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Westminster Hall

Tuesday 22 July 2014

[Mr Adrian Sanders in the Chair]


Refugee Camps

Motion made, and Question proposed, That the sitting be now adjourned.—(Lynne Featherstone.)

9.30 am

Pauline Latham (Mid Derbyshire) (Con): I am pleased to have secured this joint debate with the hon. Member for Hackney South and Shoreditch (Meg Hillier), and I am honoured, Mr Sanders, to serve under your chairmanship—for the first time, I think—on this, the last day of term.

During the past year, I have visited a number of refugee camps around the world. What has really struck me is the disparity between the conditions in different camps. In March, I went to the middle east as part of my work on the International Development Committee. I was given the opportunity to visit the Zaatari refugee camp in Jordan, which is currently home to more than 82,000 people fleeing the conflict in Syria.

Despite the fact that it is the fourth largest refugee camp in the world, Zaatari is remarkably well run and the quality of life for its resident population is comparatively very good. The accommodation provided there was far better than I have seen in any other refugee camp in the world, with the refugees living in portacabins. Although living conditions were basic, it was clear that the issues caused by overcrowding were not as prevalent as in other camps. For example, a family of up to five could live in one of the portacabin units; if a family was any larger, a second unit would be provided for them.

The relative comfort in which Syrian refugees live in Zaatari is largely due to the fact that the camp receives a lot of funding from other middle eastern states, and it is pleasing to see that aid being put to good use. Having seen its living conditions, I think that Zaatari has a greater sense of permanency than many other refugee camps I have visited.

Most people in Zaatari believed that they would be going home to Syria in a relatively short time. The reality is that in many cases there is nowhere for them to go home to because many homes no longer exist. It is perhaps a good thing that the refugees there enjoy a higher quality of life than those in many others camps do. Achieving that quality of life should be reflected in the management of camps all over the world.

The services available for children and young people in the Zaatari camp are much better than what camps usually provide, due to the provision of child friendly spaces. Obviously, a number of children in the camp have witnessed the horrors of the fighting in Syria and even seen members of their families killed. The child friendly spaces scheme, run by various global non-governmental organisations, is designed to give children a safe place to play, to ensure that they can continue to

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have a childhood and can recover from the emotional and psychological scars that conflict has caused. Many young children in the Zaatari camp start off by being able to draw only guns and tanks, but after the work of the NGOs they start to draw pictures that are much more normal for children of their age, and they even start smiling again.

I was delighted to see the particular focus on education at Zaatari. UNICEF, which runs the education programme at the camp, has set up a compound of 14 classrooms and runs two schools a day, with girls being taught in the morning and boys in the afternoon. That dedication and commitment to ensuring that the children of the camp have a good education is unusual, and will serve to mitigate some of the disruption caused to the children’s lives, and, most importantly, normalise them. It should also ensure that when Zaatari’s young people leave the camp and eventually return to their country, they will have some of the skills they need to enter the work force and thrive.

The quality of life of the residents of Zaatari is significantly better than that in many of the camps I have visited. For instance, £1 million has been spent on laying down gravel on the site to reduce the nuisance and health issues caused by excessive dust, because the camp is situated in very arid conditions. Although dealing with dust is a lesser concern than providing education, addressing it has ensured that the lives of those living in the camp are much more comfortable; people there experience far fewer chest problems, including asthma in children, than they would otherwise.

The other measure that normalised the lives of Zaatari’s residents was the way in which food was provided in the camp. As I am sure many hon. Members will have seen, food provision in refugee camps typically consists of a rationing-style system, in which residents queue and are allotted a set amount of certain types of food every day. In many cases, refugees will eat the same thing day in, day out for the length of their stay, which often runs into years. That approach undoubtedly prevents people in camps from making their own choices, and I believe that it leads only to institutionalism.

In Zaatari, residents are given smartcards, which function like cash and can be used to buy whatever their holders want, albeit from a relatively limited choice, in the supermarket-style food stores in the camp. Although choosing what to eat may seem a small concern, it is important in helping to normalise the lives of those living in the camp. I would like the approach to be rolled out in refugee camps across the world.

In stark contrast, on a visit to Rwanda with the Commonwealth Parliamentary Association earlier this year, I was presented with a sense of disorder and listlessness at a camp for refugees from the Democratic Republic of Congo. There was a huge number of young men, many of whom had been there for years; they were bored and had nothing to do. Those young men had no hope, and no chance of escaping and getting a normal life again.

Early marriage was common, due to the absence of any enrichment programmes or provision of education. We all know that education is particularly important for young women, as statistics show that those who receive education are likely to put off marriage and having children until later, meaning that they have better prospects and, above all, better health. This particular camp

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demonstrated that that is true. I learned that mortality in childbirth there was very high, because many of the girls and young women were getting married far too young, as there is nothing else for them to do.

Although there is a clear discrepancy between the provision of facilities in Syria and in other refugee camps, in camps outside the middle east a similar divide exists along gender lines, and provision for women is of particular concern. In the South Sudanese camp that I visited, toilets were non-existent and people defecated openly; when the rains come, the camp is flooded with human excrement. I heard stories of the women and girls there being too afraid to go to the toilet at night for fear of being raped. Given the duration of the crisis in South Sudan, it would make sense for more permanent toilet facilities to be built, which in turn would reduce the risk of rape that the girls in the camps face every day. However, there must be some sort of security for the toilets, so that women’s and men’s toilets are separated.

What is most shameful about the situation is that the guidelines for the protection of young girls, which specifically mention the need for the provision of lockable toilet facilities, have been in place for the last 10 years in the Inter-Agency Standing Committee’s paper on gender-based violence. It is absolutely essential that that advice should be followed in the running of refugee camps globally. In line with their strong stance on violence against women, particularly in conflict, I urge the UK Government to put pressure on the United Nations High Commissioner for Refugees and other NGOs to ensure that women are adequately protected.

It is clear that there is a huge disparity between the conditions in refugee camps such as Zaatari and those in Africa. When the residents of refugee camps eventually leave the camps, it is important that they should be able to reintegrate into normal society. Achieving that requires an emphasis on the provision of education, ensuring that children whose lives have been torn apart by the horrors of war can continue to grow emotionally and psychologically, and, most importantly, become contributors to their communities, with reasonable job prospects.

Maintaining normality is key in ensuring that adult refugees leave the camps as functioning members of society. It is clear from how Zaatari is run that self-sufficiency is encouraged there. Although the introduction of supermarket-style food provision is a positive thing, and a welcome change from how food is distributed in the African camp that I described, more could be done to encourage refugees to be more self-sufficient, ultimately ending the dependence that the camps create.

Perhaps one way to do that would be to encourage more micro-economies to be created in camps. Such micro-economies would serve to normalise life for refugees and provide lives more like the ones they will experience when they eventually leave. The fact is that the Syrian refugees in Zaatari are more educated than those in camps elsewhere, but it seems unfair that they should be able to demand one type of camp, and get it, whereas people in camps in Africa, who are generally less educated, have to put up with much more basic facilities.

It would make sense for the Department for International Development to ensure that, in its aid policy and work with NGOs, substantial facilities are put in place in

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camps. The disparity between the facilities available at Zaatari, compared with the other camps I have described, marks unfairness in how they are organised.

Although Zaatari marks what could be the global standard for refugee camps, more than 70% of Syrian refugees in Jordan and 100% of them in Lebanon live outside them. Although refugees living outside are more likely to lead lives that are more typically normal, there is a challenge in keeping them safe. Many of them are living in basic rooms, with little sanitation and poor water, but they are at least kept in family units, in individual—albeit very small—apartments.

Organisations that run the camps, such as the UNHCR, are experienced in identifying vulnerable individuals and giving them the care that they need, but that is obviously problematic when those vulnerable people are not in camps. Living outside the camps presents a number of other problems, in that refugees have to pay for their own accommodation. Of the non-camp dwelling refugees in Jordan, 90% are now in financial crisis. One reason is that refugees must obtain work permits to work in Jordan, which can often be expensive. Another factor is that some 33% of households are run by women who have been widowed by the war.

One way of assessing the needs of refugees in non-camp settings is to create community boards, consisting of elected representatives from the community. That initiative has been successful within camps and provides aid agencies and NGOs with a useful way of monitoring refugee populations. CARE, the NGO, has been running similar schemes for Iraqi refugees, and they have been very successful. Like that organisation, I believe that community boards should be rolled out in refugee populations across the globe.

Although the UNHCR does a fantastic job of co-ordinating humanitarian efforts across the middle east, especially in Jordan, it goes without saying that one of the bars to providing assistance to, and improving conditions for, refugees who do not live in camps is its reach. For example, many Syrian refugees in Lebanon are unable to access services, due to their inability to travel because of sectarian concerns. In this instance, co-operation between NGOs in these areas and the UNHCR is essential. It is to that end that I would like DFID to use its relationship and influence with the UNHCR to encourage NGOs to co-chair working groups.

It is obvious that there is much to be done in standardising the quality of life of refugees around the world. Nevertheless, it is often easy to overlook the fate of those who do not go into camps. It is vital that provision be made for those people and that they are not rendered more vulnerable as a consequence of not having entered camps. With that in mind, I strongly advocate greater co-ordination between NGOs and the UNHCR, to ensure the widest possible delivery of services and the setting up of community representative groups as standard practice with non-camp dwelling refugee populations.

I have not yet mentioned the current crisis in Gaza. People there are living in schools because they have had to flee their homes. DFID should consider what money it can forward to those vulnerable people, who probably have no homes to go back to now because there has been so much bombing. They are in a desperate situation. I hope that the Minister will take back to the Department

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my feeling, which is that I should particularly like it to get involved and help the Palestinian people to have as much of a normal life as they can under the circumstances.

Mr Adrian Sanders (in the Chair): I said privately to hon. Members that, if they wished to remove their jackets, they could. I now say that publicly.

9.44 am

Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op): It is a pleasure to serve under your chairmanship for the first time, Mr Sanders.

I congratulate my colleague the hon. Member for Mid Derbyshire (Pauline Latham) on driving forward the desire to have this debate. She and I visited a refugee camp in northern Rwanda and we were both struck by what we saw there. That sparked the idea for this debate.

I want to talk about two issues. I am not as expert as the hon. Lady on the situations in camps around the world, but I do want to talk a bit about my experience visiting Rwanda and, perhaps more pertinent to the Minister’s role, about the UK’s role in resettlement and making sure that we play our part, as a nation, to support and tackle the humanitarian crisis around the world.

As a constituency MP in Hackney South and Shoreditch, the issues in Rwanda and other parts of Africa are pertinent, day to day. I can stand at bus stops in Hackney and have many conversations about the situation at le petit barrier, the Democratic Republic of the Congo, or what is going on in other parts of Africa, particularly west Africa. Partly because of resettlement, which I will come to, these are real, living issues for communities in my constituency and throughout the country.

We visited a camp for Congolese nationals in northern Rwanda. As the hon. Lady said, we were both shocked by some of the things we saw there. It was overcrowded and there was a high number of young people, most of whom had nowhere to go and nothing to do. This is not to be hypercritical of the UNCHR, because it was clear that education was being provided up to age 11 and a few older young people had been provided with education in the community, through support from the Rwandan Government. However, with education only up to age 11, a lot of young people are idle, without the skills necessary to integrate into society and without either families or the support and ability to access anything beyond that stage. There is little education and no skills training.

We met a couple of articulate young men, who spoke both good French and very good English, we felt, and had the benefit of some education beyond the age of 11. They were desperate to play a role as young men, but felt stuck in the limbo of teenage years.

Mr Gregory Campbell (East Londonderry) (DUP): The hon. Lady is speaking about education and young people. Given the air of permanence that is emerging in some refugee camps—we do not want to consider that as a long-term solution—does she agree that, in trying to assist, we need to turn our minds to issues such as education and health care, as well as to the immediate

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problems, to ensure that those communities see that there is life beyond the next few months and to help them plan for the long term?

Meg Hillier: The hon. Gentleman hits the nail on the head. It was striking that people still believe that there is a chance of going home. We met young people born in the camp I just mentioned, who believed that there was a chance that they would be able to go back to war-torn, militia-ridden parts of the DRC—we know it is a challenging country—but who are held in limbo. We must have a big discussion as an international community about whether it is sensible to limit education. It is right that education is a basic provision—it is all funded by taxpayers around the globe, not just in the UK—but it cannot benefit our wider international community if cohorts of people misplaced through war and conflict end up in such a state of limbo and then quickly become uneducated parents.

