NHS Sustainability and Transformation Plans

Sarah Wollaston Excerpts

Wednesday 14th September 2016 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

It is a pleasure to follow my colleague on the Health Committee, the hon. Member for Central Ayrshire (Dr Whitford).

I absolutely agree that we should see this as an opportunity to move away from a fragmented system where people are perhaps commissioning and providing care in isolated silos to one that looks across the whole system, and across geographical areas, so that we can move towards a truly integrated approach between health and social care. To do that, local authorities, as well as the health system, need to be involved in the STPs—and crucially, we need to involve local people. The lesson that we learn from every major reorganisation has been that if we take local people with us on the journey, and on the thinking behind it, it is much more likely to be successful. We should not see genuine local consultation and engagement as an inconvenience but as something that improves the eventual plans.

It is a real shame that this debate has developed a hashtag of “secretNHSplans”. I am afraid that NHS England now has to look at that, take a step back, and ask how it could have been better at engaging local communities—and those who represent them. It is a great shame that Members across this House were unable to see the draft plans until they were leaked to the press. That is not the right way forward for any genuine engagement.

[Maria Caulfield (Lewes) (Con)]

Does my hon. Friend agree that if staff, whether nurses, doctors, physios or pharmacists, had been involved right from the start of the process, that would have helped staff morale in the NHS, which is struggling, and that they probably have the best ideas of anyone as to how the STPs could progress?

[Dr Wollaston]

I absolutely agree. This is about local communities and their representatives. Public meetings are important, but so are involving bodies such as HealthWatch and making sure that under-represented groups are involved. The right hon. Member for North Norfolk (Norman Lamb) talked about the need to involve mental health services in these plans. It is very important that we make sure that under-represented groups are involved, and that does include those who use mental health services.

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

The hon. Lady, with her lifetime of experience in the national health service, is absolutely right about the importance of consultation. Does she therefore understand the concern being expressed by the staff at the Dove sexual health centre in one of the poorest constituencies in England, Erdington, because none of its 2,000 patients has been consulted, and neither have any stakeholders, about a proposal to close this absolutely vital facility?

[Dr Wollaston]

I thank the hon. Gentleman for his intervention. As I said, the plans that are produced at the end of the day will be better if we involve those who are using the services and those providing them, as well as those commissioning them, as we go along, rather than present a plan, even if it is a draft, as a fait accompli, because then it becomes a binary choice rather than one where people can make suggestions to improve the plans as they develop.

[Dr Philippa Whitford]

I know that Scotland is a lot easier to get around in population terms, although size and transport are not always that easy, but one of the mechanisms that the Scottish Government use when developing strategies is what they call the national conversation, whereby the ministerial team literally go walkabout and have meetings to hear from people directly before anything goes on paper.

[Dr Wollaston]

If we get too caught up in the process of consultation, we will not address the other serious hurdles in the way of STPs achieving their aims, chief among which is the issue of finance. The NHS is now in its seventh year of a historic level of austerity, and the average of a 1.1% annual uplift in funding for the NHS over the past six years represents an extraordinary challenge in the context of increasing demand. It is good that we are living longer, but we are doing so with much more complex conditions, and the treatments available to tackle them are more expensive. We need to be clear that, because of that, and even though the settlement for health has undoubtedly been generous in relation to other Departments, a significant gap is opening up in health, and the situation is even worse in social care.

Figures from the Association of Directors of Adult Social Services show that 400,000 fewer people are in receipt of social care packages in 2015-16 than there were in 2009-10, and not only are fewer people receiving social care packages, but those packages are smaller. Many STPs are about transferring care into the community. We need to make sure not only that the funding is available to provide those social care packages, but that we have the workforce to deliver them. The proposal in the area that I represent is to close two community hospitals that are used by my constituents. As a former rural general practitioner, I know just how important those facilities are to local people. They are special to them not only because of the step-up, step-down care that they provide and to which the hon. Lady has referred, but because these are the places that more people like to be at the end of their lives. They provide personal care and allow people, particularly those in rural areas who are doubly disadvantaged by not being able to travel to larger local centres, the opportunity to be treated closer to home.

[Antoinette Sandbach]

In my constituency, Tarporley cottage hospital has been adopted by the local community and continues to provide that step-up, step-down care without being part of the NHS. I wonder whether my hon. Friend would be interested in meeting some of the hospital trustees. It may provide some hope for the future as an example of how communities can come together and support their local assets.

[Dr Wollaston]

I thank my hon. Friend for that invitation. In fact, I have visited the Community Hospitals Association on many occasions, to hear from community hospitals around the country. I will continue to do so and I commend them for the valuable role that they play.

[Dr Murrison]

Does my hon. Friend agree that community hospitals can also keep the bean counters happy? If they get the case mix right, it is much more affordable to treat people in community hospital beds than in an acute unit, which is extraordinarily costly. Furthermore, that would clearly give patients what they would like, which is care close to their homes, as my constituents in Warminster—we still have community hospital beds—will attest. I know that my hon. Friend the Member for North Dorset (Simon Hoare) would say the same for Shaftesbury.

[Dr Wollaston]

Members on both sides of the House are aware of how valuable and important community hospitals are to our constituents. Taking that a step further, I would say that the best bed for any patient is their own bed, provided that they can be given the right package of care close to home. We know that there are many people even in community hospital beds who do not need to be there. They are there for want of the right social care package that could enable them to be at home.

