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.
A few days into his Presidency, Donald Trump has signed an executive order dubbed the "global gag rule". It will have the effect of cutting off funding for overseas NGOs whose work is associated in any way with abortion services. This means that many international health workers and organisations, even those who receive part of their funding from other private sources for work or advice linked to abortion services, will have to decide whether or not to continue. These services risk losing crucial funding – meaning cuts to choice based contraception and other health services for the most disadvantaged women worldwide. Because the US is the largest health donor this will have an impact on unwanted pregnancies and could have a knock on effect on other areas of women's health care like screening programmes, prenatal check-ups and support for HIV sufferers.
President Trump's policy is also counterproductive – fewer abortion services does not necessarily mean fewer abortions but more unsafe 'backstreet' abortions and maternal deaths. It turns back the clock on women's rights to exercise control over their own bodies.
While organisations are being coerced by the new rules into reconsidering their future programmes, it is a relief to hear that the Netherlands have already announced plans to try to compensate for the new administration's draconian policy, by considering an international fund to help provide these services.
Britain should join with the Netherlands to help protect women's right to access safe contraception and termination of pregnancy alongside the other health services that will be hit by the global gag.
Following their recent consultation, the South Devon and Torbay Clinical Commissioning Group has now published its recommendations . These will be put to their governing board when it meets in public on 26.1.17.
The most controversial aspect is that the CCG continues to recommend that several local community hospitals will close as part of their plan to introduce a new model of care. In my constituency that would mean the closure of Dartmouth hospital. Many Paignton residents will also be affected by the closure of their community hospital in the neighbouring Torbay Constituency.
Reading the document I am deeply concerned at the statements on page 24 which imply a lack of support for Dartmouth hospital from local residents and their representatives. This is simply not the case. There is huge support for our local community hospital and gratitude for the dedicated work of the staff. There was however pragmatism that the consultation was likely to result in the closure of the hospital, if nothing else by further undermining the ability of the trust to recruit staff, and therefore a determination to work to make sure that we have a commitment to an effective alternative.
Dartmouth would benefit from modern primary care facilities on the same site as Dartmouth Caring, community clinics and an enhanced primary care minor injuries service. The new service must also include commissioned beds in River View for local people who need extra care and re-ablement as a step between hospital and home, or to support them close to home at the end of life. A new combined facility could also allow us to provide better training and development for our local workforce. We know that there is a serious shortage of staff across community teams which is increasing the risk of unnecessary hospital admissions. But the support for this approach will depend on a clear commitment to put this in place and have the new facilities up and running before any closure goes ahead of our much loved community hospital. Clumsy language implying a lack of support for Dartmouth hospital should be withdrawn.
On the issue of Paignton hospital, I will be supporting Kevin Foster MP and again point out the need to have high quality alternative facilities in place before any closure goes ahead. It is also vital that the community are reassured about the quality of provision of social care following the damning CQC report on Mears.
I remain deeply concerned about the financial pressures across health and social care and will continue to press at national level in my role as chair of the Health Select Committee for an urgent review of and increase in the short and long term settlements. The pressures are not just financial but also as a result of a very serious workforce shortfall across health and social care and I would like to see greater emphasis on maximising training opportunities in the final CCG document.
I also remain deeply disappointed that there will not be a minor injuries unit with X-ray support at Brixham hospital. Concentrating services and facilities at Torbay hospital not only risks driving more people to A&E and increasing the risk of avoidable admission but also far longer travel times for Brixham residents.
I will be attending the public meeting this week to put these points to the board.
On a separate note, I have also been speaking in Parliament and directly to NHS leaders about the recent threats to Torbay's nationally and internationally respected model of integrated care. Whilst I have every confidence that Torbay council and the local NHS will continue to work closely together within the Integrated Care Organisation, ICO, it makes no sense to see their work undermined by outside threats to stop them pooling their resources to work in the best interests of patients.
I wrote the following article for the British Medical Journal (published on 3rd January 2017)
The current pressures in the NHS can be traced back to 2009 and what became known as the Nicholson challenge. In the aftermath of the economic crash this ushered in an unprecedented period of efficiency savings against a headwind of rapidly rising demand and costs. The incoming coalition government then imposed a disruptive and demoralising reorganisation that distracted from the key challenges. Rather than seizing the opportunity to integrate health and social care and to design a sustainable long term financial settlement, the Health and Social Care Act 2012 led to greater fragmentation at a time when our demographic changes demanded a different approach.
