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This debate coincides with the Healthcare Commission report on the state of health care in the UK. It is right to acknowledge, first, that that report had lots of positive things to say about progress in the national health service. The Secretary of State mentioned that progress has been made on survival rates for heart disease, stroke, and cancer. Survival rates for those serious diseases have improved, which is something that we should all welcome. We should welcome, too, the substantial improvements in access to care, compared with the position 10 or 11 years ago. There has been a dramatic improvement, and it would be churlish to fail to recognise that
Norman Lamb: But the Healthcare Commission drew attention, too, to the fact that there were areas of serious concern. Ian Kennedy, the chair of the Healthcare Commission, focused on patient safety, and I want to concentrate for a few minutes on the area of most significancechild protection, particularly the tragedy involving baby P. Again, it is important again to acknowledge that the Secretary of State for Children, Schools and Families acted commendably fast in recognising the seriousness of the failings and in mapping out a way forward. However, it is also right to say that so far, the emphasis and focus, particularly in the media, have been on the failings of the local authorityand there were manyrather than on the failings of other agencies. I think that there are lessons to be learned, and it is important to reflect on them for a moment, particularly the situation in the local health service, because serious concerns have been raised with me.
I understand that the paediatric service for child protection in the borough was outsourced to Great Ormond Street. I understand that there was a team of four doctors, of whom two have resigned, one has been on special leave for a year, and one is off sick. Given the fundamental importance of that workI make these comments not in any sense in a partisan way, as we all have a common view of the importance of addressing these issuethat is an alarming situation in itself. Incidentally, if either Secretary of State is unable to respond to these points today, I am happy for them to respond in writing later. What factors have led to this situation? Why has one of the doctors whom I mentioned been on long-term special leave for a year? Is it the case that the primary care trust cut funding for a designated doctor post, and is it the case that the paediatrician who did not recognise the broken back and ribs in the case of baby P was a locum employee?
I have heard concern expressed that when children are brought into St. Anns hospital in Tottenham as possible victims of abuse, there is a tendency for no information to arrive with the child to put the medical
team fully in the picture about possible concerns. That relates to the issues of co-ordination and the sharing of information between agencies dealt with in the report released by the Secretary of State for Children, Schools and Families. I understand that when one doctor filled in a critical incident form at that hospital, in relation to another case, he was told not to do so because it would show up poor record keeping. I do not know whether there is any truth in that allegation, but it is a serious matter and it clearly needs to be investigated. What short-term steps have been taken to ensure that there are proper safeguards in place for other vulnerable babies and children in that borough? What are the longer-term lessons for the NHSas opposed to the local authority, which has had its fair share of attentionparticularly with regard to the responsibility and accountability of the clinicians involved?
That takes me to the wider question of child protection. Such tragic cases open up a debate on parenting and on how we can best protect children. The case of baby P is a stark case of failure, but throughout the country, every day, social workers are grappling with the genuinely difficult dilemma of whether to remove a child from their parent or parents and to place them in care. It is massively challenging work, and the last thing we should do is to stigmatise social workers and make that an unattractive profession, thus putting able people off going into it. After such a disaster, there is a risk that policy is shaped in response to it, and that there is a swing of the pendulum into a different approach, which may not itself be right.
I would like to mention the other side of the coin. There are many cases in which there are genuine concerns about the failure of authorities to remove a child who is at risk, but in my constituency I have been dealing with the case of the Webster family, which was covered in the national press last year. They had a little boy who was taken into the Norfolk and Norwich hospital complaining of pain, and it turned out that he had multiple fractures. The child was removed, along with his two siblings, and after a long process the three children were adopted. That family lost their three children. Subsequently, it was proved through further medical evidence that they were innocent, and that there was an innocent explanation for the fracturesa nutrition deficiency. That case is a disaster. It is a disaster in the system and a gross miscarriage of justice for a family to lose their three children when they are innocent. It cannot get much worse than that. My plea is for us to avoid another swing of the pendulum, and to focus instead on ensuring that procedures are exacting, rigorous, thorough and professional, and that we focus on standards of professionalism in social care and in the NHS.
John Hemming: My hon. Friend is well aware that I have been concerned about both false positives and false negatives in the public family law environment. Does he share my concern that it is difficult for parents to get a second, expert opinion because they require the permission of the judge, which is often refused in family court proceedings?
I share that concern, and because it is so fundamentally important that we get such decisions right, the opportunity for a second opinion ought to
exist in all cases. Had it been available in the Webster case, we might have avoided the miscarriage of justice that subsequently ensued. If we focus on standards of professionalism in reaching the right judgment, we stand the best chance of avoiding those dreadful miscarriages of justice, and of ensuring that children who are genuinely at risk are protected and withdrawn from their parents, if necessary. There should be no rush to put children into care, but the right decision, based on absolute professionalism, must be made.