In welcoming STPs, we should be realistic about the financial challenge that they also face and the costs sometimes of providing those services. That is a huge challenge for them. In my area alone the STP is facing a £572 million shortfall by 2021 if no action is taken. I can understand why, for example, it will look at the relative cost of providing care to people in acute hospitals, in community hospitals and at home, and make an argument that sounds very reasonable about how a larger number of people could be much better cared for at home.

I return to the point that the hon. Member for Central Ayrshire (Dr Whitford) made. Access to the transformation part of the sustainability and transformation plans is necessary to be able to put those services in place and very often to build the infrastructure that we need. For example, in Dartmouth in my area, the possibility of providing more care closer to home within a community hub will require the up-front funds to build a new centre that allows the workforce to be developed and more services to be provided closer to home. Unfortunately, what we often see is the closure of a much loved facility without the new service in place.

As the sustainability and transformation plans progress, I would like to see a genuine focus on the opportunities to provide more care closer to home. I fear that we will miss that opportunity because, as we have heard, £1.8 billion of the £2.1 billion sustainability and transformation fund is going towards the sustainability bit, for which read “plugging provider deficits”, and only £300 million is left nationally to put in place all these plans.

We know also that part of the way that the Government have managed to fulfil their promise to NHS England in respect of the funding that it asked for has been by taking funding out of capital budgets because those are essentially flat cash, and also by taking money out of Health Education England budgets and public health budgets. It concerns me that many of the principles behind the sustainability and transformation plans are put at risk by other parts of the system being squeezed. We have heard the point about prevention. Central to the achievements of the sustainability and transformation plans is the prevention piece—the public health piece. It is a great shame that public health budgets have been squeezed, limiting the ability of those aims to be achieved.

I know that many Members wish to speak so I shall move on and make some asks of the Minister, if I may. There is more that the Government can do. We on the Health Committee were very disappointed that none of the witnesses who came before us from NHS England, NHS Improvement or the Department of Health was able to set out the impact of cuts to social care on health planning. We need to do much better at quantifying the cost to the NHS of cuts to the social care budget.

The Minister needs to take the long view on prevention and help the service by implementing policies that could help local authorities to make changes. For example, I suggest making health a material consideration in planning and licensing, in order to provide the levers to make a difference. We need a much greater focus on workforce, because the STPs cannot achieve their aims if the workforce to achieve them is not in place. Finally, will the Minister kindly visit my area to look at the proposals in the sustainability and transformation plans in south Devon, and at the opportunities and how we would achieve them?

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. The next speech, in the same way, will not have a time limit, but after that it will be five minutes. Some people will not get in. Please explain to them why those who took advantage of the time did so—it is totally unfair.

Junior Doctors: Industrial Action

Sarah Wollaston Excerpts

Monday 5th September 2016 Commons Chamber

[Mr Speaker]

As always, I am keen to accommodate everybody who wants to take part, but I think it not unreasonable, given the relatively small number, for me to hope that we might conclude these exchanges by 10 past 7—quarter-past at the latest. Brevity is of the essence. We do not need long narratives. We just need questions and short answers. We will be led in that mission by the Chair of the Health Committee.

[Dr Sarah Wollaston (Totnes) (Con)]

I welcome the BMA’s suspension of next week’s damaging industrial action. It is clear from its statement that thousands of doctors had been in touch to say that they wanted to keep their patients safe. Doctors know that they cannot do so with full, rolling, five-day walkouts. Will the Secretary of State therefore join me in asking the BMA to ballot its members to hear their views before they proceed with the other proposed, damaging, five-day walkouts?

[Mr Hunt]

The BMA should talk to its members much more because, as far as I could tell, the consultation over the summer showed that only a minority actually wanted this extreme series of rolling one-week suspensions of labour that the BMA supported in the end. Most junior doctors are perplexed and worried about the situation and would love to find a solution. There was a bitter industrial dispute, but we actually started a process through which trust was being rebuilt on both sides. In a series of meetings, I met the junior doctors’ leader to talk through the areas of her greatest concern and we made progress in addressing two of those four outstanding areas. Building that trust means actually sitting around the table and talking, not having confrontational strikes. I think that that is what most junior doctors want.

Junior Doctors Contract

Sarah Wollaston Excerpts

Wednesday 6th July 2016 Commons Chamber

[Mr Hunt]

I welcome the hon. Lady to her place for the first statement to which she has responded and welcome her on the whole measured tone, with one or two exceptions. I will reply directly to the points she made.

First, the hon. Lady maintains the view expressed by her predecessor, the hon. Member for Lewisham East (Heidi Alexander), who is in her place this afternoon, that somehow the Government’s handling of the dispute is to blame. We have heard that narrative a lot in the past year, but I say with the greatest of respect for the hon. Member for Hackney North and Stoke Newington (Ms Abbott)—I do understand that she is new to the post—that that narrative has been comprehensively disproved by the leaked WhatsApp messages that were exchanged between members of the junior doctors committee earlier this year.

We now know that, precisely when the official Opposition were saying that the Government were being intransigent, the BMA had no interest in doing a deal. In February, at the ACAS talks, the junior doctors’ aim was simply to

“play the political game of…looking reasonable”—

their words, not ours. We also know that they wanted to provoke the Government into imposing a contract, as part of a plan to

“tie the Department of Health up in knots for…months”.

In contrast to public claims that the dispute was about patient safety, we know that, in their own words,

“the only real red line”

was pay. With the benefit of that knowledge, the hon. Lady should be careful about maintaining that the Government have not wanted to try to find a solution. We have had more than 70 meetings in the past year and we have been trying to find a solution for more than four years.

