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.
The childhood obesity strategy has been downgraded. 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.
Trying to capitalise on the feel good factor of the Olympics, the messaging has distorted the underlying evidence. Of course we need children to be more active but exercise matters whatever a child's age or weight. The key message on childhood obesity should have been front and centre about the importance of reducing junk calories with evidence-based action to match.
In completely removing whole sections from the draft strategy, it is hugely disappointing that the obesity plan puts the interests of the advertising industry ahead of the interests of children. The plan misses the opportunity to improve children's diets by reining in the saturation marketing and promotion of junk food. A staggering 40% of the food and drink we buy to consume at home is bought through promotional deals and the overwhelming majority of those deals are on junk food or alcohol. This was a missed opportunity to shift the balance of those promotions to healthier alternatives and to make them more affordable for those struggling on lower incomes. The plan has also completely failed to take junk away from the checkouts or restrict the hugely profitable end of aisle displays or deals flogging impulse purchases at point of sale. Responsible retailers wanted a level playing field in making those changes but their efforts will be undermined by the abject failure of the obesity 'plan' to recognise the impact of promotions and marketing.
Whilst it is good to see confirmation of the sugary drinks levy, the watered down obesity strategy is completely at odds with the pledge to tackle the burning injustice of health inequality. Even its title has been downgraded to 'plan' but it would perhaps have been better named a plan for inaction as even the proposals to reformulate are voluntary. Without 'teeth' voluntary reformulation looks set to be as ineffective as the miserable 'responsibility deal' which precedes it. Progress will be monitored against worthy but voluntary targets until 2020 but with no consequences for those manufacturers and retailers which put profits ahead of children's health.
Whilst all those in contact with children suffering from obesity are rightly urged to make every contact count in trying to help, they will be hopelessly undermined in their efforts. Big industry interests have been given free rein to continue to promote and advertise as they please including those that do so through online marketing masquerading as games or through the powerful use of cartoon characters on junk food aimed at children.
The confirmation of the increase in funding for school sport from a levy on sugary drinks manufacturers is very welcome but the levy will not come into force until 2018 and needs to be broadened to include all drinks with high added sugar content. The plan should also have given greater powers to local authorities to make changes to improve public health at local level. Especially at a time when their public health budgets are being cut, it was more important than ever to give them the levers to do the job by making health an objective in the planning system.
The gap between rich and poor children when it comes to obesity has widened every year since measurements began. One in four of the most disadvantaged children now leaves primary school not just overweight but obese, more than twice the rate for those from the most advantaged families. This plan for inaction will be remembered for its wasted opportunities, delays and spin when it could and should have been the opportunity to show that government is serious about tackling the gap in life expectancy between rich and poor. We will all be picking up the tab in the future costs of obesity for the NHS, already more than the police, fire service and judicial system combined, but no one will be paying a heavier price than the individual children facing a lifetime blighted by the consequences.
The independent Chilcot Report was expected to report rapidly, but such was the volume and detail of the evidence examined and the sensitivity of its conclusions that in the end it took seven years. It runs to 12 volumes and 2.6m words and the final summary should be compulsory reading for all who will in future be tasked with the heaviest decision for any government, to commit our forces to war. 179 British servicemen and women lost their lives alongside 24 British civilians and over 150,000 Iraqis. The consequences for their loved ones of our failures in Iraq have been appalling and the terrorism and violence continue to this day across the region and worldwide.
Chilcot is damning in his conclusions including that:
• Military action was not a last resort as all peaceful options had not been exhausted
• Policy on the Iraq invasion was made on the basis of flawed intelligence assessments. This assessment was not challenged as it should have been, preferably by an independent body
• The continuing threat from weapons of mass destruction was presented with unjust certainty
• The circumstances in which the legal basis for military action were established were "far from satisfactory" and the authority of the United Nations Security Council was undermined.
• There was too "little time" to properly prepare. The risks were neither "properly identified nor fully exposed" to ministers, leaving our troops dangerously exposed as a result of inadequate equipment.
