If you were about to undergo surgery, you would expect to know what the operation involved and to be informed about all the risks and benefits. It's called informed consent and no decent surgeon would go ahead without it.
Brexit certainly is major surgery with far-reaching consequences and the government is about to proceed without informed consent.
At the time of the referendum the choice was simply to leave or to remain. The type of Brexit was not on the ballot paper, which is like a surgeon asking their patient to consent to an amputation in two years' time without either of them knowing whether this would involve a few toes or their whole leg.
Voters were assured that this would be the easiest deal in history and that the world, including the EU, would be queuing at our door to trade on our terms. There would be cake and we would be eating it, alongside every fish that swam in our waters.
In the real world, instead of a bespoke deal we are all being marched briskly to the edge of the cliff. No deal and no transition look increasingly likely to be the outcome, and is the preferred option of those MPs who have deliberately and fatally undermined the Chequers plan.
The surgery looks set to be far more radical than anything set out in the referendum and the side-effects and complications of a hard, walk-away, no-deal Brexit with no transition are very different from the promised targeted surgical excision of just the parts of the EU that the Brexiteers didn't like. Shouldn't people have an opportunity to weigh up the risks and benefits before proceeding?
Once we know the final terms there is not just an opportunity but a duty to set out the unintended consequences as well as the potential benefits. There is a compelling case for that to be followed by a people's vote: we have to make it clear to government that it should not embark on potentially ruinous surgery without the informed consent of the British people.
It might be that a majority nevertheless decide to proceed, but there is no democratic mandate for Brexit until the choice is clear and an informed decision can be made. If the hard Brexiteers are confident about their walk-away, no-deal scenario they should be happy to agree.
The polls show that public opinion is turning on Brexit, especially as the sheer scale of the cost and consequences becomes clearer.
No responsible government should countenance deliberately and knowingly inflicting such economic and social harm on its people before at least checking that is what they really wanted.
During and after the referendum campaign I asked many people about the priorities behind their vote. The fact is that there was no one single issue. For some it was a promise on the side of a bus, for others, 'taking back control' over issues ranging from agriculture and fisheries to immigration and sovereignty. I met almost no one, then or now, who felt that we should accept being poorer as a result. As the reality hits home that the EU will reject sector by sector deals, 'the cake and eat it' approach, even if that means economic pain on both sides of the Channel, a stark choice lies ahead: Do we really want to march out through the exit door with no deal at all and with less than a year to put in place complex customs and borders arrangements? Rather than presenting a rose-tinted view, the hard Brexiteers need to level with the public on the scale of the unintended consequences. The government should not keep the economic impact analysis locked in a secret reading room accessible only to Parliamentarians but publish these so that everyone can examine the evidence.
In supporting New Clause 5, an amendment to the Trade Bill that would keep us in a form of customs union or customs arrangement after Brexit, I am not 'blocking' Brexit or 'obstructing the will of the people'. Britain is leaving the EU. This is an argument about the type of Brexit and that was not on the referendum ballot paper. The duty for MPs in carrying out the will of the people is to examine the evidence and press for the best possible Brexit, not to make their constituents poorer.
My view is that we should also opt for membership of the EEA and EFTA at least for the transition period. This would allow us to leave the Common Fisheries Policy and, like Norway, regain control over our fisheries, an issue of great importance to Brixham. But frictionless trade is also hugely important for both fishers and the processing sector, and in particular for exports to our most important markets in the EU.
Without a form of customs union or arrangement, border checks are an inconvenient inevitability. Without a customs union the current fudge over the border between North and South on the island of Ireland will inevitably become untenable. No one wants a return to the conflict of the past. The price of abandoning any kind of customs union is too high and I won't support it.
There is also a simple truth that there is no Parliamentary majority for a walk-away, no-deal Brexit. The small band of hard Brexiteer MPs need to stop throwing down red lines like spaghetti and stop threatening to remove the PM unless she bends to their will. The PM has herself spoken clearly of wanting a customs agreement with the EU and NC5 is compatible with that as it does not call for 'the' Customs Union on existing terms. My role as an MP is to read the evidence and to clearly state the case for what I believe is in the best interests of my constituency and the country even if that is sometimes wilfully misrepresented by those who simply want us to walk away, whatever the unintended consequences.