Sure Start is one of the Governments genuine successes. The WAVE Trust is a good organisation, which has been influential in guiding Government policy developmentI believe that it has engaged with all parties. It focuses on the first three years of a childs life, recognising the importance of getting things right in those years. It concentrates on parenting and ensures that children avoid adverse, damaging experiences that can affect their life chances, including their future health. The right hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) and the hon. Member for Nottingham, North (Mr. Allen) produced a good pamphlet, which focuses on the importance of investing in the first three years of life.
A recent article in The Lancet on a research report shows that Sure Start has started to make a difference. We should acknowledge that and recognise that it has been a positive policy move. However, an article by Rachel Sylvester in The Times earlier this week warns that there are signs that the approach in childrens centres and in Sure Start is moving away from parenting skills and towards education. I hope that the Secretary of State for Children, Schools and Families, if he is listening, will ensure that the focus on parenting in childrens centres, which has been so valuable and, according to the research, shows success, is maintained and not lost.
I want to deal with the Governments proposals for a national health service constitution. It is hard to object to the warm words and aspirations in the proposed constitution, but the Government must answer the key question of whether it will make a difference. Ten years down the line, will patients be able to say, Ah, were being treated better because of that NHS constitution? Does it tackle the key challenges that face a publicly funded health system?
Greg Mulholland (Leeds, North-West) (LD): First, the draft constitution specifically precludes discrimination on the basis of race, gender, disability, religion or sexual orientation, but not of age. How can that be right? Secondly, we all agree that the divide between health and social care can be a problem. Should we therefore also consider the possibility of a social care constitution, so as not to entrench that divide further?
Norman Lamb: I would prefer something that encapsulates both, and acknowledges that there is an artificial divide between health and social care, which is often damaging to the care that an individual experiences.
Dr. Gibson: The equality Bill is to deal with the first point that the hon. Member for Leeds, North-West (Greg Mulholland) made. We do not know until we see the detail, but the Government are well versed in the need to ensure that age is included in anti-discrimination proposals.
Norman Lamb: I welcome the equality Bill, but one has to ask why age has been left out of the list of discrimination that the NHS constitution seeks to tackle. We all know that age discrimination happens in the NHS. There is clear discrimination in mental health services: for example, elderly people who suffer from depression and anxiety do not have access to cognitive behavioural therapy. My hon. Friend the Member for Leeds, North-West (Greg Mulholland) is right that we should deal with discrimination based on age as well as that based on other matters.
The amendment encapsulates the priorities that we should address, although I do not believe that the Conservative programme tackles them properly or effectively. They include quality of care and outcomes, on which it is right to focus, as well as accountability. Sadly, the Conservative approachestablishing an independent national quangowould reduce rather than increase accountability, but the amendment is right to refer to it. It also mentions the need to tackle bureaucracy, to ensure value for money, to have a renewed focus on public healththe area that has so often suffered when the finances have got tightand to tackle health inequalities.
If the NHS constitution did not confer any legally enforceable rights or guarantees it would, similar to the Patients Charter
before it, be seen as a political device that simply raises expectations, which then cannot be met. Indeed it would hardly be worthy of being called a constitution.
That identifies the real risk of this document, which is that it will raise expectations. People will assume that it will deliver something to them that is not being delivered, but ultimately it will amount to motherhood and apple pie, and there will be no extra delivery.
Will there be any legally enforceable rights or entitlements within this constitution? It seems that there will not be; the sanctions for breaching the NHS constitution do not appear anywhere. Trusts will have to have regard to thingsthat wonderful legal phraseology means, of course, absolutely nothing, because one can be acting entirely within the legal framework if one has regard to something and then entirely ignores it. [Interruption.] I shall ignore the abuse from the hon. Member for Wolverhampton, South-West (Rob Marris), which is so uncharacteristic. The proposals contain a reference to the responsibilities of patients, but what does it amount to? There is no substance to it.
What about the issue of missed appointments? Missed appointments cause the NHS enormous additional costs, and many are avoidable. We can do a lot to reduce the number of missed appointments, by using technology and sending text messages, emails and so onbut should we not be considering the idea of charging people, where appropriate? We should recognise that some peoples condition means that they may be unreliable [Interruption.] Well, there was a great intake of breath from the hon. Member for Bury, North (Mr. Chaytor), but if we are talking about responsibilities, where are they set out? They appear to be entirely nebulous. If we are not talking about responsibilities in any meaningful sense, we should not even use the word.
Does the hon. Gentleman not realise that in most general practitioner practices and in most hospitals the normal practice would be, as it is in other
areas of our public and commercial life, to overbook the number of appointments in the first place? That happens with aeroplanes, trains, coaches and MPs surgeries; that is how one deals with this. Does he not also realise that many people who miss appointments do not do so wilfully? Such people miss appointments because of varied and complex pressures in their personal life, and fining them for missing an appointment would be too extreme.
