Tuesday 29 April 2008
[Mrs. Joan Humble in the Chair]
Motion made, and Question proposed, That the sitting be now adjourned.—[Ms Diana R. Johnson.]
My voice is fairly croaky, so I apologise if I have to give up halfway through.
It seems to be an opportune moment to be considering Zimbabwe. The purpose of the debate is to focus on the sanctions regime and the role of British companies in Zimbabwe, particularly Barclays bank. First, I will reflect on why it is important that we consider the sanctions regime. None of us needs reminding of the dire situation that faces the people of that country, not just now but over very many years. There have been years of human rights abuses. The economy is in abject ruin. There has been mass suffering, with allegations of massacres perpetrated by those close to the Government during the Mugabe regime.
Since the election, the opposition Movement for Democratic Change has claimed that 3,000 families have been forced out of their homes, and hundreds have been injured. It estimates that 10 to 15 of its supporters have been killed in Government-fuelled violence. Reports on the BBC are of hundreds of people fleeing across the border into Mozambique, and of 600 opposition MDC supporters camped out at the party headquarters in Mutare after attacks by ruling party militias, and so it goes on.
It is worth acknowledging that there are some positive signs in Zimbabwe and Africa in terms of the African response. First, there was the one-off arms embargo that was initiated by dock workers in South Africa, which then rapidly spread to other southern African countries. That was not initiated by leaders in Africa but by ordinary people—often trade unionists. Now there appears to be a growing regional consensus that there must not be any delivery of those arms—they appear to be on their way back to China—and that Mugabe’s attempt to steal the election must not be allowed to succeed.
The hon. Gentleman is right; his debate is extremely timely. I congratulate him on bringing it to the House. Does he share my concern that although we welcome the initiative of the dock workers, it should really have come from the African nations themselves, in particular South Africa and Mozambique, which should have led the way? They are betraying their region in the world by not taking an earlier lead. They are spineless and cannot expect the international community to act unless they are prepared to do so themselves.
I think that the international community has to act, but I share the hon. Gentleman’s view about the weakness of the leadership, particularly from the South African President Thabo Mbeki, who appears to have gone along with so much of what Robert Mugabe has perpetrated over recent years. However, I wanted to deal with some of the positive signs.
To everyone’s surprise this weekend, the Electoral Commission refused to buckle to intimidation and to overturn the seats won by the opposition. Subsequently, it confirmed that ZANU-PF had lost its majority in Parliament, and that is a remarkable development. There were reports yesterday that opposition parties are reuniting. Morgan Tsvangirai and Mr. Mutambara have confirmed that they will work together, which means that there will be an effective majority in Parliament against ZANU-PF. Last week, during the visit of Jacob Zuma, I heard from African business leaders that business is ready and willing to invest in Zimbabwe again. That is already happening in the expectation of change in that country. Africa Confidential confirms that expats and foreigners are starting to invest again in real estate and equities in the country in the expectation of change because they believe that change will ultimately happen. Those are all encouraging signs.
Let me focus on my real purpose, which is to look at the sanctions regime. European Union sanctions were first imposed in 2002 when there were fears that Mugabe was attempting to rig a presidential election—that sounds familiar, does it not? Article 6 of the EU sanctions regime referred specifically to the freezing of accounts and other funds of individuals who were named in an annexe to the EU sanctions document. No funds should be made available to, or be for the benefit of, those people listed in the annexe. The targeted sanctions were designed to hit the regime and its supporters, not the general population. Of course, sanctions in the past have perhaps been counter-productive because of the impact on the innocent general population. The UK firmly backed that sanctions regime, which was intended to make a difference and to make life very difficult for those leading individuals in the Mugabe regime. There were very disturbing reports in The Observer and The Sunday Times last year that Barclays, in particular, was helping to, in the words of The Observer, “bankroll Mugabe’s regime.” The article in The Observer from last January also referred to two other British-based companies, Standard Chartered bank and Old Mutual. I will deal first with the allegations.
The Observer reported that any commercial bank operating in Zimbabwe is required by Government to reinvest 40 per cent. of its profits in Government bonds. The argument from the companies is that “these are the terms on which we have to do business in the country, and so we have no choice.” However, The Observer reported that Barclays, Standard Chartered and Old Mutual had lent the Mugabe regime about £100 million by purchasing Treasury bills and Government bonds. It also reported that Barclays arranged finance facilities worth £110 million to Zimbabwean companies involved in tobacco, mining, sugar manufacturing and horticulture.
Later on that year, in November, The Sunday Times carried more serious allegations. It said that Barclays was providing agricultural loans, including to friends of Mugabe who had been given land seized during the land grab. Here is a British-based company, through a subsidiary, providing financial support to those who had benefited from the land grab. We have to remember that the land grab did not return land to the people of Zimbabwe. Those who benefited were primarily members of the ruling elite, and many were very close to Robert Mugabe. The Sunday Times reported that loans totalling £750 million were made in the first half of 2007, mostly through a Government scheme to boost farm productivity. The scheme is the agricultural sector productivity enhancement facility, known as ASPEF. Again, participation is the condition of doing business in Zimbabwe.
In the first half of 2007, according to the report, there appeared to be a 17 per cent. increase in loans offered by Barclays. At least five Ministers received loans through the ASPEF scheme to benefit them and the farms that they had been given following the land grab. Some of the Ministers involved are on the list of 131 regime individuals in annexe III to the EU sanctions regime. The MDC, which is a party that we ought to listen closely to, given its bravery, says that loans under ASPEF are used as a
“vehicle of personal wealth accumulation for the regime”,
provided by Barclays bank.
New allegations have emerged that at least two—I understand that it could be four—members of Mugabe’s regime who are on the sanctions list have received personal banking services from Barclays. They have been involved in the land grab strategy, which has wreaked economic havoc on the country, and one of them faces serious accusations of personal involvement in that process. Given that providing loans was specifically barred in the sanctions regime, the Government presumably condemn Barclays for doing that. I would be grateful if the Minister dealt specifically with that matter in her response.
How can Barclays bank, a British-based company, act in a way that is apparently in flagrant breach of the sanctions regime? Because it operates through a locally registered company, Barclays Bank of Zimbabwe Ltd. It is a public company, listed on the Harare stock exchange, and Barclays Bank plc, the UK-based company, holds 64 per cent. of the shares in it through a locally incorporated holding company, Afcarme Zimbabwe Holdings Ltd. We can see where the real ownership is.
Because that is a locally registered company, even if ultimately owned in majority by a UK-based company, it completely avoids the sanctions regime. Had the services in question been provided by an EU-based company there would have been a clear breach of the regime, but Barclays managed to avoid it. Surely it is scandalous that a British company, via a local subsidiary, is providing financial support and sustenance to a brutal regime and to key figures within it. We preach good governance in Africa—we hear that constantly from the Government, and rightly so—yet companies based in this country appear to be behaving reprehensibly.
After seeing the reports in The Sunday Times and The Observer, I took up the matter with the Foreign Office. I wrote to the Foreign Secretary at the end of last year and had a reply dated 7 December from Lord Malloch-Brown, the Minister of State. It confirmed that the Foreign Office was
“currently looking at one specific case to assess if there has been a breach of Article 6”
of the EU regulation that I have referred to. It appeared that an investigation was under way. I wrote again, asking for an update. The second letter that I received was far more general and evasive, and said nothing about that apparent investigation. I was left completely unclear whether any process to discover whether there had been a breach was continuing. All that the second letter said was that the Foreign Office was committed to enforcing the sanctions regime, but I have already described how weak it is because it is so easy to avoid through locally registered companies.
I wrote again on 12 March, making a request under the Freedom of Information Act 2000. I asked for documents relating to the Foreign Office’s investigation of Barclays bank and whether there had been breaches. I am still waiting. I informed the Minister’s office last week that I had secured this debate and wanted to raise the matter, and said that it would be helpful if I had a reply before the debate. I was informed yesterday that it would not be possible to answer my letter, a month and half after it was written. Either deliberately or by default, the Foreign Office has ended up providing cover for banks such as Barclays that appear to be helping to sustain the Zimbabwean regime. Given the seriousness of the situation there, I find it extraordinary that the Foreign Office is behaving in such a way. All the questions that I asked in my letter could have been answered in a short time. There is no reason for this endless delay, and I condemn the Foreign Office for its failure to address my serious concerns.
If the sanctions are an EU regime, who in the EU is meant to police them? Is the hon. Gentleman’s assertion that Barclays has breached the EU sanctions regime and that there has been no penalty, or that Barclays has complied with the strict law of the sanctions but managed to evade the spirit of them, and that it should be condemned for that? I am not sure of the exact allegation that he is making.
I am grateful for that intervention, which helps me to clarify what I am saying. It appears to be very easy to avoid the sanctions regime by operating through a locally based company. Barclays may well have managed entirely to comply with the letter of the law by operating in that way, but the first reply that I received from the Foreign Office said that it was investigating a possible breach. I want to know what has happened to that investigation, because so far the Foreign Office has absolutely refused to tell me.
I am also interested in whether the sanctions regime has done anything effective to bring about change in Zimbabwe. One of my concerns, which was reinforced by speaking to an expert on the sanctions last week, is that it seems that there is no capacity to investigate alleged breaches of sanctions, either at EU level or, I suspect, at Foreign Office level. We impose sanctions and then do nothing to police them.
The hon. Gentleman has just made the serious charge that the Foreign Office has refused to answer him. I think that he would like to put the record straight and say that that is not the case.
I think that others here are reinforcing my view that that is not what I said. I have not had a reply. The Foreign Office has failed to reply. It seems to me—I repeat this charge—that it would have been perfectly possible to respond to the serious allegations and concerns in my letter. A month and a half later, it has failed to respond. Despite the additional chance that I gave it last week to respond before today, it has continued to fail. I hope that I will get a substantive reply, but I know this Government’s attitude towards the freedom of information legislation that they themselves introduced. It tends to take several years to get any proper, substantive response to requests to central Government.
The Government presumably condemn what is happening with Barclays, because if loans were being provided to members of the regime by a company registered in the EU, it would be a clear breach of sanctions. Is Barclays a company that the Government in this country should be doing business with? Is it a company that other public bodies in this country should be doing business with? If these sanctions are to mean anything and if we are to be serious about what we say are our concerns about the outrages going on in Zimbabwe, surely the measures that we introduce must have some teeth, rather than being pure rhetoric, and empty rhetoric at that.
It must be said that Barclays in Africa has form. Of course, we know all about its record in South Africa under the apartheid regime. What is not so widely known, however, is that Barclays provided the finance for the sale by BAE Systems of a military air traffic control system to one of the world’s poorest countries, Tanzania. That deal is currently under investigation by the Serious Fraud Office. Barclays provided the loan finance at a time when all the allegations were in the public domain and concerns were being raised that it was a dodgy deal.
I would like to know a number of things from the Government. First, what is happening to the investigation that I was initially told about in the reply to me by Lord Malloch-Brown, the Minister’s colleague, which was dated 11 December 2007? What is happening to that investigation into an alleged breach of the sanctions regime? When will I get a reply to my letter asking for information and documents under freedom of information legislation?
Secondly, what assessment have the Government made of the effectiveness of the sanctions regime? What capacity is there within the Foreign Office to investigate breaches or alleged breaches of the sanctions regime? What capacity is there at the EU level to carry out such investigations, because I am told that there is no effective capacity to investigate those sanctions? Are sanctions merely a fig leaf, to demonstrate to the world that we care, while we actually do nothing effective to bring about change?
I end by reminding hon. Members why the issue is so important. We are dealing with a brutal regime, whose leader has defied the international community and the results of elections, and who continues to wreak havoc in his country, destroying it economically as well as perpetrating human rights abuses. My final question to the Government is this: what are we doing in an effective way to bring about change?
I congratulate the hon. Member for North Norfolk (Norman Lamb) on his speech, on securing this debate and particularly on the very interesting points that he made about Barclays, which I think we all found of great interest. May I also say, Mrs. Humble, that I too have a croaky voice, one that is probably slightly worse than that of the hon. Member for North Norfolk?
It seems clear to all of us that the international community has a responsibility to step in to try to protect any population that is being beaten up by its own Government. It remains true that, apart from a few honourable exceptions, most of the voices speaking out on behalf of Zimbabwe’s battered people come from outside Africa. There is still deep unwillingness on the part of leaders in the region to be frank and to name Mugabe’s tyranny for what it is. Any idea that Mugabe will somehow start to behave well as a result of these diplomatic and fraternal niceties is absolute rubbish. I believe that both history and the people of Zimbabwe will judge the leaders of Africa and will not look kindly on the way that, even now, some of those leaders are continuing to offer excuses for the regime and allowing the destruction of Zimbabwe to go on.
Since the election, Mugabe’s illegitimate regime has gone all-out in deploying a reign of terror on individuals and communities, out in rural areas and out of sight of any cameras, attacking people who voted for Morgan Tsvangirai and the Movement for Democratic Change. The military, the police and the secret operatives of the Central Intelligence Organisation have been unleashed, as well as the youth militia and so-called “war veterans”. ZANU-PF needs a lesson in arithmetic, because the age of most “war veterans” suggests that the war in which they supposedly fought took place long before they were born, in rather the same way that many on the Zimbabwean electoral roll seem able to cast votes long after they die.