Below is an article I wrote for the Financial Times
There is nothing new about winter pressures in the NHS. What has changed is that those pressures have become relentless, extending year round into traditionally quieter months but deepening in intensity over the winter. The current crisis is not simply caused by the number of people turning up to A&E but because those who do are far more unwell and many more need admission. With hospital bed occupancy already running at unsustainably high levels and a growing shortfall in community beds and workforce, the health and care system can rapidly become overwhelmed. An upswing in norovirus and flu over the past fortnight seems to have been the final straw. NHS England had little choice but to implement its emergency plan to ease the acute pressure by cancelling routine surgery until the end of January. Unless we address the underlying issues across both health and social care this will however become the norm for every winter. Beyond that the unsustainable pressures will result in a collapse in routine waiting time standards.
Increasing life expectancy is one of the greatest successes of our age, but as we live longer and with more complex conditions, health funding has lagged behind. There has been an abject failure on the part of successive governments to plan for the sheer scale of the long term demand and costs associated with demographic change and for the change required to integrate of health and social care,
The House of Lords Select Committee set up to examine the long term sustainability of the NHS rapidly concluded that it could not do so without including social care. The government needs to take note before repeating the mistakes of the past. A green paper that looks solely at long term funding for social care will miss the point that these two systems cannot be considered in isolation from each other. Neither should anyone underestimate the challenge of delivering policy change in a hung Parliament or under a government whose energy is so consumed by Brexit.
There is a way forward but it will take political courage from both front benches and genuine willingness to put the public interest first. Before Christmas, 90 backbenchers from across both sides of the House of Commons, wrote to the Prime Minister urging a cross Party whole-system approach to the challenges and funding of the NHS, social care and public health. Select Committees could also play a role to help to build on existing work and set out the options for the public. Theresa May's former Chief of Staff has advocated a Royal Commission but we do not have the luxury of time to kick this important issue into such long grass.
Many of the options have already been described, for example by the Barker Commission and recent House of Lords inquiry. The reality is that we will all need to be prepared to contribute more if we want the NHS to remain a universal service, free at the point of delivery and meeting our needs both now as well as in the future. This cannot in my view fall entirely on working age employed adults but also needs to consider inter-generational fairness, wealth and contributions from those who are self employed. As graduates struggle with student loans it would be unfair to expect them also to shoulder the increasing costs of health and care for those in retirement irrespective of their wealth. We could look at ideas for a hypothecated health and care tax for example paid by those over forty and with income from any source above a set threshold. Some advocate introducing charging and top ups but these bring higher transaction costs and widen health inequality. The point is that all these options should be clearly set out alongside the consequences of a failure to invest more in the NHS, care, public health and prevention.
Since 2010, total health spending has risen by an average of just over 1% per year. This is far lower than the long term average increase of around 4% and comes at a time of extraordinary rise in demand and the costs of drugs and technologies. Real terms cuts to social care have added to the strains.
It is time to stop viewing health as a bottomless pit but rather as one of our greatest successes and make increasing investment a source of national pride. I cannot think of a better way for Theresa May to celebrate the 70th anniversary of the NHS than by helping to make sure that it has a sustainable long term future.
Below is an article that I wrote for the Sunday Express
There is nothing new about winter pressures in the NHS. What has changed is that those pressures are now year round but in winter the crisis is far deeper.
NHS England has put in place a plan to deal with this by cancelling routine surgery, but this will not feel 'routine' for those in pain awaiting a hip replacement for example. I understand the need to focus here and now on emergencies but we should not have to accept that cancelling this kind of life-changing surgery becomes the accepted annual response to winter.
The causes of these pressures are well known. It is of course great news we are living longer but as we do so we are living with far more complex long term conditions and the cost of treatment and technologies continues to rise faster than increases to the NHS budget. NHS staff have done an heroic job but they and the whole health and care system are stretched to the limit as they cope with far more people who are seriously unwell.
We cannot continue to provide the service we all expect on current finances, staffing and infrastructure. It is time for an urgent review to find the funding that both the NHS and social care need in order to make it happen.