Norman Lamb: I made the point that there would be many circumstances in which such an approach would be inappropriate, but we should consider having such a power, and run pilot schemes. The hon. Gentleman raises the point about a system of overbooking, but if he were to talk to any GP or hospital clinician, he would find that there is a massive problem with missed appointments. If we are having to deal with delivering health services in a much tighter financial situation, we must examine ways of saving wasted costs, and this is one area that we should examine. The main point I am making is that if the constitution talks about responsibilities, those must be genuine responsibilities. If they are not, we ought not even to refer to them, because the concept is meaningless.
The Kings Fund also discusses whether the constitution will endure and whether it will be vulnerable to change by successive Governments for political reasons, suggesting that if it is to have any real value, it ought to be a document that does endure, and cannot simply be changed on a whim by successive Governments. However, the constitution appears to contain no mechanism to prevent that from happening, which is also a criticism. It says nothing, either, about continuing health care or the funding of people with complex needs, which is surely a critical aspect of health care. If the constitution fails to address that at all, it is surely weak. The idea of having second opinions in child care cases has been mentioned, but the constitution says nothing about the right to a second opinion either. That, too, should be addressed.
Let me turn to smoking. We all agree that action should be taken to enable people to give up smoking and to warn people, particularly youngsters, of the risks of taking it up. There is clear evidence that a proportion of young people buy their cigarettes from vending machines, so we readily support action to clamp down on the sale of tobacco from vending machines. Indeed, we might need to go further than the Government have proposed, so as to avoid any risk of youngsters below the legal age buying tobacco in that way.
However, the Governments case on displaying tobacco is not as good. The Conservative spokesman, the hon. Member for South Cambridgeshire (Mr. Lansley), referred to the risks of misinterpreting the statistics, but it was fascinating to read that the real price of cigarettes in Canada increased by 159 per cent. between 1979 and 1991. That led to the teenage smoking rate falling from 42 to 16 per cent., which clearly shows a direct link between price and teenage smoking rates. We know that price has an effect, but there has been no proposal on price. Canada cut the tax in 1994, because of concerns about smuggled cigarettes, and the real price fell by a third. That led to the teenage smoking rate increasing, from 16 to 20 per cent. We know that price is a relevant factorit was referred to by the World Health Organisationyet the Government have made no proposals on price.
We advocate other measures. We should establish a criminal offence of supplying tobacco to an under-age smoker. The Government appear to be flunking that one and have not come forward with any proposals. It is a criminal offence to buy alcohol in order to supply it to an under-age drinker, but why is it not a criminal offence to supply tobacco in the same way?
As for smuggled tobacco, the current statistics show that one in six cigarettes purchased in this country has been smuggled, as has 50 per cent. of the rolling tobacco. A recent article in the European Journal of Public Health highlighted the link between smuggled tobacco and deprived communities, saying:
the people with the highest likelihood of having bought smuggled tobacco...are...heavier smokers with higher levels of addiction, living in socially deprived areas and with low educational attainment.
People in deprived communities are obtaining their tobacco across the table in the pub or at the front door, yet we are talking about removing displays from shopsa controlled environment, after allwhich will do very little to address health inequalities.
Mr. Leigh: The hon. Gentleman and I represent similar rural constituencies. Although I have absolutely no brief for the tobacco industry, what worries me about the proposals is the fate of village shops. Does he think that one way round would be to have the ban, but to exempt small village shops and corner shops?
Norman Lamb: That is certainly an option. I share the hon. Gentlemans concern that village shops are under enormous pressure already. Many are teetering on the brinkindeed, many have already closedand any further loss of income could tip them into closure. That is something that we should all be concerned about.
I understand that it is already the practice in many areas for shops to sell smuggled tobacco under the counter. The hon. Member for Norwich, North (Dr. Gibson) has confirmed that he is aware of the practice, and I have heard of it happening in Haringey. If that is true, then removing the display of legally sold cigarettes in shops will only open the door to a vastly greater risk of smuggled tobacco being sold under the counter. How on earth can that be policed? This is one of those cases in which the law of unintended consequences might well apply.
I also want to mention smoking cessation, because there appears to be little evidence that the steps that the Government are taking having any real effect. At the moment, under the quality and outcomes framework QOFsystem, GPs get paid for mentioning smoking cessation to their patients and for telling them to suggest a date by which they could have given up. That is it; they get the payment just for doing that. There is no requirement to demonstrate success in the strategy of encouraging their patients to give up; they get the payment simply for mentioning it. In California, however, under the Kaiser Permanente insurance scheme, there is a much more intensive focus on counselling, on prevention, on mechanisms to encourage people to give up smoking, on smoking cessation programmes and on nicotine replacement therapy. Within that community of insured people in California, the smoking rate has been reduced from 18 per cent. to 9 per cent. It has been halved, and people benefit much more from that intensive approach.
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