The targeted measures imposed by the UK and other states in Europe—not only members of the EU—as well as by Australia, New Zealand and the United States of America, have achieved far more than they have sometimes been given credit for. The travel ban on Mugabe and his Ministers has been a huge embarrassment and irritation to the regime. That is why the only major demand made by ZANU-PF during the Mbeki negotiations was that the MDC should call for the lifting of so-called “sanctions”. Of course, “sanctions” is a word that has huge resonance in the region and its use has allowed Mugabe a propaganda machine to misrepresent those targeted measures.
The EU measures that have been in place since 2002 are very narrowly targeted at about 130 named individuals. They are not economic sanctions like the sanctions that were imposed on Rhodesia during the illegal regime there or on South Africa during the apartheid regime, and they do not affect the general population. They certainly cannot be blamed in any way for the chaotic mismanagement and meltdown of the economy. That is purely the fault of Mugabe’s regime.
There is strong suspicion that ZANU-PF would not even have agreed to participate in the Mbeki mediation talks if it had not believed that the process might have led to a lifting of the travel ban. Furthermore, it is significant that the communiqué from the Southern African Development Community summit in Dar Es Salaam that set up the talks:
“appealed for the lifting of all forms of sanctions against Zimbabwe”.
Of course, it also claimed that
“free, fair and democratic presidential elections were held in 2002”,
which we all know is totally false. I am afraid that communiqués of that nature and the pro-Mugabe pronouncements of SADC’s secretary-general, Tomaz Salomao, have done much to discredit SADC. Fortunately, as has been mentioned earlier, there has been a shift in attitude led by people such as the President of Zambia and the new President of Botswana. They are leading SADC forward in a more progressive direction, away from some of the dishonest and disastrous posturings of the past few years.
There are now calls for the list of names on the EU restricted list to be reviewed and revised, but I think that we need to be very careful about doing that. We can afford to be cautious. If anyone currently on the banned list sees the light and wants to work for reform in Zimbabwe, there are many things that they can do simply by standing up inside Zimbabwe or by visiting neighbouring countries; they do not need to come to Europe to make a difference. I therefore hope that the Minister will confirm that she and the rest of Her Majesty’s Government will not support any lifting of any of the targeted sanctions. People who have been happy to remain inside the system while Morgan Tsvangirai and his colleagues in the MDC were beaten on the streets should use their contacts inside the system to help to bring about change.
I am also very suspicious of people who are now calling for a Government of national unity or for an inclusive Administration. It is strange that people who have been most reluctant to comment on anything that has happened under ZANU-PF’s years of misrule, claiming that it would compromise Zimbabwe’s sovereignty, are now very ready to hand out advice to the MDC, even though it has been given its own very clear mandate to govern by the people of Zimbabwe. There seems to be a rather odd idea that Zimbabwe is a fragile gift and that a way must be found for ZANU-PF to hand over that gift very gently to the MDC, and perhaps even stay on in the long term to help the country, as only ZANU-PF really knows how to care for Zimbabwe; but we know that ZANU-PF has destroyed Zimbabwe. ZANU-PF has undermined the economic development of the whole region and jeopardised its stability.
The struggle in Zimbabwe, carried on by the MDC as a political party and by civil society participants such as the Zimbabwe Congress of Trade Unions and the National Constitutional Assembly, has been about democracy. ZANU-PF lost an election and then unleashed a new wave of violence. It would be completely anti-democratic if external pressure were to be applied on the MDC to include ZANU-PF in a new Government of national unity. What does such a proposal say to the people of Africa about democracy? What does it say to the long-suffering members of the MDC who, despite years of being victims of brutality and electoral rigging, withstood the temptation to resort to violence?
Morgan Tsvangirai and the team that he has built around him deserve enormous credit for having held together a political party under the most adverse conditions. There are far too many names in the MDC to mention, but I am honoured to call many of them my friends. I have got to know them when I have been inside Zimbabwe during my visits over the past four years. Those visits were only brief and I cannot imagine what it must be like to live under the constant threat of death and violent retribution, with no end in sight and no hope of respite. The MDC was isolated and denigrated; it was deprived of all the normal means of communicating its message, and yet it has prevailed. Imagine how much more decisive its win would have been if 3 million Zimbabweans had not been forced to flee abroad, given that most of the exiles are MDC supporters. I hope that they will soon be able to return home to rebuild their country.
Just as the government of Zimbabwe should be by Zimbabweans and for Zimbabweans, the reconstruction of Zimbabwe should be by Zimbabweans and for Zimbabweans. Huge amounts of aid will flow in from all around the world, and it is important that it be used to rebuild a sound infrastructure. The most vital element of a sound infrastructure is the local population, and Zimbabwe probably has the most able and well qualified population of any country in Africa. Having been fleeced by Mugabe and his cronies, I hope that everything will be done to guard against a bloated contingent of UN officials and international corporations being given a chance to siphon off aid to their own coffers.
The struggle has been about democracy. Democracy will work when people in Zimbabwe feel that they can influence the decisions that affect their lives. That means not only accountable politicians but accountable aid agencies. Just as outsiders must resist the temptation to try to micro-manage political solutions, they must be ready to implement the programmes that local communities want, not simply to impose grand designs that sell well in Rome or Geneva. Strengthening civil society means strengthening the voice of people at village pump level, not opening plush non-governmental organisation offices in Harare.
As an honorary vice-president of Surrey County Cricket Club, an issue that is close to my heart is the Zimbabwe Cricket Union. Mugabe is a ZCU patron, and its chairman, Peter Chingoka, and managing director, Ozias Bvute, are both deeply implicated in the financial corruption that props up the regime. Through cricket, they have access to hard currency, which they misuse to exercise corrupt patronage in collaboration with the bigwigs of Zimbabwe’s ruling party. At international matches Chingoka uses the VIP pavilion to host the ZANU-PF politicians, CIO operatives and senior army officers on whom he relies for protection.
I hope that change in Zimbabwe is imminent but, until it actually comes, cricket is one small way to show that we care about the millions of Zimbabweans who feel isolated, forgotten and condemned to misery. Zimbabwe cricket is an extension of the worst aspects of Mugabe’s regime. Those of us who care for Zimbabwe and cricket in particular, or human rights and sport in general, must do all we can to support the Prime Minister’s proposal to ban the Zimbabwean cricket team from touring in the UK. I hope the Minister will confirm that no UK visa will be given for Chingoka to come here to attend any International Cricket Council meetings, or for any other reason, in the next few months. I also want to ask whether the ICC has yet given Her Majesty’s Government a copy of the KPMG audit for which they asked regarding ZCU financial malpractice.
The most encouraging development in recent days has been the show of solidarity from the trade union movement, which was mentioned earlier. The proposal by the South African Tin Workers Union not to unload the Chinese arms shipment nails the lie that Mugabe is respected by the people of southern Africa. That is a myth put around by the establishments of the region and their cronies around the world, many of whom need to boost the myth of their own popularity. Privately, many of them probably fear the end of Mugabe, particularly if it is civil society and trade unions that bring that about. They may be looking over their own shoulder to see what is happening in their own country.
I pay tribute to the efforts of the International Transport Workers Federation and particularly Randall Howard, its president, who is also general secretary of the South African Transport and Allied Workers Union. Thanks to the ITLF, the transport workers of all the countries in the region have imposed a de facto arms ban on the Zimbabwe regime. Their action has huge practical and symbolic importance, and, again, it nails the lie that there is no support in the region for restrictive measures against the Zimbabwe regime.
I also pay tribute to the Congress of South African Trade Unions, which has stood firmly alongside its brothers and sisters in Zimbabwe. When I visited COSATU in Johannesburg last year, it was impressive to see its engagement with the struggle in Zimbabwe. If Mugabe and all his hangers-on do not vacate State house soon, I understand that the ITF may well consider an embargo on the shipment of luxury cars and other goods bound for those who are running ZANU-PF and certainly not for the badly beaten and depressed people of Zimbabwe.
The trade unions have paved the way for a formal United Nations arms moratorium, and today—almost as we speak—that is being considered by the Security Council. The call for an arms embargo has been echoed by the Archbishop of Cape Town. I am pleased and proud that our Prime Minister set out his position on Zimbabwe in such robust terms when he addressed the Security Council recently. I hope that, if things have not changed by the time the UK is chairing the Security Council, further progress will be made at that time to protect the votes of the people of Zimbabwe. Those votes embody the sovereignty and independence of the country.
I again congratulate the hon. Member for North Norfolk. What we say in this House is significant, and it must not be assumed that the things that we say help to boost Mugabe and his propaganda machine. I hope that those people all over Zimbabwe who by various methods get communications from outside the country will be absolutely encouraged by the fact that we are debating this subject. I also hope that the Minister will be able to respond to the questions that have been asked, and that very soon we will see the end of Mugabe and a Government in Zimbabwe led by Morgan Tsvangirai.
I shall contribute briefly to this debate. We are all running out of adjectives with which to describe the regime in Zimbabwe. In a way, describing its actions is a waste of time, because we want to get down to discussing other details, but last night I sent to the hon. Member for Vauxhall (Kate Hoey), who is the courageous and highly respected chairman of the all-party group on Zimbabwe, some e-mails that had been sent to me about precisely what is happening. There is an organised campaign of terror by Mugabe’s Central Intelligence Organisation and senior echelons in the army against the Movement for Democratic Change and the courageous people of Zimbabwe. It is highly moving and deeply distressing to hear exactly how brutal and vile the regime is being at this time.
To the outside world, one of Mugabe’s most perverse acts is the abandon with which he prints money. The Reserve Bank of Zimbabwe is printing money as though it were confetti, because Zimbabwe’s Government believe that, by so doing, they have more money. That is the most economically illiterate thing that they could be doing. It is driving a nation that has been impoverished by the regime into even greater poverty.
I pay tribute to the hon. Member for North Norfolk (Norman Lamb) for securing this debate. In a debate on sanctions, we must ask how that Government are physically able to print money, because what is absolutely certain is that the banknotes are not being printed in Zimbabwe. As a Back-Bench MP, it is relatively difficult to find out precisely where they are being printed, but I suspect that it is relatively easy for the Foreign and Commonwealth Office to find out. Through rumours and articles that we might read in Africa Confidential or other papers, we have been led to believe that they are being printed in Germany. If that is the case, I want to look into the eyes of the company’s directors to see whether they are ashamed of their complicity in the impoverishment of Zimbabwe; I want to find out from the German Government what they are doing to bring pressure to bear on the company; and I want to find out from the European Union Commission what pressure it is bringing to bear on companies, such as that one, which support the vile and perverse actions of the Government of Zimbabwe.
At times, I have a problem with the approach of the FCO to what is happening in Zimbabwe. I visited the country in 2000 or 2001 with my right hon. Friend the Member for Horsham (Mr. Maude), who was then the shadow Foreign Secretary, after having gone there many times in the past and having worked with members of the Movement for Democratic Change. I saw that the MDC was rising as a real political force in that country, but diplomats in our high commission were saying, “No, no, we should not be talking to the MDC. We should be talking to the young bloods in ZANU-PF. They are the future.” That was not my reading of the situation.
I was alarmed recently to discover that an enormous amount of weight was being put behind Simba Makoni as a possible future political figure in Zimbabwe. In fact, he did not have much traction with the electorate. I feel that the tentacles that diplomats put out in Zimbabwe are not really bringing back the true message—which perhaps they do not want to hear—that the MDC is the Opposition, whatever we hear about different factions, and we should be putting our weight securely behind the MDC.
I have often raised another aspect of sanctions—I raised it with the right hon. Member for Blackburn (Mr. Straw) when he was the Foreign Secretary. Many family members and followers of the cronies and thugs who are part of Robert Mugabe’s coterie come to this country and benefit from our education and health systems and various other aspects of our tolerant western liberal democracy. The right hon. Gentleman said, “You cannot visit the sins of the fathers on their sons, daughters, cousins and aunts.” Well, I am sorry, but we have reached the stage where we just jolly well can and we must, because if those people are denied education and benefits from our health service and are prevented from doing business in this country, they will take a strong message back to Zimbabwe and will be forced to live in the country to whose impoverishment they have contributed.
If Barclays bank has been complicit, it has strong questions to answer, but in a debate such as this we should really look at who the true villains are in supporting the Government of Zimbabwe. We all know from history that the Government of South Africa can turn the switch off on the Government of Zimbabwe, given the way that Vorster turned the switch off on Smith in Rhodesia. I will not delay hon. Members any longer expressing my disappointment—that is a mild word for it—and deep frustration with the Government of Thabo Mbeki. I hope that Jacob Zuma will take a different approach. I sense that the new people moving into the governance of countries in the Southern African Development Community have a more modern, enlightened approach, and we must hope for more from them.
I do not believe that we as a Parliament can ignore—particularly at this time of the Olympics—the complicity of China in many of the problems in southern Africa. China supports the Governments of Sudan and Zimbabwe and they have been found out. Many hon. Members know that, while our Foreign Office is deciding how to cut costs here and different missions there, China has been buying up Africa—buying the infrastructure and companies—and providing arms, financial support and, no doubt, banking support to Governments such as the Government of Zimbabwe. How could they do that at a time like this? I hope that the Minister will tell us today that the Foreign Office is being as strong as it possibly can in saying to the Government of China, “You are in the eye of the storm now. The world is looking at you at the time of the Olympics. You have to join the world condemnation of such regimes, not just by warm words but by your actions. You have the power, as the Government of China, to turn off the tap of your support for regimes such as the one in Zimbabwe.”
I congratulate the hon. Member for North Norfolk (Norman Lamb) on securing today’s important debate.