The question then arises whether we should negotiate or proceed with the introduction of the new contracts. Let me say plainly and directly that if I believed negotiations would work, that is exactly what I would do. The reason I do not think they will work is that it has become clear that many of the issues upsetting junior doctors are in fact nothing to do with the contract. Let me quote a statement posted this morning by one of the junior doctors’ leaders and a fierce opponent of the Government, Dr Reena Aggarwal:

“I am no apologist for the Government but I do believe that many of the issues that are exercising junior doctors are extra-contractual. This contract was never intended to solve every complaint and unhappiness, and I am not sure any single agreement would have achieved universal accord with the junior doctor body.”

The Government’s biggest opponents—in a way, the biggest firebrands in the BMA—supported the deal and were telling their members that it was a good deal, which got rid of some of the unfairnesses in the current contract and was better for women and so on. If the junior doctors are not prepared to believe even them, there is no way we will be able to achieve consensus.

If the hon. Lady wants to stand up and say that we should scrap the contract, she will be saying that we should not proceed with a deal that reduces the maximum hours a junior doctor can be asked to work, introduces safeguards to make sure that rostering is safe and boosts opportunities for women, disabled people and doctors with caring responsibilities—a deal that was supported by nearly every royal college. If the alternative from Labour is to do nothing, we would be passing on the opportunity to make real improvements that will make a real difference to the working lives of junior doctors.

The hon. Lady and I have a couple of the more challenging jobs that anyone can do in this Chamber. She has been in the House for much longer than I have, so she will know that. The litmus test in all the difficult decisions we face is whether we do the right thing for patients and for our vulnerable constituents, who desperately need a seven-day service. The Government are determined to make sure that happens.

[Dr Sarah Wollaston (Totnes) (Con)]

I welcome today’s statement and thank the Secretary of State for dealing with many of the extra-contractual issues that have blighted the lives of junior doctors. I join him in regretting the outcome of the ballot. Like my right hon. Friend, I welcome Doctor Ellen McCourt to her post. I know that my right hon. Friend will work constructively with the junior doctors committee to try to resolve the outstanding issues. In proceeding in a careful, measured way with the imposition of the contract, will he work to reassure the public that if patient safety issues arise during that process, he will deal with them?

[Mr Hunt]

I thank my hon. Friend for her measured tone and for being an independent voice throughout the dispute. I spoke to Dr Ellen McCourt earlier this afternoon. I appreciate that she is in a very difficult situation, but I wanted to stress to her that, as I told the House this afternoon, my door remains open for talks about absolutely anything and that I am keen to find a way forward through dialogue. I had lots of discussions with Dr McCourt when we were negotiating the agreement in May, and I know that she approached those negotiations in a positive spirit.

We have set in place processes, and that is one of the reasons why Professor Bailey recommended phased implementation—so that if there are any safety concerns, we can address them as we go along. The Minister with responsibility for care quality, my hon. Friend the Member for Ipswich, is leading a process that will keep looking at the issues to do with the quality of life of junior doctors. NHS Employers is leading a process that will look in detail at how the contract is implemented. Absolutely, the point of the changes is to make care safer for patients; we will continue to keep an eye on this to make sure that it does so.

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 5th July 2016 Commons Chamber

[George Freeman]

The hon. Gentleman will know that the Under-Secretary of State for Health, my hon. Friend the Member for Battersea (Jane Ellison), opened an exhibition on this topic yesterday and that the Chancellor recently put an extra £5 million into mesothelioma research. Through the National Institute for Health Research, the Government are committing to invest in that disease area. We are also committed to ensuring that we drive up both research and better treatment for such diseases.

[Dr Sarah Wollaston (Totnes) (Con)]

Prevention of ill health has to be given a higher priority if the NHS is to meet the challenges set out in the five year forward view. Central to that will of course be the childhood obesity strategy. Has the Secretary of State had any discussions with the Prime Minister about the strategy’s future? Is he in a position to take over the strategy should No. 10 become distracted?

[Mr Jeremy Hunt]

I welcome my hon. Friend’s close interest in ensuring that this important agenda does not get swept aside. I can assure her that we have had many discussions inside Government about what to do. There is a strong commitment to take it forward as soon as possible, and I hope that she will get some good news on that front before too long.

Junior Doctors Contract

Sarah Wollaston Excerpts

Thursday 19th May 2016 Commons Chamber

[Mr Hunt]

The hon. Lady is wrong today, as she has been wrong throughout this dispute. In the last 10 months, she has spent a great deal of time criticising the way in which the Government have sought to change the contract. What she has not dwelt on, however, is the reason it needed to be changed in the first place, namely the flawed contract for junior doctors that was introduced in 1999.

We have many disagreements with the BMA, but we agree on one thing: Labour’s contract was not fit for purpose. Criticising the Government for trying to put that contract right is like criticising a mechanic for mending the car that you just crashed. It is time that the hon. Lady acknowledged that those contract changes 17 years ago have led to a number of the five-day care problems that we are now trying to sort out.

The hon. Lady was wrong to say that an all-out strike was necessary to resolve the dispute. The meaningful talks that we have had have worked in the last 10 days because the BMA bravely changed its position, and agreed to negotiate on weekend pay. The hon. Lady told the House four times before that change of heart that we should not impose a new contract. What would have happened if we had followed her advice? Quite simply, we would not have seen the biggest single step towards a seven-day NHS for a generation, the biggest reforms of unsocial hours for 17 years, and the extra cost of employing a doctor at weekends going down by a third. We would not have seen the reductions in maximum working hours. We would not have seen many, many other changes that have improved the safety of patients and the quality of life of doctors.

