Sunday, 4 October 2015

Commons Debate on "No Confidence in Jeremy Hunt" petition

An epetition calling for a vote of No-confidence in Health Secretary Jeremy Hunt was debated in Parliament on 14th September.


The governments response can be read here

Video of the debate can be seen here and the Hansard record here

Below are some extracts (from the Hansard record) that particularly caught BFTF's attention. Incidentally, the Handsard record, and indeed the official response, are more informative than much of the fuss and bluster reporting of the issue in the mainstream media.

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Helen Jones (Warrington North) (Lab):
“…the Petitions Committee does not have the power to initiate a vote of no confidence, and so we decided that the debate should be on the issue underlying the petition, which was the contracts and conditions of NHS staff.”

"NHS staff have been badly treated by this Government. Since 2010 pay increases have been deliberately kept low and last year we saw some staff being told that they could not have even a 1% increase if they were due to get an increment as well. …Indeed, in the previous Parliament the NHS was told to make £20 billion of what the Government call efficiency savings but the rest of us call cuts. That is due to rise to £30 billion by the end of this Parliament…Ministers criticise spending on agency staff, but the Government’s first act on coming into office in 2010 was to cut nurse training places by over 3,000 a year."


Maria Caulfield (Lewes) (Con):
"I declare an interest as a former NHS nurse—in fact, I still work as a nurse…one of the single biggest factors in demoralising nurses and leading many skilled nurses to leave the practice was the last Labour Government’s change to the skill mix. That was crucial, because we were forced to cut our budgets, particularly on the wards, and junior nurses were left in charge of wards, instead of experienced senior staff nurses and sisters..."

Helen Jones (Warrington North) (Lab):
"I am afraid that I do not agree with the hon. Lady. What has demoralised most of the nurses I see is the cuts they have to cope with day in, day out, as well as the shortage of sometimes even basic equipment … "

"What, exactly, is the Secretary of State trying to do? If he is trying to bring about a seven-day fully elective service, he needs to say so. As far as I am aware, no major health system in the world has managed to do that. If he is not trying to do that, he needs to tell us clearly—perhaps the Minister will do so when he winds up—which services he thinks should operate at the weekend."

"The Secretary of State also needs to recognise that, to have the service he proposes, he needs not only more doctors, consultants and nurses on the wards, but back-up staff. Doctors operate by leading teams. If they do not have the ancillary staff—the people to do the MRI scans, the radiology and the lab tests—they cannot operate properly. We need to hear how the Secretary of State will implement his proposals. Will he recruit more staff, or will he worsen the terms and conditions of staff who are already not well paid, to introduce weekend working?...As an example, if an operating theatre does not have a full complement of staff, there is no one to send out with the patient who is in recovery, and a doctor must go with them. That slows the turnaround time for theatres, and staff are told that their turnaround time is not good enough..."


[Interruption.]

"If the Minister’s Parliamentary Private Secretary, the hon. Member for Winchester (Steve Brine), will stop chuntering from behind the Minister, I will wind up my remarks."


Dr Sarah Wollaston (Totnes) (Con):
"It may help the House if I comment quickly on the background. I thank Professor Freemantle and his team for their excellent updating of the data following the last analysis of data in 2009-10. He and his colleagues carried out the exercise again based on data from 2013-14, and it may help if I put some of that in context. What he shows is that 1.8% of NHS patients will die within 30 days of admission. It is important that we look not only at the data relating to what happens within a few days, which he has also analysed, but at the longer-term data. He shows a very real effect: if someone is admitted to hospital on a Friday, there is a 2% increase in the risk that they will die within 30 days; if they are admitted on a Saturday, the increase is 10%; if they are admitted on a Sunday, the increase is 15%; and if they are admitted on a Monday, the increase is 5%. Those are relative, not absolute, statistics and are on a background rate of 1.8%, so it is important that we do not alarm people unduly with those data. However, they mean, very importantly, that around 11,000 more people die if they are admitted between a Friday and a Monday, relative to what we would expect had they been admitted on a Wednesday."

"That is extremely important, and the Secretary of State is absolutely right to take that very seriously, but we need to look at it in its wider context. Is it simply because a different group of people are being admitted in the middle of the week than are being admitted at weekends? Is it because they are a sicker group of people? Both of those are true, which is why it was important that Professor Freemantle made adjustments for those kinds of data. He showed that even if we take account of the fact that there genuinely are sicker people coming into our hospitals at the weekend, the effect was still present, but it was reduced. There was a 7% increase on a Saturday and a 10% increase on a Sunday, so it was still important. As for people admitted to hospital for routine procedures, it was shown that the nearer it gets to the weekend, the more their chances of mortality increase."