I must admit that I am not an expert on Zimbabwe. I have never been there. The closest I ever came to it was playing rugby with two Rhodesian guys in the early 1970s at college in Bristol; who were really good eggs, as we say. However, we need to consider sanctions in the context of the post-election crisis in Zimbabwe and the humanitarian implications of further sanctions.
Many religious leaders in Zimbabwe feel that, if nothing is done to help the people of Zimbabwe, we will soon be witnessing genocide similar to that in Kenya, Rwanda, Burundi and other African hotspots of the past. There is widespread famine in the countryside, basic goods are unavailable or too expensive and there are no medicines to treat people injured in the post-election violence. There is no doubt that people are being tortured, humiliated and abducted for voting for the wrong candidate in the recent election.
My hon. Friend the Member for Vauxhall (Kate Hoey) mentioned the trade unions active in the Southern African Development Community area that are trying to oppose the regime in Zimbabwe. I recently received evidence from my former trade union in Britain—the National Association of Schoolmasters Union of Women Teachers—via e-mails about what is going on in Zimbabwe at present. I received an e-mail from a former head teacher in my constituency, Tony Skipworth, who now lives in Darfield and was head teacher at Shafton primary school, which I used to serve as a governor. His e-mail included a couple of graphic photographs of a guy who had been beaten up in Zimbabwe. I showed those photographs to Lord Malloch-Brown last week at the meeting of the all-party group on Zimbabwe and I shall pass them to the Minister at the conclusion of this debate. They are pretty graphic.
Mr. Skipworth’s e-mail reads as follows:
“These are the latest pictures and report from out of”
“Please forward onto anybody, your local MP, human rights organization, etc., that you know, demanding something is done to help the people in Zimbabwe.
The attached pics are of a young man (38) from Dzivarasekwa, Harare who was abducted by ‘soldiers’ militia in full combat camouflage kit with fringed hats who beat him for hours with chains and fan belts on his back and chest. Also on his feet and hands. The reason for this terrible beating is that he transported MDC supporters to the pre-election rallies.
Ambulances went to Kotwa Hospital on Saturday evening to uplift five critical cases and they were stopped just short of the hospital by CIO agents who threatened their lives and then followed them for 100 kms back to Harare. Now the ambulances refuse to go out there. I really fear for those peoples’ lives. We have been trying to get them out in civilian trucks, but Police road blocks surround the Mudzi area”,
preventing them from doing so.
“This is a shocking situation we find ourselves in, when we are prevented from taking our battered and burned members to hospital.”
That is the reality of Zimbabwe today under the Mugabe regime.
I should like briefly to mention the Archbishop of York’s stance against the regime in Zimbabwe. Hon. Members might remember that he cut up his dog collar on a political programme on television just after Christmas. He also instigated a day of fasting at York cathedral this Sunday. As a Yorkshireman, I am proud to have John Sentamu as the Archbishop of York; he is doing a fantastic job.
Many political pundits in the immediate aftermath of the election felt that Mugabe was ready to stand down. It is only certain party officials and senior military and police personnel who have stopped him doing so, protecting their own backs. Many of those are among the 130 people identified by the resolution and the sanctions embargo. I agree with many of the points on sanctions made by my hon. Friend the Member for Vauxhall. If sanctions are to be increased, we must try to target those individuals more and expose them more in the eyes of the media to exert more pressure on them to comply with change. The difficulty with increasing sanctions is that, if we instigate broader economic sanctions, it is only the people of Zimbabwe who will suffer and they are suffering enough at present.
I share the concern of the hon. Member for North Norfolk about the role played by three British banks—particularly Barclays bank, which he named—that appear to be assisting the Mugabe regime. I hope that they will review their business activities in Zimbabwe once they have read this debate. As a member of the all-party group on cricket, I also agree with many of the points made by my hon. Friend the Member for Vauxhall about Zimbabwean cricket.
In efforts to resolve the current impasse, it is difficult for us as the former colonial power to be in the driving seat. In my opinion, the main driver in the first instance has to be the Southern African Development Community, which needs to take a much firmer stance in not allowing the desperate position in Zimbabwe to deteriorate any further. Most hon. Members who have contributed this morning have made that point. All 14 member states of the SADC need to be much more vociferous than they have been. In particular, South Africa, via President Mbeki, needs to set the future agenda. After all, the former Rhodesian leader, Ian Smith, knew that he was finished when South Africa pulled the plug on him. History could repeat itself. In addition, I believe that Kofi Annan and the United Nations could play a positive role in resolving the situation.
People speak of an African solution to an African problem. There has already been an African solution for Zimbabwe, which the people of Zimbabwe voted for about a month ago. The will of the people of Zimbabwe must prevail.
The debate has demonstrated that while such a discussion in Westminster Hall is valuable, the subject should be debated as soon as possible on the Floor of the House. It is astounding that the usual channels and the business managers have not made such a debate possible, and I hope that that will happen in the not-too-distant future.
Since the horrors in former Yugoslavia and Rwanda, there has been an emerging doctrine of responsibility to protect, but I am becoming increasingly depressed and pessimistic about the international community’s ability to deliver consistently on that concept. If one thinks about it, there are four possible mechanisms by which one can deliver that.
The first is by way of military intervention but, as we have seen in Darfur, with the considerable difficulties of getting together even a UN and African Union military force, unless there is a fairly serious military lift capability, mobilising an effective peacekeeping maintenance or intervention force is extremely difficult. I am fairly pessimistic about what the combined UN and AU force will be able to do in Darfur, where the situation continues to disintegrate, with an increasing number of warlords seemingly having a stake, as we have seen with the deterioration in Somalia. One consequence of NATO’s involvement in Afghanistan is that very few NATO countries have spare troops for peacekeeping responsibilities elsewhere in the world. The civilised international community’s capacity to enforce civilised norms by military intervention seems to be pretty thin.
The second mechanism is sanctions. This debate, which the hon. Member for North Norfolk (Norman Lamb) introduced, demonstrates a number of difficulties with sanctions regimes. The hon. Member for Barnsley, East and Mexborough (Jeff Ennis) made it clear—I think we all support his point—that sanctions must be targeted to be effective, otherwise they may end up simply hurting the weakest and most vulnerable in the community that we seek to protect. If there are to be targeted sanctions, who in the EU or the UN will police them, and what are the penalties for people who breach them, either in the letter or in the spirit? For example, who in the EU will report back to the European Parliament and who will report back to this House on sanctions regimes, or will there just be a declaratory statement with no follow-through?
Sanctions against South Africa were probably effective over a period, but what effect have EU sanctions against Zimbabwe had and who has monitored their effect? I am fairly pessimistic, but I hope that the Foreign Office is considering how to assess sanctions regimes and their implementation. It will be interesting to see in the Security Council today whether China signs up to an arms sanctions regime, not just against Zimbabwe, but against Africa as a whole. It is increasingly disturbing and distressing that arms shipments from China are increasing and enhancing African instability.
The third mechanism is the International Criminal Court, but we saw with Rwanda and the former Yugoslavia that it is perilously and tortuously slow. Two individuals from the Sudanese Government were indicted by the ICC, but absolutely no progress has been made on arresting them or sending them to The Hague following the indictments on Sudan. That is depressing.
The final mechanism is regional pressure. Since 2000 and the millennium declaration and summit, there has increasingly been a concept of a covenant between Africa and the rest of the world. It was best demonstrated perhaps in the New Partnership for Africa’s Development, which was a trade-off under which the developed world would increase the amount of its development aid and assistance to Africa, and Africa would introduce peer review and seek to exert mutual pressure on other African states to bear down on corruption, to promote good governance, and to ensure that donor funds were used wisely. It is with some distress that I say that Africa has failed that test in relation to Zimbabwe.
A couple of weeks ago, I was fortunate enough to be invited to a meeting at the South African high commission where I heard President Mbeki speak. He was at Sussex university at about the same time as me. Indeed, I think there are more graduates of Sussex university in the South African Parliament—quite a number of African National Congress members were there—than in the UK Parliament. However, some distinguished Members of Parliament—for example, the Secretary of State for Environment, Food and Rural Affairs and the right hon. Member for Neath (Mr. Hain)—were at Sussex.
What I found really depressing when listening to President Mbeki, who is a very nice and civilised man, is that he just did not get it. We were not on the same page. He told the audience honestly that he had almost not come to London for the meeting with the Prime Minister and others—Tony Blair arranged for a collection of Heads of Government from the new left to come together—because he knew that he would be lobbied about Zimbabwe. He then gave a long explanation about the electoral process in Zimbabwe, but there was not a scintilla of a shadow or a suspicion of a suggestion of any criticism of Robert Mugabe. There was not even a semiquaver. I found that deeply depressing because President Mbeki is not distanced from what is happening in the world or incapable of understanding what people are saying, and the fact that there was no resonance makes me deeply depressed about the capacity of peer and regional pressure to work on trying to ensure that the norms of responsibility to protect prevail.
The difficulty in Africa—this is an African problem that one does not find in other continents—is a covenant that states and Heads of Governments do not interfere in other Governments’ countries. There has been a mutual tontine about that, but the world has moved on and Africa as a whole must recognise that many countries, particularly the United States and elsewhere, see Africa as one entity. Zimbabwe at the moment is a disgrace to Africa as a whole. What is happening in Zimbabwe not only hurts Zimbabwe, it hurts the whole of Africa and people’s willingness to invest in Africa, to do business with Africa and to provide continuing donor support for Africa.
In the context of this debate, we must collectively do a lot more work on how to deliver the concept of responsibility to protect. How do we ensure that the international architecture is better capable of delivering on the responsibility to protect? Otherwise, we may have wonderful declaratory statements about EU sanctions or about AU/UN peacekeeping troops in relation to Darfur, but if those statements are not effective, they are just ashes in the mouth. As part of their work, I hope that the Foreign and Commonwealth Office and the Government collectively are considering how to ensure that the international civilised community can better deliver on what is now the accepted norm of the responsibility to protect.
First, I would like to comment on the excellent speech of the hon. Member for Banbury (Tony Baldry), particularly the fact that he brought the notion of responsibility to protect into the debate. I agree with him: we need to have that philosophy behind the way in which we approach these situations. The problem is that that concept has not been taken up and international law is still way behind in the development of it. I welcome the recent speech made by the Pope at the United Nations in which he pushed for the concept to be taken more seriously. If that were to happen, we would be far more effective and diligent in considering how to make sanctions work. Clearly, sanctions are very much a part of that whole notion, but I do not think that either at a UK level, as my hon. Friend the Member for North Norfolk (Norman Lamb) has shown, or at an EU or UN level have we learned the lessons on how to make sanction regimes work, how to implement them, how to monitor them and so on.
The Canadian commission that began to develop the notion of responsibility to protect in 2001 subdivided it into responsibility to prevent, to react, and to rebuild. The notion of responsibility to prevent is also something that those dealing with foreign policy need to get to grips with, whether in the FCO, the Department for International Development or elsewhere in the Government. Doing so would change the way in which we gather intelligence, focus our foreign policy and decide our budgets. If we are to take the notion of responsibility to protect seriously—and it is right that the concept is brought into the debate—we must think more deeply about it.
I agreed with the comments of the hon. Member for Banbury about President Mbeki, and similar remarks have also been made by other hon. Members. However—and I hope that the hon. Member for Vauxhall (Kate Hoey) will confirm this—at the all-party group on Zimbabwe, Members from the other place said that we should be careful about how we talk about the recent record of President Mbeki. I am not saying that I share this analysis, but the defence that is made of President Mbeki is that in the background he has skilfully pushed for the free and fair elections that have occurred. I do not know enough about what has happened to say whether that is true, but the results seem to show that the people of Zimbabwe have gone against Mugabe in a huge way, despite the intimidation of ZANU-PF. Therefore, history may show that there was a contribution by Mr. Mbeki. I totally agree with what other hon. Members have said: South Africa should go further and has been too dilatory in using its muscle to bring the denouement to this sorry affair.
I congratulate my hon. Friend on securing the debate and on the dogged determination with which he has questioned the Government. Although we are right to say that China must do this and South Africa must do that, we are elected to this place to hold the Government to account, to question their actions on ensuring that measures—sanctions and regimes—are in place, and to ask how those provisions are monitored. The Government are saying that we, in Britain, will have a sanctions regime. However, the sanctions regime that has been designed is not effective because it allows a bank, such as Barclays, to bankroll Robert Mugabe and his Cabinet. That really is not good enough and my hon. Friend is right to bring that issue to the House and to ask questions. I congratulate him on the detail that he has given.
I apologise for not being present at the beginning of the debate. I understand that Barclays was mentioned. As well as making the accusation inside the House, has the hon. Gentleman made the accusation outside it, without parliamentary privilege, that Barclays has bankrolled ZANU-PF and the Cabinet? He might want to be a little more cautious.
When the hon. Gentleman reads the record, I think he will regret making that intervention because my hon. Friend quoted from newspaper articles in this country which have made similar allegations. He has also asked detailed parliamentary questions and obtained detailed answers from Ministers. I hope that the hon. Gentleman will read the record and apologise to my hon. Friend. He should have been present at the start of the debate when those allegations were made.
When the hon. Member for Newbury (Mr. Benyon) talked about the involvement of Barclays, he seemed to go soft pedal a little. I am afraid that that is not good enough. My hon. Friend has produced detailed evidence and it is incumbent on the Minister and her colleagues to answer the questions that he has pursued through parliamentary questions and letters.