We also need to end the culture of short termism and look not just at the here and now, but plan properly for the future and look at health, social care and public health together.
The public are being let down by a political failure over past decades to plan ahead, to be honest about the scale of the challenge and to work across Party lines to find a fair solution.
Before Christmas 90 back bench MPs from across political parties tried to change this, we wrote to the Prime Minister calling for this approach. Likewise in my role chairing the committee that calls the PM to give evidence, I told Theresa May that Select Committees (which work across Party political lines), stood ready to help. The fact is that no Party has a monopoly on good ideas on how this funding could be achieved and in a hung Parliament it needs cross Party working to get change such as this across the line.
No one wants to have to fork out but the truth is that we need to be prepared to pay more to support health and care services or services will decline. There are serious questions about whether it is fair for this to fall entirely on those of working age through taxes. My personal view is that it is not and that we should look at how it could be shared fairly across generations.
I know many people argue it is time to introduce charges to the NHS but this risks widening inequalities and also introduces costs and bureaucracy associated with collecting these relatively small payments. I know, as a former GP, that many of my sickest patients struggling on low incomes would have delayed coming to see me had there been a charge. This can end up not only with worse consequences for health but costing the NHS more in the long run. I also feel strongly that charging for appointments would go against one of the great founding principles of our NHS, that it is free at the point of need. It's what makes our system the fairest in the world and we should beware undermining that.
I believe the best way forward is stick with our tax and National Insurance based system as the core funding but look again at how National Insurance is collected and from whom so it can became dedicated to funding the NHS and social care.
It is time for an NHS and care convention to explore all the funding options and explain these clearly to the public and to look again at the options for sharing the costs of social care so that we no longer have the awful care costs lottery of one in ten people over 65 facing catastrophic costs.
A convention should not ignore the ongoing need to reduce waste in our NHS and I hear many examples of this in my work as chair of the Health Select Committee. Making sure that all areas learn from the best performing Trusts for example. Progress is being made in many areas already, for example driving down the huge variation in the amount the NHS pays for identical products. We also have to go further on prevention. Anyone who has spent time in an emergency department on a Friday or Saturday night will know how much drunkenness adds to the workload and avoidably ramps up waiting times.
It's easy to focus on the negative stories but the fact remains that our NHS and is doing a remarkable job and in its 70th year we should should celebrate it's successes and grasp the opportunity to make sure that it can not just survive but thrive. Rather than seeing health and care spending as a 'bottomless pit' we should view funding these properly as a source of national pride. These discussions have now become a national emergency and its time to ditch the Party politicical bickering and make it happen for the whole system our NHS, social care and public health.
This week I voted for an amendment to the European Union Withdrawal Bill because it was necessary to guarantee that there can be Parliamentary scrutiny and sovereignty as we return control of our laws from Brussels. There have been strong opinions on both sides of the argument about this, and even suggestions that by backing this amendment I have somehow blocked Brexit, or increased the likelihood of another election. This is not true. I respect the referendum result and voted to trigger Article 50. We are leaving the European Union but need to do so in a way that leads to as few unintended consequences as possible.
In returning powers from Brussels we must not exchange one system with poor democratic oversight for another. As we take back control of our laws, Parliament has an important role to play in scrutinising the government's work. Both in my role as Chair of the Health Committee and as a Constituency MP it is my duty to be look closely at both the pitfalls and opportunities of the various options for the type of Brexit ahead.
Clause 9, which I and colleagues voted to amend, had such far reaching consequences that I have copied it verbatim below:
A Minister of the Crown may by regulations make such provision as the Minister considers appropriate for the purposes of implementing the withdrawal agreement if the Minister considers that such provision should be in force on or before exit day.
If left unamended, this clause would have been incompatible with the Prime Minister's pledge to give Parliament a 'meaningful vote' on the deal. In effect, it allowed Ministers to make changes to laws with no democratic check by Parliament. Its breadth even concerned Brexiteers like Jacob Rees-Mogg, who said during the debate, "clause 9 gives some powers that trouble even Eurosceptics. I have never felt comfortable with the self-amending part of the Bill."
I and my colleagues had made our concerns clear to government for many weeks ahead of the vote and we feel that this vote was entirely avoidable. The clause should have been removed and the government could easily have done so. This would have avoided the need for an amendment.
