Dr Andrew Murrison
MP for South West Wiltshire · Conservative · United Kingdom
“It is good to hear that the Government plan to replenish the dwindling stocks of Patriot missiles in Ukraine, which I suspect it will need this winter. However, Patriot is low volume and high cost. What the Ukrainians need is high volume and low cost.”
“Currently, the Royal Navy has an offshore patrol vessel permanently stationed in the Falkland Islands, but given the threat that is being faced and our need to demonstrate resolve—the sort of thing that, sadly, we did not demonstrate in the early 1980s, which led to miscalculation—will the Minister consider speaking to her MOD colleagues…”
“Since the Foreign Secretary is not going to get the co-operation, fulsome or otherwise, of the Israeli state in differentiating goods and services made in the settlements from those that are assembled, repackaged, produced and grown in Israel itself, how is he going to distinguish the one from the other?”
“The Government insisted on applying the social time preference rate to the disastrous Chagos deal to make an appalling deal look slightly better.”
“Will the First Secretary of State’s exercise in delivering democracy and local accountability and empowering local people include a look at large organisations that cannot be described as governmental or as quangos but that nevertheless exist firmly within the public domain, are established by statute, serve the public and are big employe…”
“I congratulate the Government on the hiring of Alistair Burt—he is a good hire and will do great things for some of these most complex of cases—but does the Minister agree that many of these cases are extremely difficult and exceptionally traumatic, and that it is far better to prevent them happening in the first place?”
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“It is always a pleasure to follow the hon. Member for Oldham East and Saddleworth (Debbie Abrahams). It is a privilege to be able to speak in today’s debate. I start by echoing the comments by my hon. Friends the Members for Harrow East (Bob Blackman) and for High Peak (Andrew Bingham), in particular, and other hon. Members, about the digital economy Bill. I am delighted that the Minister for that business area, my hon. Friend the Minister for Culture and the Digital Economy, has just walked into the Chamber. This Government have done a splendid job in trying to roll out broadband. It is very difficult to make inroads into the last 5%, but the universal service obligation and the commitment to 10 megabits is absolutely right.”
“I share my hon. Friend’s confusion, but in fairness, it is only right to point out that weekend working means meeting the four key clinical standards that Sir Bruce Keogh outlined. I fear that my hon. Friend will probably not be getting his physiotherapy at the weekend.”
“People in land-based employment feel frustrated by term times and holidays based in an agrarian past. Does my hon. Friend agree that communities in rural locations often have small village schools that stand to suffer disproportionately in the event of disruption in the classroom due to absences such as he has described?”
“I warmly congratulate both sides on reaching this agreement. Our NHS is different at weekends, and my right hon. Friend is right to inculcate Sir Bruce Keogh’s four key clinical standards on a Sunday and a Saturday. Does he agree that it is important not simply to rely on mortality data, which are often difficult to interpret, to underpin the case for a seven-day NHS? Will he look closely at other metrics based on clinical standards for things like routine lists for upper gastrointestinal endoscopy on a Saturday and Sunday? Will he also look at palliative care, which of course does not feature in any hospital mortality data?”
“I apologise for not being here for the start of the debate. I congratulate my right hon. Friend the Member for Broadland (Mr Simpson) on bringing it forward. Does the Minister agree that one of the biggest tributes that we pay to our fallen is the sheer quality of the work that the Commonwealth War Graves Commission does, as evidenced by its workshop in Arras? Its metalwork, stonemasonry and carpentry are second to none. Does he share my hope that, in 100 years’ time, that level of workmanship will have endured?”
“Outcomes in cancer are not just about survival. Does the Minister agree that nowhere is the case for a seven-day NHS stronger than in palliative medicine, and will he say what can be done, in rolling out the 7/7 NHS, to address the scandal whereby only one in five hospitals has specialist palliative care cover on a Saturday and Sunday?”