"To go back to my earlier point, the Secretary of State is absolutely right to take this issue seriously. This is not just an effect in Britain; it is observed internationally, but it matters. Yes, those people are sicker, and yes, a different group of people is coming in, but there is also the issue of what we should do about it. We must not give the impression that all those 11,000 deaths are preventable. We have to be very careful not to rush into action that leads to a levelling down, rather than a levelling up. We want to bring the data up as far as we can, but when hospitals have done a deep analysis of the deaths that have occurred within 30 days of people being admitted at weekends, it is sometimes very difficult to say what could have happened differently."

"We need to look at this issue, but it is not just about consultant presence. Senior supervision at weekends is undoubtedly part of it and is very important, but other issues are at stake. Is there access to diagnostic tests? We need to look beyond this being just about consultants; it is about nursing staff, too. We have to be careful not to shift resources into trying to sort out one part of the issue—consultant presence—because if that means a continuation of a worrying trend of shifting resources out of primary care, we could inadvertently end up with a sicker group of people coming into hospitals at weekends. In other words, we have to be very careful about the balance and potential unintended consequences of what we do."

"However, there is another aspect, which is more difficult. When resources are very restricted, should we prioritise access to primary care out of hours for people who would prefer to be seen at the weekend than mid-week…. I speak as someone who, before I came to this House, was a clinician in rural Dartmoor in a two whole-time-equivalent practice. It was a very rural setting, and if we were to try to provide an 8-till-8 service on Saturdays and Sundays for routine GP appointments—if we were, as this is sometimes presented to the public, to enable people to see their doctor at any time—the cost would be enormous...I would like the Secretary of State to be very clear about what he means by a seven-day NHS when it comes to primary care, and about how we will make those fair funding decisions and divide the cake, so that we get the very best for people. "


Paul Flynn (Newport West) (Lab):
Many speeches by the Secretary of State contain valuable, intelligent thoughts about how to improve the health service...The one question is a simple one. If we are to increase the services at weekends, where will the staff come from? Are we suddenly going to magic up special weekend surgeons? If we improve the service at weekends, we have to reduce the service in the week. Perhaps the Minister can explain that to us."

Helen Whately (Faversham and Mid Kent) (Con):
"The Royal College of Surgeons strongly supports seven-day care. It has said that one reason why outcomes are worse at weekends is that patients are less likely to be seen by the right mix of junior and senior staff; that such patients experience reduced access to diagnostics; and that earlier senior consultant involvement is crucial. Research from the NHS National Health Research Institute shows that 3.6 more specialists attend acutely ill patients on Wednesdays than on Sundays. More senior doctors need to be available at weekends—not just on call, as many consultants are at the moment, but present in hospitals."

Paul Scully (Sutton and Cheam) (Con):
"We also have a manifesto commitment to deliver. We talked in our manifesto about having a seven-day NHS, and we have been elected as a Conservative Government, so it is important that we deliver our promises...The 2003 consultant contract made the seven-day move a lot more expensive to deliver, so we need to change things... Removing the opt-out will leave a new limit of working a maximum of 13 weeks in a year—one in four weekends—which still gives plenty of opportunity for family life and for flexibility in rotas, while delivering better patient outcomes."

"I have talked about convenience, and GP services cannot be boiled down to some sort of retail operation such as late-night shopping or Sunday opening. None the less, we need flexibility. The 2004 GP contract led 90% of GPs to stop providing out-of-hours care at night and at the weekend. That contract, in many cases, helped to break the personal link between patients and those responsible for their care, which has been especially hard on elderly people. Caving in to the unions at that point effectively restricted GP services to a five-day service, which created extra pressure on A&E."

Maria Caulfield (Lewes) (Con):
"I have been a nurse for more than 20 years. I have worked in the community on weekends, when patients without access to a GP have needed painkillers or an urgent dressing and it is difficult to get hold of a doctor...We are not asking staff to work more hours—we have been very clear—but we are asking staff to work differently. I do not think that there is anything wrong with that if it provides a better service for the patient and takes the pressure off those front-line staff who are without radiology support, laboratory support and senior cover support."

Will Quince (Colchester) (Con):
"I am passionate about our NHS, because it has always been there for me and my family when we needed it... I cannot fault the care and compassion that the NHS gave me and my family, and I will never forget that. Yet, I am bombarded with criticism that, as I am a Conservative, I must somehow care less about the NHS than the Labour party does. The scaremongering and empty rhetoric is patronising and insulting. It has to stop."

Dr Philippa Whitford (Central Ayrshire) (SNP):
"I declare an interest: I am a doctor and member of the British Medical Association, and I still work in the hospital."