I am sorry if I gave that impression; that was not at all what I was saying. I said very clearly that if Barclays has questions to answer it must do so, but in the context of all the organisations and Governments who are complicit in the situation in Zimbabwe, many other villains also need to be held to account.
I am glad that I gave the hon. Gentleman the opportunity to make his position clear.
Hon. Members from all parties would certainly condemn Mugabe’s regime and its history, going back to the appalling atrocities that verged on the genocide in Matabeleland between 1983 and 1987. They would also condemn the way in which thugs have intimidated people before and since the election. When we talk about sanctions, the question is whether we can improve the sanction regime that currently exists. There may be questions about whether travel bans can be tightened up, and I am certainly in favour of considering whether the families of those on travel bans should be included in them.
There is also an issue about what signals we should send to people under the ZANU-PF regime about how they should think about the future. It is interesting that my information shows that Simba Makoni is still on the travel ban list. Will the Minister confirm whether that is the case? That is an example of someone who has been brave enough to stand up against Mugabe, yet he is still on the list when there is clearly a case for him to be removed.
The really pressing case for improving the sanctions regime is with respect to the arms embargo. The UK, US and EU have had an arms embargo in place, but the fact that there was a huge shipment of arms from China shows that there is the potential for leaks through that embargo. If it were not for the spotlight of the world being on southern Africa, those arms would have ended up in Zimbabwe, make no mistake about it. It was only because of the courageous actions of those trade unionists—the South African dock workers—that that did not happen. They should be celebrated.
Having been to Lord Malloch-Brown’s briefing, I know that the Government are trying to get the different countries in the region—Zambia and Botswana in particular—to sign up to an arms moratorium. I celebrate that and think it is a good approach. However, it is time to take this matter to the UN and to have a UN arms embargo. There are arguments against that, and two of the five permanent members, presumably Russia and China, might vote against it. However, with good diplomacy, Russia, for whom southern Africa has never been a real sphere of influence, would not vote against the proposal. China is the real issue, but it is under severe pressure in the run-up to the Olympics. We know China’s position on Tibet, Darfur and elsewhere, so the last thing it wants is more bad publicity. We have a real chance to use good diplomatic skills to force China to sign up to a UN arms embargo. If we could achieve that, it would be the strongest signal that the British Government and their allies—the UN Security Council—could send.
We could talk about many other issues in relation to an arms embargo and sanctions. There are many lessons for us to learn from the experience that we have had in Zimbabwe and from other embargoes. It is particularly difficult to have embargoes on African countries because they have the poorest borders, and a lack of capacity to implement them in terms of resources and political will. I hope that the FCO, for the reasons that the hon. Member for Banbury gave, is studying those problems.
However, there is a flipside to sanctions, and we are beginning to get to that point—the holding out of incentives. As my hon. Friend said, there are encouraging signs. We need to do all that we can to promote those, because with the right incentives—the promise of aid, more development, investment and the opening of trade—people from across the political spectrum in Zimbabwe will realise that it is time that they respected the democratic will of the people, which is in the long-term interests of Zimbabwe, and, hopefully, they will help to give the final push to Mugabe and his cronies.
It is a pleasure to serve under your chairmanship, Mrs. Humble. I congratulate the hon. Member for North Norfolk (Norman Lamb), my parliamentary neighbour, on initiating this debate at a very apposite time.
I agree with other hon. Members that Zimbabwe should be debated on the Floor of the House in Government time. It is no good the Leader of the House saying, “Well, it is up to the Opposition parties.” As I recall, the last time that we had a proper debate on the subject was on a Thursday afternoon last July on a one-line Whip. The Minister probably has an unhappy memory of that debate. Perhaps it was unfair to her, but she was well and truly scragged by hon. Members on both sides of the House. It is very good that certain situations in Zimbabwe have moved on and that the Government policy has moved on and firmed up, not only because of a debate within Government perhaps, but because of the pressure brought to bear by hon. Members on both sides of the House.
I shall not repeat the points made by the hon. Member for North Norfolk. Quite rightly, he asked a number of questions for the Minister to answer. On the wider issues relating to sanctions, I recall that the other place produced a vast report last year on the whole business of sanctions, which concluded that, on the whole, sanctions often did not work, not only because of the blunderbuss approach, but because of the business of implementation.
I accept that, but many interesting questions were raised.
I shall concentrate on several points relating to sanctions in the few minutes that I have in which to speak. To begin with, I am continually astounded by the bravery and resilience of the people of Zimbabwe. In spite of what they have suffered—not only economic disruption and starvation, but massive brutality aimed at them—the regime has failed to get them to do what it hoped they would do, which was start some degree of insurrection so that they could be brutally put down. Their stamina is outstanding.
All those of us who have recently been involved in discussions with members of the MDC and people from other African countries have been impressed by the fact that they keep saying to us, “What you say and do is of absolute importance because it is reported in Zimbabwe.” As much as anything else, what is important is the fact that the international community will not let this issue go away.
I have always been aware, as I know the Minister and other hon. Members are, of how far we can go as British people, with our colonial legacy, in being seen to criticise the Mugabe regime. The idea is that we are playing into Mugabe’s hands and that he will be able to use us, as he did recently at a rally. There is a sort of guilt complex. However, it has been put forcefully to me by members of the MDC and people from other countries that we should not have that kind of colonial guilt at all. Indeed, not only do we have an important role to play, but the fact that Britain is seen to speak up on this issue is very important, and Mugabe monitors that.
The real question before us at the moment is what happens next. The situation seems to be so fluid that Mugabe has a number of options. First, he could allow the state of limbo to continue and rule under some form of emergency powers. Secondly, he could announce that he won the election—I think that that is almost impossible now—and somehow nominate a hand-picked successor. Third, he might have to come up with some form of exit strategy, one part of which, as members of the MDC have recognised, given the harsh world of political realities, would undoubtedly be that Mugabe is allowed to leave Zimbabwe and go into retirement somewhere else—Malaysia seems to be high on his list—with some of the moneys that he has acquired. Most of us would react to that idea with disgust, but it may well be the political reality; it has happened before.
The origin of the debate initiated by the hon. Member for North Norfolk is, quite rightly, the question how we plug the sanctions regime for which we are responsible, but there is no doubt that countries such as Malaysia have provided much of the financial support that Mugabe’s regime has required. The real question is how we help to shift Mugabe and his party. I think we will do so, first, by doing what we are doing now. Secondly, we should provide as much publicity and support as possible for those who are attempting to effect change and give a lot of support to those in the Southern African Development Community countries—I spoke recently to some senior Kenyan politicians about this—to bring pressure to bear on their Governments. Thirdly, we should make certain that there is no let-up in the sanctions that we are already applying. Once again, members of the MDC say that what happens to the children and other family members of senior members of the regime in terms of the education that they have been privileged to have outside Zimbabwe has an impact on the regime.
We also have to recognise—the hon. Member for Vauxhall (Kate Hoey) might disagree—that there are splits within ZANU-PF. The MDC has, either directly or indirectly, been talking to people in that party who wish, for whatever reason, to see change. Some genuinely recognise that the system cannot continue; others are like Fouché and Talleyrand, whom experts in French history will know managed to glide seamlessly from supporting Napoleon Bonaparte to supporting the Bourbons. They want to survive regime change.
A number of hon. Members have made the point that the international community and Britain in particular should be thinking now about how we prepare for the regime change that will undoubtedly come. It could come very quickly or within the next year or two, but I take the point made by the hon. Member for Vauxhall that the last thing we want is the international aid caravan to descend on Zimbabwe, and not only on the grounds that vast profits will be made. Many of us, including my hon. Friend the Member for Banbury (Tony Baldry), have seen that happen in vast parts of the world—the descent of hundreds of 4x4 caravans and people looking for the best hotels and so on. The people of Zimbabwe and many of the politicians are perfectly able to run their own country. It is not a backwoods, third-world country at all. They need some help and advice to turn it into a modern democracy that is capable of being a powerful regional force and of providing the economic aid that is necessary to help to feed and develop the rest of southern Africa.
I congratulate the hon. Member for North Norfolk on initiating this important debate. Let us look forward to having such a debate in Government time on the Floor of the House.
I congratulate the hon. Member for North Norfolk (Norman Lamb) on securing this important and timely debate. It seems that I might have caught his sore throat, from which I hope he recovers soon.
The subject of the debate is Zimbabwe and the application of sanctions, but hon. Members rightly and inevitably referred also to the current situation—a subject that preoccupies us all. The concerns about the terror there and the pressure that is being exerted were mentioned by a number of hon. Members, but particularly by my hon. Friend the Member for Barnsley, East and Mexborough (Jeff Ennis).
I shall deal first with the issue that has provoked today’s debate. We will respond shortly to a freedom of information request from the hon. Member for North Norfolk, who asked for information on the investigation being held into the activities of a British bank in Zimbabwe. We take seriously the obligations of the European Union common position, and carefully investigate suspected breaches. We are reviewing all the details that we have in order to present the hon. Gentleman with a full reply. That led to the need for an extension to the original deadline, which we will meet.
I appreciate the Minister’s response. If the allegations in respect of Zimbabwe are true, and if it is engaged in activities that would have breached the sanctions regime were they the activities of a company based in Europe, will she condemn Barclays for that activity?
That is a lot of ifs. I shall make some progress, and I can then happily come back to the hon. Gentleman.
We are determined to see that EU-targeted measures are properly enforced. The activities of banks incorporated in Britain and operating in Zimbabwe are subject to EU regulations. A number of hon. Members asked about the matter. Member states investigate such matters. We take allegations of possible breaches seriously, and we will always investigate. If there is a breach, we will act.
The Treasury leads on the issue, but with the support of the Foreign and Commonwealth Office. However, as the hon. Gentleman has observed, the EU common position applies only within the EU’s area of jurisdiction. It is therefore possible for EU-based companies to own parts of business entities that are incorporated in Zimbabwe. I confirm that, to date, there have been no cases in which British banks have been found to be in breach of prohibitions under the EU regulations. We are confident that the common position is robust enough to prevent regime members from doing business with UK companies.
I turn to the specific issues raised by the hon. Gentleman regarding the response of the Foreign and Commonwealth Office. He first wrote on 12 November, and my noble Friend Lord Malloch-Brown replied on 7 December saying, “We share your concerns” and agreeing to look into the matter. The hon. Gentleman wrote again on 16 January, and the response was as follows:
“I can confirm that to date there have been no cases where British banks have been found to be in breach of the prohibitions of the EU regulations.”
The hon. Gentleman has indeed had a response.
The common position targets those at the top. It consists of a travel ban and an assets freeze on 131 named individuals responsible for repression or human rights violations in Zimbabwe. However, targeted measures are not the only means by which we are trying to bring about peaceful and democratic change in Zimbabwe. Only regional action backed by support from multilateral bodies can solve Zimbabwe’s crisis. The EU has made clear the need for the election results to be released without further delay, and it has expressed deep concern about the deteriorating human rights situation. We hope that another strong EU political statement will be issued today to underline member states’ concern about the ongoing situation.
At the UN Security Council today, the UN Secretariat will hold a briefing on Zimbabwe. We welcome the involvement of the Security Council and hope that it will facilitate further activity, particularly in allowing a greater focus on action to tackle human rights abuses.
I need to make progress.
As a number of hon. Members said, even at grass-roots level, regional action has proved effective. When considering our response to regimes such as that in Zimbabwe, it is important to remember that we have available a whole range of responses, and not only sanctions. Civil society has an enormously important role to play, and we have seen it in action—for example, the South African dock workers who refused to unload a ship bearing weapons destined for Zimbabwe sent a clear message.
I welcome the firm response of the South African Development Community countries in preventing the unloading and transhipment of the arms. The concern that those weapons could fuel violence during the election period was very real. It was a credit to those who stood against it that the shipment did not reach those who would have used the weapons to repress and violate innocent Zimbabweans. The reaction against that ship’s load shows the strength and breadth of feeling. It also highlights how important international co-operation can be.
The message from Africans that they would not allow the weapons to reach Zimbabwe was the most effective means of preventing the shipment from reaching its destination. We played our part in that, delivering the message that supplying arms to Zimbabwe while its people are being subjected to violence and intimidation cannot be right. However, it is international and African action that will lead to changes on the ground. We are now considering ways to halt the sale of deadly weapons to the regime in Zimbabwe, at least during the current period of instability and crisis. The EU and the US already have arms embargos in place.
Hon. Members raised a number of other questions. We are pressing for others to match the embargo, and we are working to get it translated into international policy. The subject will be raised at today’s meeting of the Security Council, following the UN Secretariat’s briefing. Ultimately, our intention is to aim for an embargo by the Security Council, particularly if the constitutional crisis in Zimbabwe continues, but our current priority is to prevent arms from reaching Zimbabwe, and we are open on how states achieve that. The Security Council discussion is a useful opportunity for taking that forward.
On the current situation, our primary focus is to find a resolution that upholds the democratic choice made by the people of Zimbabwe over a month ago. Robert Mugabe is trying to steal the election, and we will support all who are working for democratic change. The African Union and the Southern African Development Community are both calling for the presidential results to be released. Africans across the continent have expressed their growing concern that Zimbabwe is sliding further away from a peaceful solution. We continue to work with those states in the region that are best placed to apply pressure on Robert Mugabe and those who surround him.