In the decade to 2015, the number of people living to age 85 and beyond increased by 31%.1That is a cause for celebration, but there has been a striking failure to plan for what this means for health and social care. The same is true for the rapidly rising cost of preventable conditions and expensive new drugs and technologies.
Over the last parliament, funding for the NHS increased annually by an average of just 1.1%, far below the actual increase in costs or the long term average of around 3.8% since 1978-79.2 The real terms increase in Department of Health spending for the current review period is just £4.5bn3 (€5.3bn; $5.5bn) and will result in reduced spending per person.2 The accompanying cuts to social care combined with a serious workforce shortfall have left more than a million older people going without the personal care that they need to live with dignity in their own homes.4 It is no surprise that so many are ending up in more expensive settings in an already overstretched NHS.
The political response to a health and care system in severe distress, and more importantly to the people it serves, has been dismal. No one listening to the yah boo of debate in the Commons would be filled with optimism. There has been a failure to grasp the scale of the financial challenge facing both health and social care and the consequences and inefficiency of their continuing separation. A serious shortfall in capital, as a result of ongoing raids to plug deficits, is undermining the prospects for the transformational changes necessary to produce future savings.
Likewise, area based joint commissioning is at risk if the financial squeeze is so unrealistic that health and social care retreat to protect their own budgets. Sustainability and transformation plans hold the possibility of moving away from a competition based approach to one based on integrated commissioning but they must be realistic and supported by the funds to deliver.
There have also been missed opportunities in public health. In her first speech on the steps of Downing Street, the Prime Minister, Theresa May, spoke compellingly of tackling the burning injustice of health inequality. That ambition now needs to be matched by effective cross government policies across the wider determinants of health. It will also require investment in public health in order to achieve the radical upgrade in prevention which underpinned the Five Year Forward View.5
At her recent appearance before the Liaison Committee of all select committee chairs, Theresa May confirmed that the government is working on a new settlement for social care but also that this doesn't currently include the NHS or involve other political parties. She should urgently revise her terms of reference to include them both.
The public has repeatedly made clear the value it places on our NHS and that it wants to see it properly funded. The financial challenge of providing sufficient funding for health and social care to cope with inexorably rising demand will be the same for whichever party is in power over the coming decades. It is in all our interests for them to work together to agree a way forward compatible with the founding principles of the NHS. Political instincts, however, have tended to focus on division and to duck the problem through arguments about data.
The most remembered statistic of the EU referendum campaign was the £350m a week for the NHS—a cynically deployed and rapidly disavowed non-fact for which no one can be held to account. Misleading data have consequences. If the chancellor believes that the NHS is receiving an extra £10bn, it is easier to see why he and the prime minister might resist the calls for more, especially having overseen far reaching cuts to the Ministry of Defence and the Home Office in their former roles.
The public has a right to expect accurate and consistent figures on total health spending, and it matters that we correctly insist on the true figure of £4.5bn. It also matters to keep setting out the facts on rising demand as well as the efficiency, fairness, and value of our NHS.
I often meet health professionals who think that politicians have no grasp of the scale of the problems they are facing. Never underestimate the impact you can make during a personal visit to MPs' surgeries or through an invitation to your workplace. We need as many MPs as possible to understand the urgency that they work together to find a sustainable long term settlement and the consequences for their constituents of political failure.
Celebrating the success of nature friendly Devon farmers:
This Friday (18th November) I will be celebrating the great progress in saving a bird that was nearly lost and the great contribution of Devon's farmers in making this possible.
The bird is the lovely cirl bunting, for which I am delighted to be a 'species champion MP'
Often called 'Devon's Special Bird' because, while it was once much more common across southern Britain, by the 1980's its numbers had declined and range pulled back into a small zone in south Devon. At this stage then, this bird of mixed farmland was in real decline and it began to look as if we might lose it altogether in this country. Devon had a special role to play. With these signals something stirred, the nature organisations, especially the RSPB, got stuck in. What was the problem? What has happening on the farms? Could farmers help save the bird? From what I have heard about the work, something wonderful began to happen.
Collaboration around the RSPBs research, the trialling and testing of farm based solutions, all swung into place. Saving this bird of farmland was absolutely dependant on farmers rising to the cause, and they did. The RSPBs 'recovery project' supported farmers, helping them turn the key that opened recovery success.