I will not repeat the excellent points made by the hon. Lady about girls. The girls in the Rwandan camp, as in camps around the world, become mothers while still children themselves, because there is little else for them to do. Becoming a mother is a rational choice for them, because it gives them a purpose in life. However, in overcrowded conditions, where families are all living cheek by jowl and are crowded in, sleeping together, it is no surprise that pregnancy is rife.

The camp met with UN requirements—there was no sign that it was badly run—but the challenges in that region mean that camps quickly become overcrowded. This one had been closed to new admissions, but of course the birth rate means that the number of people carries on growing.

It was striking that children talked about going home, but for many there could be much better immediate prospects locally, as the hon. Gentleman said, if they could be given support to integrate—although perhaps not always in the country where the camp is located—through a proper regional integration and relocation policy. That would not mean that those refugees never had the chance to return, but it would give them the chance to build skills and opportunity, so that, if the happy day came when they were able to return to the DRC, they would be able to contribute massively more. We saw that directly with some of the MPs and Senators who accompanied us on visits around Rwanda. Most of those Rwandans had been refugees who fled Rwanda and worked in other parts of the world. They kept their skills up, had a good education and then came back to lead Rwanda out of the horrors of the genocide of 20 years ago. We can see what happens when people have support; there was a direct contrast.

On the UK’s role, I had the privilege when I was a Minister in the previous Government to have some oversight of the gateway scheme, through which the UK Government take refugees from United Nations camps around the world. The Government accept those who meet the UN criteria. For the record it would be useful to remind Members what those are. The categories for vulnerable people include

“women and girls at risk…survivors of violence and/or torture…refugees with medical needs or disabilities…LGBTI refugees at risk…vulnerable older adults…refugees in need of family reunification and…those who face serious threats to their physical security, especially due to their political opinion or belonging to a minority group.”

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The first categories are probably more pertinent, day to day, in camps.

When the Government talk about reducing immigration from the hundreds of thousands to the tens of thousands, we must not lose sight—I hope the Minister will make clear the Government’s position on this—of our international humanitarian responsibilities in this regard. When I became a Minister, we were accepting 500 people from the camps annually, but we aimed to raise that to 1,000 a year. Can the Minister tell me what the figures are over the past two or three years, so that we can see what the trajectory is and what the projections are? If not, perhaps she can write to me.

We also face pressures—I will come back to the gateway scheme in a moment—within the European Union, where Mediterranean countries continually receive boatloads of desperate and vulnerable people from north Africa. Discussions about burden sharing, as those countries put it, absorb a lot of time at EU Justice and Home Affairs Council meetings. We need to have a greater and wider view on the matter. I sat next to the Maltese Minister for three years. Every time I sat next to him, he asked whether we would take refugees who had arrived in Malta. We were, however, also trying to take refugees from camps around the world. We need to see that bigger picture across the EU much more. Some EU countries take good numbers of people from UN camps. Others take very small numbers. We need to look at that as part of a wider strategy. It is a sensible strategy for Europe to enable those in great need to resettle in Europe, where appropriate, and have them contribute to the European Union. It sends a message that we are supportive, but it is important that we have immigration controls more generally.

On the gateway project, it was a privilege to work with the Home Office officials who work to support resettlement. They visited the camps—I was prevented from doing so at the time by pregnancy—to see for themselves the families that they, working with the UN, felt could be relocated in the UK. There was a joint resettlement between Northern Ireland and the Republic of Ireland, so that there was a critical mass of people from a particular region, which meant that there was language support and the other support necessary for that group. Scotland was also very good at receiving groups of refugees. The idea was that local authorities would bid to take on refugees from the camps, and there was no shortage of willing volunteer local authorities. I was slightly worried that there would be.

It is perhaps pertinent for the Minister to take this back to some of her colleagues in Government, but what was heartening was that communities—often, churches and community groups—that knew they would be receiving people who had lived through desperate times would work positively to receive and welcome those people into the community. The media coverage locally was positive and it was seen as humanity, not as a burden to the UK.

Mr David Ward (Bradford East) (LD): I endorse what the hon. Lady is saying. Bradford as a community accepted the Rohingya—I believe they were part of that gateway programme—which shows that, even in an area where there is tension from increased immigration,

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there is still a positive and welcoming response when people understand the circumstances of where these groups are coming from.

Meg Hillier: Absolutely. It is wise for all of us who sit in this House and have the opportunity to speak about these issues to be moderate in our discussion of immigration. I was a Home Office Minister and I partly dealt with immigration issues. I absolutely believe that we should have an immigration policy and criteria, but the rhetoric that sometimes comes out—unfortunately we often saw that coming out very negatively during the European elections—is deeply unhelpful. I am sure the Minister will want to put on record her position and that of the Government on how they want to support people from around the world whose lives have been torn apart by conflict.

When I was a Minister, we looked at the Canadian model and it would be interesting to know whether there have been any further developments on that. The model could boost the numbers by allowing local groups, particularly religious groups—churches and mosques and others—to raise money locally to accept more from a particular community into their area, effectively match-funding some of the Government money going into the project. The model would build on the good will and humanitarian support that is embedded in the British psyche and ensure that we do everything we can to support these groups.

On the wider issue of refugee camps, we have to have a bigger debate internationally. We all look at the issues, particularly what is happening in Syria, where many have been displaced. A young man, Chris, who is going to Palestine, came to visit me at my surgery yesterday. He said, “Remember that a lot of the people in those camps have already been displaced once. They are being displaced again.” There are whole areas of the world where people are not settled and do not have the right to a stable home, to education and to get on with their lives. They do not have that opportunity. It is important that as a community, not only in the UK, but in the EU and the other partnerships in which we work, we recognise the instability that that causes to the world.

Our Government need to do all they can to support and stabilise what is happening in Syria. It is difficult for one Government to achieve that alone, and that is why we must work with our international partners. We must also ensure that we think about the long-term consequences of having camps that sit, grow and become communities that are almost sub-sections of a society in their own right. We must also ask questions about whether that is desirable in the long term. We should be shifting the boundaries of the debate, helping more of those refugees to resettle, whether that be in the region or elsewhere, and giving them the chance, as the hon. Member for Mid Derbyshire put it so eloquently, to normalise their life so that they can adapt, when the opportunity arrives, to life outside of the enclosed and artificial environment of the refugee camp, of which there are many around the world.

9.57 am

Mr David Ward (Bradford East) (LD): I am delighted to be serving under your chairmanship, Mr Sanders—it is the first time, I think, for me and thee. I do not know whether I need to mention this for any particular protocol

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reasons, but I would like to thank the Council for European Palestinian Relations for supporting me and a number of other parliamentarians in a delegation last November to Jordan to see a number of camps, including Zaatari. That is in the Register of Members’ Financial Interests, and I will come back to it in a moment.

I want to talk about what is often regarded, certainly by its members, as a forgotten group of refugees—those from Gaza in the refugee camp in Jerash, Jordan. I suppose I cannot talk about them without talking about Gaza today. The Gazans I will be talking about are those who fled in 1967, which causes particular problems for them with citizenship, but there are 1.8 million or so Gazans who cannot flee from Gaza today. They are hemmed in by air, sea and land by what many regard to be a brutal and powerful military force, and they are at the mercy of that force. Our thoughts must be with them, as they should be with innocent Israelis who are caught up in this and are under threat from rocket fire in retaliation—others would deny this—for the suppression. Either way, whatever the reason, it must be condemned. Hopefully, more and more innocent Israelis will see that the way to their security is not through military or other suppression of the Palestinians.

When we visited Jordan, we were fortunate to meet the Prime Minister and the Foreign Minister and have a wide-ranging conversation. It is unsurprising that they thought the numerous wars surrounding Jordan, which it has sat amidst for many years, can be traced back to the Israeli-Palestinian conflict. The expulsion and displacement of Palestinians across the region has created tensions and animosity towards Israel. We raised the issue of Palestinians wanting to flee Syria and the policy of denying them access to Jordan. Some do get through, but the response that we received, which must be accepted, was that more than 2 million Palestinian refugees are registered in Jordan.

It is difficult to deny that Jordan is making a phenomenal contribution at huge cost. Yes, it receives funding from other countries and from agencies, but we must never forget the contribution that Jordan, which is sat in the middle of all this, makes year in, year out. As the hon. Member for Mid Derbyshire (Pauline Latham) mentioned, many of the 2 million Palestinian refugees in Jordan—some 70%—actually live in people’s homes with them. You covered well the fact that that is not an ideal situation. Just because they are not in a refugee camp does not mean that they are living well. They are often in poverty and in situations that create understandable tension in those homes.

The scale of the Zaatari refugee camp is staggering. It is unbelievable. The majority of the refugees are Syrian, because they are flooding over the border. As I said, Palestinians are not actually allowed into the country—bizarrely, they are seen as Syria’s problem and therefore are not eligible for refugee status in Jordan. Some do get through, but the policy is not to allow them in. The camp was opened in July 2012 and when we there at the end of last year it was estimated that there were some 120,000 refugees, 60,000 of whom were under 17, which is mind-boggling. Every day, 4 million litres of water are brought in and garbage and the sewage from the 1,500 toilets must be disposed of. Simply coping is a mammoth task. Schools and hospitals do exist, and additional funding has gone in since our visit, but it is

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hard to believe the scale of the enormous task before the Government and the agencies in dealing with, for example, the vaccinations of 60,000 children.

Around the time when we were at the camp, a figure of 80,000 was regarded as being its core, settled population. When we were there, 300 to 400 refugees were arriving every single day. Busloads were arriving not on one or two days a week but day after day, and they all had to be accommodated, sorted out and provided with somewhere to stay. Many were leaving and heading back to try to find work. Harvesting, for example, means that some will come and go, depending on whether they have work to return to. They will be in danger, but they have to go back.

I was left with a couple of memories, the first of which is the fantastic work being done by the various United Nations organisations. All the UN workers there are incredible human beings who face unbelievable circumstances. My second memory is of the resilience, ingenuity and enterprise of the refugees themselves. When we walked down the middle of the camp—you will remember it—there were some 650 stalls, selling everything under the sun, which shows that enterprise and initiative can flourish even under the most difficult of conditions.

I want to discuss the Gaza refugee camp at Jerash, where conditions are stark compared with Zaatari. Whereas most of the Palestinians to whom I have referred have been granted Jordanian citizenship and enjoy all the related rights, the refugees who came from the Gaza strip, which was Egyptian-controlled in 1967, are almost stateless. They are regarded as Egypt’s problem, because they were under Egyptian jurisdiction when they fled Gaza and took refuge in Jordan. The camp was opened in 1968 and is somewhat smaller than Zaatari, holding some 20,000 refugees. They live in deprived conditions and do not enjoy the rights that come with citizenship. They cannot vote or work for the Government and are not supposed to benefit from Government services. They also cannot progress educationally. Schools do exist, provided by the United Nations Relief and Works Agency, but those who attend are treated as international students. Many have lived there since 1967, but they are still treated as international students for the purposes of tuition fees.

Perhaps the clearest example of the difference between the Zaatari camp for Syrian refugees and the Gaza refugee camp for Palestinians is that, although it was some two years old at the time of our visit, the Zaatari camp is being upgraded with a fully functioning sewage disposal system. The Gaza camp, which was created some 47 years ago, still does not have a sewerage system. There are 20,000 people but no sewerage system.

We met some remarkable people on our visit to the Gaza refugee camp in Jerash, including a dozen or so young girls from the local school parliament. The school has over 1,300 girls, so conditions are cramped, and next door is a boys’ school of a similar size. The schools cannot contain all the pupils, so both operate a shift system with morning and afternoon schools. The girls were brilliant and inspirational. They are full of self-confidence and are quite outspoken about demanding that something be done to support them. They told us of their high ambitions and their desperate desire for access to higher education. The teaching in the schools is delivered by UNRWA and is of a high standard, but

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resources are of course quite pitiful by our standards. There is internet access, and I told those girls that I would try to establish a link with a school in my constituency, which has now taken place, so there is a link between Laisterdyke high school in my constituency and the school that we visited.

The young girls’ tales were of hardship and family stress. I mentioned resilience and determination, but that camp was more than 45 years old, and they must fear that in practical terms little will change in the future, because of their failure to gain citizenship however long they might have been there. Unlike some of the camps in Lebanon that we have heard about, people in the Gazan camp are free to come and go as they please, but there remains an overwhelming sense of lives being constrained, and indeed they are constrained. People are not starving, but the diet is poor and there is deprivation and stress, all of which take their toll on refugees’ health.