“I very much support the pragmatic and responsible position outlined by the Minister on unaccompanied children, but does it not assert a worrying incapacity, particularly on the part of France and its structures, for maintaining the safety and security of vulnerable children?”
“If the Dublin convention is to work optimally, it requires the collection of biometric data from migrants. Perfectly understandably, the more savvy migrant declines to co-operate with that process, probably with the connivance of Italian and Greek officials. What can be done to strengthen that part of the Dublin arrangements?”
“The hon. Lady is making a spending commitment. Why then, only a few months ago, did she stand on a manifesto that opposed the Government’s £10 billion investment in the NHS?”
“We need to understand that nursing graduates may be tempted to migrate as a result of the introduction of these fees. I ask the Minister, in his consultation, to think of all the unintended consequences that may develop, given our general historical tradition in this country of doing health workforce planning so abysmally.”
“I hope that as we design the future for nursing, we keep that very much in mind. A few hon. Members have commented on workforce planning. Historically, the NHS has been absolutely abysmal in this regard, and we need to do much better in future. We need to avoid unintended consequences of the changes that we are making. We need to ensure that the £21,000 threshold that would apply for nursing graduates does not mean that people are inclined to avoid it by working part time where they might otherwise work more full-time hours. That would be a great disservice to the overall workforce. The 10,000 new places created must not be denuded by our offering them to applicants from overseas, because that would not be in the interests of our national health service.”
“Naturally enough, nursing associates will not be SENs revisited, because we now live in a very different age, but there is surely a place within healthcare and our national health service for a group of people who may not want the academic rigour that goes with a nursing degree—or indeed be fitted for it, at their stage of life—but who nevertheless want to nurse, and to enter an intrinsically hands-on, caring occupation. The important difference, though—this is where SENs, I am afraid, suffered so badly all those years ago—is that there must be a sufficiently pervious system to allow nursing associates, if they want to and have the necessary skill sets, to enter a professional nursing stream. It was a tragedy that so many well-qualified SENs were unable to develop their careers in that way.”
“Member for Lewisham East (Heidi Alexander), who speaks for the Opposition, did—to distinguish between graduates and to say that one graduate is more worthy than another. She may have in mind a view of a typical graduate, but those graduates are also potential teachers, engineers, biomedical scientists, and all the rest. We start down a very difficult path if we try to hold up one graduate as being superior morally, or in some other sense, to others. That is a very difficult thing to sustain. I very much support the notion of a nursing associate. I am old enough to remember state-enrolled nurses. These were nurses who would not satisfy the entry criteria for a course leading to state registration but wanted to be members of a caring occupation.”
“However, the fact remains that as part of Project 2000 in the 1990s, the nursing profession decided to move away from a hospital-based training structure to a structure based around universities—that was driven by the profession itself. The debate we are having today is part of that process—the process by which nurses become graduates, in exactly the same way as anyone else, including those who are preparing, for example, to teach in schools. When we design the finances for student nurses, it is of course important that we understand the difference between a nursing degree course and a normal degree course, as it were. We must also accept that this is a graduate profession, and that it is not right to try—as I think the hon.”
“Friend the Member for Totnes (Dr Wollaston) will remember, as do I, that they were essential to the working of hospital wards, and one or two of the good points made by Opposition Members revolve around that issue. The question is whether, in this day and age, we are still heavily reliant on that workforce for the proper functioning of hospital wards. If we are, there is a good case to be made for allowing for that in the bursary arrangements for student nurses, because it is simply not right to expect those people to do service work and not be compensated in some way for it. I hope very much that that strand of thought will be taken up as part of the consultation.”
“Lots of young men and women who wish to study nursing and to be nurses are being turned away. That is a double tragedy because we have a gross shortage of nurses in this country, and nothing I have heard from the Opposition gives me any confidence that they have any plan as to how we are to satisfy the two imperatives of allowing those who want to study nursing to do so and of plugging the shortage in our national health service. At the moment, I am afraid, we are able to deal with that issue only because nurses from overseas are prepared to come here—nurses, very often, from countries that can scarcely do without them. Historically, student nurses have been an intrinsic part of the NHS workforce. My hon.”