The hon. Lady was also wrong to say that the previous contract discriminated against women. In fact, it removed discrimination. Does that mean that there are not more things that we can do to support women who work as junior doctors? No, it does not. The new deal that was announced yesterday provides for an important new catch-up clause for women who take maternity leave, which means that they can return to the position in which they would have been if they had not had to take time off to have children.

The hon. Lady asked what would happen if the ballot went the wrong way. What she failed to say was whether she was encouraging junior doctors to vote for the deal. Let me remind her that on 28 October, she told the House that she supported the principle of seven-day services. As Tony Blair once said, however, one cannot will the end without willing the means. The hon. Lady has refused to say whether she supported the withdrawal of emergency care, she has refused to say whether she supports contentious changes to reform premium pay, and now she will not even say whether doctors should vote for the new agreement.

Leadership means facing up to difficult decisions, not ducking them. I say to the hon. Lady that this Government are prepared to make difficult decisions and fight battles that improve the quality and safety of care in the NHS. If she is not willing to fight those battles, that is fine, but she should not stand at the Dispatch Box and claim that Labour stands up for NHS patients. If she does not want to listen to me, perhaps she should listen to former Labour Minister Tom Harris, who said:

“Strategically Labour should be on the side of the patients and we aren’t.”

Well, if Labour is not, the Conservatives are.

[Dr Sarah Wollaston (Totnes) (Con)]

I congratulate both sides on returning to constructive negotiations and on reaching an agreement. I pay particular tribute to Professor Sue Bailey and the Academy of Medical Royal Colleges for their role in bringing both sides together. I welcome the particular focus, alongside the negotiations around weekend pay, on all the other aspects that are blighting the lives of junior doctors. I welcome the recognition that we need to focus on those specialties that it is hard to recruit to and on those junior doctors who are working the longest hours, as well as the focus on patient safety.

However, we are not out of the woods yet. We need junior doctors across the country to vote for this agreement in a referendum. May I add my voice to that of the Opposition spokesman on health to say that what is needed now is a period of calm reflection? We need to build relationships with junior doctors into the future. Will the Secretary of State comment on his plans for building those relationships with our core workforce?

[Mr Hunt]

First, I very much agree with my hon. Friend in her thanks to Professor Dame Sue Bailey for the leadership that the Academy of Medical Royal Colleges has shown in the initiative that, in the end, made these talks and this agreement possible. I know it has been a very difficult and challenging time for the royal colleges, but Professor Bailey has shown real leadership in her initiative.

I also very much agree with my hon. Friend about the need to sort out some of the issues that have been frustrations for junior doctors—not just in the last few years, but going back decades—in terms of the way their training works and the flexibility of the system of six-month rotations that they work in. This is an opportunity to look at those wider issues. We started to look at some of them yesterday. I think there is more that we can do.

It is important that this is seen not as one side winning and the other side losing, but as a win-win. What the last 10 days show is that if we sit round the table, we can make real progress, with a better deal for patients and a better deal for doctors. That is the spirit that we want to go forward in.

Oral Answers to Questions

Sarah Wollaston Excerpts

Tuesday 10th May 2016 Commons Chamber

[Mr Jeremy Hunt]

The answer, regrettably, is that for many years we have not got our act together. That is why I have changed the system of incentives for trusts to make sure that they get a premium for identifying EU nationals they treat and that we can then recharge the treatment to their home countries. We are, as a result, now seeing significant increases in the amount we are reclaiming from other countries.

[Dr Sarah Wollaston (Totnes) (Con)]

Community hospitals are immensely valued by the communities they serve. Will the Secretary of State meet me to discuss the proposals for south Devon, which will particularly affect my constituents living in Dartmouth and in Paignton?

[Mr Hunt]

Yes, I am happy to do that. I have a number of community hospitals in my own area. It is really important that even as the functions and jobs that community hospitals do inevitably change, we recognise that they have a very important long-term future in the NHS.

NHS Bursaries

Sarah Wollaston Excerpts

Wednesday 4th May 2016 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

Let me start by congratulating the shadow Health Secretary on calling this important debate. First and foremost, it matters because of the impact on patients of a nursing workforce shortfall. When the Health Committee’s recent primary care inquiry took evidence, Professor Ian Cumming estimated that shortfall to be between 15,000 and 20,000 nurses. This is not just about the overall shortfall; it is also about shortfalls geographically and in certain key areas, particularly primary care, community care and mental health. We therefore need to look at the big picture.

The workforce shortfall adds costs. We know that the agency staffing bill was about £3.3 billion in the last year and that three quarters of trusts are still breaching the agency price caps, although we are making some progress on that, with the relevant figures being £303 million in October last year and £287 million in February this year. These resources should be spent elsewhere, on patient care. There is an over-dependence on nurses who are trained overseas. They are a very valued part of our workforce but they are often being recruited from countries that can ill afford to lose them. We will need to train more nurses—that is the prime consideration of this debate, along with how we achieve that.

I congratulate the Minister on the proposals to open up many more places to nursing students, but we should consider some unintended consequences and I wish to touch on those further in this debate. We must do this without disadvantaging or cutting off our current core nursing workforce. It is absolutely right that we pay particular attention to the impact on mature students, because we have heard the data on that: 23% of all nursing applicants are over 30; more than half are over 21; and, as the hon. Member for Lewisham East (Heidi Alexander) said, the average age is 28. The question is whether this core mature nursing workforce are going to be deterred from applying.