As I said, the refugees are not fully accepted in Jordan. Most have temporary Jordanian passports, which they have to renew every two years, and let us not forget that many families have been there since ’67 or ’68. The unemployment rate is very high, at 81% for women, which is double the rate of non-Gazan Palestinians elsewhere in Jordan.

Most donors want to contribute aid to much higher-profile areas—I am sorry to have to say that—such as Gaza itself and the west bank. My plea is not to forget the forgotten group of refugees who seem to have been left behind when so much is quite rightly done in many other areas. They have the unique circumstances of being almost stateless and of feeling forgotten.

Mr Adrian Sanders (in the Chair): Will Members remember to make their comments through the Chair and not use the term “you”? Just a polite reminder.

10.12 am

Jim Shannon (Strangford) (DUP): It is a pleasure to make a contribution, Mr Sanders, and I thank the hon. Member for Mid Derbyshire (Pauline Latham) for securing this debate and creating the opportunity. It is a pleasure to follow all the speakers, as it will be to listen to those who follow.

I am pleased that the issue has been raised today, although I feel that we do not remind ourselves of it often enough. It is good to have such debates, because they give us the opportunity to remind ourselves of the appalling conditions that refugees endure on a daily basis. Unfortunately, because they are not in our backyard, we tend to have the ability to forgo images of cramped tents, dirty water and malnourished children. It is important that we remind ourselves of those in the world who need help and about how our Government can help those who need help most.

For thousands of people, that is their everyday life—the hardships and challenges that they face every morning when they wake up. In the United Kingdom, we complain about traffic jams, the tube or queues for coffee in the morning. Thinking about the challenges that others have in the world puts things into perspective, and this debate gives us that opportunity.

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The number of refugees and asylum seekers worldwide has exceeded 50 million for the first time since the first world war. In 2014, that is a sad statistic to read. The largest refugee camp is the Dadaab camp in Kenya, with a total of 355,709 refugees recorded as living there, 95% of whom were Somalis. Registration facilities were closed in October 2011, so in excess of 500,000 refugees are now reckoned to call Dadaab “home”. As the hon. Lady indicated, we do not want the refugees to think of the camps as home—the camps are not home, but a staying point until they can go back to where they come from.

Médecins sans Frontières conducted interviews with refugees living at the camps in 2013 and its findings were truly shocking, with 41% complaining about the condition of shelters that did not even protect them from the rain, while a further 11% had no access to toilet facilities. The situation is no different in Ethiopia’s Dollo Ado camp, which is home to almost 200,000 people, of whom 170,000 are Somalis. In February 2013, it was estimated that between 150 and 200 Somalis were arriving at the camp each day. Unsurprisingly, therefore, the International Medical Corps found that refugees in Dollo Ado were at risk of malnutrition and poor hygiene facilities due to overcrowding. Such conditions are being compounded every day.

In Jordan, the Zaatari camp houses 122,673 refugees, but provides slightly better conditions than those I have mentioned, boasting three schools, two hospitals and a maternity clinic. That is not the norm but, none the less, lots of problems still exist there. As in every refugee camp, women are at high risk of violence, which perturbs me greatly. That is one of the things that has come to my knowledge as an MP that I would not otherwise have known—the level of violence against women in the camps, as well as elsewhere. In 2013, according to a UNICEF report, Syrian women and girl refugees felt unsafe using toilets and communal kitchens; in some instances, they simply did not leave the tents that they were housed in, staying there for safety.

Refugee camps are particularly dangerous for women and children. For example, on 6 June, members of the Danish Refugee Council went to the Ifo camp in Dadaab to train men in the prevention of and response to sexual and gender-based violence. In the Ifo 2 camp, the Kenya Red Cross held sessions for adolescent girls on issues of HIV/AIDS, early marriage, forced marriage and female genital mutilation. Although that work is commendable, the fact that such training and sessions are necessary shows just how commonplace sexual and gender-based violence is. Reports suggest that that is the same in refugee camps worldwide, which worries me greatly. The Minister, I know, is well aware of those issues and I look forward to her response. Such violence is truly devastating, and we must do more to stop it.

The situation at the camp in the Gaza strip, which is home to 110,000 refugees, is fairly bleak, with some 90% of the water unfit for human consumption. Concern about poor drinking water and, in turn, the spread of disease is widespread across the camps. In South Sudan, the Yida camp, which contains about 71,000 refugees, has witnessed a sudden cholera outbreak—the disease is spread by poor hygiene conditions and a lack of drinkable water. We have had many debates in Westminster Hall and the main Chamber about the need for better

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drinking water. Wateraid helps, but the need is a basic one in refugee camps, because of the poor hygiene conditions.

UN aid agencies have claimed that hundreds of thousands of refugees live in unacceptable conditions in the camps, blaming food and safe drinking water shortages. Those two problems combined can lead to, and certainly seem to aid in, the spread of life-threatening diseases, such as cholera, malaria, jaundice and malnutrition. In South Sudan, in one camp, officials have reported cases of hepatitis E, which is yet another disease spread through contaminated water.

UNICEF estimates that 400,000 children aged under five will need treatment for malnutrition. To put that into perspective, I should say that the population of Belfast is more than 280,000 and that of Newtownards, the home of my constituency office, more than 77,000—a total of some 358,000. The entire population of the city of Belfast and the town Newtownards still do not account for that number of 400,000 children—that is the vastness of the issue.

We must remember that the global theme for this year’s world refugee day is “1 family torn apart by war is too many”. Refugees have suffered inconceivable losses, from family members and friends to their homes and neighbourhoods, because of conflicts going on in their countries and beyond their control. Sometimes they are involved neither physically nor personally. The camps should be a safe haven for them, but instead many are faced with squalid conditions, widespread disease, a lack of food and water and, for women in particular, fears of being subject to violence and even rape, in a place where they should feel safe.

I understand that tablets have been provided in some camps in an attempt to purify the water, and that although people have tried to teach refugees how to stay healthy and safe, that is not always possible or indeed enough. I appreciate the difficulties of funding for camps, but an attitude that there is only so much that we can do is not good enough when we are talking about an average of 10 children under five dying in those camps every day. That is the magnitude of the issue.

Furthermore, some Syrian refugees are not even receiving aid because they are too scared of endangering themselves or their families back home by registering with UN agencies and, in turn, camps. Even though they have escaped, they cannot register because that would have an impact on their families back home.

For me, without doubt the greatest tragedy is that there are children who have lost out on so much: their childhoods, their education, to which my hon. Friend the Member for East Londonderry (Mr Campbell) referred, and their homes; in some cases they have lost family members and friends. According to UNICEF, nearly 2 million Syrian children have dropped out of school since 2012. Climbing trees, playing football in a park or visiting a neighbouring village are normal activities for children as far as we are concerned, but for children in refugee camps such activities are distant memories. Half of the total Syrian refugee population in Iraqi Kurdistan are children. Camps provide very few child-friendly spaces or schools and there are a limited number of areas where children can play.

The hon. Member for Mid Derbyshire has a passion for this subject. I have spoken to her before about it and listened to her comments and questions on it in the

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House. It is clear that she understands the issue. We hope to hear a significant response from the Minister on how best the Government can help those refugees in far-off camps.

A total of 328,000 people have left South Sudan to head for neighbouring countries. At Kakuma refugee camp in north-west Kenya, 1,750 children arrived alone and over 5,000 accompanied by an adult. So far, over 2,000 children have arrived there in need of psychosocial support and assistance of all kinds. The figures are simply horrendous.

We in this Parliament have a responsibility to those in a less fortunate position than ourselves, no matter where in the world they are. For many, the camps are only just better than the war-torn states that they have fled from. There is an old saying, “Out of the frying pan, into the fire”; for many refugees, that is exactly how it is. They still face the prospect of death, although it comes in a different form—from disease or starvation rather than from bullets or rockets. Many live in fear of physical and sexual violence each time they leave the security of their tents. For many children, education is simply out of the question and they face very uncertain futures. That is why this debate is so important.

10.22 am

Guy Opperman (Hexham) (Con): To misquote Charles Dickens in 2014, these are the best of times and the worst of times. It is an age of wisdom and an age of foolishness. There is a season of light, there is a season of darkness. There is a spring of hope and there is a winter of despair.

To look at the worst of times, others have set out graphically the vast scale of the problem. There are 50 million refugees, and huge numbers of Syrians, for example, are fleeing that conflict zone—it is that country I particularly want to focus on. We debate the issue on 22 July with conflict in Gaza and Israel, with no cessation of rockets or hostilities, no durable ceasefire and no progress to a two-state solution. At the same time, Russia and Ukraine are in a separatist dispute that is producing ever more refugees, and there has been the horrifying loss of flight MH17.

One could say that the debate brought by my hon. Friend the Member for Mid Derbyshire (Pauline Latham) is particularly timely because there is a risk that while all those atrocities are going on and being shown on the television, conflicts and refugee situations that have been going on for a considerable time have almost been forgotten. It is a fantastic aspect of the House of Commons, first, that when we get this job we gain a greater understanding of the huge complexity of the problems faced around the world and secondly that, on a hot and steamy morning, Members from four different parties are here, making the case that we genuinely all care, on a cross-party basis, about the suffering of the individuals involved in these situations.

I will touch briefly on what I consider to be the best of times. In January this year, I travelled with a number of colleagues to the Nizip 2 camp. It is on the River Euphrates, a wonderfully peaceful and soulful spot on the Syrian-Turkish border that is revered in religious history. Right next to the Euphrates are 17,000 people in the Nizip 2 camp in a combination of tents and containers.

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We are debating the conditions in refugee camps. Like my hon. Friend the Member for Mid Derbyshire, I have had the privilege of seeing the amazing work that the Turkish Government in particular are doing to make the Syrian refugees, who have fled primarily from Homs and Aleppo, feel very welcome. I have also seen the quality of care and of the camps there. My hon. Friend talked about the gold standard of the camps that she visited; I recommend wholeheartedly the efforts of the Turkish Government in looking after Syrian refugees in Nizip.

We travelled there to see in particular how taxpayers’ money is spent. One of the benefits this Parliament has over the previous Parliament is that the argument that international aid is money worth spending is almost overwhelmingly won. It was patently clear that British taxpayers’ money was being used constructively and properly, particularly in the systems for payment for food and the debit card system for the supermarkets there. That drives away the dependency culture and creates an independence that is vital. The House of Commons Library debate pack featured an outstanding article by Mac McClelland in The New York Times from 13 February 2014, which is helpfully entitled “How to build a perfect refugee camp”. If anyone wishes to understand how we should be doing it, that sets it out.

In Nizip we saw many things. I can only praise the container system there—it works and is way better than the usual tents and the difficulties with those. I certainly praise the remarkably open and welcoming approach of the Turkish Government. It was refreshing to see people so frank in their desire to help their fellow man and also to see the degree of support given by a multitude of agencies: DFID itself is very much involved and there is support from UNICEF and from some of the Arab nations, particularly Qatar.

It was noticeable that the quality of life and the optimism about going home, as well as the lack of a dependency culture, were so much better in Nizip because of the quality of the camp. It was not creating a dependency culture but a desire to regroup and to go home at some stage in the future. That is what I understood from all the people I met during my time there. My hon. Friends the Members for Braintree (Mr Newmark), for Pudsey (Stuart Andrew), for Huntingdon (Mr Djanogly) and for South Basildon and East Thurrock (Stephen Metcalfe) also attended, and my hon. Friend the Member for The Cotswolds (Geoffrey Clifton-Brown) did the majority of the organising. We were all struck by the fact that these were people who, fundamentally, simply wish to go home.

As for the situation going forward, I have to raise the fact that on 29 April this year I held a debate with this same Minister about aid and relief getting into Syria. It was six or seven weeks after the passing of UN Security Council resolution 2139. I will remind the Minister of what she said on that occasion. That resolution was adopted unanimously, which is rare for Security Council resolutions on refugees. It calls for an immediate end to all violations of international humanitarian law and violations and abuses of human rights, and demands that all parties fully implement the provisions of the Security Council. It asks them immediately to lift the sieges of populated areas and—this is the crucial point—

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provide unhindered cross-border and cross-line access for UN humanitarian agencies and their implementing partners, stressing the need to end impunity for violations.