• Plans for post-Saddam Iraq were wholly inadequate
• The consequences of the invasion were underestimated and this left a space for extremists to flourish.
I listened to Tony Blair's apology and his acceptance of responsibility but like many was aghast to hear that he would take the same course of action again.
Next week Parliament has dedicated two full days to debate this crucial report and how this should influence the future conduct of those who advise on or take the final decisions to take us to war. Whilst I do not feel that the lesson from the Chilcot Report is that we should never engage in military action, it should be a last resort and all future governments must make sure that the grave lessons are learnt from this catalogue of disasters.
Britain has spoken and now it is for Government and Parliament to respect the result of the referendum and carry forward the instruction to take us out of the European Union. It has been a long campaign which has divided families, communities and the nation. Almost three quarters of those under 24 voted to remain whilst their grandparents' generation voted decisively to leave. In Torbay the clear majority embraced Brexit whilst in the neighbouring South Hams most people did not. Scotland and Northern Ireland wanted in whilst England and Wales voted out. In the end, months of complex arguments seemed to boil down to a tug between immigration and sovereignty on the one hand versus the economy, stability and our links with Europe on the other. Now it is time to put the divisions behind us and move on.
My job as your MP will be to do everything I can to help to support the long task ahead. Taking us out of a 43 year relationship will not happen quickly. The tone of the debate with our 27 partners must remain positive if we are to grow Britain's place alongside them as European neighbours rather than descend into an acrimonious divorce. In setting that tone, the government must set out early to reassure those who are already living in the UK from other EU nations that they are welcome to stay. Without the 130,000 valued staff who qualified elsewhere in Europe, currently working in health and social care for example, our NHS would not be able to function. An atmosphere of mutual friendship and respect will be equally important for the hundreds of thousands of our fellow citizens living across the Channel. Britain has voted to leave the institution of the EU, not Europe and voted to be able to control our borders in the future, not to slam them shut.
David Cameron has made a dignified decision to step down to allow fresh leadership to negotiate the complicated path which lies ahead of us. My view is that this needs to be someone with experience, statesmanship and stamina who can be a unifying figure at home and command respect on the world stage. Britain needs us to move quickly and decisively on this so that the negotiations can begin. A long period of uncertainty will be damaging for an economy already under pressure as a result of such a seismic shift.
Our next leader will also need to be someone capable of handling complex negotiations at home as well as with our EU partners. So much of our own legislation is in some way connected with EU directives or regulations that it will be necessary to adopt the majority of them and then take a thoughtful measured approach to repealing or amending them in our best interests. Whilst the most urgent issues can be prioritised, given the timescale for legislation to pass through Parliament, this is likely to take many years and put many other important issues on hold.
Some have called for an early General Election, but under the Fixed-Term Parliaments Act 2011, no Prime Minister or their Government can dissolve Parliament without a 2/3 majority in the Commons. Others are calling for Parliament to block the result and there is a rapidly growing petition to re-run the referendum but I would strongly oppose such a move because Britain has already delivered its verdict. Those MPs who, like myself, came to a different view during the campaign must not seek to obstruct the decision of the people but actively to make it a reality in the most constructive way possible. My job as chair of Parliament's Health Select Committee will also be to hold Leave campaigners in the future Government to account for the promises they made to provide extra support for the NHS from the money which we currently send to the EU. The Government should also continue the essential support for farmers and poorer communities which flows back from our gross EU contributions as well as the scientific research which has long been a net beneficiary.
Challenging times lie ahead for all of us as a result of this momentous decision but our leaders must work together, not sow further division as a result.
My postal vote sits unopened in the kitchen. Far from tearing it open to do my bit for Brexit, I have been imagining how it would feel to wake up to that result on June 24th. It would not be elation or freedom but a profound sense that something had been lost and guilt too if my vote had contributed to the turmoil ahead.
It's far easier as a politician to stick immovably to a declared position but more honest to set out why I will now be voting for Britain to remain a member of the EU.