Far from obstructing Brexit, this vote strengthened its democratic underpinnings, preventing major constitutional change from potentially being pushed through purely by ministerial decree.
I have been dismayed with how irresponsibly my vote has been misrepresented in some parts of the press. I welcome robust debate and I am always willing to listen and to defend what I believe. Labelling MPs 'traitors' for defending a fundamental democratic principle or judges 'enemies of the people' for upholding the law, just fuels a hateful division. It also entirely misrepresents why I voted as I did and why I felt it was necessary.
As we build an independent Britain – we will need to work constructively with our European neighbours. The more I hear, during Select committee hearings, about the consequences that would arise from a disruptive and chaotic Brexit, the more I feel that we must try to achieve a soft landing. The consequences of no deal and no transition would be very serious indeed.
Following concerns about long waits for ambulances and the withdrawal of local Rapid Response Vehicles, I invited South Western Ambulance Service NHS Foundation Trust, SWASFT, to an open meeting at Kingsbridge Community College. Chief Executive, Ken Wenman and the team leading operations in South Devon came to set out why services are changing and to answer questions. Many volunteer Community First Responders also joined the audience to share their experiences.
The Ambulance Service has undergone huge changes from one which primarily transported people to hospital to one staffed by highly trained paramedics with specialist equipment also capable of delivering treatment at home, backed up by a network of community first responders and co-responders from other emergency services.
The key challenge has been the rise in demand for their services. Over the past five years the number of calls has risen by 19.2% in the Totnes area, 29% in Plymouth and 23.7% in Torbay. One effect of this has been that once ambulances based in the rural South Hams have taken a patient to hospital in Torbay or Plymouth, they often get diverted to other calls in those urban areas rather than returning to base. The way that targets have been set in the past can mask poorer services in rural areas. Until now, those response targets only covered the most urgent calls with a requirement that a vehicle arrived on scene within 8 minutes in 75% of cases. Overall SWASFT met that target for the South Devon and Torbay CCG area at 75.65% of calls over the past year. But the figures I obtained for the Totnes constituency, which is more rural, tell a different story, with ambulances reaching just 61.1% of those calls in 8 minutes over the past three months. Targets need to be set in a way that doesn't lead to unintended consequences such as focusing on urban areas where they are easier to reach or allowing the arrival of an inappropriate ambulance vehicle to 'stop the clock' when measuring response times.
Now that many more treatments are available in specialist centres to help people who have suffered conditions like acute stroke and heart attack, it is more important than ever that the right vehicle attends a call. Ambulance cars, known as Rapid Response Vehicles, cannot take people to specialist centres but can distort the figures for waiting times. These vehicles are being removed but the meeting was told by SWASFT that overall ambulance hours cover would increase for the South Hams through a double crewed ambulance based at Totnes and use of a 'dynamic coverage tool', otherwise known as getting vehicles back out from urban centres to be closer to respond to emergencies across rural areas like the South Hams. Changes to targets will mean that all calls will count, and using mean average response times as well as the time taken to reach 9 in 10 calls will help to keep a focus on reducing long waits especially in rural areas. I will be following this carefully to make sure that the changes do lead to improvements in the service. These are being put it in place following the national Ambulance Response Programme trial and the following links give further background to this and to the changes:
At the meeting, volunteer community first responders spoke of their concern about not being able to deliver pain relief whilst waiting for an ambulance to arrive. Ken Wenman confirmed the good news that they will now be able to receive training in the use of pain relieving gas and air.
The service has been under increasing pressure due to rising demand and this has meant that it has been coping with 2.46% less funding per call over a three year period. SWASFT's operations director Neil Chevalier, told the meeting that they had received a £3.6m uplift in funding to implement the changes from the Ambulance Response Programme trial and, in response to questions about pay, said that paramedic staff had been put onto band 6 of the NHS pay scale up from band 5.
SWASFT representatives heard direct from volunteer community first responders and local residents about the pressure on services including examples of long waits and these were all examples of why the service needs to provide a better response to rural areas. I will be following this closely.
The message that came over loud and clear was the value that we all place on our ambulance service. Thank you to all our paramedics, support staff and volunteers.