I regret to say that not a lot has happened about implementing resolution 2139, so I would very much like the Minister, who promised on 29 April to take the matter back to the United Nations, the Secretary of State, and the individual organisations involved, to explain why aid is still not getting through—why that is not being enforced by the United Nations—given that a Security Council resolution makes it clear that it should be provided, and should get through. The overriding impression is that a resolution was passed and that nothing was done about it.

One cannot talk about the future without hope springing up, and, much like the hon. Member for Bradford East (Mr Ward), I was tremendously struck by the young women and children whom I met at the Nizip camp. They were overwhelmingly positive about the life they would lead in the future. We did a straw poll of the year 6 and 7 children we met. Most of the young ladies wanted to be doctors; most of the young men wanted to be engineers. All intended to go back to their country, rebuild it, and look after the people.

I met a young man called Suleiman, who had come from Homs and had left behind many members of his family. He was a qualified engineer, aged about 21. He was trying hard to teach people in the camps. One could talk a lot more about the quality of the education. Today’s debate is about conditions in refugee camps, and I urge DFID and the humanitarian agencies to bring more attention to bear on the quality of education, because a silo system is operating, to some extent.

The overriding impression is that individual charities, DFID and the nations that are involved provide fantastic amounts of basic aid, and then allow limited education to be provided, effectively from within the camp. I am utterly convinced that we could do more to provide education, and assistance with education, in individual camps. That might include providing books, with charities organising that in the camps. There is massive need, and there is a huge role for DFID and others to play. Without a shadow of a doubt, I want more such work to be done.

The need for refugee camps will clearly never disappear. The quality of what I saw at Nizip was amazing. I look forward to visiting Jordan with the Tearfund charity, which has invited me to go there in the near future. I praise my hon. Friend the Member for Mid Derbyshire, and look forward to a response from the Minister about resolution 2139.

10.33 am

Alison McGovern (Wirral South) (Lab): It is a pleasure to serve under your stewardship, Mr Sanders.

I congratulate the hon. Member for Mid Derbyshire (Pauline Latham) on securing this important debate, and I thank the Backbench Business Committee for granting time for us to discuss the vital issue of refugees and the conditions in the camps where so many have no choice but to reside. I congratulate my hon. Friend the Member for Hackney South and Shoreditch (Meg Hillier), who spoke movingly of the camp for Congolese refugees that she saw in Rwanda. She was eloquent in speaking about the many issues that have to be faced. The hon.

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Member for Bradford East (Mr Ward) made important points, as did the hon. Member for Strangford (Jim Shannon) in his comprehensive remarks about the serious challenges that exist. Finally, I have not visited a refugee camp, but the hon. Member for Hexham (Guy Opperman) made it clear why it is important for Members of this House to do so, and to share with us the experience of people who live in camps. I commend the work he has done on that.

There is a simple fact at the heart of today’s debate. The world’s refugee problem is growing, and that trend shows no sign of reversing. By the end of 2013, according to estimates of the UNHCR, there were more than 51 million people worldwide—almost the population of England—who had been displaced, whether by persecution, conflict, violence, or human rights violations. Over the 12 months of 2013, 1.1 million people became refugees or asylum seekers, while just 415,000 returned to their countries of origin. The net impact on the global numbers suffering displacement is clear from those figures; there is a rapid and continuing expansion. The cost and impact of that growth falls overwhelmingly on the poorest nations. Developing countries host 86% of all the world’s refugees. In the light of such figures, it is absolutely right that we should discuss what we can do both to pre-empt the process of people becoming refugees through conflict prevention and poverty alleviation, and to improve the lot of those who are already displaced—particularly the vulnerable millions scattered across the world’s refugee camps.

As has been mentioned by several Members, the terrible, unabating conflict in Syria is one of the key drivers of the upward trend in refugee numbers, as civilians forced from their home by the violence stream across the borders of neighbouring countries. Many end up in refugee camps, while others filter informally into the existing Syrian diaspora communities in those areas. More than 2.8 million refugees have fled Syria, and the vast majority are now located in Lebanon, Turkey and Jordan. There is still much to do to improve conditions for refugees housed in camps in those nations, but it is right to pay tribute to the work of the Governments of those countries, all of which have their own significant domestic issues to deal with, for their commitment to and support of hundreds of thousands of new residents.

Perhaps the starkest example of what I have described is Lebanon, which is home to more than 1.1 million Syrian refugees—a figure equivalent to a quarter of that nation’s permanent population. Given the unimaginable strain that such situations place on the often fragile and overburdened systems of health, education, employment and security in host countries, it is essential that the UK should do what it can, alongside the international community and the development sector, to support people in refugee camps.

Hon. Members have already mentioned some high-profile failings at refugee camps, and I will not describe those again. They are often due to a shortage of support, a lack of planning or a failure to learn the lessons of previous experience. In the Syrian crisis, the Zaatari camp, just across the border in Jordan, is worrying in many ways. Apparently uncapped expansion of the camp has been allowed, way beyond what local resources can support; later arrivals have been housed in makeshift, unsanitary conditions, in tents with little protection from the extremes of heat and cold of the Arabian

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desert. The camp sprawls over five square miles, with limited and often constrained food supplies. Security is limited, and violence—especially sexual violence—is a threat and a worry, as are health facilities that are less than we might want. There are also constraints on education provision.

However, as hon. Members have described in depth, incredible work is under way to improve the situation at Zaatari, and some of the other Syrian camps have learned the lessons. Those lessons include localising facilities around the camps rather than concentrating them in one spot, improving access and reducing potential for conflict. My right hon. Friend the shadow Secretary of State for International Development has visited the Azraq camp, which is also in Jordan. It works on the basis of villages, each with its own clinic, playgrounds and facilities, and there is accommodation in prefabricated huts housing a maximum of five refugees each. That is hardly a great home, but it is better than what passes for refugee accommodation elsewhere, as was forcefully described in the opening speeches. What is the Minister’s assessment of the effectiveness of that model, and what logistical and technical support is her Department providing to Governments in conflict-ridden areas, who suddenly find they must establish such camps, so that lessons will be learned and best practice will not go to waste?

The hon. Member for Mid Derbyshire asked, as I do, whether the Minister has had the opportunity to examine the effectiveness of top-up cards for refugees to pay for food and supplies—the shadow Secretary of State saw that in the Azraq model—instead of relying on sporadic handouts of aid.

The financial and resource strain that a sudden influx of refugees places on host nations such as Lebanon, Jordan and countries in Africa is unimaginable to us. Inevitably, with the need to provide shelter, water, food and security for hundreds of thousands of newly arrived refugees, other needs, including education, tend to be neglected by the host nations. The hon. Member for Hexham made that point well. Yet a failure to provide at least a basic education can have the most damaging long-term impact. Those who flee conflict and violence are often disproportionately young, and it is the young we are trying to remove from the violence. In Lebanon, there will soon be nearly 500,000 children of school age in camps, yet few have access to schools in the camps or in Lebanon’s towns and cities. The Lebanese Government lack the funds and teachers to provide that education safety net.

As the Syrian conflict drags on, the prospect of many children missing out completely on education rises, ingraining illiteracy and poverty. Will the Minister update us on what support her Department is providing to help to ensure that when refugee numbers are so great that they overwhelm the resources of host nations, young people, particularly those fleeing Syria, can receive at least a basic education? Will she assure us that her Department is making long-term funding available for education for young Syrian refugees, as well as supporting emergency schemes to get some basic provision in place now?

All too often, refugee situations, whether in Syria, Palestine, Somalia, South Sudan or the Central African Republic, switch from being short-term humanitarian emergencies to long-term challenges for the refugees, the host nations and the international bodies that support

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them. Refugee camps that were intended to be temporary become homes to hundreds of thousands of refugees for years, or even decades in the worst cases. It is crucial that we choose how to use our limited resources sensibly. The urge to give aid to tackle an emergency refugee situation is strong and often right, but we must examine carefully how that can be balanced against the long-term funding that is so necessary in refugee camps that persist for many years, to ensure that they do not become homes for the hopeless—those without education, without health care, even without the hope of moving out of extreme poverty and living their lives securely.

I pay tribute to everyone in this country who supports the City of Sanctuary movement and all UK volunteers who work to support refugees. Their work is not unnoticed, and we are very grateful for it. I again congratulate the hon. Member for Mid Derbyshire on securing this debate, and I look forward to hearing the Minister’s response to the many vital points that have been made this morning.

10.43 am

The Parliamentary Under-Secretary of State for International Development (Lynne Featherstone): It is a pleasure, Mr Sanders, to serve under your chairmanship. I congratulate my hon. Friend the Member for Mid Derbyshire (Pauline Latham) on securing this important debate and all hon. Members on their contributions. Hon. Members throughout the House are genuinely committed to the plight of refugees, wherever they are in the world. Meeting the needs of refugees and other forcibly displaced people is at the centre of the UK’s humanitarian work, and I welcome the opportunity to discuss it. I will try to respond to as many points as possible.

The debate is timely. A month ago, on world refugee day, the United Nations High Commissioner for Refugees reported that in 2013 the number of refugees, asylum-seekers and internally displaced people worldwide had, for the first time in the post-world war two era, exceeded 50 million people. The increase from 2012 has been driven mainly by the Syria crisis, as many hon. Members said, but there have also been major new displacements in Africa, notably the Central African Republic and South Sudan.

My first visit to a refugee camp was to the north of South Sudan where refugees came across from South Kordofan and Blue Nile. That was also when I had my first trip in a helicopter, because there were no roads and the rainy season had started. The logistics of bringing in life-saving supplies were quite extraordinary in the direst of circumstances. Having to fly everything into refugee camps there partly explains the cost of the camps. I will go into the different costs, because where camps are situated and the countries they are in are critical to those costs.

This rise in the number of refugees is part of a worrying global trend reflecting the complexity of protracted crisis situations with regional and cross-border dimensions and the quadrupling of overall humanitarian need over the past decade. Increasingly, many refugee situations are continuing for extended periods. In 2011, a UNHCR study of 30 major protracted refugee situations

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found that the average length of displacement now is almost 20 years, compared with an average of nine years in the early 1990s.

Many hon. Members referred to the longevity of the camps, and I reiterate that primary responsibility for the assistance and protection of refugees lies with the host state. The UNHCR is mandated to lead and co-ordinate international action to protect refugees and resolve refugee problems worldwide, and to seek durable solutions to refugee displacement. I agree with all hon. Members who have said that we must normalise situations that last for a long time by providing skills, education and the hope of life beyond the camps. Solutions may include voluntary repatriation, assimilation within new national communities or resettlement to third countries. In 2013, refugee returns were fewer than 500,000.

The focus of this debate has been conditions in refugee camps, but it is important to note that the majority of today’s refugees do not live in camps. In 2012, a UNHCR study showed that only 35% of the 9.5 million refugees assessed lived in planned camps, and that the majority were living in private or rented accommodation. The hon. Member for Hackney South and Shoreditch (Meg Hillier) referred to that, and I will respond in due course. More recently, it was estimated that 86% of Syrian refugees live outside camps.

It is critical to ensure that those with responsibility for meeting refugees’ needs are able to tailor their responses to different contexts. Camps are not usually the preferred solution for refugees, because they are expensive and often do not have good security. I have seen jealousy in host communities. Many hon. Members referred to education, and when it is provided in camps in countries where children outside the camps are barely in school, the balance must be carefully considered. My Department must consider the context or there may be all sorts of trouble between those inside and outside the camps.

The 1951 United Nations convention relating to the status of refugees and its 1967 protocol laid down the basic minimum standards for the treatment of refugees. The UNHCR has further developed them into detailed standards and guidelines in every sector of humanitarian assistance and protection. Today’s debate has rightly highlighted the fact that conditions vary widely from one camp to another. The issue is complicated. It depends partly on the political willingness and economic ability of a country to host refugees. In the middle east, as my hon. Friend the Member for Mid Derbyshire said, host states are relatively wealthy compared with those in Africa and perhaps more politically willing to help with refugees. Certainly, as the hon. Member for Hexham (Guy Opperman) said, the Turkish refugee camps are of the highest quality. They are quite astonishing. I was at an iftar meal, as I am sure many Members in the Chamber have been. It was a Turkish evening, and the quality of the camps was referred to many times over.

Conditions vary widely depending on how well the camp has been planned in advance and where it is located. Often, as I said, camps are situated in very poor circumstances without proximity to natural resources such as water or wood. The capacity of the camp to expand to more refugee influxes is also a factor, because if different cultural groups are sited in the same place or in close proximity, it results in overcrowding and tension.