I came into politics to campaign on health so I've listened carefully to the evidence from both sides on this. The claims about health from the leave campaign have been shameful. They have knowingly placed a financial lie at the heart of their campaign, even emblazoning it on their battle bus alongside the NHS branding to imply a financial bonanza. It's an empty promise and one which would soon backfire. A strong economy has always been the cornerstone of funding for the NHS and for all the arguments about the scale of the economic turbulence, the clear consensus is that the effects would be significant and negative. Far from a leave dividend there would be an economic penalty and the NHS would suffer the consequences. The chilling effect would not just be financial, but on the workforce. If you meet a migrant in the NHS, they are more likely to be treating you than ahead of you in the queue and very many of our core health and social care workforce come from the EU. How does it feel for them? I know from my correspondence and from private conversations how intensely painful and alienating many of my EU constituents have found the tone of the debate.
The NHS is not just a passive beneficiary of a strong economy, health is a key driver for economic growth. Listening to the evidence, the EU has played a positive role in promoting good health whether that be in terms of water and air quality or the scientific research for which the UK is clearly a net beneficiary. We contribute 11% of the EU research budget and receive 16% of its allocated funding. The UK also plays a strong leadership role in the surveillance, shared intelligence and response to the health threats which are no respecters of national boundaries as evidenced by our ability to respond to the Ebola outbreak, saving countless lives.
Could services, research and public health be put at risk in the event of a vote to leave the EU? I believe the balance of evidence is that the isolation and instability of Brexit should come with a health warning.
I've also spent time over recent weeks observing the professionalism and care of the NHS from my father's bedside as he recovered from a heart attack and a triple bypass. We had the time for long conversations about the referendum and our place in Europe. Now 81, he started training whilst still a teenager, as a mine clearance diver with the Royal Navy. For him, the risk of war in Europe is not some abstract debate but a fearsome horror against which the EU, for all its imperfections, has brought us the protection of peace. He pressed this home all the way to the doors of the operating theatre. Whilst some would celebrate the instability that would be triggered across the EU by Britain's exit, even if that lead to its collapse, I do not. We all benefit from a stable Europe.
The leave campaign has redrawn its battle lines around immigration for the final weeks of the campaign. It looks increasingly indistinguishable from UKIP but the immigration card may prove an empty promise if the price of trade with the EU requires the free movement of people. It will also have left a bitter legacy of division.
This has been an unnecessarily acrimonious and divisive campaign. It has also highlighted the scale of our disconnect from the European institutions which control so many aspects of our daily lives. If the outcome is a vote to remain then we urgently need to reset that relationship and, before we slide back into indifference, start to connect with our MEPs and make our voices count in Europe.
With a month to go until the EU referendum, the public deserve better from this campaign. I came into politics urging for better use of data and, like so many who are grappling with the questions at the heart of the debate, I'm dismayed by the disingenuous and at times downright misleading claims from both official campaigns.
We have seen a spiral in recent days, with both sides making ever more outlandish claims. Most recently Vote Leave has blamed EU migration for NHS pressures, brazenly hijacked their branding and continued to make the absurd claim that Brexit could divert £350million extra per week to the NHS.
There are many reasons for the pressures on the NHS, but largely because we are living longer and with multiple and complex conditions. As many have commented; if you meet a migrant in the NHS they are more likely to be caring for you than ahead of you in the queue. The NHS Chief Executive, Simon Stevens, set out the stark dependence of the service, on overseas staff during his interview on the Marr Show and, whilst many health and care workers come from outside the EU, a vote to leave would have consequences if those from the EU were made to feel unwelcome. He also highlighted the dependence of the NHS on a strong economy and the knock on consequences for any uplift in funding of financial turbulence. In my view, it is an increase in the percentage of our national income that we spend on health and care that will save the NHS, not Brexit. After the rebate and funds already committed to support farmers, exporters, regional development projects and science, the leave campaign clearly does not have an extra £350m per week to promise the NHS and they should stop treating the public as fools.