We all share the wish of the Zimbabwean people to secure their democratic rights. We commend civil society groups in Zimbabwe, which continue to fight for democracy and good governance under incredible pressure. It is a sad fact that the election process has already been undermined, as hon. Members have outlined. Robert Mugabe has unleashed a campaign of violence and intimidation. We cannot be fully confident that what is ultimately announced will not have been manipulated by those who want to keep Robert Mugabe in power.
The international community will continue to work for a peaceful resolution to the crisis in Zimbabwe. The UK, with many other countries and international organisations, stands ready to assist in the economic recovery process of Zimbabwe once conditions allow. Zimbabwe needs change and it needs sensible economic and political policies. Once there is evidence of such change, we will give substantial support to recovery there. It is important to note that the UK already provides aid to support the people of Zimbabwe—£49 million in 2007 and a total of £173 million since 2000.
The UK and the international community are committed to seeing a return to democracy and prosperity for Zimbabwe. That cannot happen until the will of the people is respected. We are clear that EU-targeted measures do not hurt ordinary Zimbabweans; they target the regime. That is what we must continue to do. The crisis must not continue. We believe that the solution to the crisis must be an African one, and we hope that it will come soon, for the sake of the people of Zimbabwe.
Primary Care Trusts (Exceptional Cases)
I am delighted to serve under your jurisdiction for the next hour and a half, Mrs. Humble. The debate has caused many different organisations to pick up this issue and put forward points of view on which I should like to expand today. I thank the bowel cancer groups that have been in touch with me. There might be over-emphasis on cancer in the debate, which also relates to drugs used to treat macular degeneration, for example, but cancer has received most publicity, and reports have appeared in every major newspaper. Almost daily, the issue of the availability of drugs in exceptional circumstances arises, so I shall concentrate on the meaning of “exceptional”.
I thank the NHS Confederation, Macmillan Cancer Relief and the various lawyers who have been in touch with me. The latter seem to do rather nicely out of taking up cases around the country—some 110 such cases have been taken up to protest against decisions made by primary care trusts on exceptional cases. I also thank the specialised healthcare alliance and the Pamela Northcott Fund for the information that they have given to me on their experiences. All that makes me confident that this is a major issue. If I were Prime Minister for a day—God forbid, but it could happen given the way things are going these days—I would recognise that inequality in the health service and the unavailability of drugs is a major problem in this country. It should be a priority to get rid of something we often call the postcode lottery, but which I shall call “exceptionality” in our debate. Finally, I thank Myeloma UK. Myeloma is a rare cancer, but the debate involves rare cancers as well as bowel, breast and lung cancer, which are more common. The chances of obtaining a drug for the rare cancers are pretty poor in this country because of the financial considerations that I shall discuss.
PCTs commission health care services for their local populations. The majority of services are commissioned through a process that involves contracting arrangements with health care providers, but there are occasions when patients and clinicians may request a treatment that is not ordinarily provided. I shall concentrate on those situations, rather going through the usual arguments about drugs approved by the National Institute for Health and Clinical Excellence. Such cases usually arise because of the rarity of the treatment or condition, as I have pointed out, and the use of high-cost drugs.
The NHS has a finite budget, and tough decisions must be—and are—made to determine which treatments should be routinely available. NICE—a fine organisation—must consider the clinical cost-effectiveness of treatments and issue guidance as to why a PCT should fund them. If NICE issues positive guidance on a particular treatment, PCTs in England have three months, I believe, to make arrangements for funding; if NICE turns down a treatment, having judged that the NHS should not fund it, or if does not provide guidance, it can be difficult for clinicians and patients to gain access to those particular treatments, as we know. That is illustrated effectively by the Health Committee report that we shall debate later this month—I am sure that everybody will be present for that debate.
On the exceptional case and exceptional funding process, some PCTs have a system that allows individual patients to apply for a treatment that is not usually funded by the PCT concerned. I have lots of anecdotal evidence from organisations and individuals who have tried to use such systems, as I am sure every MP does. Not every PCT has a system in operation, and there are no countrywide standard processes or criteria for making decisions on whether patients can access treatment in exceptional cases. I shall give one or two examples later, but the measures used are commonly referred to as “exceptional case processes”, although their titles vary according to PCT.
The issue was brought to public attention as a result of Ann Marie Rogers’s fight to access Herceptin for early breast cancer. The Court of Appeal ruled that Swindon PCT’s policy of prescribing Herceptin in exceptional cases was irrational and unlawful. The court did not rule that Mrs. Rogers should be able to receive Herceptin, but rather that the PCT needed to formulate a lawful policy on which to base such decisions, which I believe was a fair comment. Lots of different names for the practice are used by different PCTs, but we all know that going to court is stressful and extremely costly, and people are inhibited by such a system. The inequalities that are created by the exceptional case process have become apparent. Every PCT has its own system, and they are given different names—some are called “special funding”, some “special circumstances”, but there is no uniformity to define that arena of activity.
I apologise for arriving late and also for the fact that I must leave early.
Having spoken to the hon. Gentleman before the debate, I know that he is aware of the case of a constituent of mine, Mr. Barry Humphrey—the hon. Gentleman has a local newspaper article on the case in front of him. Mr. Humphrey has been refused cancer drugs by Norfolk PCT. As the hon. Gentleman said, the PCT must decide whether the circumstances are exceptional, but no one seems to be able to clarify what that means. Does he agree that there is no transparency or guidelines on what test must be applied? In that particular case, everything, including the clinicians’ view, points to the fact that Mr. Humphrey should receive the treatment that he needs and which would give therapeutic value.
I agree with the hon. Gentleman—sorafenib, which would slow the growth of the cancer in that case, is available, but it is has not been made available by the PCT under its exceptional circumstances rules. People in other counties would be able to get the drug from their PCTs, but that is not the case in Norfolk. Lawyers around the country have been in touch with me about the matter. The availability of the drug is unequal and unfair. I have promised not to say anything about Scotland, because I no longer know what is true there and what is not. I am rather fed up being told, “If such and such happens in Scotland, why don’t you go back there”—that is a familiar argument in politics—but it is possible to say that the situation in Scotland is different.
If my hon. Friend went back to Scotland, he would have to wait twice as long for his operation.
The point made by the hon. Gentleman’s Norfolk compatriot, the hon. Member for North Norfolk (Norman Lamb), applies to my constituents in Dorset. Does the hon. Gentleman agree that part of the problem, apart from the inequities, is that the process is highly non-transparent? In fact, it is almost impossible to obtain clarity on what South West Dorset PCT means by “exceptional circumstances”, so apart from questioning whether it means the same as it does for other PCTs, one cannot find out for one’s constituent what rule is applied.
I agree. It is also true that the systems that have been set up to examine whether exceptionality, special needs or whatever they are called in a particular county are different, and are not transparent. It is not even clear whether people can appeal against decisions—some PCTs say that people can appeal and some say that they cannot. I might well come to the obvious conclusion that we need uniformity throughout the country, and a discussion on that subject so that we do not have a postcode lottery.
Although such systems exist, patients who, together with their clinicians or oncologist, believe that they face a unique set of circumstances, and that the NHS should make the treatment or drug available to them and fund it because of the clinical benefit, can apply for it to be made available as an exception to the usual rules. A panel will typically consider such cases on their individual merits, and the factors that may be considered include the patient’s medical history; the medical need that the exceptional funding is requested to meet; the expected benefits of the drug or treatment; details of any relevant research or trial supporting its use; and the patient’s personal circumstances. Although a patient in one PCT may be considered an exceptional case and receive the treatment requested by their clinicians, they may not qualify under the criteria used by a different PCT.
That creates a decision-making lottery. The Department of Health does not give PCTs guidance on how, or whether, they should consider individual applications for treatments that are not routinely funded. In 2007, I asked the Minister about the committees established by PCTs to consider such cases, and he told me:
“Primary care trusts are able to appoint committees of the trust, but there is no requirement for a special exception committee, an exceptional circumstance committee or other committee to approve treatments. There is no national guidance on the functions and operation of any such committee.”—[Official Report, 11 July 2007; Vol. 462, c. 1566W.]
So, no messing there. As has been said, little is known about the operation of exceptional case processes. Committees do not publish details of their process, their membership and the outcomes of their meetings. However, data about the usage of the rarer, often higher-cost treatments would be invaluable to NHS planners and could be useful to NICE when such treatments eventually become part of its appraisal and review process.
I have been the chair of the all-party group on cancer for 10 years—indeed, we will celebrate our 10 year anniversary in a few weeks’ time on the Terrace. We are very proud of the process that the Government have carried through under cancer plan one, the reform strategy and so on. We have seen real movement on the treatment of cancer right across the country: money has been put in, structures have been set up and people are living longer, which is a great tribute to the Government and to what they have done since 1997.
The all-party group is, however, concerned that applications from patients and clinicians are not always fully assessed case by case. In some cases, people are discouraged from proceeding, while some PCTs predetermine the outcome of cases. According to anecdotal evidence from Bayer Schering Pharma, clinicians have told members of its sales force that their PCTs tell them not to bother applying for certain drugs under exceptional case processes.
I am listening carefully to the hon. Gentleman. He mentioned resolving such issues case by case, but he also said that he wanted more uniformity. Is there not a paradox here? I understand that people want uniformity of procedure, but is there not a real difficulty about trying to deal with exceptional cases in a wholly uniform way?
Yes, there will always be difficulties—not least the availability of funding. Provision will differ in different parts of the country, and a certain tumour might, for example, be more prevalent in one part of the country than another. Although there is a process for assessing cases, we must bear in mind how helpful the treatment would be for the individual concerned. To take another example, Herceptin was not the best thing for everybody with early-stage breast cancer. People had to have a particular genetic factor—HER2—before the drug became active, although it was hard in the climate that evolved at the time to stand opposite a patient and say, “This is not going to affect you.” However, the day is coming when personalised medicine will allow us to say that a certain drug will work with A, but not with B, although it might work with C. That is happening more and more, and we should encourage it to bring a certain rationality to the use of drugs. However, such knowledge must be plugged into the system before we can make decisions in Dorset, Norfolk or wherever.
Many people use Macmillan Cancer Support’s helplines to seek information about the exceptional funding processes operated by PCTs. Such processes can be lengthy, arduous and difficult for patients, and the problem is often perpetuated by the lack of information and support. An attempt has been made in the reform strategy to keep the process to 31 days, although that is still a long time. My instinct is that information and treatment should be made available much more quickly, and that should happen right across the country. That would be a real advance, and it would be extremely popular with the public.
I know that fellow MPs receive correspondence from constituents on this issue, because they often give it to me. In conjunction with groups such as Macmillan and Cancerbackup, which have now merged, of course, I use that information for other individuals. Exceptional case studies and processing are an important part of the PCT process, as PCTs’ resources are finite, and treatment decisions must be made. The system could, however, be more equitable and transparent, and patients and clinicians should expect to receive the same decision wherever they live.
I do not want to go into lots of different cases, and I will mention just a couple. One woman, whom I will not name, was being treated for bowel cancer by Enfield PCT, and details of her case were sent to me for a view. She had had six years of treatment, involving chemotherapy and radiotherapy, but her condition was advancing. Her oncologist advised her that the next line of treatment would be a substance called Erbitux. The PCT does not routinely fund the drug, but the oncologist was allowed to appeal to the trust. That would have taken four to six weeks, so the woman, who was concerned that it would take such a long time, contacted the trust. She was told that funding decisions were taken at a monthly meeting on the seventh of the month. Eventually, her appeal was turned down. She was told that the extra life that the treatment might provide was not worth the money. She will apply again. As hon. Members can see, that takes us into the private sector, where there is the money and all the resources. The Library has sent me details of many such cases, which have featured in the newspapers over the years.
In another case, from a constituency next to mine in Norfolk, a patient sought Sutent from the PCT to treat kidney cancer. The drug is going through the NICE process, and there is no final guidance yet. Reissued health service circular 1999/176 states:
“It is not acceptable to cite a lack of NICE guidance as a reason for not providing a treatment”,
which is fine. According to the press coverage of the case, Norfolk PCT said that the treatment is not cost-effective and that it cannot prescribe it. However, PCTs have a duty in such cases to consider not only cost-effectiveness, but clinical effectiveness. The individual concerned is using £3,000 a month from a nest egg to pay for his treatment—that is the level of commitment that individuals need to make.
The hon. Gentleman is making a powerful and important speech. Has he come across cases in which somebody has said, “Okay, you won’t provide this on the NHS. I’ll pay cash for the drug,” but where the NHS has said, “If you do that, we won’t carry on with NHS cancer treatment”? That seems wholly unfair.
Yes, there are such cases. Somebody will offer to use the co-payments systems, under which the individual will pay something and the NHS will pay something. That is not allowed under the current system, and the NHS cannot work on that basis—it must operate at the level that the PCT has decided.
I mentioned Erbitux and I want to say a little more about it. In Kent, co-payments are refused, and it is not possible to give Erbitux for bowel cancer. At Maidstone hospital, however, the PCT allows co-payments and Erbitux, so there are differences within counties, and the position is not always clear. The patient in Kent has been happy to talk to me about his case, but I have said enough to illustrate what happens.
I have a whole list of places to illustrate the differences that I have described. Surrey, Sussex and Bromley are not good for allowing exceptionality. In North Yorkshire and Dagenham, there is a 50:50 success rate, but only if people threaten, or actually undertake, a judicial review. In Cumbria and north Lancashire, there is some mixed funding, and treatment is carried out on a case-by-case basis. In the Birmingham area, there is little exceptionality. In Manchester, however, there is nearly 100 per cent. success. That is the extent of the variability. That information comes from lawyers who have taken up the cases.