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A number of Members raised the issue of women and girls in refugee camps. As I am sure everyone knows, DFID puts women and girls, and particularly preventing violence against women, at the heart of all its development programmes. The Secretary of State gave a call to action to address the danger to women and children and their vulnerability in refugee camps, as has been mentioned. One of my earliest meetings was with a number of the agencies involved, and I said that this was a first-order issue. For a long time, food, water, shelter and sanitation were the first-order issues, but it is now becoming recognised that that is not enough any more.

Pauline Latham: Is it not true, however, that in these camps, we still do not separate the girls’ and women’s toilets from the men’s toilets and provide security so that they can go safely to the toilet without fear of rape?

Lynne Featherstone: My hon. Friend is right, but that is beginning to happen. Camps are at a variety of stages in their evolution. The newest and most modern camps most definitely have separate, safe toilets and all those things, but other camps that have been in existence longer do not necessarily have them. The issue has been raised and everyone is now aware of it. The Secretary of State’s call to action has highlighted the issue and put it on the front page, so that the agencies understand that it is as much a part of humanitarian aid as the more traditional first-order issues. I think we all recognise the danger that women are in. They are vulnerable if they go outside the camps to look for wood; they are at risk of violence and sexual assault, and we have called on others—UN agencies, donors and non-governmental organisations—to do the same as we have and put women, girls and children at the heart of their humanitarian response.

I want to try and answer more directly some of the questions that have been asked. I thank my hon. Friend the hon. Member for Bradford East (Mr Ward) and the hon. Members for Strangford (Jim Shannon) and for Hexham for their contributions. Education and food were raised in particular. Enrolment rates in education are higher in camps than outside—in Iraq, they are 57%, in Jordan, they are 67%, and in Turkey, they are 80%. There are three schools in Zaatari and 20,000 children, but there are still problems maintaining regular attendance and reducing the overcrowding in classes.

On food, in camps in Jordan refugees receive a daily allocation of bread and food vouchers valid for two weeks. Those can be redeemed at shops inside the camp, which also benefits the local communities. It is a kind of win-win situation. In one camp, the Emirates Red Crescent provides full catering. Malnutrition rates in those camps remain low, but there is a real spectrum in what is available and where. DFID certainly encourages the use of our cash transfer system, and we are very proud of it. That is one of the great innovations of recent years, because it ensures that money is spent locally, so it benefits the community. As my hon. Friend the Member for Bradford East said, the ingenuity of refugees in camps beggars belief. Stalls arrive and there is a marketplace, and I understand that there is also not the best-tasting alcohol—not in the Muslim countries, but in Africa for sure.

Jim Shannon: Will the Minister give way?

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Lynne Featherstone: I will try and get through the points that all the Members have raised, and if I have time, I will come back to the hon. Gentleman.

Gaza was mentioned. Currently, only UNRWA, the International Committee of the Red Cross and the Palestinian Red Crescent Society have sufficient access even to respond. DFID is funding both UNRWA and the ICRC, and we have increased funding to both in response to the crisis. More than 100,000 people are now taking shelter in schools and communal buildings under the aegis of UNRWA. The Secretary of State announced £2 million of funding yesterday to the flash appeal, which was launched by UNRWA, but it is a moving situation, as I am sure my hon. Friend the Member for Bradford East appreciates. It is relatively new.

On the Palestinian refugees from Syria, many of them have fled Syria to Lebanon, Jordan, Egypt and elsewhere. They receive assistance from UNRWA in Lebanon and Jordan, and from the UNHCR in Egypt, because UNRWA does not have a mandate in Egypt. There are reports that the Palestinian refugees are finding it increasingly difficult to cross the borders out of Syria, which is a cause for concern. The UK has so far provided £25.5 million to UNRWA to assist it in Syria, Lebanon and Jordan.

Dr Phillip Lee (Bracknell) (Con): Will the Minister give way?

Lynne Featherstone: I will, because the hon. Gentleman has not spoken.

Dr Lee: Has the Minister’s Department made any assessment of the need for additional medical services, particularly in the Zaatari camp in Jordan? I say that in the context of a debate I held a few months ago in the House, which was on a mobile army surgical hospital facility that Britain could build up and deploy in a place such as Zaatari.

Lynne Featherstone: If the hon. Gentleman will forgive me, I will write to him on that, because it adds a whole new area to the debate and I have only three minutes left.

The gateway protection scheme was mentioned by the hon. Member for Hackney South and Shoreditch. We want to focus our assistance on the most vulnerable people, rather than subscribing to a quota scheme. We have a vulnerable persons relocation scheme, which runs in parallel to the UNHCR’s own Syria humanitarian admission programme. We are determined to ensure that our assistance is targeted where it can have the most impact on the most refugees and those at the greatest risk. Our programme focuses on individual cases where evacuation from the region is the only option, and in particular, we are prioritising help for survivors of torture and violence and women and children at risk. The gateway protection scheme is operated by the UK Visas and Immigration partnership, as the hon. Lady knows, because she was a Home Office Minister. That is the Department from which the immigration side comes. It offers a legal route for resettlement for up to 750 refugees to settle in the UK each year.

We continue to be very concerned about the plight of the Syrian refugees. That crisis is not abating, and the UK has been at the forefront of the humanitarian response. The UK’s total funding for Syria and the

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region is now at £600 million, which is three times the size of its response to any other humanitarian crisis. My fear is that there are protracted crises looming, all coming together at a time when the world’s humanitarian effort is at its greatest, and resources are being severely stretched.

The UK tackles these issues in three ways. The first is at the global level, by providing support to the UNHCR to fulfil its mandate. In 2013, 43 million people relied on UNHCR assistance. We have a strong engagement with the UNHCR and participate in its executive committee. We also provide predictable and flexible global funding that allows the organisation to respond to the most urgent need.

The second way is through engagement on international humanitarian reform and, together with the Foreign and Commonwealth Office, international advocacy on the rights of refugee and other vulnerable populations. I can assure hon. Members that there is a real debate—for a long time the humanitarian effort was stuck, but I think that is moving now and the debate is opening up. The third way is at the country level, where the UK is engaged in many of the world’s most severe crises.

Effectively meeting the needs of growing refugee and other forcibly displaced populations is placing ever-increasing demands on stretched host states and the humanitarian system. The majority of those needs are concentrated in protracted crises in fragile and conflicted states. Access is a nightmare in many countries, and the situation is terrible. I appreciate the difference between the camps, but I think it is explicable by the circumstances in which those camps arrive—

Mr Adrian Sanders (in the Chair): Order. We now move on to the next debate. I call Mr Paul Burstow.

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Care Home Top-up Fees

11 am

Paul Burstow (Sutton and Cheam) (LD): It is a pleasure to have the opportunity under your chairmanship, Mr Sanders, to debate an issue that is of growing importance and will increasingly find its way into the mailbags of hon. Members on both sides of the House. The issue is how much people pay for care in the 10,000 or more care homes up and down England and, in particular, whether the top-up payments that some residents and their relatives make to secure care home accommodation are fair and transparent. With the Department currently consulting on draft guidance for the Care Act 2014, this is a good time to turn the spotlight on these issues.

The legal framework setting out what local authorities need to do when a resident who qualifies for means-tested support enters a care home has been fairly clear for a long time. The “Charging for Residential Accommodation Guide” and the 2004 choice of accommodation directions are straightforward, at least in so far as they clarify that, if local authority-supported residents would like to move into more expensive accommodation—for example, they might want to secure a place in a home nearer their family—they can, provided that a third party, normally a relative, can pay a top-up payment, make that choice. The rules are also clear that if, for whatever reason, no care home places can be provided at the rate that the local authority would normally pay, it is the responsibility of the council, not the resident or their relatives, to pay more to secure reasonable care home accommodation.

The rules are clear. The trouble is that evidence is mounting that they are being broken. Local authorities are confused about how to apply the rules consistently, so that families can be informed about the rules on choice and choose more expensive accommodation, knowing that that will involve additional costs, while at the same time being protected from paying a top-up payment for essential care that it is the council’s responsibility to pay for and meet.

An estimated 54,000 local authority-funded adults are part-paying their care home fees. That is 28% paying top-up fees. Just over one in 10 of all care home placements involve someone paying a top-up fee.

Mr Barry Sheerman (Huddersfield) (Lab/Co-op): I congratulate the right hon. Gentleman on securing the debate, because up and down the country and certainly in my constituency of Huddersfield, there is real concern about this issue. Does he agree with the finding of a recent survey that many councils do not know what is going on? It is not that it is malign; they just do not know what is going on.

Paul Burstow: That is really the thrust of this debate. Whether it is malign or not, it is ignorance, and when it comes to a local authority, that ignorance is not acceptable.

The problem is that the people I am talking about are often out of sight and out of mind. We do not know how many of the 54,000 people who pay a top-up know that a top-up is intended to allow relatives to pay a little extra for a care home place that is above and beyond the “standard” level available from the council. We do not know how many of the 54,000 people know that their

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council or care home should not be requesting a top-up for any care; it should request it only for a higher standard of accommodation.

Based on the evidence that I have seen, I believe that we need to examine whether the rules governing choice and charging for residential accommodation are working as intended and that we need to look again at what we can do to clarify local authorities’ responsibilities now that the legal framework is being strengthened by the Care Act. We need to get this right because top-ups look set to grow in number, not least with 35,000 more care home residents qualifying for some level of means-tested support when the upper capital threshold is increased to £118,000 from 2016. It is in councils’ interests to get it right because, again thanks to the Care Act, there will be a new appeals process for each local authority. Unless the often grey area of top-ups is sorted out, it is likely that a growing number of residents will be challenging the decisions that councils have made about care home fees. Councils can take steps to minimise the risk of legal challenges, but they need the Government to provide clear and practical guidance on what they are required to do and, crucially, what they cannot do.

Mr Sheerman: Will the right hon. Gentleman give way, just on that point?

Paul Burstow: I cannot because—

Mr Sheerman: May I intervene very quickly just on that point, because it is very important?

Mr Adrian Sanders (in the Chair): Order. It is for the Member who secured the debate to give way.

Paul Burstow: I will give way, but I need to stress to the hon. Gentleman that this is a half-hour debate and I need to make quite a few points myself.

Mr Sheerman: I was trying to intervene on this point only because it means so much to some of my constituents. Some of them have said that the trade association for care homes, which is a very powerful one, should have a charter of rights. As someone goes into a home, it should be there and should show the clear responsibilities and clear duties of care.

Paul Burstow: That is a very good point and one that I am sure Care England and other organisations representing care homes would want to take on board.

It is important to understand the scale of the problem. Research carried out last year by the charity Independent Age highlighted the fact that 72% of local authorities—there was a very high response rate to this freedom of information request—were unable to demonstrate that they met their legal obligations with an overview of top-up payments in their area. In other words, they were not routinely monitoring and reviewing whether third parties remained “able and willing” to make top-up payments. That is a core requirement of the existing guidance. The onus is on councils to check that families are not unwittingly making top-up payments for care that should be paid for and met by the council as part of its duties to meet assessed, eligible needs. Those payments can range anywhere from £31 a week to perhaps £131 a week. In some cases, it is probably even higher than that.

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The research also found that just under 30% of councils said that they did not hold or collect information about top-up fees in their area. This was a typical quote from a council:

“As a Council we’ve never had any involvement in top-up care home fees...The Council does not know how many top-ups are in place, in any financial year”.

Perhaps most disturbing was that so few councils knew what was taking place in terms of top-up fees arranged between care homes and families in their area. Almost 80% of councils did not routinely check up on the health of top-up payments as part of their annual reviews, and 75% of councils did not signpost families of care home residents to independent advice before entering into third party top-up agreements.

Mr David Ward (Bradford East) (LD): Will the right hon. Gentleman give way, just for two seconds?

Paul Burstow: It will have to be two seconds.

Mr Ward: Very few Members are present at the debate. What we are discussing is an enormous problem. Why do so many people not know about it? It is such a serious problem, yet that is not reflected in the number of Members here today. Why do people not know about it?

Paul Burstow: I hope that this debate will help with that. The hon. Member for Huddersfield (Mr Sheerman) and my hon. Friend the Member for Bradford East (Mr Ward) are here and will, I am sure, help to spread the news about the debate. My hon. Friend makes a good point. I attempted to get a 90-minute debate. We have a half-hour debate, and I am very grateful that other hon. Members are here, supporting me on this very important issue.