"We are talking about data showing that people admitted at the weekend are more likely to die within 30 days that those admitted on weekdays. It is important to listen to what Bruce Keogh said, which is that it would be misleading to assume that all of those deaths could be prevented. On a Saturday, there are 25% more people in the most ill category and on a Sunday there are 35% more people in that category."

"There are a few myths going around, including the idea that the opt-out clause is a major barrier. The opt-out clause that was cited was for routine work. Consultants do not get to opt out of emergency work at night or at weekends if they work in an acute service. "

"research by Bray looked at 103 stroke units, including units where there was seven-day consultant review through the day, and compared them. There was absolutely no difference between that seven-day service and units where there was a routine ward round and no ward rounds at the weekend. What made a significant difference was the ratio of fully trained registered nurses to patients. When that ratio was halved, so that there were twice as many nurses, the mortality was reduced by a third."


"The money would be the easiest bit because we do not have the extra staff 5,000 extra GPs and yet the British Medical Association shows that we will lose 10,000 GPs in the next five years. That means that we would need 15,000 GPs, and we simply cannot produce that number."

Andrew Gwynne (Denton and Reddish) (Lab):
"It is no good for Government Back Benchers to laud the ring fence for the NHS budget when, as we heard from my hon. Friend the Member for Warrington North, social care budgets have been ransacked. I should not need to remind Government Members, but the fact is that social care cuts are NHS cuts because of the pressure that they cause throughout the health system. "

The Parliamentary Under-Secretary of State for Health (Ben Gummer):
"I am glad that we have these petitions, although perhaps a little less glad that this particular petition contains such stridency of language…Members may not be surprised to hear that I have read—several times, as it happens—the Secretary of State’s speech on this matter. I have also seen the coverage on it, and there is dissonance between the two. At no point did he attack NHS staff or suggest that they are not working in conditions that are often heroic, and at no point did he suggest that we have ended up at this impasse because of a wilful wish on the part of NHS staff not to work at weekends. What was construed from that speech has unfortunately meant that our debate has been about a number of words and phrases that were not used, intended or even suggested."

"I want to run through in detail where NHS England’s thinking comes from and why the Government have decided to act as they have. As the hon. Member for Central Ayrshire knows, there have been various academic papers from the United States and some from the United Kingdom on differential mortality, and they contain many of the questions and answers that have been alluded to today."

"That assortment of academic research, together with the wide anecdotal evidence from people who have experienced poor care in good hospitals, either for themselves or for their relatives, led NHS England to conduct the Seven Days a Week forum in 2013, which gathered together clinicians to look at the challenge. It produced a clear strategy for dealing with differences in care quality at weekends, compared with the week, and set out 10 clinical standards that it believes hospitals must meet to eradicate the difference between weekday and weekend working. Many hospitals are implementing the 10 clinical standards on a variable basis during weekdays, so the work done for weekends was helpful in determining a standard clinical approach for maximising the ability to reduce avoidable deaths for weekend and weekday admittances. The product of that forum was taken forward by NHS England and incorporated into its five-year forward view, in which the NHS, separately from the Government, made a commitment to seven-day services. It did so not because of the benefits to patients—as my hon. Friend the Member for Sutton and Cheam (Paul Scully) said, that is a secondary reason for pursuing the agenda—but purely because of the need to reduce excess mortality where possible."


This is a challenge on the scale of infections in hospitals. It is our duty not only to find out precisely why excess deaths are happening—as the hon. Member for Central Ayrshire correctly said, further work is needed and the data must be understood—but to do what we can as quickly as possible to reduce them where we think they are preventable. That is why NHS England incorporated the seven-day service into its five-year forward view. NHS England asked for an additional £30 billion of spending between 2015 and 2020, of which it said £22 billion can be achieved through efficiencies within the service. It is important to point out to the hon. Member for Warrington North, who made that point, that they are not cuts but genuine efficiencies within the organisation. On top of the £22 billion of internal efficiencies though a better use of IT, to which she alluded, and better job rostering—I will turn to that in a minute—there will need to be an injection of £8 billion to make up the rest of the £30 billion. That package will implement the five-year forward view, which includes seven-day services and many other things of great importance and about which all parties agree, such as shifting resources from providers to primary care, social care and the community sector."


"I turn to the changes in the contracts, which are at the heart of the … The contract terms are based on a review by the doctors’ and dentists’ pay review body, which identified a number of areas where contract reform is needed, including the systems of opt-out and on call...It is important to point out, as several of my hon. Friends have done, that we are talking about ensuring that, at most, consultants work no more than one weekend in every four. That is the basis on which they will be contracted to work in a seven-day NHS. We are not talking about seven days at a time, but about shift rotas and patterns…We are recruiting close to record numbers of nurses, doctors and consultants, and we are doing so in many of the diagnostic specialties as well."



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