base, as Kate Barker said, whereby by it does not stop when people retire and does not stop at the upper national insurance limit, as it does at the moment at only 1% over it. Broadening the base of national insurance should make it possible to keep the percentage rate reasonable for all while paying for the services needed.

I welcome this motion and the proposal for cross-party work, whether through a commission or whatever, but I would plead that it be fairly focused. It should not cover ground on the details of healthcare that has been well covered elsewhere—probably better than we could cover it—but it should look at integration and, most important of all, future finance for the next 20 or 30 years.

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

I, too, attended the debate on 2 June last year, and I remember expressing my shock at the violence that was taking place between the Dispatch Boxes. I considered leaving the Chamber, because it did not seem to be a very useful debate and I did not see the point of taking part in it, but then I thought “No, let us get in and tackle this”, and I did make a comment. I said that, regardless of the differences in the way in which politicians would “do” the NHS, the public absolutely believed in it. We have had a fantastic debate today, because people have expressed different views and different outlooks, but have done so calmly.

As was mentioned by the right hon. Member for North Norfolk (Norman Lamb), the challenges of increasing demand caused by age and multi-morbidity are found not just north and south of the border, but throughout the developed world. We also face the challenge of not having enough doctors, in both primary and secondary care. That, too, applies throughout the nations of the United Kingdom.

There are some challenges that we do not face in Scotland. We have not experienced the fragmentation that resulted from the Health and Social Care Act 2012. Indeed, we got rid of hospital trusts back in 2004. We have gone, therefore, to geographical boards—we just have health boards—so there is no barrier between primary and secondary care, which people used to pitch across. Since April of last year our joint integration boards have become active. They ran in a theoretical way for about a year, but the vast majority of them went live last year and the last one will go live in April this year. That is putting the pot of money into a joint space where health and social care work together, break down the barriers and realise there is no benefit in sticking a person in a bed and then looking to see who should pay for it. What purse the money is in has often been the biggest problem.

We cannot develop integration if what we are actually developing is fragmentation and competition. That is why we have not gone down the route of outsourcing to private providers. It wastes a lot money and effort, and people are competing instead of co-operating.

We obviously have different systems in Scotland. We have free personal care, the level of which has been increased to allow us to keep at home people with more complicated conditions. That is important. Since June of last year we have been going through a national conversation. Whether we have a commission, a committee or whatever, it is important that the public and the staff are involved, as well as the people who have written all the reports—Marmot, Wanless, Barker, the King’s Fund, the Nuffield Trust. There must be a way of bringing these together and picking out the good bits to get a shape. Our piece of work is looking towards 2030; that is what we are working on at the moment.

We did a piece of work that started in 2011-12 called “2020 Vision”. It was very like “Five Year Forward View” and addressed where we wanted to be and what shape we wanted. That identified that the No. 1 thing was integrating health and social care.

Talking about the money for this and where it comes from is always going to be political. At the moment national insurance is bizarre; it starts when people earn £7,000 when we would not tax them, and it stops when people retire, although they might be incredibly wealthy. I do not think people see it as national health insurance, which is how it started. Where the money comes from and what it is put towards is a political decision.

To get some kind of shared view of where NHS England and indeed the NHS in all the nations want to be in 2030 could be a useful piece of work. I totally agree with the hon. Members who have expressed anxiety about kicking this into the long grass. I certainly do not think it needs to stop any piece of work going forward. To me, this provides a place where that can come. One of the features in Scotland in developing quality measures is bringing groups of people together for an annual conference; I am a great believer in getting people into a room—maybe not always a room like this one; maybe a more co-operative room—so that people can say “This is what we found difficult. This is how we fixed it. This is where we are stuck. I see you solved that.”

One of the projects that Nicola Sturgeon has taken forward is called “once for Scotland”. It is not eternally going through local projects and experiments that never get shared with anybody, and everyone reinvents the wheel. That is a huge waste of energy.

Obviously the Government have committed to the £10 billion and that has been welcomed, but more than £2 billion of that is already gone in the deficits. That increase is focused purely on NHS England, whereas normally funding is described in all the Department of Health responsibilities. The other responsibilities are facing a cut that is described as approximately £3 billion. The King’s Fund, the Nuffield Trust and the Health Foundation identify the increase as in fact about £4.5 billion—so not exactly the headline figure.