What is driving an increase in top-up payments is the key question. I think that an issue of funding is at the heart of this. More specifically, personal budgets are being set at a rate that simply does not reflect the actual costs of purchasing large numbers of care home places. My right hon. Friend the Minister will know that, in the three years from 2010, local authority baseline fees fell by almost 5% in real terms and rose by 1.8% in 2013-14. It is hard to imagine that that has not had some impact in terms of the numbers of requests for top-up payments during this period.

The problem affects large numbers of people across a wide range of local authorities. The local government ombudsman has said as much. She found Southampton guilty of maladministration causing injustice in the situation of an older woman. The council had sought, wrongly, additional fees beyond the assessed contribution, because no care home places were available within the council’s usual rate. The ombudsman published her report. She considered that that was in the public interest, because

“councils across the country are faced with similar situations”.

The LGO also carried out an investigation into a council near me, the London borough of Merton, in which a contracted private home asked a family to pay a top-up fee that the LGO says it had no right to demand. The report from the LGO serves as a stark reminder to councils that they cannot contract out their legal responsibilities. It was hoped that these reports by the

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LGO would stop councils turning a blind eye to care providers taking payments from relatives, on the basis that that is outside the agreed care contract. However, the practice continues to affect families up and down the country, which makes the need for today’s debate all the more urgent.

In her report on complaints in relation to adult social care, the LGO revealed that she receives complaints that

“providers have sought to charge…‘top-up fees’ in circumstances where the person’s care needs should be fully covered by public funding.”

The investigations have shown that 17% of all complaints received last year included concerns about the financial elements of care provision; that more than half of those complaints in 2013 raised issues about fees being charged where they should not be; that in 50% of these cases the LGO is upholding complaints; and, specifically in relation to top-ups, that people are

“not being given clear and comprehensive information about their financial liabilities.”

Let us not forget that we are talking about an increasingly frail care home population. The Alzheimer’s Society estimates that eight in 10 residents live with dementia or significant cognitive impairment. Given that, what is the Minister’s assessment of the LGO’s most recent report on all complaints made in 2013, which concluded that complaints about local authority social care increased by 16% and that the LGO often finds fault with top-ups being charged when they should not be? Does the Minister agree that the problem seems to be getting worse?

Soon-to-be-published research by Independent Age based on in-depth interviews with 13 councils reveals a wide variation in local authorities’ practices for arranging top-up fees, in terms of who the contract is with, the terms of the third-party agreement, what and how much information and advice is provided, and how the affordability of a top-up payment is assessed. It is essential that the regulations and the statutory guidance that are being developed in the Department address each of those issues. Perhaps the most striking aspect of that research, which I believe will be presented to the Department later this week, is that none of the councils that participated in the research had any openly agreed or consistent approach to reviewing whether third parties remained willing and able to pay top-up fees. That is a serious problem, which risks becoming bigger still when own-resource or first-party top-ups are permitted much more widely from April 2016.

There are many stories about the subject, and I suspect that other hon. Members who are present have stories from their constituencies. I want to refer briefly to two stories, one from the Alzheimer’s Society and one from Independent Age. The Alzheimer’s Society has told me that it was recently contacted by the daughter of an 84-year-old mother who has dementia and is virtually bed-bound. The mother lives in a nursing home, and the daughter agreed to pay a top-up payment of £35, but that payment keeps being increased and now stands at £75. The daughter feels that the payment is becoming unsustainable, but she is worried about the consequences of not paying and the impact of moving

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her mother to another care home. Families have to make such hard, emotional and often distressing choices every day.

The example from Independent Age is no less typical. The organisation was contacted by a daughter whose 87-year-old mother has only £7,000 in savings. The mother has Alzheimer’s and has been in a hospital for a month, and she has now been assessed as needing residential care for her own safety. She wants to live near her daughter in Gloucestershire, because her daughter is the only child. The council in London, where the mother lives, has explained that it will pay £441 towards the mother’s care but it has only found one placement at that rate, which is nowhere near where she wants to live. The local authority is trying to achieve a quick outcome, because it wants her to be moved out of hospital as soon as possible, and it is asking for a top-up payment as part of the process. The 87-year-old mother is being informed that she will be moved to the local home at the local authority rate, regardless of her wishes.

Clearly, the guidance on that point needs to be strengthened. Let me offer the Minister some suggestions on what might be done to strengthen the guidance on which the Department is consulting. I hope that my contribution to the debate will be treated as a formal contribution to that consultation. Local authorities must meet their legal obligations, so third-party top-ups are only ever a matter of choice, not a necessity. The best way to ensure that that happens is to make sure that all top-up agreements are agreed in the open between residents and their relatives, the local authority and the care home provider in a genuine three-way written agreement. It is good to see that that is set out in the draft regulations.

Will the Minister ensure that the guidance underpinning those regulations, to which people will refer to find out what scope, discretion and flexibility there is, states that residents should be offered more than one care home place within the amount of their personal budget? At the moment, the draft guidance simply states that at least one setting should be offered that could meet the person’s needs within their personal budget. If that were interpreted in a mean way—not all councils will do this, but I am certain that some will—the council would offer one home at the rate at which it will pay, and that would be that. In the worst case, an individual might be offered a place in a home rated by the Care Quality Commission as poor or inadequate. Provisions should be put in place to ensure that a person has a genuine choice, particularly if the home that they are offered has been rated as failing some of its fundamental standards.

Will the Minister ensure that the new framework actively enables residents to access independent information and advice, so that they can make a decision about whether to pay a top-up and what level of top-up they can afford? How will the new framework actively support residents to understand their entitlements? Does the Minister share my concern that simply calling on councils to consider

“when it is in residents’ best interests”

to signpost them to information and advice is not sufficient? Three quarters of councils do not signpost residents to independent information and advice now, so what will change unless the guidance signals that there should be a change? That is how the draft guidance is currently framed, but surely it would be better if

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councils routinely signposted people to information. That could be achieved by including a generic statement or section in a model agreement developed by the Department that checks with the local authority, the care home and the third party whether there has been a signpost to independent information and advice. That is a simple, honest check that could be built into the contractual arrangements. I emphasise that information and advice should be independent.

Should it not be incumbent on local authorities to review annually whether top-up arrangements remain affordable and whether people remain willing and able to pay them? Surely that should happen at the same time as the annual review of care needs and an adult’s finances. The draft guidance is too vague on that point; it states that local authorities should review top-ups “from time to time”. It should be made clear that at a minimum, the arrangements should be reviewed annually.

We have to consider the rates that local authorities pay care providers, and whether those rates really keep pace with the real market costs of care. The guidance should make it clear and unambiguous that, where a personal budget needs to be adjusted to meet an adult’s assessed eligible needs and top-up arrangements are not possible, a local authority must always adjust the amount of the personal budget and not seek a top-up to cover the shortfall in local authority funding. That point is absolutely fundamental, but the relevant section of the draft guidance merely states that the local authority should consider adjusting the amount of the personal budget. If a local authority chooses not to do so, it is breaking the law, but it is invited to consider doing something that would be unlawful. There should be no discretion.

Families are being separated. Vulnerable older and disabled people, together with their families, are not being informed of their rights. People who can ill afford hundreds of pounds in top-up fees are unwittingly paying out extra money for essential residential care that is really the council’s responsibility. That is why the guidance should be strengthened.

11.17 am

The Minister of State, Department of Health (Norman Lamb): I congratulate my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) on securing the debate. It would be wrong for the debate to be an exclusively Liberal Democrat affair, so I am delighted to see the hon. Member for Huddersfield (Mr Sheerman) in his place. This debate is, in some ways, a unique event.

My right hon. Friend raises an important issue. He provided two case studies, which almost smack of exploitation of vulnerable older people. The ratcheting up by a care home of the top-up fee for someone in the latter stages of their life who suffers from dementia is completely unacceptable exploitation of that individual, and it should be condemned.

Equally, the idea that it is suitable or appropriate to shove someone into a home far away from London but a long way from where she wants to be goes against the central principle of the Care Act 2014: the individual’s well-being. I know that my right hon. Friend is committed to upholding that principle. The issue that he raises is of

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real importance, and the findings of the local government ombudsman’s report from last year, to which he referred, are of real concern.

People should have a choice over the establishment in which they receive care and support. That establishment will, after all, become their home. Where the local authority is involved, it has a responsibility to ensure that the establishment meets the person’s needs without costing more than it needs to. However, another important principle, which we must respect, is that people or their loved ones should have the choice to use their own resources as they see fit. If by doing so they can improve their surroundings by having a bigger room or a better view, they should have that choice. I emphasise that that must be a positive choice on the individual’s part—something that they understand the costs and consequences of, never something that they feel pushed into.

Mr Sheerman: Will the Minister give way?

Norman Lamb: Very briefly.

Mr Sheerman: The right hon. Member for Sutton and Cheam (Paul Burstow) put his finger on it when he talked about secrecy. There are many excellent people in this field doing a fantastic job—my mother-in-law is in a care situation—but a certain percentage of people do not know what is going on. They need to know, and it should be in the public domain.

Norman Lamb: I agree with the hon. Gentleman. He will find that the Care Act has a much greater focus on transparency, and it strengthens the legal obligation by providing that personal budgets must reflect the cost to the local authority of meeting the adult’s needs. That is a legal requirement in the Care Act, whereas previously it had been guidance.

Paul Burstow: Will my right hon. Friend give way?

Norman Lamb: Yes, but I will not be able to respond to all the issues.

Paul Burstow: I understand, and I am grateful to my right hon. Friend. The guidance allows local authorities to consider whether to make an adjustment to a personal budget, but guidance should not give such discretion. If it is about care costs to meet eligible needs, an adjustment should be made.

Norman Lamb: I take that point. I do not want to pre-empt the outcome of the consultation, but I am happy to ensure that the Hansard report of this debate is counted as part of the consultation exercise. The comments of all right hon. and hon. Members will be included in that report.

Although we all agree that, in an ideal world, local authorities would be able to fund a person’s chosen accommodation, that is simply not possible in every circumstance. We are in a tough financial situation, and local authorities need to take great care in how they spend their resources to ensure that they can meet the care and support needs of the whole population that they serve. There are clear rules in place on the operation of top-up fees, which we are strengthening to achieve

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greater clarity and force under the Care Act. It is important that everyone is aware of those rules, as my right hon. Friend said.

We are aware of concerns about top-ups, particularly the concerns raised in the research by the charity Independent Age. That is why in March 2014 the Department wrote to all local authorities in England to remind them of their responsibilities under existing regulations and guidance, let alone the rules coming in through the Care Act. We reminded them that the existing guidance is clear that a top-up fee should be sought from a local authority-supported person only where they have chosen to go into more expensive accommodations and a third party or, in limited circumstances, the person themselves, is willing and able to pay the additional cost.

The person should not be asked to pay a top-up fee where it is necessary to arrange care in a more expensive home to meet their assessed eligible needs, nor should a top-up fee be sought where accommodation is not available at the local authority’s expected rate due to a failure of commissioning. In such cases, the local authority must meet the full cost of care and should not seek to make a top-up arrangement.

Where a local authority arranges care it is responsible for the full cost of that care, including any top-up fee to the provider. That ensures that, if a top-up fee is not paid for any reason, the person can continue to receive care and support in their accommodation while a decision is made about their future care. A care home, therefore, should never ask a local authority-supported resident for a top-up fee without the involvement of the local authority, but it appears that that sometimes happens.

The local authority is responsible for the full cost of care, including the top-up, so it should not arrange more expensive care unless it is satisfied that the person paying the top-up has the resources to keep paying the fee. Local authorities should regularly review the position to ensure that a person will continue to be able to make those payments—that is another point raised by my right hon. Friend. It is in a local authority’s interest to do that, as it will be liable to pay the full costs if the person is unable to pay the top-up.

We are maintaining people’s right to choice in the accommodation where they receive care under the Care Act. As part of that we will give people more rights to top up their own fees from 2016. We would have liked to have been able do that from next year, but we need to ensure that extending the right to self top-up is sustainable and that those receiving care are not adversely affected. We are working with stakeholders to resolve those issues.