“May I start by declaring my interest as a member of a healthcare profession allied to nursing? Two thirds of those who apply for nursing school places are rejected and have to look at other trades or professions—that is tens of thousands of people every year. Despite the comments of some hon. Members, those are good, high-quality applicants. I took the trouble of looking at the entry requirements of the three universities that accept adult candidates on to general nursing degree courses in the south-west—Bournemouth University, the University of the West of England and Plymouth University. The typical offer is 300 UCAS points—three Bs at A-level—so there is not a shortage of applicants who are academically well-qualified and, indeed, qualified in every way.”
“I congratulate my hon. Friend on his remarks. The right hon. Member for Barking (Dame Margaret Hodge) mentioned turbulence as a reason for funding certain schools, particularly in London. Does my hon. Friend agree that London is not the only place where turbulence is suffered, and that the pupil premium that the Government rightly introduced to allow for the fact that service families move all the time is germane to this debate and needs to be reflected in the funding formula?”
“The Health Secretary is doing the right thing for patients, and I welcome his statement. However, does he accept that there is more to be done in contractual terms for the NHS workforce if Sir Bruce Keogh’s 10 clinical standards are to be implemented? Although he may not wish to reflect on it at this particular point in time, what does he think can be done to improve contracts for non-training grades and consultants in the NHS?”
“I very much welcome the Foreign Secretary’s statement and, in particular, the reassurances it contains about the use of British troops exclusively in training and mentoring, if that becomes necessary. Does he recall the disaster that was the training of Libyans in the UK? Will he assure the House that those mistakes have been noted and lessons have been learnt, and that, if he does intend to train Libyans in the UK, as his statement suggested, we will not make those mistakes again?”
“Does my hon. Friend agree that Army 2020 and the creation of regional forces will help to grow future defence attachés and will enable officers to follow a career path that includes a substantial element of foreign service, allowing them to get the skills necessary to be effective defence attachés?”
“The Health Secretary rightly mentioned the excellent Salford Royal, which the BMA has used to suggest that the new contract is not necessary, because of the progress that it has made on seven-day working and on Sir Bruce Keogh’s clinical standards. However, is it not the case that what might be right in a large hospital in a densely urban centre might not be applicable right across our national health service? Is that not why the very radical changes to working practices that he is rightly prosecuting are necessary?”
“What progress has been made in implementing Sir Bruce Keogh’s 10 clinical standards, published in December 2013, which are absolutely essential for rolling out the seven-day NHS?”
“That is a tribute to our NHS and to some great pioneering work in therapeutics and interventions, much of which has been trialled and researched in the UK.”
“For the avoidance of doubt, let me say that upper gastrointestinal bleeding is what was so vividly portrayed by Hugh Bonneville, as Lord Grantham, in Julian Fellowes’s “Downton Abbey”. As the New York Post said, the Downton ulcer his lordship had been moaning about for weeks finally erupted all over the dinner table and all over Lady Cora. That is at the extreme end of the spectrum, but when it happens it needs to be dealt with very quickly and proficiently. I want to start with a little bit of good news. Lord Grantham was lucky to survive in the 1920s, but mortality from upper gastrointestinal bleeding has been falling in the UK, with modest improvements in recent years as new treatments and innovative therapies have emerged, despite an ageing demographic.”
“I am sure we are all very relieved to be having the Adjournment debate at this hour, rather than at two o’clock in the morning, as was previously rumoured. I must first declare my interest as a doctor. I am grateful for the opportunity to bring forward this extremely important debate—it is certainly important for our constituents—about the management of acute upper gastrointestinal bleeding. I am grateful to the British Society of Gastroenterology, and particularly to its president, Dr Ian Forgacs, for helping me with research in preparing for the debate. The BSG has done a great deal of work over many years to highlight this issue. Between 50,000 and 70,000 people every year are admitted with acute upper gastrointestinal bleeding, and 10% will, sadly, die. That presents a significant challenge to our national health service.”