So what is the solution? We must make sure that we provide the best treatment available under the NHS. In relation to drugs, there is—never mind about NICE approval—the exceptionality process. For the system to continue to operate in the national health service, there must be national guidance outlining the obligations of PCTs. A framework should be set up to help committee members decide what should be considered an exception. For the patients with whom I have been in contact, one of the hardest things is that there is no way of knowing whether their case will be heard, let alone whether they will finally get the treatment they require. The additional stress and uncertainty is detrimental to the health and quality of life of patients with cancer.
A recent report on NICE by the Select Committee on Health—I am pleased to see a member of the Committee, the hon. Member for Wellingborough (Mr. Bone), present for the debate—made several recommendations on tackling postcode lotteries, including the need to assess all medicines at launch and to involve PCTs in developing guidance. However, in my opinion the recommendations fall somewhat short of what is required, as they would still leave a discrepancy between PCTs in the matter of exceptional cases. That was not clear in the report.
Patients should have all the information that they want, at the appropriate time, to make informed decisions about their treatment. The lack of transparency and the postcode lottery affecting exceptional funding are not acceptable. PCTs are autonomous in the way they spend their limited resources, and must provide the best health care for the community they serve. Patients should be informed about how resources are distributed within the local PCT, and arrangements for exceptional funding should no longer be “shrouded in mystery”—to use a phrase from a judge’s deliberations—from the general public.
Macmillan is in the process of surveying all PCTs in England by way of a freedom of information request, to discover how many have a formal exceptional funding process, what the processes are, details about the decision-making panel, how much it is used, patient criteria, whether information on the process is published, and so on. That information will be used to inform PCTs of how their processes compare with those of other PCTs.
Other organisations in the cancer community are doing the same thing—finding out how different PCTs operate. Some hon. Members will have been involved with the screening procedures that Cancer Research UK is examining to see whether different PCTs have different ways of carrying out screening for particular cancers. The current mood is that in addition to what was outlined by the Select Committee, an attempt should be made to do something about the differences between PCTs in certain fields. Those concerned will of course share their findings with MPs when the information is obtained.
I call on the Government to provide direction to PCTs and to support them in operating equitable and accessible exceptional case processes. That should include guidance on how exceptional cases should be dealt with, what criteria exceptional case committees should use to decide whether a case should be approved, who should sit on the committees and what patients should be able to expect, regardless of where they live. I want all PCTs to publish their exceptional case processes on their websites and through the local office of the patient advice and liaison service set up by the Government. The information should be freely available. PCTs should ensure that patient information about the exceptional case process is made widely available, in different formats and languages. I am continually astonished that in Norfolk 108 different languages are used, and I found that the PCT used only one—English. Suddenly Portuguese, Lithuanian and other tongues must be fed into the process, so that everyone gets the appropriate treatment, even within a county. It is a more complex matter than just trying to equalise what happens county by county. PCTs should provide all members of exceptional case committees with training in considering the relevant situation. They should collect data on how many cases are heard, the numbers approved or refused, and the therapy to which the decisions relate. That data should be considered by NICE when it gets round to appraising or reviewing its guidance.
The issue is an extremely important one in dealing with a facet of the work in question. Drugs are a major part of the treatment of patients in the national health service, and there will be more cancer drugs coming on to the market. It is estimated that in the next two years there will be 12 new drugs for different cancers. We should be proud that our scientists and medics are coming forward with new treatments—new cures, even—prolonging life and the quality of life. Politicians should ensure that if those treatments are available, they are available to everyone, wherever they live in this country.
It is a privilege to follow my hon. Friend the Member for Norwich, North (Dr. Gibson)—I can call him my hon. Friend because sitting in the middle I can have Friends on both sides. I pay tribute to him for his work as chairman of the all-party group on cancer. For 10 years he has been indefatigable in working for cancer patients.
I shall try to illustrate my remarks from my local experience in Worcestershire, where we have what is called a complex case panel. I have had several battles with it over the years. The first related to anti-tumour necrosis factor drugs for rheumatoid arthritis, several years ago when Worcestershire had three PCTs and postcode rationing was even more ridiculous, in that one of those small PCTs would not fund anti-TNFs and the other two would. A huge advantage resulted from the merging of PCTs into larger areas, from that point of view. Since the merger I have had battles over biventricular pacemakers, cochlear implants and drugs for wet macular degeneration—all before NICE has made a ruling.
There is a tremendous difficulty, even with technology appraisals, which are mandatory, because they may override local clinical priorities. I remember that during the first inquiry into NICE by the Health Committee, several years ago, we received objections from St. Thomas’s, over the water; the hospital representatives could not equate the demands from the technology appraisal for implantable defibrillators with their much greater desire for more nurses in accident and emergency. There is a tremendous conundrum: local priorities against national uniformity. I do not pretend to have an answer to that, but we must think about it.
My most recent, continuing, failing battle with the complex case panel is over the drug called sunitinib, which the hon. Member for Norwich, North mentioned under its proprietary name, Sutent. Sunitinib is for renal cell cancer, and amazingly has been approved as a first-line treatment for renal cell carcinoma in the north of England. On 23 July 2007, the north of England cancer drug approval unit, taking the cost into account, approved the drug not for second-line but for first-line treatment of patients with renal cell carcinoma, and listed such evidence as improved progression-free survival and improved survival in patients who had failed on, or could not tolerate, current therapy. That was enough for the north of England patients, and for medical oncologists in Birmingham. One with whom I have had dealings in connection with two patients in my area wrote, in reply to an inquiry from me about the current position in the west midlands:
“I have worked with most PCTs in the West Midlands and Worcestershire regions and in many cases the PCTs have funded treatment with this drug. I am aware that Worcestershire PCT is funding treatment with Sunitinib in at least two cases.”
That seemed to me rather more hopeful.
I tried to find out more about the prescribing of sunitinib across the country, and tabled a parliamentary question:
“To ask the Secretary of State for Health which primary care trusts in England provide funding for Sunitinib for patients with renal cancer who have failed to respond to all other treatments.”
I do not really blame the Department of Health, but this is one of the many matters on which it does not hold information. However, the Minister who responded said, because we all know that NICE is appraising the drug:
“In the meantime, it is for local PCTs to decide whether to make Sunitinib available to patients. In doing so, they need to take into account the available evidence. It is not acceptable for national health service organisations to refuse to fund a treatment simply because it has not been appraised by NICE.”—[Official Report, 19 November 2007; Vol. 467, c. 599W.]
On 22 November, Mr. Nicholson, the chief executive of the NHS, came before the Health Committee. That was just when we had heard the revelations that the NHS had gone out of deficit and into the most magnificent surplus. When we asked him about the surplus, he said quite clearly that the Department of Health was not telling PCTs not to spend their money on measures to undo postcode rationing. He said:
“What I can say is that the kind of decisions that you have described can now be taken wholly on clinical grounds, not on the basis of whether we have the resource.”
I went back to the PCT, because in the meantime my two constituents who need the drug had failed in their appearances before the complex case panel and their appeals. Worcestershire PCT’s reply quoted the PCT’s area prescribing committee. In his letter to me, the chief executive said:
“Sunitinib is not routinely used or funded for patients in Worcestershire with metastatic renal cell carcinoma.”
He went on to list the guidelines issued by the area prescribing committee:
“1. There should be no funding of these agents until further evidence is available to support use. It is expected that this should be in the form of mortality data.”
My two constituents are literally waiting to die.
The second guideline is a very good way of getting rid of exceptionality:
“2. No cases are likely to be exceptional in nature, and in view of the current available treatment it would not be equitable to consider any case as exceptional in the future. All cases considered as such to date merely represent the natural progression of the disease and response to existing treatment options. It is not appropriate to consider any further requests in line with previous requests considered.”
So exceptionality can just be got rid of. I looked up “exceptional” in my huge “Webster’s” dictionary. It just means “uncommon or rare”, nothing more. The chief executive went on:
“I trust that this reassures you that the prime decision for not funding this treatment is the lack of sufficient clinical evidence with which to support use; and that the way in which this drug was considered for use is consistent with the mechanism by which all new drugs are introduced into clinical practice in Worcestershire, i.e. through the Area Prescribing Committee.”
I was further confused by a letter from the chief executive of the West Midlands strategic health authority; I was trying to apply a little pressure higher up. I cannot resist reading this paragraph, which she herself admitted she did not understand:
“I understand from the Cancer Network that an improvement in progression free survival alone is not accepted as reason for approval of a drug and, in this situation, if a drug is on the NICE agenda then the Network would await a decision from NICE, as the survival of patients is not compromised. They add that an improvement in progression free survival is not evidence that a drug changes the natural history of the disease; progression may be delayed but there may be accelerated repopulation of the tumour after the drug stops being effective. As a clinician, I assume this statement is more readily understandable to you than to the lay person.”
It was completely un-understandable to me, even as a clinician of some years’ retirement. I found it very difficult.
Is there an answer? Ideally, NICE should make its appraisals, which are mandatory, much quicker. We shall debate that here in about a week’s time. That would be the ideal, as we all know that NICE goes into incredible detail to find out the facts. Another answer would be—please do not think that I am asking for more money for the health service—for more of the money in the health service to be made available so that more of the new, expensive drugs can be afforded and NICE can use its quality-adjusted life years to let a few more drugs through. I am seeking not more money but more efficient use.
The Department has made a start with its NHS better care, better value indicators. We must stop waste and the inappropriate use of drugs and reduce medical mishaps, which so often arise as a result of drug errors. As I have said many times, I believe that we must have a public debate on health care rationing, because I do not think that the NHS will ever be able to afford everything. That debate must be both national and local. Many people have mentioned co-payments, and there must be a national debate on that too. The very idea of co-payments underlines the fact that the NHS is free to everybody, because only those who can afford it could make co-payments, but there should be some way to tap into that. I do not know what that is. I hope that hon. Members might have some ideas. We also need better input from the public and patients into the commissioning system at PCT level. I am grateful to have taken part in this debate, and I hope that some answers will come out of it.
It is a great pleasure to follow—I am not sure whether I can say “my hon. Friend”—the hon. Member for Wyre Forest (Dr. Taylor), my colleague on the Select Committee on Health, and to participate in the debate so ably introduced by the hon. Member for Norwich, North (Dr. Gibson). I listened to his opening speech, which seemed to go by in five minutes. He raised so many important issues that I could have sat here and listened to another hour of it.
To return to the point made by the hon. Member for Wyre Forest about co-payments, rationing and the NHS—we must have a grown-up debate about those issues on another occasion—my blood boils to think of it. Imagine that your mother was seriously ill with cancer, Mrs. Humble—unfortunately, my mother died of it—and that there was an opportunity for a drug that might help. Imagine being told, “We won’t provide it on the NHS.” You might ask, “What if I use my life savings to buy it? That’s okay,” but you would be told, “No: if you do that, you’ll have to fund all your treatment privately.” Most people cannot possibly afford that. What we are saying is that we will allow only very rich people to be treated with the new drugs. That is where the whole system falls down.
I believe that the unique NHS system into which we have got ourselves may have many advantages—terrific doctors and nurses work within it—but it has a flaw: it is actually a rationing system. Of course, in an insurance-based marketplace system, people would get the new drugs. One problem is that this country has one of the worst take-ups of new treatments.
I shall touch on two personal matters to illustrate the problem with exceptional treatment. First, many years ago, my father was diagnosed with the first signs of Alzheimer’s, at which time he lived in Southend. The doctors said, “We have a new drug that we think might help your father. Would you like to try it?” We tried it, and not only did it stop the onset of Alzheimer’s, but it actually improved his quality of life, and for the rest of the eight or nine years that he lived there was no deterioration. However, that very drug can no longer be prescribed in the early stages of Alzheimer’s, which is nonsense.
For me, the second, and classic, case involved my wife: five years ago, local general practitioners spotted a lump in her chest and quickly referred her. It turned out that she had both liver and bowel cancer, and she was given a 30 per cent. chance of survival. She had an immediate bowel cancer operation, after which she received chemotherapy with a new drug. Luckily, we had private insurance, which it seemed right to use to save the NHS money—over the whole period, I suppose that the private insurance company paid up £40,000 or £50,000. After the chemotherapy, she underwent a major NHS liver operation—it was at the top of the scale for liver operations—performed by Mr. Ashley Dennison, a marvellous consultant in Leicestershire. After the operation, she again received chemotherapy, and tomorrow—thankfully—she goes for her five-year check-up, after which we hope she will be released from check-ups.
Listening to this debate, it struck me that if we had not had that private insurance, we would probably have been denied that drug, without which I do not think my wife would have survived. At the moment, only the rich, or those with private insurance, which tends to mean that they had the money in the first place, will get the treatment. That goes completely against the principle of the NHS being free to everyone based on clinical need. That is where the system is falling down. I am sure that that is not what the Minister, who is very able and caring, and the Government want. Sometimes these things happen without anyone realising it.
I agree entirely about the standardisation of exceptional circumstances. There is no clear guidance across the country. My only worry is that if the Government introduced that, it could bring in the lowest common denominator, so that fewer people might end up being treated, which I do not want to happen. My personal view is that if a consultant says, “This person should benefit from this drug,” they should get that drug. I know that that is frowned on within the NHS’s rational system, but it happens in other countries.
Does the hon. Gentleman agree that behind-the-scenes consultants sometimes campaign through patients and using militancy or The Sun newspaper in order to get their way? Others adopt approaches different from the straightforward methods being suggested today.