Currently, as I am sure my right hon. Friend knows, the circumstances in which people can top up their own fees are restricted. People can top up during the 12-week period only when their main or only home is disregarded, or when they have a deferred payment agreement—in effect, where they have a property to sell that can meet the cost of the top-up fee. People should be able to decide how to spend their own money, and they should be able to pay more for care if they wish. Under the Care Act we will enable people to self top-up using other assets, not just property, from April 2016 at the same time as we implement the cap on care costs that,

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for the first time ever, will protect people from the risk of catastrophic care costs—protection that my right hon. Friend fought for before I took over this role.

We are also strengthening the regulations and guidance on top-up fees, which will apply from April 2015. That will make the position on top-up fees even clearer and provide additional protection to cared-for people and their families. We will make further changes in April 2016 to give people greater scope to self top-up. The draft regulations and guidance currently out for consultation set out that the local authority must ensure that the person paying the top-up is willing and able to meet the cost for the likely duration of the arrangement. The local authority must also ensure that the person enters into a written agreement, thereby ensuring that all involved are fully aware of their responsibilities and any consequences should the arrangement break down. Again, my right hon. Friend referred to the written agreement in his speech. The local authority must review top-up arrangements from time to time.

Paul Burstow: Will my right hon. Friend give way?

Norman Lamb: Very quickly.

Paul Burstow: “From time to time” are classic words that can be wriggled out of—they mean nothing. It is important that the guidance is clear that “from time to time” means at least annually.

Norman Lamb: I note my right hon. Friend’s point, but I will complete my comment.

The local authority must set out in writing details of how the arrangements will be reviewed, what may trigger a review and when any party can request a review. Although the regulations and guidance do not set a specific review period—my right hon. Friend’s point is now in the consultation responses, as I indicated—we expect top-up arrangements to be reviewed at the same time as the local authority reviews the financial assessment of what the person can afford to pay for their care. That normally happens at least annually, around the time when changes are made to the charging regulations.

Additionally, the local authority must make clear in writing the consequences should the top-up arrangement break down. That may result in the resident’s having to move to alternative, less expensive accommodation, where such accommodation is suitable to meet their needs. As with any change of circumstance, the local authority must undertake a new needs assessment before considering that course of action, including an assessment of health needs and having regard to the person’s well-being, which is the central principle of the Care Act. Local authorities should already be monitoring all top-up arrangements for the people they support because they are ultimately responsible for the full cost of accommodation. Local authorities should also discourage arrangements for top-up payments to be paid directly to a provider.

The new regulations and guidance under the Care Act are being consulted on at the moment, and I encourage all right hon. and hon. Members to contribute to that consultation alongside their contributions today. The consultation closes on 15 August, and we will consider all the responses that we receive. We are aware that, although our approach has been welcomed as a

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big improvement, there is always a desire to do more. We are continuing to engage with stakeholders and will await the close of the consultation before making any decisions on further changes.

The intention of the Care Act is to enable self top-ups in other circumstances, which is entirely right, but also to ensure that top-ups are not inappropriately used and to strengthen the rules on top-ups.

Paul Burstow: In the past 12 months I have been leading work with Demos on the future of residential care, and we will publish our report in September. Will the Minister meet me and colleagues from that commission in the autumn to discuss our recommendations?

Norman Lamb: That sounds like an interesting session in principle. I would like to attend that meeting if possible, but I cannot guarantee it at the moment because of the nightmare that is my diary.

I hope my comments have been helpful. The points that have been raised today are an incredibly important part of the consultation process.

11.29 am

Sitting suspended.

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Healthier Together Programme (Greater Manchester)

[Mrs Linda Riordan in the Chair]

2.30 pm

Mrs Linda Riordan (in the Chair): Before the debate starts, I should say that I will allow gentlemen to remove their jackets.

Graham Stringer (Blackley and Broughton) (Lab): Although it is the last day of term, it is still a pleasure to serve under your chairmanship, Mrs Riordan.

I am going to be critical of the Healthier Together programme, but one facility that it does have, of which I was unaware until about half an hour ago, is the gift of prophecy. It has just put out a press release in response to what I am about to say, which is particularly clever because I have not yet fully decided what to say. Although the programme has failed in many ways, it clearly has attributes that most of us do not have.

As it stands, the Healthier Together programme is both a shambles and a charade. I shall start by talking about the shambles. So far, more than £4 million has been spent on the process leading up to the consultation. Some of that money has gone on producing 200,000 leaflets for the consultation, which started two weeks ago. Unfortunately, as far as I am aware not a single one of those leaflets is yet in a public library—there were certainly none in the library near my office in north Manchester when I checked an hour or so ago, and I cannot believe that that library has been discriminated against. That is a failing of organisation.

That is not the only such failing. The website is complex and not easy to navigate. If someone can find the consultation document, they can download it, and they will find that at the end it says, “Please fill in the questionnaire opposite”. But there is no questionnaire opposite; it is elsewhere. If someone can continue to struggle through the website they can find it, but it is not where it is supposed to be.

I am not the only person who is critical of the consultation. The University Hospital of South Manchester wrote to me to say that the proposed changes are incomprehensible and full of NHS jargon. That is an improvement on the previous document that was produced, which was totally and completely incomprehensible. The more recent document varies between NHS jargon and “Janet and John” talk, which is almost as meaningless. There are phrases in speech bubbles saying:

“Knowing the council and the NHS will work together to look after mum.”

There is no reasoning or line of thought, just nice ideas about things that we would all hope the NHS would do. The University Hospital of South Manchester also criticised the fact that the consultation meetings—the proposed engagements, some of which may have already happened—all take place during the day. That means that the vast majority of people of working age cannot attend.

It is not only me and other members of the public who are greatly concerned about the proposals; as far as I can see, there is little clinical support for them. The

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chief executive of Wrightington, Wigan and Leigh NHS Foundation Trust, Andrew Foster, said that there is

“a lack of widespread support for the consultation process”,

and he went on to say stronger things as well. I have been sent information from a GP survey showing that almost 50% of GPs are concerned about the process and certainly do not support it in its current form. The University Hospital of South Manchester says that the process is “flawed and misleading”, and

“not an integrated care consultation…but rather a consultation on changes to a small number of acute providers”.

Healthwatch England has been very critical of the process, because until March this year all meetings took place in secret. It has been allowed to attend meetings since March, but, as I will explain later, many decisions had already been taken by that point. I would be interested to hear the Minister’s response to a more worrying point: according to Healthwatch England, the Healthier Together body—the combined committee of the commissioning groups—has no power to spend until the draft Legislative Reform (Clinical Commissioning Groups) Order 2014 is passed, and that has not yet been passed by either House. I would be interested to hear whether there will be a power to spend or to go ahead with the proposals, although I would be surprised if the proposals were not challenged.

There is not only the problem that legally, perhaps, the £4 million should not have been spent; the consultation document also refers time and again to hospitals co-operating with each other. However, the competition authorities ruled that the attempt by the Royal Bournemouth and Christchurch hospital and Poole hospital to work together was unlawful. If, after the consultation, it is decided that the proposals will go ahead—I hope that it is not—will they be lawful? Behind all that, £4 million may have been spent unlawfully, and could have been better spent on nurses, doctors and the health of people in Greater Manchester.

I turn to the charade aspect of the Healthier Together programme. It is a charade in many different ways. Who is conducting the consultation? The document contains statements from the chair of the Association of Greater Manchester Authorities, Lord Peter Smith, and from a number of doctors on the clinical commissioning groups, but if one looks deeper, one finds that a large multinational corporation called Mott MacDonald is involved but not declared. It has all sorts of consultancy interests in areas ranging from engineering to private and public health care. Why were we not told?

Part of the charade is that we are not told who is conducting the consultation, but the real charade is that a number of decisions have already been taken before the consultation has gone out to the public. The document itself does not show to the public the configuration of health services as they currently are in Greater Manchester; it presents a number of decisions that have already been taken without any form of consultation. I will return to that point later.

It is also unclear what the consultation is about. The University Hospital of South Manchester said that it thinks it is about the reorganisation of acute care in hospitals. I do not think that it is. It is not clear—it is muddled—but it could be about primary care, because

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there is talk of more GPs and more access to primary care services. There is no financial plan for that and it is not clear how it would happen, which is not a bad thing in itself, but it is mentioned in the consultation document without it being clear what anyone is expected to say about it, apart from their wanting better care for their relatives, mother, sons, daughters, wives or anyone else.

There is an absence of financial information in every part of the document, not just the primary care part. So is it about money? It is indicated and implied that there is not sufficient money. The background document makes it clear that, within two-and-a-half to three years, there will be a £1 billion, or 16%, black hole in Greater Manchester’s health budget of £6 billion. Is the consultation about that—it certainly is not clear—or is it a south Manchester thing? Is it about hospital reorganisation? If it is about hospital reorganisation, creating more specialist hospitals and downgrading some hospitals, why were we not consulted?

Fairfield hospital in Bury, Tameside hospital and North Manchester hospital have been downgraded to so-called community general hospitals, but that is not in the consultation. We are told that we are going to get almost immediate access to GPs, but there is no mention of what has been happening in the health service in Greater Manchester over the past few years. Fifty per cent. of the walk-in centres in Greater Manchester have been closed down, and they gave people immediate access to a GP. They have closed, but the Government are talking about improvements.

The Government are talking about improving care in the community, and specialist nurses would certainly help to keep people out of hospital and reduce costs in the long term, yet when I put in a freedom of information request to Tameside metropolitan borough council, half a Parkinson’s nurse was available for the whole of Tameside, which is shocking. One can go through the other specialist nursing services and find the same. Why have we not been told the proposals for those specialist nursing services, which are vital for keeping people out of A and E and out of long-term care within hospitals?

The proposals are a charade. In the original consultation, and when the Healthier Together people had a meeting with Greater Manchester MPs, we were told there was a guarantee that no hospitals or A and E departments would close. Why is that missing from the consultation document? Why is it not still a commitment? When the commitment was given, I did not believe it because I do not believe, when there is a looming financial crisis in the NHS in Greater Manchester and across the country, that any group of medics or health bureaucrats can guarantee that hospitals will stay open. A 16% gap is looming in the care and health service budget, and the gap might get bigger. That is equivalent to two or three hospitals in financial terms. We were given that guarantee yet, arrogantly, three hospitals have been downgraded without any consultation.

A similar guarantee was given when maternity provision was taken out of Hope hospital during a review five or six years ago. It was guaranteed that a midwife-led maternity service would continue in Hope hospital, but there is currently a consultation on removing that service. Those of us who have been discussing, debating and arguing with the health service for some time about the provision of services are sceptical about all guarantees.

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There is also an ongoing trauma review in relation to Wythenshawe hospital, yet Wythenshawe hospital is being downgraded. It is an extraordinary decision to say, “We will have this discussion, but we have already taken some decisions. We want to know what should happen to these hospitals but, although two other major service reviews are ongoing, we will completely ignore them and not mention them at all in the consultation document.”

I am sure my hon. Friend the Member for Wythenshawe and Sale East (Mike Kane) will want to mention Wythenshawe hospital, so I will not steal his speech. I am an ex-chair of Manchester airport, and downgrading Wythenshawe hospital from its grade 1 status is appalling because it has the nearest A and E unit to Manchester airport. If there was an unfortunate air crash, people would want to go to the nearest hospital. The downgrading of Wythenshawe hospital is another extraordinary decision.

We have been here before with such consultations. At the moment, the Healthier Together people are saying that there is 98% support on Twitter for the proposals. They are in a feedback loop in which they are twittering to themselves, and we know what the Prime Minister thinks two twitters make. We were in exactly that position on the congestion charge. When the people running the scheme ran opinion polls and consultations, they all showed huge support for the congestion charge—anyone who talked to anybody in Greater Manchester would have found that support unbelievable—and of course when it came to putting crosses in boxes in the referendum, 80% were against the congestion charge. That is exactly the position we are in at the moment. There is an unreality about the people who are doing this, and they are trying to fiddle things. This is a scandalous fiddle.

At the end of the debate, I do not want to be accused of pretending that there are no real problems—there are. I have mentioned the financial problems, and there are also the differences between Greater Manchester hospitals. Given the survival rates for similar operations, people are clearly better off in some hospitals at certain times of the week. People are clearly better off in other parts of the country than in some Greater Manchester hospitals. That needs to be put right, but the consultation will not do that. We need to consider why there are problems—it is not just about recruitment, although recruitment is part of the problem—and try to solve those problems, rather than wishing them away with yet another reorganisation of the health service.