There are legitimate concerns about pressures of population growth on housing, schools and certain areas of health provision but the current pre-occupation exploiting the NHS, and its protected branding, to support the leave campaign's argument on the EU is a cynical distortion which undermines the credibility of their other arguments. I will not hand out Vote Leave's deliberately misleading leaflets about the NHS.
The issues around this referendum are complex. People are sick of the deluge of misinformation and don't know who to trust. We cannot point to either official campaign as a trusted source. I'm suggesting people look at websites like Full Fact or the detailed research published by the House of Commons library.
I remain very torn about this referendum. I had never imagined that I would vote to leave the EU and welcomed the renegotiations as an opportunity for the institution to take account of the serious concerns not just from Britain but from across the continent. I wanted to stay in a reformed EU and yet the renegotiation only served to highlight that the EU appears neither interested nor capable of genuine reform. The democratic deficit at the heart of the institution and our own detachment from it are deeply troubling.
We tend to think of the EU as benign and remote but what if a federal and ever more centralising Europe moves against our national interest? We will be powerless to effect meaningful change just as we are already unable to vote its leaders from power. The situation in Austria should act as a wake up call to those who feel that the direction of the EU could not change. My fundamental concern is that in our own mature democracy we must retain the ability to remove from power those who make the decisions which govern our lives.
I am concerned about the increasingly ugly tone of the Leave campaign but I'm also sceptical about the wild claims of a descent into chaos, war and the collapse of security from the Remain camp. In the event of Brexit wise heads would surely prevail to ensure essential cross border cooperation.
Project fear however, appears to be working. I meet many people who are switching to Remain because they have been spooked by the relentless messaging on security and the economy. They will be holding their noses to vote for remain, not endorsing the status quo. There is still a powerful feeling that people want a relationship based on trade rather than tied to the rim of an ever more centralised and powerful federal Europe.
If the majority vote to stay - which I think is likely – we must fundamentally rethink how we engage with the EU and develop a meaningful relationship between people and the currently remote bodies which make up this institution.
The remain campaign is anxious, and as a result – they and the government are overhyping both the risks of leaving and the benefits of remaining rather than leading a nuanced and honest debate. The danger of that approach is that the result will be interpreted by the EU as a ringing endorsement of business as usual.
Our community hospitals are immensely valued and so any changes, especially those that could lead to bed closures are a serious concern. Community hospitals are about far more than their bricks and mortar, they are at the heart of delivering a service to local communities that allows people to be cared for closer to home, sometimes to be able to be cared for near loved ones at the end of their lives or to avoid having to be admitted to a larger hospital too far away for friends and family to be able to visit. Community hospitals provide personal, high quality and supportive care and are extraordinarily important to all the communities and individuals they serve.
To be clear, I do not want Paignton or Dartmouth hospitals to close. But our ageing population and the rising demand for services especially as a result of the growing number of people living with long term conditions mean that those planning services have to look at how we can care for as many people as possible close to home within the resources available. That means looking at the whole system of primary care, community nursing, social care, mental health services and voluntary services alongside community hospitals and Torbay hospital. We cannot look at them in isolation.
Across South Devon our primary care and community services are under great pressure with difficulty recruiting staff and in some cases working from totally inadequate premises. The closure of the minor injuries service at Dartmouth happened because they could not recruit or retain the highly skilled staff to maintain a safe level of service. Local health and social care is also under great financial pressure and our Clinical Commissioning Group is on course for a £15million shortfall in 2016/17.
Torbay and South Devon Foundation Trust and the CCG will be publishing their final plans on April 22nd but it is worth looking now at the links from the CCG website for Paignton and Brixham as well as Moor to Sea. These set out the challenges around age, deprivation and health inequality as well as the financial pressures facing our local area alongside the draft proposals.
If the plans just involve cuts to services and beds I will not support them. If a strong case can be presented for how money would be invested in genuinely improving services for patients then I think there must be a clear promise about how that will be guaranteed and greater detail on what it will look like.
The beds that are so valued by communities, close to home, can sometimes be provided as beds with extra support within a nursing home or residential care but there must be complete honesty about what the money saved, estimated at £3.9m would be invested in to make the overall service better at allowing people to be supported in their own homes without needing hospital admission in the first place.