We have already seen an example of innovation, with the University of Bolton partnering the Lancashire Teaching Hospitals NHS Foundation Trust to start offering places where students apply through the UCAS route. They introduced 25 places in the first pilot, with the first intake being in February last year, and there were 650 applicants for those places, even though they knew that they would have to access loans. There has been a very successful second round, with an increase to 75 places this year, and so the assumption that people will simply not apply for these courses just is not correct. We need to bear it in mind that we cannot necessarily extrapolate from there to a wider increase in numbers, but I ask the Minister whether there is any room, as we start to roll this out, to retain some bursaries for our very valued core mature nursing workforce for at least the first few years, until we know what the impact is. Will he address that in his summing up? Is there any role for a period of transition? It is important that we bear in mind the potential for unintended consequences.

Two thirds of those who apply for nursing places are unsuccessful, and it is unreasonable not to increase the opportunity for those students. I very much welcome the Minister’s plan to roll out other opportunities to enter the nursing workforce. We know from the Cavendish review that one reason we lose so many from our core healthcare assistant workforce is because there are no continuing professional development opportunities for them. Very many of those people, whom we know to be fantastic at their job, are not able to progress in the way that we should be allowing them to do. The key focus for us in this House should be: what is best for patients? What is best for patients is for us to train up a more diverse workforce, through many routes. There is a case for saying, “Let’s not completely abolish bursaries in the first round. We could phase things in more slowly.”

Another opportunity we could look at to try to attract people into nursing is through recognising that the clinical component is very high in the nursing course, at about 50%. Is there any way we could recognise that with a limited grants system for those who would otherwise be deterred? Perhaps at the end of a nursing course we could recognise mature students, particularly those who have taken on a second degree. Is there a way we could allow an extra payment to go to those nurses, particularly those who are going to go on to train in specialties where there is a shortage, linked with a period of NHS service. I know that we are using such an approach in general practice to try to attract people into shortage specialties. Would the Minister also consider that in responding to the legitimate concerns about the impact on the mature nursing workforce?

In summary, there are things we are doing where we are making progress, but there are things we can recognise as being unintended consequences. I hope the Minister will also look at some of the other recommendations from the recent Health Committee inquiry on primary care and say, “What can we do, as we increase the number of these courses, to increase the exposure to shortage specialties within the training period?” Too many of our healthcare workforce are staying within acute care and we know that if they have increased exposure to primary care during their training, they are more likely to want to go into those specialities.

Finally, as we increase these other opportunities for nursing and physician associates, may I ask the Minister please to touch on registration? We have heard evidence that, sometimes, not being registered can deter people from taking on physician associates. Allowing those associates to be registered is a recognition of their skills. These should be professional qualifications, and I hope that he will refer to that in his summing up.

--- Later in debate ---

[Wes Streeting (Ilford North) (Lab)]

I thank the shadow Health Secretary and the shadow Health team for securing this important debate this afternoon, which effectively gives us the opportunity to debate early-day motion 1081, which is set to become the most popular early-day motion in this Session of Parliament. It has been signed by Members from across the House, including Government Members, because of the concerns that people have bravely shown about the potential consequences of the Government’s proposed decision on the NHS bursary.

As I have argued before in Adjournment debates on the Floor of the House and in Westminster Hall, what we are debating this afternoon is the biggest shake-up in the funding of nursing, midwifery and allied health subjects since 1968. It was announced, without adequate evidence and planning, as part of the Chancellor’s Budget rather than being a carefully thought-through policy proposal; that is why the Government are consulting people only through a technical consultation rather than through a consultation of all stakeholders on the principle of the policy, as they ought to have done.

Although I and others will refer to “student nurses and midwives” as shorthand, it is important to acknowledge, as my hon. Friend the shadow Health Secretary did, that this will affect students of all sorts of subjects and vital workers being trained in a range of aspects of the NHS—physiotherapists, occupational therapists, chiropodists, dieticians, podiatrists, radiographers, paramedics, prosthetists and others. That is why more than 100 right hon. and hon. Members signed the early-day motion and thousands of members of the public have spoken out through the online petition.

At present, nursing, midwifery and allied health subjects are not subject to tuition fees and students on these courses receive a non-means-tested grant of up to £1,000 a year as well as a means-tested bursary of up to £3,191 a year. That recognises that students of these subjects have to work considerably long hours during their courses—not just in the libraries and lecture theatres like most students, but on clinical practice as part of a full 24-hour care cycle. Indeed, it is estimated that student nurses work at least 2,300 hours across the course of their degree. I am not sure that many of us with degrees in this House could claim to have put in so many hours when we were at university. We should recognise the effort that such students need to make to secure their qualifications.

Those who work outside course hours to fund their degrees can end up working up to 60 hours, and we should not expect them to do so: it can have a deleterious impact not just on their academic studies but on their approach to clinical practice. Under the Government’s proposals, the changes will mean that students of these subjects will be charged tuition fees in excess of £9,000 a year and, as a result, will be burdened with £51,600 of debt. They will begin paying that back as soon as they graduate, which means that nurses will take on average a pay cut of £900 a year.

As if that were not unacceptable enough on its own, will the Minister explain when he winds up how it can possibly be fair that under the proposed approach there is no recognition in the student support system of the unique demands placed on these students? The NHS bursary, as it exists, alongside the tuition fee remissions that these students effectively receive, at least recognise that for many of the students it is difficult, if not impossible, to take on the sorts of part-time work that I did when I was studying, either during my A-levels at McDonald’s or during university at the now-defunct Comet. For those students, it is simply not possible to fund their degrees in that way.

The student support system should recognise that it is more expensive to study these subjects and that the opportunities to earn extra income on top of taking the courses are not as readily available as they are for other students. It is a real mistake for the Government not to recognise that in their plan.