I could give more examples, but time is limited. The current booking system in Greater Manchester must waste many millions of pounds a year. The NHS authorities regularly criticise patients who do not turn up for appointments, but they do not criticise themselves when they fail to organise appointments properly. From the past 12 months I can give five examples from my close family, and from my constituency casework, of where the booking system has been appalling. I know of people who have been sent to closed service centres in hospitals and people who have been told that the plaster on their arm would be examined to see whether it has set when, in fact, the plaster should have been taken off. I could go on about the booking system’s failings. Addressing those failings would save millions.

Cleanliness is not a cost issue directly, but it is a health issue, and there is a massive difference in cleanliness levels both within hospitals and between hospitals, which

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could be addressed. There could be improvements in other areas. There are big decisions to be made on hospital configuration, finances, how much money should be put into primary care and the structure of the health service. Those questions will not be addressed by the current process. There are genuine differences between the Labour and Conservative parties on how those issues will be resolved, and those differences will be resolved at the general election.

The process is trying to do two things. First, it is trying to usurp the political process at the general election, when those big decisions will be taken. Secondly, it is asking for a blank cheque. If the Government put out such a rubbish consultation document that people do not know whether it is about primary care, secondary care or hospital reorganisation, and if Healthier Together is already saying that it has 98% support, what do they want to do? They are asking for a blank cheque to do whatever they want, and it should not be given to them.

I will finish with another quote from University Hospital of South Manchester, which I completely agree with, although I would add other things to it:

“Wait until the trauma review is finished and do the consultation properly.”

In other words, withdraw this consultation, do it properly, wait until the review of maternity and trauma services is in, wait for the general election and then we can have a serious, proper and grown-up discussion about how we can make health services in Greater Manchester better.

2.50 pm

Kate Green (Stretford and Urmston) (Lab): It is a great pleasure to speak in this debate, and I am grateful to my hon. Friend the Member for Blackley and Broughton (Graham Stringer) for introducing it.

I am here to express the concerns of my constituents in relation to what my hon. Friend has rightly described as a consultation that people are either completely unaware of, or, if they are aware of it, unsure what they are being consulted about, what the next steps might be, where decisions will be taken and by whom. As he said, everyone understands the pressures that we face within the NHS in Greater Manchester and across the country.

Andrew Bingham (High Peak) (Con): I know that the consultation is about Greater Manchester, but may I just put it on the record that the impact of this consultation will go far beyond Greater Manchester? My constituency is split between relying on Stepping Hill hospital and Tameside hospital, so this consultation affects us as well. I just wanted to put that on the record, so that people are aware of it.

Kate Green: The hon. Gentleman is absolutely right, and I am pleased to see that the hon. Member for Macclesfield (David Rutley) is also present this afternoon. The ripple effect of the consultation, on hospitals in neighbouring areas and indeed—as I will go on to talk about—on the wider north-west and northern region of the country is quite significant in one reading of what is going on.

It is true that the pressures of rising demand on the NHS are well recognised, as are the cost constraints on social care provision. However, my constituents in Trafford

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were told all that three or four years ago, and we went through our change programme. We feel that we have been here before and, for us, this is groundhog day and a bit worse than that. We underwent the consultation “A New Health Deal for Trafford”, which took place in 2012 and culminated in the downgrading of Trafford general hospital. Looking at how the current consultation has been launched, I am concerned that a number of lessons that were learned from that Trafford process are being totally ignored.

I say clearly that I am not against sensible reconfiguration of acute services. I am very much in favour of concentrating expertise and specialisms in a small number of expert sites. I am entirely in favour of as much provision as possible being pushed into the community to front-line, preventive, community-based care, and of keeping people at home to receive that care for as long as possible.

However, if this is a consultation about the provision of integrated community-based care, it is not possible to go down the road of consulting about that provision and withdrawing services in acute settings before we are clear what the landscape and the reality of that community provision is. Nor is it possible to go down the route of suggesting that some acute services might be rationalised or closed when existing acute services are under so much pressure already. In particular—I know that my hon. Friend the Member for Wythenshawe and Sale East (Mike Kane) will talk about this issue too—one consequence of the downgrade of Trafford general hospital’s accident and emergency provision is that during the past nine months the waiting times and queues at Wythenshawe hospital have been significant, with little sign yet that they will be reduced.

In addition, I point out that we have some real uncertainty. My hon. Friend the Member for Blackley and Broughton mentioned the uncertainty that exists around trauma services, maternity services and so on, but we also have uncertainties in Trafford in relation to some of the primary provision that will be in place. We know that the NHS local team and the clinical commissioning group envisage a two-hub model of primary care and community-based care for our borough. The provision in the south is largely established, but in the north—including in my constituency, where we have some of the worst health outcomes in the borough—we are still completely unsure what sort of hub will be put in place, as the NHS local team and NHS England are quite unable to tell us what the funding for that kind of hub model will be.

I know that the Secretary of State for Health is aware of that particular situation and I am grateful to him and his office for what they are doing to try to unscramble it, but from the point of view of my constituents the idea that they will be consulted on a major reconfiguration, either of primary care or of acute services, does not inspire their confidence, because currently they simply see deficiencies in those services and particularly because they believe that their voice counts for little when it comes to the decision that will ultimately be taken.

Not only is there pressure in the system, but the NHS seems to make some really perverse decisions as it goes along, because of its rather hand-to-mouth approach to planning this kind of reconfiguration and strategic change. When the decision was taken to downgrade the

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A and E services at Trafford general hospital, the hon. Member for Altrincham and Sale West (Mr Brady) and the late Paul Goggins, my good friend and former colleague, managed between them to secure around £11 million of new investment in Wythenshawe hospital to provide for the extra capacity that it would need. We are now unclear, of course, about what will happen with that £11 million of investment; it would be good if the Minister could put it on the record today that it will continue. Given that the hospital cannot envisage even its short to medium-term future, that is a worrying situation.

We saw something similar in Trafford, when investment of around £300 million in the intensive care unit was pretty well written off two years later when the new health deal for Trafford was implemented and the ICU was closed down. That may have been the right decision, but it was certainly a waste of money if investment was being poured into a hospital just two or three years before the whole status of that hospital was changed.

Lisa Nandy (Wigan) (Lab): I am grateful to my hon. Friend for giving way, and I apologise for being late for the start of this debate, Mrs Riordan.

Does my hon. Friend agree that part of the problem with the process is that it does not take into account the particular needs, circumstances and history of our individual communities? For example, in Wigan we have invested in a number of our specialist services. However, we are a big borough, we have our own particular health challenges and we have real transport issues as well, which are different from those affecting other areas of Greater Manchester. Quite simply, a centrally driven top-down process that lacks any kind of democracy whatever, as far as I can make out, is not capable of delivering the sort of services that we need in our areas.

Kate Green: I absolutely agree with my hon. Friend, and the issue about democracy that she raises is one that we are all particularly concerned about.

David Rutley (Macclesfield) (Con): I would just like to put it on record that my hon. Friend the Member for Altrincham and Sale West (Mr Brady), who cannot be here because of a commitment, shares concerns about the process and the way in which things are moving forward, which I think he has also expressed to the hon. Member for Wythenshawe and Sale East (Mike Kane). I just want to put it on the record that other Members are also expressing their concerns.

Kate Green: I am grateful to the hon. Gentleman for that contribution.

I am sure that my hon. Friend the Member for Wythenshawe and Sale East will talk particularly about the situation at Wythenshawe hospital, which is in his constituency, and our particular concern for the status of that hospital as a fixed-site specialist centre of excellence for a number of specialisms that matter not only to the population of south Manchester, or even to the population of Greater Manchester, but to the whole population of the north-west region. Some of those specialisms matter to the whole population of the north of England, and parts of Scotland too. It is deeply concerning to us that the Healthier Together consultation appears not only to be unaware of the difficulty of protecting those specialisms

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in the proposed process of remodelling hospital configurations, but to be completely unaware of the interdependency of specialisms and general acute and medical provision. If one element is removed from a cocktail of clinical support that is available to support high-level specialisms, those specialisms are completely undermined and eventually will probably be unable to survive.

I have a particular example of that process that I will draw to the Minister’s attention; it arises from my visit last week to Wythenshawe hospital and its highly regarded cystic fibrosis unit. The doctors and clinical staff there told me that the unit benefited from being part of a much broader, fixed-site specialist team, and indeed survived on that basis. It draws on a range of other specialisms around the hospital, including interventional radiology, transplantation, urology, nutritional support teams, gastroenterology, diabetes, endocrinology, ear, nose and throat services, obstetrics, extracorporeal membrane oxygenation and so on. Picking out some specialisms and moving them cannot be done in isolation, but Healthier Together does not seem to be aware of that at all.

Finally, as my hon. Friend the Member for Blackley and Broughton said, there are concerns about process—about how the public are being engaged in this debate. He said that we have a consultation taking place over the summer holidays, exactly as happened with the new health deal for Trafford, although we told them not to do that again, and during the working day. I understand that few people attended the public meeting in Trafford; I am not surprised, because it was difficult to know that it was even taking place. I would not be able to tell when it happened, because I was not notified directly, let alone my constituents.

Andrew Bingham: I thank the hon. Lady for giving way again; she is being generous. I tend to agree. There is a consultation meeting in the High Peak as we speak, although it is a Tuesday afternoon. I, for one, should have liked to be there. I just wonder: next week during the recess would have been a lot easier for me.

Kate Green: I agree.

Meanwhile, Healthwatch Trafford says that there is concern about whether the committee-in-common model in Manchester is sufficiently transparent, regarding its ability to engage with and represent the concerns of local people and to oversee, in the wider public interest, what is being proposed.

I am utterly unconvinced that local people are aware of or understand the steps that are being put forward now that could result in major changes to health care provision in our area.

Julie Hilling (Bolton West) (Lab): Before my hon. Friend moves away from the consultation, does she agree that the questions asked in the consultation document are ridiculous? For example:

“Do you…disagree that children and young people should be cared for closer to home where appropriate?”

Nobody would ever disagree with such questions.

Kate Green: That is absolutely right. Again, that is exactly what we saw in the consultation on the new health deal for Trafford. We raised concerns about that

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at the time, but the NHS has learned nothing about how proper engagement and debate with the public can be managed and take place.

There is real concern that a lot of groundwork has gone into producing this consultation but that much of it has happened behind closed doors. If the significant changes that are being advocated, or significant changes in other forms, are needed— the document says that they are, which may well be the case—it is imperative that the public be brought on board through a process of careful, systematic, dedicated engagement. It is not good enough to land a document out there without that work being put in and without any clarity about how decision makers will be informed by the views and opinions of the public at large and of elected Members who represent them.

3.2 pm

Mr David Nuttall (Bury North) (Con): It is a great pleasure to serve under your chairmanship, Mrs Riordan.

Some may find it surprising, given our political differences, that I agree with much of what has been said by the hon. Members for Blackley and Broughton (Graham Stringer) and for Stretford and Urmston (Kate Green). Like them, I entirely accept that things cannot always remain as they always have been in our NHS. There have to be changes in any large organisation, from time to time.

Of course, I am speaking purely from the perspective of my constituents in Bury North, including the townships of Bury Ramsbottom and Tottington. They are only too aware of the repercussions of health service reorganisation, having recently lost the children’s services at Bury Fairfield hospital. Pledges were made before the last general election. The process of the “Making it Better” scheme was stopped. Local GPs had an opportunity to say, “We will keep the services”. I do not know about 98% of people on Twitter agreeing with this. I always used to say it was about 99% of people in Bury, when I asked them. I could hardly find anybody who thought it was a good idea to close maternity in Fairfield. Notwithstanding that, and notwithstanding the clear steer of the Secretary of State about wanting to keep those services open, local health officials, backed by local doctors—the GPs—said, “No, we’re too far down the line. We’ve got to stick with the ‘Making it Better’ scheme and with what has been agreed.” Those services at Fairfield have now been lost.

Residents in Bury could be forgiven for being somewhat sceptical about the nature of consultation. I share that. I took part in the after-the-event analysis that was done by some professional surveyors. I said to them, “Look, if you’re going to do a genuine consultation, you’ve got to be clear about what the options are. It’s got to be a genuine consultation and the public have not got to be left thinking that, actually, it is a foregone conclusion and the decisions have already been made.”

A proposal is before the people of Greater Manchester now. Out of all the hospitals in the area, only at Wigan, Bolton, South Manchester and Stockport is there some element of choice. With all the others, it is the same: it is a done deal. So I understand why many of my constituents will say, “Well, there’s not much point in us taking part in all this. Nobody listened to us last time; nobody will listen to us this time.”