“The answer is dedicated GI bleeding units that are seven-day NHS-compliant, and, with very few exceptions, no unit that cannot match the BSG’s guidelines should take patients with acute upper GI bleeding. I look forward to hearing how the Minister will make this so. I invite him to return to the House after 12 months, if I am fortunate enough to secure another Adjournment debate of this sort, to tell us how the position has improved.”
“That is pretty hard hitting from a very senior NHS manager, and I wonder how individuals can justify salaries well in excess of the Prime Minister’s if they are failing to get a grip on the sort of shortfalls described as “A Bleeding Shame” by NCEPOD. Dame Julie is right to ask why incredibly expensive senior NHS managers who are managing failure on this scale are still in post. Last year’s NCEPOD report on acute upper GI bleeding is a wake-up call. Its first and prime recommendation —that patients with any acute GI bleed should be admitted only to hospitals with 24/7 access to on-site endoscopy, on-site or formally networked interventional radiology, on-site GI bleed surgery and on-site critical care—must be implemented without further delay.”
“That is despite Simon Stevens’s five-year forward view, which does not come close to addressing what is needed to make progress, given the assumptions on which it is based, which we know we cannot rely on. It is not just about money, however. The impression given by the studies that I have relied on is that the management of acute upper GI bleeding is a hit-and-miss affair. The BSG blames a “lack of engagement from senior managers” for that patchiness. That ties in with the remarks made last week by Dame Julie Moore, who said that there was a “culture of indecision” in the NHS, and that there was “gross incompetence” and a “failure of leadership”.”
“I am proud to support a Government who are spending more on the NHS than ever before—spending, let it be remembered, that was opposed by the Labour party at the general election. However, outcomes in the UK routinely compare unfavourably with those in similar countries, with which we can reasonably be compared. I have no specific comparative data for acute upper GI bleeding, but I have no reason to suppose that they run counter to that general trend. The unavoidable truth is that our neighbours spend significantly more on healthcare than we do. The right hon. Member for North Norfolk (Norman Lamb) and I, with colleagues across the House, have called for a commission to achieve consensus on long-term funding.”
“That highlights some broader issues around right-sizing the NHS estate for optimal acute and critical care outcomes, which is a subject that I have raised before. Because critical care requires multi-specialties, because of the need for increased sub-specialisation and all that implies for populating staff rosters, and because of the better outcomes in large specialist units, not to mention the cost pressures, optimal management of this range of conditions underscores neatly the need for the model hospital concept outlined in February by Lord Carter of Coles. Why are we not moving faster towards having secondary and tertiary care in regional and sub-regional centres, where critical mass, and therefore quality of outcome, can be more readily assured?”
“They would need to be scoped on a routinely scheduled endoscopy list the following day, and they should not be subjected to delay in investigative and interventional radiology if that is necessary to manage their case optimally. As far back as 2004, a large study by Sanders published in the European Journal of Gastroenterology and Hepatology showed that dedicated GI bleed units are associated with reduced mortality. NCEPOD asserts that patients with upper gastrointestinal bleeding should only be admitted to units with on-site endoscopy, on-site or networked interventional radiography, on-site surgery and on-site critical care. It promotes the model of comprehensive, dedicated GI bleed units in hospitals on acute medical take. We are far from achieving that.”
“In my view, there is a firm argument for a seven-day-a-week NHS, but we need a common understanding of what that actually means beyond the soundbite. Upper GI bleeding is a good case in point, which the Government could perfectly reasonably use to support their proposals for seven-day working without resorting to selective quoting from, for example, the Freemantle paper. Most people are really not bothered about the inability to get an outpatient appointment in dermatology on a Saturday afternoon. That is a luxury bordering on an indulgence. However, if their Downton ulcer erupted on a Friday night, they would not really want to wait until a chaotic Monday morning list before getting endoscoped.”