The “Five Year Forward View” has been mentioned, and that asks for £8 billion but it also identified £22 billion that had to be found. That is fairly eye-watering. Let us think about two of the things that were identified within that. One was a change in how people worked.

[Norman Lamb]

The hon. Lady is talking a lot of sense, as she always does. The “Five Year Forward View” set out three scenarios, but it did not ask for £8 billion; that is just the narrative that has developed. The efficiency assumptions on which the £8 billion—or £10 billion, or whatever we want to call it—is based are unimaginable. They are at least 2% to 3% throughout the period between now and 2020, and everyone knows that that is not going to be delivered.

[Dr Whitford]

I thank the right hon. Gentleman for his intervention. Even without recognising that no one has ever achieved those levels of efficiency savings, we need to acknowledge that a big chunk of this is about prevention. More than £5 billion of the £22 billion has been identified as relating to people not going into hospital and not getting sick, yet public health expenditure has been cut by £200 million in-year, with another £600 million to go. That amounts to a 3.9% cut. Lots of people will think that that just means less smoking cessation and less preventive work around alcohol, but public health should be much bigger than that.

I understand that there used to be a Cabinet Committee on public health in this place. Public health should be feeding into all the decisions that are made here. We also need to ensure that our directors of public health are strategically involved in local government, because the shape of our town centres will determine whether we have car-based or active transport, how we design our schools and whether we flog off our playing fields. All those things will interact with health.

It has been said that secondary care always gets the bigger bite of the cherry. We talk about fixing the roof while the sun is shining, but in fact, when the window has just come in or the door has just come off its hinges, that is what we fix first. That is very similar to secondary care, which is actually the national illness service. It responds to people who are already ill. We are developing more complex and expensive treatments that allow us to keep people alive, and we need to recognise that. People talk about the catastrophe of ageing, but I would like Members to focus on what the alternative is. People used to say, “Age does not come alone, and it is terrible.” In the field I worked in, however, not everyone gets old. Age is something that we should value, because wisdom and a sense of community come with it.

However, we need to be ready to develop the services around older people, and that means not always just patching things up at the end. We need more intermediate care to allow step-up and step-down beds, and we are working on that in Scotland. In particular, we need to focus on primary care, as the hon. Member for Stafford (Jeremy Lefroy) said. That is the real generalism. The GP is the person who is able to make a diagnosis because they have known the patient linearly over many years. However, GPs are on their knees and that is a UK-wide problem. They are under huge pressure because of the demand and the complexity. Within that, of course, we must talk about the lack of mental health services. They have been ignored for a long time, but that is beginning to change. In Scotland, we have a waiting time target for child and adolescent mental health services. Unfortunately, it is proving very challenging to meet that target, but we have doubled the number of staff in those services and we hope eventually to see improvements.

We need to be looking at these issues more broadly. The hon. Member for Oldham East and Saddleworth (Debbie Abrahams) and I—I am not very good at learning constituencies that have two names; I find one name a challenge with 650 people here—are members of the all-party parliamentary group on health in all policies. We have been taking evidence on the health impacts of increasing child poverty, of which we are going to see even more. We need to recognise that every decision we make feeds into whether our citizens are healthier, physically and mentally, or less healthy. That is about welfare. It is particularly about housing, which has one of the biggest impacts on health. The hon. Member for Stafford mentioned those impacts in our debate yesterday on supported care. If we lose supported care in the community, we are never going to get people out of hospital. I want to make the plea, as I did in my maiden speech, that we in this place should put health and wellbeing—meaning mental health—across all our policies and measure our decisions against those factors. Far too many decisions are made in a broken up, narrow way without looking at the ramifications for everything else.

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[Alistair Burt]

I said that we have met the challenge that was put before us, which was to support what NHS England said it needed. We have done that through the financial commitment we have made. We looked very hard in the spending review to see what social care would need, and the Chancellor came up with the £2 billion social care precept, plus the £1.5 billion from other resources, so that is £3.5 billion extra by the end of 2020. We have put in place the financing that we believe will allow the delivery of health and social care over the next few years. But—and it is a big but, which I will refer to later—it is not just about the resources; it is also about how they are spent. Most colleagues have spoken about variability and how best practice is not always available elsewhere. We have to ensure that best practice comes in, and that is not just about resources; it is also about how things are done.