[Dr Wollaston]

Does the hon. Gentleman also accept that there is a serious problem with hardship on the existing bursaries, particularly given that the amount of the bursary drops in the final year?

[Wes Streeting]

I am grateful for that intervention. I shall come on to thank some of the people who have been in touch, but I will never forget the very first conversation I had with a student nurse in my constituency who sat with me in the Members’ area of Portcullis House and cried because under the existing system she struggled to meet the costs of training to be a nurse, even with the NHS bursary currently provided.

I want the student support system to be more generous for these students because other students like my constituent have dreamed of being a student nurse. It is not right that financial support, or the lack of it, should be a barrier to their taking on this valuable vocation, which does so much for so many.

The Government’s policy is riddled with risk. Earlier the Minister challenged my assertions on mature student numbers. It is a fact that in the wake of the introduction of the coalition’s reforms to higher education, there was a fall in part-time and mature student numbers. The Minister claimed that there were record numbers of mature applicants to higher education; I can only assume that he was referring to last year’s figures. We should not identify a trend from one year’s figures, not least because UCAS figures for the 2016 application cycle published on 4 February 2016 show an increase in 18-year-old applicants, but a fall in most other older age group categories. I am more than happy to look at the data and conduct an evidence-based debate, but let us have an evidence-based debate and not take one year’s worth of figures and claim that there is some sort of trend.

Southern Health NHS Foundation Trust

Sarah Wollaston Excerpts

Tuesday 3rd May 2016 Commons Chamber

[Alistair Burt]

I thank the hon. Lady for her response. We are not actually debating the Government’s failure to respond at all. The Secretary of State did exactly what he said he was going to do, and the CQC’s inquiry and work that followed can be seen in the report that was produced last week. The report contains a number of further concerns—there is no doubt about that—and people are right to be angry, but there is a process to find out what is going on and to do something about it and that process is in place. That is what NHS Improvement is doing and it is important that that is done.

There is an issue of urgency, which is really important. There are things that are discovered and things take time to get done. I am not content with that in any way, but the process is in place to do something about that. The CQC has been engaged and has ruled out no option for further action. Its options are quite extensive, including prosecution for things that it has found. The process started by the Secretary of State is not yet finished. That my right hon. Friend has demonstrated his commitment to patient safety from the moment he walked into that office cannot be denied by anyone, and this is a further part to that.

I asked the same question that the hon. Lady asked about safety directly to the CQC this afternoon, and I spoke to Dr Paul Lelliott who compiled the report. I asked whether people are safe at the foundation trust today. People are safe because, as we know, the CQC has powers to shut down places immediately if there is a risk to patients. It has not done so, but I am persuaded that if it had found such a risk it would have closed things down. There is therefore no risk to safety in the terms that the hon. Lady suggests.

On the chief executive’s position, the power to deal with management change is held by NHS Improvement. I also offer a brief word of caution. There is a track record of Ministers speaking out, at great cost, about the removal of people in positions over which they have no authority. That is understandable in situations of great concern when an angry response seems right, but it is not an appropriate response. The chair has gone, and processes are available should any more management changes be necessary, which is important. Colleagues in the House can say whatever they like, but a Minister cannot and must say that appropriate processes can be followed, because that is right and proper.

I do not yet know about an inquiry, and I want to wait and see what comes out of the further work being done in the trust. I do not rule out some form of further inquiry, but an inquiry is physically being carried out now by the actions taking place on the ground. What needs to follow is urgent action to respond to what the CQC has said, and a long drawn-out public inquiry is not necessarily the right answer. More work might be necessary, but I need to consider that in relation to further work being done at the trust.

On preventable deaths, as I made clear in my statement, I am sure that not enough attention has been given to those cases that require further investigation across the system, often dating back many years and preceding this Government. We have turned our attention to that issue, and we will make changes because such inequality must end.

[Dr Sarah Wollaston (Totnes) (Con)]

The report on Southern Health makes disturbing reading, but we will never tackle unacceptable levels of health inequality and early deaths among those who live with learning disability and mental health issues unless we address safety and risk. Will the Minister go further on the mortality review and set out how we can see where differences exist around the country? Will he reassure the House that duty of candour will in future be more than a tick in the box?

[Alistair Burt]

A tick in the box for duty of candour, which the report mentioned, was unacceptable—it must mean much more than that. The learning disability mortality review programme is important and will support local areas to review the deaths of people with learning disabilities, and use that information to help improve services. In time, it will also show at a national level whether things are improving for people with learning disabilities, and whether fewer people are dying from preventable causes. That review is already under way in a pilot in the north-east in Cumbria, which will help to inform us how the programme operates as it is rolled out. Plans are in place to roll out that review across all regions of England between now and 2018, with pilots commencing in other parts of the country between 2016 and 2017. That work has never been done before, and it is right that we are doing it now.

Junior Doctors Contracts

Sarah Wollaston Excerpts

Monday 25th April 2016 Commons Chamber

[Mr Hunt]

The shadow Health Secretary can do better than that. She talked about the judgments that I have made as Health Secretary, so I will tell her what is a judgment issue—it is whether or not you back a union that is withdrawing life-saving care from your own constituents. Health Secretaries should stand up for their constituents and their patients, and if she will not, I will.

The hon. Lady also talked about the trust of the profession. The Health Secretary who loses the trust of the profession is the Health Secretary who does not take tough and difficult decisions to make care better for patients—something we have seen precious little evidence of from the hon. Lady or, if I may say so, her predecessors.

The hon. Lady also talked about putting oil on a blazing fire. What, then, does she make of the shadow Chancellor’s comments recently when he said:

“We have got to work to bring this Government down at the first opportunity…Whether in parliament, picket line, or the streets, this Labour leadership is with you”?