Our community hospitals were gifted to local communities and supported over many years by generous donations and bequests. If any are sold, and it remains a big if, that resource must stay for the benefit of the local communities to which they were gifted and be used to build primary and community care facilities that are fit for the needs of today's patients. Those changes must have the support of communities and that will only come if the case can be clearly made for why the service could be better if provided in a different way. We know for example that NHS community bridge workers working alongside voluntary services can make a great difference in supporting people as they leave hospital and in reducing the risk of unnecessary admission. Community teams can include physiotherapists, occupational therapists and community mental health professionals as well as community nursing and social care but they need a base. Multidisciplinary teams can work even better if located alongside primary care so the consultation needs to set out a vision for the whole service and clear evidence for why that would be better than our highly valued local network of existing community hospitals. There is a strong case for community hospitals to do more, not less but that may mean using them in a different way focusing on prevention and care for people living with long term conditions.
There is not enough detail in the draft proposals on how the new arrangements would improve or work alongside GP services and far more detail is needed about where nursing home or residential 'intermediate care' beds would be provided if not at the local community hospital. The proposed closure of 28 beds at Paignton and 16 at Dartmouth would be a great loss and local people will need a clear explanation of how the money saved from closures would be invested both to improve services for local people and allow care to provided more efficiently rather than it just being sucked into plugging a financial gap.Whilst some admissions can be avoided with better community care, that is not always going to be the case. Torbay hospital is already under pressure and, without a clear plan for community beds, there is a danger that we could see people being admitted to even more costly hospital beds further from home as well as greater difficulty discharging patients at the end of their stay, one of the main causes of delays in casualty departments. It is very important that the beds from St Kildas are also taken into account.
The proposed closure of minor injuries units also means more people turning up in A&E from where they are more likely to be admitted unless there are really effective measures in place to avoid this. Anyone who has tried getting from Brixham to Torbay at peak times in the summer will know how difficult this can be and a Brixham hub should include access to a MIU in my view.
Amongst the many principles set out for the proposed reorganisation, there is a specific reference to improving life expectancy especially in the most deprived areas. There is a serious question therefore about the impact of closures on our most deprived communities in Townstal and Paignton and what services would be put in their place to reduce inequality and improve health and wellbeing.
I will be closely studying the final plans once these are published and attending as many of the community consultation meetings as possible. As Paignton hospital is in the Torbay Parliamentary constituency, Kevin Foster MP will be leading the discussions on the proposals there whilst I will be doing so for Brixham and Dartmouth hospitals. We will be working together as people from across the Bay use and value all our community hospitals.
I wrote the following article for the Guardian
I have great respect for junior doctors; it has always been a demanding role. Alongside my clinical practice, I spent over a decade teaching them before changing my initials from GP to MP. I should also declare a personal interest as my daughter is one of them, albeit currently working in Australia.
There is a long tradition of juniors spending a year or two abroad early in their careers before settling down to specialist training back in the UK, but now there is a genuine concern about the balance between leavers and returners. Many of my daughter's colleagues are not planning to join her on the journey home next year and there has been a marked increase in the numbers applying for certificates to work overseas.
The toxic dispute between the government and our core medical workforce risks driving an exodus of skills that we cannot afford to lose.
The contract sits like a festering boil with neither side ready to agree a way forward, and the dispute looks set to erupt into a dangerous full walkout by junior doctors. The British Medical Association (BMA) claims that the contract will harm patients by stretching doctors too thinly across seven days while reducing their take-home pay. The government insists that patients are being put at risk by understaffing at the weekends and that the contract reduces doctors' maximum hours and consecutive shifts while increasing basic pay by 13.5%.
The Department of Health and the BMA have spent so long shouting at cross purposes that they have forgotten their common purpose. In using them as pawns, both sides have lost sight of patients, the very people both claim to want to protect.