Local communities woke up to their special bird too, schools projects, a football team with the bird as its badge, and even a Devon village – Stokeinteignhead - celebrating the countryside around it as being special for this bird, all signalled peoples support for our special bird.
So, I will be enjoying celebrating some great news from Devon this Friday. And alongside this I'll take a serious message with me – that with the right approaches, and done well, we can do so much more for nature. The story of the cirl bunting - the bird we nearly lost - the farmers who have helped so much, the nature bodies like the RSPB, and all with the right kind of support from government and others, shines a light on how we can all do better.
This could not be more important right now as we look beyond Brexit and how subsidies might operate. I'm clear that these must continue to support the vital habitats for the cirl bunting and so many of our other native species.
(Photo courtesy of Matt Adam Williams)
I wrote the following article for The Guardian
In her first speech as Prime Minister, Theresa May promised to tackle the nine-year gap in life expectancy between rich and poor, placing this at the top of her list of burning injustices. This yawning inequality has defeated successive governments, and the gap is even wider between rich and poor for years lived in good health. Closing it will require action across areas such as poverty, housing and education, as well as those more conventionally thought of as affecting health. May will need to start early and look far beyond the short-term political cycle for results.
Public health seldom makes headlines. We tend not to recognise, let alone thank it for preventing disease or life-changing accidents, despite public health measures transforming our life expectancy. We are more likely to focus on and appreciate the specialists who treat a condition than to complain about the absence of the expertise or policy that could have helped to prevent it.
The childhood obesity strategy was the first test of the government's determination to take action on health inequality. It was greeted with near-universal dismay because of the wasted opportunities to make a difference. Whole sections from earlier drafts, covering promotions and advertising, were conspicuously erased and reformulation yet again left to ineffective voluntary agreements. The final paragraph sums up the tone that it will be "respecting consumer choice, economic realities and, ultimately, our need to eat". This crass statement entirely misses the point; of course children need to eat, but the childhood obesity strategy needed to make sure that they benefitted from a better diet.
Five years ago, amid the huge controversy surrounding the Health and Social Care Act, one proposal received a cautious welcome: the transfer of responsibility for public health from the NHS to local authorities. It was felt that local authorities could make a greater difference to the health and wellbeing of their communities if the right expertise, powers and funding were based there rather than within a health service more focused on treatment than prevention of disease. In a report published today, the Commons health select committee has looked at those changes and made a number of recommendations about how public health could be strengthened to make sure that it has the tools to do the job. These will be key to helping to narrow health inequalities.
The chief executive of the NHS, Simon Stevens, has rightly called for a "radical upgrade" in public health and prevention, not only for the benefits to health but because it will be essential to reducing future demand for health services. The future financial sustainability of the NHS depends on the prevention of more expensive long-term conditions. This was not the time to undercut the role of public health with budget reductions, including in-year cuts. Witnesses before the committee described their extreme frustration at these decisions, which they described as "irrational" given the current focus on reducing demand.
While local authority public health teams are doing their best to cope with funding cuts, the potential impact of this was clear, and unsurprising – figures from a survey conducted by the Association of Directors of Public Health show that large proportions of local authories are already having to reduce a wide range of different public health services.
Perhaps more surprising was that we heard from witnesses – both from local authorities and from NHS organisations – a sense that prevention is no longer seen as the responsibility of people practising in the NHS. While local authorities now hold the ring for funding and co-ordinating public health and preventative work across their local area, every NHS professional has the potential to advance the prevention agenda in every patient appointment they carry out – but they will also need the time and space to do so. It is also a shame that those messages on improving health will continue to be drowned out by the unfettered advertising and promotion of junk food and alcohol.
While the local mechanisms are in place to embed health in all policy decisions, this will not succeed without stronger, more joined-up action at a national level. At a time of budget cuts it is more important than ever that local authorities have the levers to make a difference. Unfortunately, they have their hands tied when it comes to negotiating with business interests even where the health of local communities is at stake. The government could and should introduce health as a material consideration in planning and licensing to allow proportionate action to develop healthier communities, homes and workplaces.
I hope that the government will prioritise health inequality, but the early signs are not encouraging. If future policy is to be judged by the childhood obesity "plan", we can expect little real progress. Tackling health inequality requires far more than warm words on education and personal responsibility.