That is entirely true.
Leaving that aside, however, I want to spend most of my time talking about wet age-related macular degeneration, and the campaign in which I was involved, which provides a clear case of something going fundamentally wrong. As the Minister will know, last year, NICE considered this issue, because of three new drugs that can cure the disease. For those who do not know, wet age-related macular degeneration applies to the elderly—obviously—and those suffering from it go blind unless they get treatment. Until last year, there was no real treatment, and the disease would simply progress towards blindness. Three drugs then came along: Lucentis and Macugen, which were developed purely for this disease, and Avastin, which is a bowel cancer drug but was found to do the same job.
The problem was that NICE made a pig’s ear—unusually—when it published its draft recommendations. A massive row followed, and NICE withdrew its representations and reconsidered. Each year, 30 to 40 people per constituency contract this disease, and they were left with no NICE guidelines. In many parts of the country—in Liverpool, Somerset and Scotland, for example—patients received that treatment automatically. However, the thing that annoyed me the most was that it does not cost hundreds of thousands of pounds, but a few hundred pounds per injection, of which anything from three to 12 are needed to cure and reverse the disease.
I disagree with the term “postcode lottery”—it is no lottery, because my constituents will never win. Ours is the worst-funded PCT in the country, according to Government figures, so we will never provide something that someone else does not.
That brings us back to exceptional treatment—I think that my PCT called it low-priority funding. Bear in mind the rapidity of the disease—within three months the patient will go blind: there will be a delay before the patient can visit a consultant; the patient is diagnosed with the disease, and the doctors say, “You will go blind unless you receive the treatment. The good news is that there is treatment that will cure you, but the bad news is that we do not provide it on the NHS,” which is what a consultant at Kettering hospital rightly told my constituents. He then added, “For £1,500 you can come down the road and I will give you the injections,” which seemed rather a lot for an injection. However, someone with a relative who will go blind unless they pay for the treatment, will pay for the treatment somehow.
When I first challenged Kettering hospital, it was very good, admitted that it was wrong, and paid for somebody’s treatment privately. That was one case solved, but then of course I received many more cases, and I realised that the denial of treatment was commonplace. The PCT said, “It is not that we are denying treatment. Either they are exceptional cases, or low priority.” This is what happens: the consultant makes a decision, which goes to a meeting a few weeks later, after which the patient is referred to Leicester for a second opinion, even though the first consultant has already said that they need treatment. Of course, by the time the final decision is taken, the patient will be blind. It is a Catch-22 situation: patients cannot win.
I am very pleased to say that after campaigning in Parliament, and with the help of local media and even the Prime Minister who got involved and said that it was unfair, NICE produced provisional guidelines in the middle of December saying that people should get treated on the NHS, which made complete sense. Not only was it right morally to stop people going blind—there could be no argument about that—but it was financially sensible. When people go blind, the cost of social services is enormous. So it did not even make sense monetarily.
My hon. Friend has reached the point on which I wanted to speak—this should spare hon. Members the need for a full speech from me. His example affected a run of my constituents. As we investigated, it became clear that the regime under which NICE operates does not allow it to consider the knock-on consequences for social security, benefits, tax credits and other forms of personal and social care and support, which might—this is the case here—on any analysis, and regardless of the discount rate applied, hugely outweigh the up-front cost. Does he agree that one of the most urgent necessities, as well as trying to find means of speeding up NICE’s consideration, is to find some means of injecting into the regime a consideration of the genuine economics, so that NICE can operate on a rational basis, rather than being forced to operate on an irrational one?
It must be clear to everyone that that is what should happen. There was a prime example of wet age-related macular degeneration in my constituency. Two people were living independently. I think that the lovely lady was 84 and her husband might have been slightly older. He had a mild disability and she was looking after him. She then got wet eye in both eyes and the PCT was going to allow her to go blind, which would have meant that the couple could not have lived independently and would have had to be looked after. The cost would have been enormous. Luckily, a private company stepped in and paid for their treatment, but we should not be operating at a level in which a local company steps in because of a media campaign. To its credit, the PCT changed its mind in February and decided to implement the provisional guidelines. However, that is not always the case across the country. This nonsense of exceptional decisions taking weeks and weeks to make does not help our constituents who are suffering from wet eye or cancer. If a cancer patient is fearing for their life and their whole world has been turned upside down—as happened in my family—they do not want to go through a bureaucratic process to see whether they can get treatment. That is fundamentally wrong and totally against what the NHS was set up to do, and I hope that the Minister might have some answers for us.
I congratulate the hon. Member for Norwich, North (Dr. Gibson) on introducing the debate and on having said so many wise things, as he often does, on subjects as diverse as health and taxation. Health care has been rationed from time immemorial, and that is because time and resources are limited. A lot of prioritisation, or rationalisation—whatever one wants to call it—is uncontentious. It is hidden behind the labels that we give to complaints, such as acute, chronic and minor. We are all familiar with prioritising when it comes to the very young, the accident victim, the heart attack patient or the victim of a life-threatening disease. Some prioritisation, however, can be contentious. The treatment of a drug user, a reckless individual, those with a smoking-related disease, victims of irreversible, incurable conditions that nobody knows what to do with, and those in need of cosmetic surgery can be set against therapies for common and widespread and more frequently met complaints. There will always be a public debate about the choice to prioritise, favour or rationalise—to favour treatment of group A at a partial cost to the treatment of group B, or to fund one kind of therapy as opposed to another. Ultimately and inescapably, how we resolve those issues boils down to the issue of society’s values. However, the issue may be how those choices are made. Clearly, there are a number of different ideas about how they should be made. For example, such choices can be made by open democratic debate, by the popular press or by medical experts. Whichever choice is made will be contestable, because either the public—if they make the choice—may not know enough, or the medics may not share our values or be attuned to the values that the public hold. Whatever we do, different and hard-to-explain variations will exist in different areas and hospitals.
Here NICE enters as a kind of solution. It is a very professional outfit, but it does not get us off the hook. We cannot criticise NICE for not getting us off the hook or for attempting and failing. What NICE does is inform choice: it does not make the choice for us. It provides benchmarking of therapies and guidance. If it fails to make an appropriate mark or benchmark, it makes a recommendation to the people who have to make the choice—the PCTs—to fund or not fund. The debate primarily is about those PCTs that ignore, bypass or overcome those recommendations, either in general or in selected cases, funding things that NICE thinks they should not.
What the hon. Member for Norwich, North has shown very capably is that PCTs vary, and that they vary for a variety of reasons. They vary across the board and there may also be a lack of internal consistency within PCTs. Certainly, and most culpably, PCTs vary in procedure as to how they address very difficult issues.
[Mr. Greg Pope in the Chair]
I take a slightly different tack from the hon. Member for Norwich, North. I reckon that NICE is always going to leave room for judgments: it is not an oracle. It endeavours to do three very obvious things: first, to assess the cost of drug therapy; secondly, to evaluate the evidence of its benefits; and thirdly, to link those costs to the benefits using a strange unit of measure called the QALY—a quality-adjusted life year. In every stage in that process, controversy almost inevitably lurks. The cost, for example, is normally the UK market cost and not the cost of production plus a reasonable profit. We must be very wary in all such debates—it has been mentioned in other debates in the House—of drugs companies persuading patients and patient groups that the real problem is NHS parsimony and not drug company greed, because sometimes it is the latter.
In exceptional cases in particular, the assessment of the benefit by NICE is also a matter of debate. It considers the statistically average benefit, which ignores the fact that some drugs, for reasons unknown, benefit considerably some, but not all, targeted patients. That was almost certainly true of the Alzheimer’s drugs that seemed to work partially, but not across the board. Doctors can often, and quite legitimately prescribe—the hon. Member for Norwich, North is a doctor so he can correct me if I am wrong—therapies that may work, but cannot be guaranteed in all probability to work. When needs must, they will try something that is possibly, but not necessarily, the likely solution of the patient’s problems.
To make matters worse, the problem of linking the cost to the benefits by calculating the QALY is also methodologically questionable. The QALY is a bit like a unit invented in the 19th century by the utilitarian philosopher Jeremy Bentham called the hedon, which was a unit of happiness. He thought that one could solve all moral and political debates very quickly by totting up the number of pleasure units caused by adopting one policy or another. He recommended the unit to Government. It was a kind of hedonic calculus: one did one’s sums and got the right answer. We could add up on one side the pleasure caused by compensating the millions of losers from the change in the 10p tax band and set against it the embarrassment and discomfiture caused to the Prime Minister and the Chancellor and then we could work out on a scientific basis what we ought to do.
The QALY enjoys the same fate as the hedon, because we can question whether we should or can rate a drug that, for the same money, delivers a 5 per cent. benefit to thousands against a drug that for the same money, not the same price, delivers a 50 per cent. benefit to a handful of severely affected individuals, or exceptional cases. How can we, or should we, distinguish a drug that may add a year to the life of a child as opposed to a drug that adds three years to the life of a middle-aged man or five years to the life of a person with a history of voluntary substance abuse?
The most touching case I came across in preparation for today’s debate was in the Library notes. It was the case of a young lad who had to go to Germany to get a drug to sustain him so that he could live on for a few extra years. He was not likely to live for long, but without the drug he would die very quickly. That very vividly made the case that a young life is worth far more than the life of any of us here today. As the right hon. Member for West Dorset (Mr. Letwin) pointed out, NICE benchmarking does not tell us about social effects or the effects on others, which are particularly poignant in the case of children.
NICE offers guidance, identifies downright useless therapies and aids comparison, but it does not and cannot eliminate the need for judgment calls, by the PCTs or by whomever we think ought to make them. The question, which the hon. Member for Norwich, North put well, is whether that judgment should be unfettered and ad hoc, as it currently appears to be. I suggest that, however the PCTs exercise their discretion, or clinicians exercise their discretion in advising the PCTs, they should do so in a reasoned fashion, and not because they are stampeded into it by, for example, a press campaign. The process should be transparent, so that people know what has been done and why. It should be open to both expert and public scrutiny, and it should certainly be accountable, however we want that accountability to work.
I join colleagues in congratulating the hon. Member for Norwich, North (Dr. Gibson) on the excellent way in which he opened the debate. He is a diligent campaigner, particularly on behalf of the cancer community and cancer groups. I congratulate him in advance on his 10 years of work with the all-party group.
I wish to touch on the points that very learned hon. Members have made, and also on NICE. I know that there is going to be a debate about NICE in the near future, but we cannot do justice to this debate without considering it, or without considering how the funding formula in the NHS works, particularly in England.
I have looked at a Library paper setting out figures for exceptional circumstances appeals in the hon. Gentleman’s constituency. Some 57 per cent. won their appeal, and 31 per cent. lost. I do not know what happened to the other 22 per cent.—I have not had the opportunity to ask the Library whether they are just sitting out there in limbo—but there is obviously a problem. Those figures relate to people’s lives. I do not think that the Minister and I will disagree about much in the debate, because we care passionately about getting things right.
In the constituency of the hon. Member for Norwich, North, 31 per cent. of those who were told that they needed a drug or treatment and appealed under the exceptional circumstances rule were declined. Many of those patients and their families will have known that, in another part of the country, they may well have had their treatment funded. That is right at the heart of the problem. The hon. Member for Southport (Dr. Pugh) was right that it is impossible to fund every treatment that experts come up with, and that the NHS has rationed treatment for the past 60 years since its inception. However, patients and their loved ones deserve as much open and honest information as possible about why they are likely to need treatment, why they will not get it and, as was said earlier, whether the treatment will work.
That is why I was worried by what the hon. Member for Wyre Forest (Dr. Taylor) said. He has generations of experience in the medical profession—probably longer than I have been alive. Having sat with him on the Select Committee on Health for two and a half years, I know that his knowledge is invaluable to the Committee. He said that the document that he had got from an SHA was—I shall use my language rather than his, which was much more generous—complete gobbledegook. He said that not only did he not understand the letter, but that nor would the patient, and probably none of the consultants who have seen it.
We are moving towards having drugs specially prescribed for a patient with a particular genetic footprint. How will a patient have faith in a consultant telling them, “This drug is no good for you, because you do not have the genetic footprint for it”, if we cannot even get the basics of an appeals procedure into language that is common to us all. The hon. Member for Norwich, North, mentioned the diversity of his community and the number of different languages that are spoken, but here we are dealing with only one language, English, and even a retired senior consultant with years of experience could not communicate to his constituents what the SHA meant.
I was also concerned by what my hon. Friend the Member for Wellingborough (Mr. Bone) said. He is a doughty fighter for his constituents, and I congratulate him. How can we explain to anybody that they or their loved one will not get a drug that may well help them, because they are on the wrong side of an arbitrary border? I know that the Government are examining the funding formula as a result of the Health Committee’s excellent report on the funding and deficits of the NHS. As the Minister knows, I am sceptical about how we have suddenly leaped into a wonderful period of surplus in the NHS.
My hon. Friend is laying out the arguments clearly. Before he moves away from formulae, I wish to say that the national capitation formula is worked out at great expense and is used to decide how much each PCT should get. Every year since that formula was introduced, my PCT has received less than 100 per cent. How can that possibly be fair? The Government cannot even fund their own formula.