“Sir Bruce Keogh is right to say, however, that general hospitals are under-resourced at weekends, and the Academy of Medical Royal Colleges is right to point out that junior doctors are, to a certain extent, “winging it” out of hours, because consultants do not tend to be around to the same extent and many support functions are not, either. I remember it very well indeed. Sir Bruce was also right, in his 2013 review of 14 trusts with persistently high mortality rates, to commission Professors Nick Black and Ara Darzi to try to bottom out the relationship between excess mortality rates and avoidable deaths. Sadly, the report published last year did not seem to take us much further forward, other than to call into question the basis of the selection of trusts for the original Keogh review.”
“As Professor Matt Sutton’s work, reported by the Office of Health Economics last year, has shown, the quality-adjusted life-year evidence just does not support the cost of translating midweek working to the weekend. Data on increased mortality for those admitted at the weekends are alone insufficient to justify organisational change. The much cited Freemantle paper on weekend deaths does not say that excess weekend deaths are avoidable. Unfortunately, it has been quoted incorrectly by some who have confused association and causation.”
““Organisational issues” is a polite way of saying poor management, such as failure to organise rotas—the “Bleeding Rota”, as NCEPOD graphically puts it—and I will come back shortly to how that can be addressed with minimal resource implications. I support the concept of the seven-day NHS, or at least my interpretation of what a seven-day NHS actually means. The management of this range of conditions provides an excellent case study of why seven-day working is important and why Ministers are right to pursue it. Overall, the evidence does not support the proposition that relatively poor weekend healthcare outcomes for conditions across the board are attributable to a lack of seven-day working.”
“Alarmingly, a quarter of all hospitals treating upper gastrointestinal bleeding were found not to be accredited by the joint advisory group set up 20 years ago to set standards for endoscopy. More hospitals told NCEPOD that they could deliver open surgery of the sort Lord Grantham had in the 1920s than interventional radiology for this particular range of conditions. Some would say that that is down to inadequate resources. That is the mantra we often hear, particularly from the Labour party, but the situation is far more complicated than that. Alarmingly, NCEPOD reported that organisational issues led to less than satisfactory care in 18% of cases.”
“I am grateful to the hon. Gentleman, who takes an interest in these matters. He is right to say that we need to do more networking, to ensure that good practice is understood and inculcated. I will deal with some of that in my remarks. Two major studies—one by NHS England and the British Society of Gastroenterology in 2013, and the other by the National Confidential Enquiry into Patient Outcome and Death in 2015—highlighted significant shortcomings in provision, confirming earlier studies. The foreword to the NCEPOD report is starkly entitled “A Bleeding Shame”. NCEPOD found that the clinical care of 45% of acute GI bleed patients was sub-optimal, with a similar number receiving care judged to be good overall.”
“In issuing travel advice to the public, which they rely on to make an informed choice, will the Home Secretary ensure that we have safety first, but that we do not allow terrorists to close down our way of life and are mindful of the impact of that advice on partner nations? I am thinking in particular of north Africa in recent times and of the impact that advice has had on Tunisia, specifically.”
“The “Five Year Forward View” said that the NHS would need between £8 billion and £21 billion extra from the Treasury by 2021. It got a commitment of £8 billion, which was opposed by the party opposite. Can the Secretary of State say when the Stevens plan will be formally reviewed, and where in the range between £8 billion and £21 billion he expects the real requirement will be found to lie?”
“In congratulating the ship’s company of RFA Mounts Bay, may I draw my right hon. Friend’s attention particularly to the embarked medical team, whose work under the most professionally challenging, extraordinary circumstances is surely in the best traditions of the naval service?”
“I congratulate my right hon. Friend on his appointment and statement. In May, he and I stood on a manifesto that pledged to protect pensioner benefits, so I am sure that under his stewardship there will be no backsliding on our commitment to older people.”