Yes, it is with the strikers, but also against the patients. Labour should be ashamed of such comments from the shadow Chancellor.

Let us deal with the substance of what the hon. Lady said. She talked about her proposal for pilots. If this was a genuine attempt to broker a deal between all the parties, why was it that the first the Government knew about it was when we read The Sunday Times yesterday morning? The truth is that this was about politics, not peace making. If she is saying that we should stage the implementation of this contract to make sure we get it absolutely right, I agree. That is why only 11% of junior doctors are going on to the new contract in August. She says she wants more independent studies into mortality rates at weekends, but we have already had eight in the last six years, pointing to the weekend effect. How many more studies does the hon. Lady want? Now is the time to act, to save lives, and to give our patients a safer NHS.

The hon. Lady talked about legal powers, which we discussed in the House last week. The Health Act 2006 makes very clear where my powers are to introduce a new contract, either directly or indirectly, when foundation trusts choose to follow the national contract.

I have given very straight answers today. Will the hon. Lady now tell us yes or no? Will Labour Members now tell us yes or no? Do they or do they not support the withdrawal of life-saving care from NHS patients? Last week, the hon. Lady’s answer was “no comment”. Well, “no comment” is no leadership. Labour used to stand up for vulnerable patients, but now it cares more about powerful unions. It is the Conservatives who are putting the money into the NHS, delivering a seven-day service for patients, and fighting to make NHS care the best in the world.

[Dr Sarah Wollaston (Totnes) (Con)]

There are only losers in this bitter dispute, but those who have the most to lose are patients and their families. Tomorrow people will visit hospitals to see those whom they care about more than anything in the world, and will ask themselves why the doctors on the picket line are not inside looking after the people they love. May I ask the British Medical Association directly whether it will show dignity, put patients first, and draw back from this dangerous escalation? May I ask all sides, whatever provocation they may feel, to put patients first in this dispute?

[Mr Hunt]

My hon. Friend has spoken very wisely. She recently wrote, in The Guardian, something with which I profoundly agree: she wrote that there could have been a solution to this problem back in February, when a very fair compromise was put on the table in relation to the one outstanding issue of substance, Saturday pay.

I understand that this is a very emotive issue. The Government initially wanted there to be no premium pay on Saturdays, but in the end we agreed to premium pay for anyone who works one Saturday a month or more. That will cover more than half the number of junior doctors working on Saturdays. It was a fair compromise, and there was an opportunity to settle the dispute, but unfortunately the BMA negotiators were not willing to take that opportunity. I, too, urge them, whatever their differences with me and whatever their differences with the Government, to think about patients tomorrow. It would be an absolute tragedy for the NHS if something went wrong in the next couple of days, and they have a duty to make sure that it does not.

Meningitis B Vaccine

Sarah Wollaston Excerpts

Monday 25th April 2016 Westminster Hall

[Dr Sarah Wollaston (Totnes) (Con)]

It is a pleasure to follow my hon. Friend the Member for North Devon (Peter Heaton-Jones), and I apologise to my hon. Friend the Member for Bath (Ben Howlett) for missing his opening statement, because of a statement in the main Chamber.

I start by thanking all the families who gave evidence to the Petitions Committee and the Health Committee. Through their very brave and dignified testimony, they have done more to raise awareness and save lives than any Government-led awareness campaign could possibly hope to achieve.

It is wonderful to be in a debate in which we are airing the positive benefits of vaccination, which has undoubtedly been one of the greatest achievements of modern science. We stand on the brink of eradicating polio from the world, and it is worth pausing to thank all those who have been involved in the development of vaccination over the years.

[Neil Carmichael]

At this point, I would like to salute Dr Edward Jenner, who worked on a smallpox vaccination and was based in my constituency. That underlines the importance of vaccination, and that work then is directly linked to the work of Meningitis Now.

[Dr Wollaston]

I thank my hon. Friend. In fact, I will take us back even further by mentioning Ben Franklin, who said that

“an Ounce of Prevention is worth a Pound of Cure.”

He was referring to fire services in Philadelphia, of course, but the principle still stands.

In paying tribute to all who have brought us to where we are today, we should remind ourselves that vaccination is becoming increasingly complex to develop. Bexsero is being developed through reverse antigen mining and is extraordinarily expensive. That is why we have to consider cost-effectiveness, because in a system where finances are limited, what might be displaced if a new intervention is funded? In other words, we in this House and beyond have a responsibility to ensure that the money we spend can save as many lives as possible, and to consider that in the round.

That is why it is important to take account of the work of the Joint Committee on Vaccination and Immunisation in making its incredibly difficult decisions and judgments. It is absolutely important that we allow the JCVI to carry out its work without undue political interference. The role of this House is, of course, to raise awareness and to hold the Government to account for the way in which—and the framework under which—the JCVI operates. However, our role must never be to lean directly on members of that committee in the very difficult decisions that they make. I pay tribute to the JCVI—to Professor Andrew Pollard and his team—for their work. Their decisions are extraordinarily difficult, and they need to apply the science with a combination of judgment and sensitivity. It is absolutely right that we regularly review the criteria that they are able to take into account.

I thank the Minister for her letter today confirming that the cost-effectiveness methodology for immunisation programmes and procurements working group, or CEMIPP—it may need a catchier title—is going to publish its work in full. Perhaps she will say whether she has now received that report. It is absolutely important that the principle of transparency applies, so that we can all be clear about the decision-making process.