It was perfectly reasonable for the government to try to tackle the higher mortality at 30 days for those admitted to hospital at weekends, but entirely unreasonable to blunder on asserting that the new contract is the answer. Ministers are undermining their case and inflaming tensions by misquoting the evidence, which points more to the need to improve senior decision-making, nursing cover and rapid access to investigations at the weekends than to increase junior doctor cover. If the objective is to tackle excess weekend mortality at 30 days, the government should have followed the evidence and focused elsewhere.
It seems to me that the contract is more about the manifesto commitment to a seven-day NHS and the perceived barrier of premium Saturday pay rates. There needs to be a far clearer and more consistent definition of what the government means by a seven-day NHS and how it will be staffed and funded. Is it about convenient seven-day access to routine services and surgery, or about making sure that urgent and emergency care is available to the same standard every day of the week?
The Department of Health should have been more robust with No 10 that a routine seven-day NHS is unachievable within the current workforce and financial pressures and refused to accept underfunded new commitments.
Mine was the last generation of doctors to endure crushingly unsafe 120-hour working weeks and I have no romantic nostalgia for the 72-hour shifts commonplace in the late 1980s. Tired doctors can be dangerous doctors. What struck me, however, from the juniors I taught before coming to parliament, was that they felt every bit as exhausted and demoralised, not through lack of sleep but because while on duty they too often felt stretched to the limit. Medicine has also lost the supportive team structures and flexibility to work near partners and accommodation that once compensated for the stresses of the job. Today's juniors, feeling powerless and undervalued, are now prepared to walk out on their patients – but that will have lasting consequences.
A failure to recognise this until too late in the negotiations, alongside a disastrously timed and clumsy announcement, risks scuppering an important opportunity for change. The appointment of Professor Sue Bailey, chair of the Academy of Medical Royal Colleges, to examine how to improve juniors' working lives, should have been unequivocally welcomed by the BMA. Anyone who knows her will know that Prof Bailey is no mouthpiece for government and would be a powerful advocate for change.
Pressing ahead with a full walkout however, will serve only to harden attitudes and solves nothing. Most importantly, it will be disastrous for patients. The BMA has no doubt calculated that people will blame the government, but a strike that leaves patients without junior cover even for emergencies puts lives at risk. It cannot justify such drastic action by claiming to protect patients.
Given the agreement to pay the premium rate all day to any doctor working one Saturday or more every month, how can it be argued that patients will be safer only if all Saturdays are paid at the premium rate, however infrequently worked? Given the scale of concessions and protections on maximum hours and consecutive shifts, the BMA could have declared victory and moved on to focus on the deeper and longstanding causes of discontent.
Junior doctors are understandably concerned about being pressured into working unsafe hours despite the proposed safeguards, but this was all the more reason to work with Prof Bailey and new provisions in the contract to make sure that whistle-blowers are confident to come forward and fully protected when they do.
Both sides now need to put patients first and step back from this dispute. The government should do as it promised under the Health and Social Care Act and to stop trying to micromanage the NHS. If there was a clearer definition of their purpose behind a seven-day NHS, the service could better design the solutions and set out the costs.
It would also help for the government to make a clear statement of the obvious: that come August, junior doctors will see little change to their shift patterns. The simple reason is that there are not yet enough of them to achieve a truly seven-day service. That ambition requires a change in the workforce and a commitment to supporting and working alongside it rather than in an atmosphere of conflict.
NHS England, Health Education England and the BMA should work with Prof Bailey to undertake a fundamental review of junior doctors' training programmes, responsibilities and working lives, including facilitating them to coordinate placements with partners. Many more of their duties could be shared with others such as pharmacists, physician associates and admin staff. Patients are already benefiting from the greater use of the professional skills of specialist nurses and far more could be achieved.
In some hospitals, such as Salford Royal in Manchester, electronic patient records are finally reducing the scandalous waste of time and resources that come with duplication and paper trails. More could be done to make sure that best practice benefits patients everywhere.
A constructive relationship between doctors and government will take time to rebuild; it cannot be imposed and it will not happen unless both sides put patients first and start listening. Saving lives must take priority over saving face.