Public sector pay increases, including for NHS staff, have been capped at 1% since 2013–14 and for two years prior to that subject to a pay freeze affecting the majority. NHS employees' pay fell by 10 per cent in real terms between 2009/10 and 2014/15 and continues to fall.
It is time in my view for pay restraint to be loosened but that cannot be done without a clear plan for how it will be funded.
In 2015–16, the Department of Health spent £48.7 billion on NHS provider staffing costs. The IFS estimates that each 1% increase in staff pay would add approximately £0.5 billion to the pay bill, just for the NHS. This means either additional funding for the service or painful reductions in other areas of the NHS or DH budget.
I agree with the pay review body that there are also costs in ignoring the need to increase pay. As the gap between NHS pay and jobs outside the public sector widens, this is hitting the recruitment and retention of key staff, especially when there is fierce international competition for skilled healthcare professionals. The fall in real incomes is also affecting morale, especially where staff are having to work under greater pressure to compensate for unfilled posts. Vacancies and staff shortages can also affect patient safety as well as lead to higher agency costs. Pay restraint is becoming a false economy.
For all these reasons I believe it is time for a rethink but it will require a clear plan from the Treasury as to how it will be paid for. Ending the pay cap won't happen through a simple amendment to the Queen's speech.
It is essential for all Political Parties to face up to the scale of the funding challenge across the NHS and social care and to work together to find a way forward. The reality is that the wider challenge in funding these vital services, in the face of an extraordinary increase in demand and costs, will be there for which ever Party is in Government after the next election. It is in everyone's interests for MPs to work constructively together across Party lines in the national interest. We have a responsibility to level with the public and with each other because the reality is that we are all going to have to pay more to put the NHS, social care and our other valued public services on a sustainable long term footing.
Much of the ground work has already been carried out and we should look again at the full range of proposals from the Barker Commission and the House of Lords inquiry into the sustainable long term funding of the NHS and social care.
This is the original article I wrote that appeared in the Times today.
One of the the most striking figures set out by the Chief Executive of NHS England, Simon Stevens, in his recent update to the NHS Forward View was that life expectancy is increasing by five hours a day. This extraordinary success has also driven an unprecedented rise in demand for health and social care to levels which can no longer be met from current spending. The Care Quality Commission is not alone in describing social care as being at a tipping point. In her manifesto, Theresa May has acknowledged that the elastic can stretch no further and promised to increase funding for social care as well as per capita spending on the NHS. The manifesto also includes a much needed boost for capital projects described as 'the most ambitious programme of investment in buildings and technology that the NHS has ever seen'. Funding promises have to be realistic and fair. The Prime Minister is right not to duck the issue of intergenerational fairness in meeting the challenge of funding social care and it would not be fair for the increasing costs of both the NHS and social care to fall entirely on the working age population. The options were never going to be easy but failure to increase spending risked the collapse of social care provision and a downward spiral of NHS performance. Hard choices on the means testing of winter fuel payments and downgrading a triple lock to a double lock on pensions after 2020 are fair if the money raised rescues social care from the brink for those who will need it the most.
It still takes many people by surprise that if they have assets over £23,250, they are liable to meet the full costs of their residential care and raising that threshold to £100,000 will be welcomed but the long awaited cap on the total that families will have to spend meeting the cost of care has been dropped. The greatest change however, is that many more people will be liable for care costs because the value of their family home will no longer be exempt if they need care in their own home. Any policy must avoid unintended consequences and ministers will need to clarify what period of grace will be applied for those who may only need short periods of care. Currently this so-called 'disregard' is set at 12 weeks for those needing residential care and it is essential that this also applies to home care. If not, it will exacerbate rather than reduce delays to hospital discharges.
The dropping of the care cap sadly leaves social care uninsurable, leaving in place the miserable lottery of care costs. A future government should at least look again at supporting state backed insurance for those who have not yet reached retirement age, so that they can begin to protect against this.
This is an article that I wrote for the Times.