I support Members who have said that we should review the so-called discounting rate if it means that, as my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) has pointed out, by the time someone is in their 20s, effectively no account is taken of them. It clearly seems reasonable that we apply the same principle that is applied to public health decision making in the NICE methodology, with its lower discount rate, so that we can take full account of that situation. It is also right for the House to reflect on views beyond this place by thinking, for example, about the social costs. I do not wish to repeat the many important points that have been made about that today.

The JCVI’s independence is absolutely vital. We in this House are not in a position to make judgments about the effectiveness and safety of vaccination. We have to rely on experts, and we are very grateful to them for their work. However, one thing that we have to do is hold the Secretary of State to account for implementing the decisions of the JCVI in a timely manner and for the time that it takes to carry out the negotiations on the cost of vaccines.

I would like to make a further point, which I do not think Members have brought up today. The level of variation in the roll-out of existing vaccinations needs to be looked at. During the Health Committee’s current inquiry into public health, we have been hearing evidence about the difficulty that public health professionals and directors of public health have in being able to access the data and information that they need to tell them where the gaps are in the roll-out of vaccination. Perhaps the Minister will update the House on where we are in that regard, because it clearly cannot make sense that artificial barriers have sprung up between those who are responsible for implementing the programme and those who are delivering it on the ground. It would be helpful to have an update on that issue.

It is also absolutely right that the House holds the Minister to account on what is being done to follow up the work that is happening on sepsis. As she will know, early diagnosis is critical. Although we want to focus on the number of cases that we can prevent, we cannot prevent them all, so we must also focus on early diagnosis and intervention and on ensuring that we have the right pathways in hospitals, so that the time it takes from the moment someone enters a hospital until they receive life-saving antibiotic therapy is kept to a minimum. Perhaps the Minister will update us on that.

[Geoffrey Clifton-Brown]

I hesitate to intervene on my hon. Friend, especially as she is such an expert on this subject, but as I understand it, Bexsero was licensed by the European Medicines Agency on 1 January 2013. It was not introduced in this country until more than two and a half years later, and people will have died of the disease in the interim. Does my hon. Friend not think that is too long a process when the argument is not about the safety of the drug but purely about the price? Something needs to change. The negotiation with the drugs companies needs to be done in a different way.

[Dr Wollaston]

I agree that there needs to be a better and faster procedure for negotiating about cost, but we cannot get away from cost, because, as I mentioned, cost-effectiveness is not an abstract concept. It means asking, could we save more lives by spending the same amount of money differently? If the cost of the drug is exorbitantly high, would it be better to invest the money in, for example, early diagnosis and intervention? Those complex decisions should not be made by politicians. Politicians and the public should be part of the process that sets the guidelines and advises the committee, but it is not for this House to make those decisions, although I absolutely agree that of course it would be better if the negotiations could be done more quickly.

I end where I began, by paying tribute to the very brave families for the evidence that they gave. I hope that the Minister will do everything in her power to ensure that we reach decisions as quickly and as fairly as possible.

[Philip Davies in the Chair]

--- Later in debate ---

[Jane Ellison]

I can assure the whole House that the JCVI keeps that under constant review. It is not something that is occasionally dusted off and looked at every four or five years. The committee looks at all the factors that go into making the relevant decisions. When the factors that contribute to its decision making change, it looks into them. I have already given the House the assurance that the JCVI will keep that under careful review. The Select Committees heard directly from Professor Pollard and had that assurance from him. However, I will draw the JCVI’s attention to the concerns raised in this debate and the huge level of interest in the matter in the House and among the wider public.

As came out in the evidence that the JCVI gave to the Health Committee and the Petitions Committee, under the current cost-effectiveness criteria, the men B vaccination programme was only just cost-effective even for infants on JCVI’s final analysis, but we did not shy away from introducing it because we know how devastating meningitis can be and how important protecting children from it is to parents. That is why we became the first country to have a programme of using Bexsero. Many other countries have asked experts to consider men B vaccine programmes, but because the cost-effectiveness is so borderline, to date only Ireland has recommended a programme. I understand that it will start in the autumn, using the same criteria as the UK’s programme. We are leading the way in protecting our children from men B.

As I draw my remarks to a close, I want to reiterate Members’ thanks. I appreciate the fact that so many Members have expressed their thanks to Professor Pollard and the JCVI for the complex and important work that they do. That also goes for the many clinical experts who give us their expertise on which to make these enormously difficult decisions.

[Dr Wollaston]

I am intervening because the Minister mentioned that she is drawing her remarks to a close. Can she comment on the issue I raised about the variation in roll-out and the communication issues for public health directors in being able to assess the variation in their areas?

[Jane Ellison]

I am not able to give my hon. Friend an answer today. If she does not mind, I will write to her about that. I have had a conversation about that with the public health director in my own borough, so I am aware of some of the frustrations that have been expressed. If my hon. Friend does not mind, I will write to her with more detail rather than give a response off the top of my head—her question deserves a better answer.

I want to put on the record my thanks to the meningitis charities that work tirelessly to support families affected by this terrible disease and have done so much to advance their cause. Many of them have circulated their 10-point action plan. I have touched on most of those points and indicated how the Government are responding.

Like other Members, I recognise the courage and dignity that, as has rightly been said, Mr and Mrs Burdett and the other families affected by meningitis in such a tragic way have shown over recent weeks. Nothing I can say today can make up for their loss, but I have listened very carefully to the evidence that they have bravely given to the Select Committees, and particularly the emphasis that they have put on raising awareness, which they have done so much about. I hope it is some comfort to them to know that not only their own efforts in bearing testimony but the new awareness campaign, alongside our vaccination programmes, will save lives in future.