“Very conveniently, most of our ancient churches are built east-west, which means that there is a southerly elevation that is convenient for photovoltaic generation. What more encouragement will my right hon. Friend give the Church Commissioners to make sure that this important community resource is used to turn our ancient churches from the chilly places they currently are into something more accommodating?”
“Does my hon. Friend remember the same concerns being expressed when this country was considering whether it would be wise to join the eurozone?”
“Bravo to the Chancellor for listening to Action on Smoking and Health. Well done for raising the duty by 2%. I would like to see it higher. Well done for the innovative minimum excise duty tax to head off trading down. In all, it is a good Budget—a good Budget for the next generation.”
“It causes 20 times as many smokers as die to have smoking-attributable diseases and disability. If we are serious about public health, we have to be serious about smoking, and although rates have fallen in recent years, they appear to have reached a plateau, and we need to drive them down much more and much more rapidly. There is no safe threshold for smoking. Unlike many substances which we might like to control—I am thinking particularly of alcohol—there is no safe threshold. It is surprising, maybe, that this product is available for sale at all. Half of all health inequality between social classes 1 and 5 is thanks to cigarettes. Poorer people consume more, draw on their cigarettes harder, use higher tar products and leave shorter stubs. Their smoking is worse not only in quantitative terms, but in qualitative terms.”
“Part of the answer is right-sizing the national health service estate, and we will increasingly have to get to grips with the need to regionalise our acute sector and secondary care hospitals. That will involve some difficult political decisions, but we must not baulk at them if we are to drive up healthcare outcomes. Yesterday, I was called a health fascist by a colleague for my views on the sugar tax and on taxing tobacco. I make absolutely no apologies if indeed that is the case. I am particularly exercised about tobacco. Smoking is the captain of the men of death in this country. It kills 100,000 people a year, far more than obesity, alcohol and illicit drugs put together. It causes death before normal retirement age in 50% of those it kills.”
“In so doing, I hope that he pays attention to Lord Carter’s review of efficiency in hospitals, which was published last month. It is a marvellous piece of work that draws attention to the unwarranted variation across our national health service that is costing somewhere in the region of £5 billion a year. The concept of a model hospital and metrics such as the adjusted treatment cost and the weighted activity unit are absolutely necessary if we are to make what is an efficient service even more efficient, and bring our healthcare outcomes up to the level of the very best in Europe, and not, as is so often the case, around about the level of the worst. Simon Stevens’ £22 billion funding gap seems unbridgeable without measures of the sort that has been presented by Lord Carter of Coles.”
“I am very conscious of Robert Chote’s clarification of the position of the Office for Budget Responsibility on Brexit and the importance of not misrepresenting organisations such as his. However, as we have already had talk of the European Union as part of this Budget debate, I would like to weigh in with my own observation about the tampon tax. I commend the Chancellor for his imagination in finding £12 million from this tax to spend on relevant women’s charities, but it is a great pity when a country such as ours has to tiptoe around a requirement instituted by the European Union. Where on earth is the sovereignty in a state that cannot determine even the tax paid by its citizens on tampons? The Chief Secretary to the Treasury will be undertaking a drive for efficiency and value for money.”
“Maths can be great, particularly vocational or lifestyle maths—the sort of maths that my hon. Friend the Member for Chippenham (Michelle Donelan) had in mind—but it can also be demotivating and a somewhat depressing experience for children for whom maths is not their bent. I would be a little bit of cautious about making the introduction of that particular discipline compulsory to the age of 18. I am a strong supporter of the sugar tax. The Opposition has suggested that this may be a pun-rich artifice to draw attention away from the three fiscal tests. That is grossly unfair, because the sugar tax will come to be seen as an historic tax. It is an indication that the Government are prepared to act on important public health measures when it becomes clear that voluntary measures have not succeeded.”