[Dr Philippa Whitford]

Is it not the case that the idea of seven-day-a-week, 8 am to 8 pm GP practice was not included in the NHS England estimates, and therefore the cost of that has been added on top? Will the Minister commit to taking the evidence from the pilot studies on whether that is a good use of money?

[Alistair Burt]

I will. We had this discussion in the Health Committee the other week. I will of course look very hard at the evidence, whether it comes from Greater Manchester and shows that somebody is working effectively and appointments are being filled, or from places where that is not currently the case. We have to wait and see in that regard.

The spending review showed our continued commitment to joining up health and care by confirming an ongoing commitment to the better care fund. Again, the integration process is extremely important. In terms of the general argument about what should be done, a clear commitment was made, based on an independent assessment of what was required. That required a Government who were prepared to make difficult decisions, and a strong economy, and we assumed that responsibility.

Let me deal with some of the remarks made by right hon. and hon. Members during this conversation—for it is, as the hon. Member for Central Ayrshire (Dr Whitford) said, a conversation, and a really good one. If more debates about health had the flavour of this afternoon’s discussion, the public might be happier. She said that her preferred method for dealing with things, as with most of us, is bringing people into the same room and having a conversation—but perhaps not this room. However, there are other rooms in this place in which to do that. Indeed, my hon. Friend the Member for Totnes (Dr Wollaston), the Chair of the Health Committee, does so regularly. This place can provide opportunities for the sorts of discussions that would be at the heart of any cross-party consideration of what we want to do. We should not neglect the fact that we can do that, and we have had a good conversation today.

I agree with the hon. Member for Lewisham East (Heidi Alexander) in that I am fundamentally shy of the idea that we can just put this on to others and with one bound we are free. I understand the sentiment that we somehow need to get, if not the politics, then the heat of the politics, out of it in order to allow for the conversation that we need to have. However, at the end of the day, that still requires a process. Like her, I believe that the process is that we discuss it, come to conclusions within our own party about what we can do, and offer it in a sensible way to the electorate. I entirely agree with those who say that there are times when we have all been guilty of the most ridiculous adverts. At the end of the last general election campaign, I was in a marginal constituency and had a piece of paper in my hand that was our last-minute leaflet. I knocked on doors and said, “Look, we have a choice—I can either hand you this leaflet, which is complete nonsense, or you can give me 20 seconds to explain why you should vote for David Cameron tomorrow and keep a Conservative Government.” They laughed and said, “Go on, then”, and I had my 20 seconds. We all know that we are sometimes guilty of producing material that in the cold light of day we would not wish to, and in relation to health we need to be extra-careful about that.

As the debate went on, I was concerned about whether the commission that the right hon. Member for North Norfolk and his colleagues is proposing can bear the weight of the many different things that we would like it to cover. My hon. Friend the Member for Totnes wanted it to report rapidly, but my right hon. Friend the Member for Sutton Coldfield (Mr Mitchell) intervened to say that it had to be for the longer term, so which is it to be? My hon. Friend also spoke about the problem of variation in the system, but that is not to do with resources. No commission could be so directive as to make sure that best practice is delivered everywhere. We have to do that in another way.

The hon. Member for Leicester West (Liz Kendall) in, as always, a very thoughtful and sensible speech, recognised the political problem in agreeing on this, and she was right to do so. It is very difficult for her, or any other Labour Member, to talk about the introduction of private medicine. If I did not stand here and say, with no deviation, that the Conservative party and the Government believe in a tax-funded health system free at the point of delivery, the roof would fall in. Therefore, there are constraints on what we can say politically, and we have to be thoughtful about how we deal with those responsibilities.

My hon. Friend the Member for Bracknell (Dr Lee) added more weight to the commission by talking about structure, and how we deal with these reviews of where hospital premises might be located. Again, there is this problem of politics. When approached by patients or doctors with a vested interest in keeping a physical bit of bricks and mortar and in saving “our” hospital, it would be a brave one of us who said, “Do you know what? That may not be the best thing.” That difficult problem was alluded to by my hon. Friend the Member for South West Wiltshire (Dr Murrison). No commission can get us over that sort of problem.

The hon. Member for Strangford (Jim Shannon) invited me to Northern Ireland to see some integration at work, and I would be keen to visit. My hon. Friend the Member for South West Wiltshire and a number of colleagues made the point about public health. Prevention is about not just the public health budget—significant resources are still going into public health—but what we are trying to do with the shift from secondary to primary care to ensure that people are seen earlier.