As the Chancellor finalises his 2017 Budget he can no longer afford to ignore the stark warnings about the impact on individuals and the NHS from the crisis in adult social care. Last year the Care Quality Commission described the fragility of the system as approaching a 'tipping point'. The situation looks set to worsen without an immediate lifeline and one that goes beyond the uneven and inadequate sticking plaster of a 3% increase in council tax precepts. To put this in context, last year's uplift in the precept raised £382m but this was entirely swallowed by the £612m increase in costs from the National Living Wage. Precepts also entrench inequality as those areas least able to raise money also have a greater proportion of residents who are fully dependent on their local authority to fund their social care. The 2017 Budget needs to bring forward the so-called Better Care Fund already planned for later in the spending review and it needs to be 'new' money, not a smoke and mirrors device to transfer funding from an already overstretched NHS.
Over the last review period 09/10 to 14/15, local authority spending on adult social care fell by 10% at a time of profound and ongoing demographic change. Despite rising demand for services, more than a million people are estimated to be going without the care they need. It is a false economy because they are increasingly ending up in A&E or stuck in hospital when they could and should have been discharged. The knock on effect on NHS services has been the marked rise in waiting times, 'trolley waits', and cancelled appointments and admissions. What is surprising and unacceptable is that no government has assessed the full impact and cost of the shortfall in social care on the NHS.
The number of people with care needs is expected to rise by more than 60% over the next 20 years whilst the proportion of individuals of working age will continue to shrink in relation to those living in retirement.
It's time to stop presenting longevity as if it were a negative. It is amongst the greatest achievements of our age and government needs to highlight and support the extraordinary value that older people add to our communities. It also needs to set out how we will fund social care for the rising numbers of people who will need help to live with dignity in older age. There has been an abject failure of successive governments to plan for the future. Councils also need certainty about the Care Act provisions, delayed to 2020, which bring in a cap on care costs and change the financial threshold for entitlement.
The Prime Minister has already confirmed that she is looking at social care but it is worrying that her review currently excludes the NHS. The two systems are inextricably linked.
In his 2017 Budget, the Chancellor must show that he has grasped the seriousness of the situation and announce an immediate cash injection for social care. He should also set out plans to tackle the greatest domestic challenge of all; how to bring forward a fair and sustainable long term settlement for both the NHS and social care.
This is an article that I wrote for The Guardian
Donald Trump made no secret of his deeply divisive instincts during his long campaign for the White House. Vile racial and religious stereotyping, misogyny, his support for torture, even parodying those with disabilities. All his prejudices were worn as a badge of honour, displayed from campaign platforms and television studios for months on end.
Locker room talk, we were told, of his boasts of 'grabbing women by the pussy' as voters were assured that the office of Presidency would surround him with wise counsel and bring out the statesman in him. Less than a month since his inauguration, the stark reality must be dawning on Americans, that their choice of President isn't 'draining the swamp' but dragging them into one of his own making. We don't have to join them.
It would be a mistake to dismiss Donald Trump as some oafish 'man baby' impulsively blurting whatever comes into his mind. His actions seem calculated to offend, bully and control.
Some touted the hand holding with Theresa May as the seal of a special relationship and a gentlemanly gesture. To me it smacked of the unwelcome infantilising of a strong female leader, more than capable of negotiating the White House steps on her own.
In the rush to forge a trade deal Mrs May should remember that Trump's executive orders since assuming office don't just affect millions of Americans but our own citizens. Nadhim Zahawi MP, is just one of many thousands of our fellow Britons who are now barred from the USA for no reason other than the nation of their birth. All those countries on his banned list are predominantly Muslim countries apart from, as Andrew Neil points out, 'those where Trump Org has business interests'.
A shameful curtain of prejudice and discrimination is drawing across the Land of the Free and, if we are truly in a special relationship, true friends should be frank in saying so. By his actions as well as his words Trump is also turning back the clock on women's rights across the world. His executive order bringing in the so called 'global gag' will restrict access to safe contraception and healthcare as well as to safe termination of pregnancy for the world's most disadvantaged women.
The State Visit looks set to go ahead but symbols matter. Westminster Hall has long been reserved for those Statesmen and Stateswomen who have made a lasting and positive difference in the world. That does not include Mr Trump. No doubt there will be those who wish to fawn over him, but that must not be from the steps of our nation's greatest hall.