The hon. Member for Central Ayrshire talked about ensuring that we keep people well longer. She said that instead of seeing the national health service as an organisation that looks after just the ill, we should consider what it can do before that, which is very important.

The right hon. Member for Sheffield, Hallam (Mr Clegg) spoke principally about mental health. As a Health Minister, I know full well what the coalition Government as a whole did in relation to mental health. They picked up a trajectory that had been disappointingly low, but we are now well on track. I wish gently to correct something that has been creeping into the narrative, which is that it was all going fine until six months ago, but it has slightly come off the rails now. It has not. It was not all sorted during the coalition, and I reject the charge that it is now all about rhetoric and not delivery. We are delivering, and making sure that CCGs spend the increased money that they get on mental health, and we are tracking it for the first time.

That £1.25 billion for children and young people’s mental health, which was a very significant delivery by both the right hon. Gentleman and the coalition, has been increased to £1.4 billion, and it will all be spent in that area by 2020. We are dealing with the issue of mental health tariffs as well, and we want to have waiting and access times for children and young people’s mental health services.

I encourage the right hon. Gentleman to see, at least in this part of my portfolio, that what I seek to do is to build on what the right hon. Member for North Norfolk did in my role. I would rather that the right hon. Member for Sheffield, Hallam did not talk in that manner and think that it has all come to a halt, because it has not. We are having to repair one or two things, such as perinatal mental health, in which we have put significant resources. The conversation has been advanced enormously in exactly the right way by consensual discussion, and we will certainly carry that on.

--- Later in debate ---

[Alistair Burt]

I think that engagement with all involved is essential. When I am away from Westminster, engaging with patients, the public and staff is fundamental to the visits that I make to the services for which I have responsibility.

There is nothing to stop any of the work that the right hon. Member for North Norfolk is suggesting from starting. It is essential that everybody is fully involved. I do not think that the Government or the Opposition will make any of their decisions on the NHS or its expenditure by excluding anyone.

The hon. Member for Walsall South (Valerie Vaz), in a turbo-charged contribution, also spoke of the importance of getting integration right. She reminded us that Dick Crossman started it all off. I am sure that we have all had election manifestos that have spoken of an integrated transport system and integrating health and social care. Now we just have to make sure it happens. She made the point that no amount of talk or number of recommendations relieves someone of the burden of doing it. At the end of the day, it is doing it that counts. That is the role of the Government, while being appropriately challenged by all others.

I am delighted that my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) spoke of the importance of the workforce, particularly the workforce in social care, who have a very difficult time of it. They have great skills and need to be on a career pathway where they can acquire more. They also need to be valued. Again, my hon. Friend believed that the current mechanisms were better than others for dealing with these difficult problems.

To conclude, I will give my sense of the debate. I found it slightly hard to distinguish what the foundations of the debate were—whether it was about the quantum of funding or how the funding was gathered into the health budget in the first place. The commission is expected to cover a breadth of issues, but I am not certain that it can bear the weight. Decisions need to be made, no matter how the information comes forward.

We do not need a commission to deliver the process or to take the heat out of the debate. We have to be careful about how we speak about these subjects. By and large, what happens upstairs gives the public a good sense of how we deal with witnesses who come in from outside, members of the public and each other. We can do much more of that without the need for a commission. We must remember to handle things carefully.

I am not sure that structural change could be handled through a commission. That is very much a local decision. This is not all about funding; it is about how the funding is used. We have to ensure that we do not get into the trap of measuring everything by what we put in, rather than by output. One of the most telling points was when the right hon. Member for North Norfolk said that in the Commonwealth Fund analysis that gave the NHS such a good rating, the one thing it dropped down on was outcomes—treating people and whether people stayed alive. To most people, that is probably the most important outcome of all. We have to make sure that, for all the other good things that we are doing, such as the work the Secretary of State is doing on transparency and all the efforts we are making to give people more information, we recognise the importance of that.

[Dr Philippa Whitford]

Just on the Commonwealth Fund analysis, the standard that the UK did badly on was actually healthy life expectancy. That is not the same as an outcome in hospital. We may have successful operations, but we have underlying deprivation and ill health.

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

I just say to the Minister that I did give him the nod. I have been very generous. When we say that he has “up to 15 minutes”, he is meant to take 15 minutes. As he can see from the clock, he has taken a lot longer.