My hon. Friend has raised the core issue that the Select Committee, a Labour-dominated Committee, examined. We had grave concerns about how a formula that has cost huge amounts of money to decide could be so fundamentally flawed. My constituency is not a long way from his, and during the Committee’s proceedings I asked the then Secretary of State why her constituents would get some £400 a head more than mine each year, which was causing extensive rationing, cuts and closures in my constituency. She simply said, “Your constituents are more healthy than mine, which is why you get less money”. I think that the hon. Member for Wyre Forest was present at that evidence session.
I cannot say strongly enough that there is a dire need to address the anomalies in the funding formula. In my opinion and that of my party, many of the anomalies exist because there is not enough attention allocated to the age profiling of the particular area. Naturally enough, where there is social deprivation and there are early deaths because of that deprivation, we need to work on the public health side of matters. At the same time, however, if there is an ageing population in a constituency—the particular disease that my hon. Friend the Member for Wellingborough referred to is age-related—that constituency is penalised, because people are living longer, which is when that disease affects them; that is the situation in his constituency.
My right hon. Friend the Member for West Dorset (Mr. Letwin), who I am sure has gone to carry out very important duties elsewhere, talked about joined-up government and we would all like to see more of that. It is very difficult for NICE to make decisions without the knowledge of how those decisions will affect the community as a whole.
I would now like to look carefully at some ideas for NICE, and my party would be very happy if the Government took them up before the election, whenever that comes; I say all this completely in good faith. Often the problem with NICE is that, by the time it starts to look at a drug, that drug is a long way down the line. Perhaps lots of articles have already appeared in the press or consultants have talked about it, but NICE’s assessment has not taken place early enough. It is very important that NICE starts to assess new drugs and treatments during the drug licensing process, so that it communicates much earlier with the drug companies and it knows what drugs are coming down the line. Therefore, it can start its assessment while the licensing process takes place. At the present time, the assessment takes place after the licensing process. Obviously, that situation applies not just to drugs but to treatments.
It is important that NICE is an independent body and that it is autonomous. However, it must also be set out as an autonomous body, and as one that is accountable. Perhaps we need a Bill before Parliament to give it that statutory role. At the moment, it has a special health authority role rather than a statutory role.
Earlier on, several colleagues alluded to the issue of the QALY, the quality adjusted life year. Colleagues, we must think of another title for this measurement; we are talking about people’s lives here. It is imperative that we not only look at the term “quality adjusted life”, but that we look at what it actually means and whether it will give quality of life. On the Health Committee, we always looked at the top figure; how much is a life worth? It is much more detailed than a QALY would suggest.
NICE must also look much more at producing evidence-based commissioning guidelines. It must be much more involved with the whole process whereby evidence is given to different PCTs around the country.
Finally, I return to where I started, which is that we must not get away from the fact that this issue is about people, lives, futures and relationships with loved ones. The system is struggling to cope. I think that we would all agree with that; it is why we are debating this issue today. All too often my constituents come to me and say, “I have been denied this”, or “My loved one has been denied that”. People expect an openness and a frankness about decisions that are made which sadly, in many PCTs around the country, are not there.
I say to the Minister that, if the Government want to pick up on anything that I have said today, particularly on NICE, we would support them on that. We would also very much support the Government on establishing a much better practice within the PCTs around the country as to how they deal with these exceptional circumstances. I do not think that it is acceptable for a PCT not to have an appeals procedure, but some PCTs still do not have one. I do not think that that is acceptable in society today and certainly people should be able to appeal after they have applied.
I start by congratulating my hon. Friend the Member for Norwich, North (Dr. Gibson) on securing this debate; Norwich is my home city. I also apologise that the Under-Secretary of State for Health, my hon. Friend the Member for Brentford and Isleworth (Ann Keen), who is the Minister responsible for this policy area, cannot be here to respond. She is away on departmental business.
My hon. Friend the Member for Norwich, North and other hon. Members have raised a number of specific points about how the local health service across England manages and considers exceptional cases for cancer drugs. I hope to respond to as many of those issues as possible today.
Let me start by trying to define “exceptional cases”. They are cases where a primary care trust considers whether or not to fund a treatment where NICE has either not issued an appraisal or not recommended the treatment in its appraisal. It is worth remembering that, before the establishment of the National Institute for Health and Clinical Excellence, guidance on new drugs and treatments was being issued by numerous bodies at national, regional and local levels. Those bodies had very different ways of appraising evidence and developing recommendations. The status and implications of the guidance produced were not clear. That was confusing for doctors, who wanted to know what care they should be expected to give, and for patients, who wanted to know what care to expect.
That lack of coherent guidance led to big variations in prescribing practices across the country. It is precisely because of the complexities of modern treatment opportunities and also the need to ensure equity, clinical effectiveness and value for money for NHS patients that this Government established NICE as an independent body in 1999.
NICE is responsible for producing guidance for the NHS on the clinical effectiveness and cost-effectiveness of new and existing treatments, and it has become widely recognised as a world leader in its field. As I think my hon. Friend the Member for Norwich, North acknowledged in his speech, any taxation-based health care system will sometimes need to take difficult decisions on what to fund.
NICE’s guidance is based on a thorough assessment of the best available evidence and is developed through wide consultation with interested parties, including the drug manufacturers, patient groups and the NHS itself. Its appraisal and clinical guideline programmes have been both assessed and commended by the World Health Organisation.
As part of its technology appraisal process, NICE calculates the cost per quality-adjusted life year—if the hon. Member for Hemel Hempstead (Mike Penning) has any suggestions for a better name for that measurement, or a better means of assessing appraisals, I am sure that NICE would be very pleased to hear from him—to assess both the health gain arising from a particular treatment and the cost of that treatment.
Again, I am sure that NICE would be grateful for any constructive suggestions in that regard.
NICE does not operate a fixed threshold for the approval of a treatment but uses a broad range, to enable it to consider a broad range of evidence. The chair of NICE often refers to NICE’s use of the quality-adjusted life year as a “tool not a rule”.
NICE is currently carrying out a scheduled review of two of its key documents that provide a framework for its technology appraisals. These are the “Guide to the Methods of Technology Appraisal” and “Social Value Judgements: principles for the development of NICE guidance”. These documents cover a range of important issues, such as NICE’s use of QALYs and its consideration of orphan drugs, which I will come on to in a moment and which my hon. Friend mainly concentrated on in his speech. Draft documents have recently been subject to a full public consultation and NICE is considering all the comments that it has received.
Clearly, as hon. Members have said, it is vital that when NICE issues guidance, it is implemented consistently across the country and the Government have a role in facilitating that implementation. Provision for NICE guidance is made in funding allocations to PCTs, and NICE’s technology appraisal guidance is supported by a funding direction that requires NHS commissioners to make funding available for NICE-recommended drugs within three months of guidance being issued. These measures ensure that NHS clinicians across the country should be able to prescribe any treatment recommended by NICE. NICE guidance does not override the clinician’s responsibility for individual patients, but we expect NHS doctors to take NICE guidance fully into account in their decision making.
Compliance with NICE’s technology appraisals is now a core standard against which NHS organisations are judged. NHS organisations are required to demonstrate for the annual health checks that they are providing funding for NICE-recommended treatments within three months of guidance being issued.
There is an important point to be made here. I think that the Minister is saying that, once NICE has reached a decision, it is three months until implementation of that decision. However, there is of course the whole procedure where NICE gathers evidence, then the matter goes out to consultation and there is a three-month period. What does he think that PCTs should be doing in that period?
I will come on to that subject in a moment, if I may.
Where an NHS organisation fails to comply with NICE’s technology appraisal guidance, it is the responsibility of the strategic health authority in the first instance to support any of its organisations to achieve the necessary improvement. My Department has made it absolutely clear that if evidence comes to light that a particular body is failing to comply with the statutory funding direction to put in place funding for NICE technology appraisals within three months, it would expect the relevant strategic health authority to ensure that action is taken. If any hon. Member in this Chamber or elsewhere in the House has examples of where that is happening, I would be happy to draw them to the attention of the relevant SHA.
No, I must make progress. I have to get through many responses.
Trusts are monitored against the core standards by the independent Healthcare Commission in its annual health checks, and each NHS organisation’s rating is published. In 2006-07, 89 per cent. of NHS organisations were compliant with the standard relating to the implementation of NICE’S technology appraisals. That was a 5 per cent. improvement over the previous year.
A report issued in 2006 by the national cancer director, Mike Richards, showed a continued increase in the uptake of new cancer drugs by the NHS following positive NICE appraisal. It also confirmed a reduction in the variation around the country of the use of such drugs. That was partly due to the big increase in spending on cancer drugs—£729 million in 2006—which is expected to grow by between £60 million and £80 million a year for the next few years.
The improvement in implementation shown by Mike Richards’s reports can be attributed to several factors. In addition to the comparative data presented in the reports themselves, the period also saw the establishment of NICE’s implementation directorate and the introduction of the Healthcare Commission’s independent assessment. Professor Richards will repeat his evaluation of NICE-approved cancer drugs during 2008 to ensure that patients across the country continue to have access to such treatments. The evaluation will assess the period July to December 2007 and is expected to be published by the end of the year.
Where NICE guidance does not exist, either because it has not yet been developed, as in the case of the renal cancer drug referred to by the hon. Member for Wyre Forest (Dr. Taylor)—incidentally, the letter that he read out is a good example of why a plain English campaign is needed in the health service—or because it is not part of NICE’s work programme, it is for PCTs to make decisions based on the evidence that is available on whether to fund the drugs locally.
Such decisions are not new to PCTs. The principle of some local autonomy in decision making is supported by all parties in the House. It is important, as the PCTs are usually best placed to determine and meet the health needs of their population and to know more about the exceptional needs of individual patients.
Concerns have been raised about the speed between drugs being licensed and NICE appraisals being finalised, and the different decisions that might be made by PCTs around the country during that time. Four actions have been taken to try to address that. First, NICE introduced a new fast-track process so that for certain treatments it can provide guidance within weeks of a drug’s being licensed. That process was used for the appraisal of Herceptin.
Secondly, we issued management guidance to NHS organisations in December 2006 reiterating the message that decisions on funding for individual treatments should be made on the basis of the available evidence. The guidance makes it clear that it is not acceptable to refuse to fund a treatment solely because NICE guidance does not exist. It also pointed PCTs to useful sources of information to help them in reaching their decisions.
Thirdly, the cancer reform strategy, which was published in December 2007, set out several sources of information that PCTs should consider as a minimum when making decisions on treatments not yet appraised by NICE. Finally, the strategy also proposed a default position that all new cancer drugs will be referred to NICE for appraisal if there is sufficient evidence and a large enough patient population to justify doing so.
My hon. Friend the Member for Norwich, North raised a couple of specific issues. He discussed the problem that he had encountered in respect of transparency and the democratic deficit in decision making by PCTs. He has a point. It is general good practice for PCTs to be open and transparent about their processes. Indeed, my noble Friend Lord Darzi will address the whole issue of democratic accountability of PCTs when he publishes the final report on his review of the health service later this summer.
The hon. Member for Wyre Forest also stressed the importance of commissioning. He is absolutely right. Again, we need better commissioning and better accountability in commissioning decisions, which I think will be helped by the recommendations that we expect will be published this summer.
The hon. Member for Wellingborough (Mr. Bone) repeated his affection for a social or private insurance system of co-payments. That is not a position that we hold or, indeed, that his Front-Bench spokesmen support. We do not think that the solution to the problem involves any kind of subsidy for the private sector.
The hon. Member for Hemel Hempstead discussed the funding formula. He will be aware that we are awaiting the final recommendations of the independent body that gives the Government advice on such matters, and we will be making announcements in due course.
Let me turn to orphan drugs, on which my hon. Friend the Member for Norwich, North concentrated. Orphan drugs treat a condition that affects fewer than one in 2,000 people within the population, and it is true that they can often be expensive. However, it is not the case that they are less likely to receive a positive NICE appraisal. Over the past seven years, for example, NICE has completed 46 appraisals of cancer drugs, representing about one third of all its technology appraisals, and 41 of them have partly or fully recommended the treatment.
Up to 2007, NICE had appraised 26 orphan drugs. Three had negative appraisals and the other 23—including, for example, riluzole for motor neurone disease—received either a complete or partial approval. Indeed, information from NICE suggests that the proportion of orphan drugs that are considered cost-ineffective is not out of line with the technologies that it appraises for more common conditions.
Because cancer drugs are usually given for a relatively short period of time, even quite expensive ones can secure a positive NICE appraisal if they are effective. I know that the communities involved with less common cancers have expressed concerns about the use of cost per quality-adjusted life year in the NICE technology appraisal process for orphan cancer drugs, but, as I said, that specific concern is being considered as part of NICE’s review of its framework for technology appraisals.
The drugs that NICE cannot really deal with are those that are both very expensive and require long-term, sometimes lifetime, treatment; for example, treatments for rare genetic conditions. Such drugs are sometimes referred to as ultra-orphan drugs, and some are considered outside NICE by the national specialised services commissioning group.
If a disease is rare, PCTs can collectively arrange a risk-share through their specialised commissioning group so that the planning and delivery of interventions that cannot be made available everywhere can be made available in enough hospitals to serve their population. Alternatively, if it is important to concentrate expertise, services can be commissioned through the SCG or the national commissioning function. I can tell my hon. Friend that the treatment for some 40 diseases, including primary malignant bone tumours, retinoblastoma, or cancer of the eye, and coriocarcinoma, or cancer of the placenta, is commissioned by the national commissioning group.
I know that my hon. Friend has had an opportunity to discuss some of his concerns with my colleague the Under-Secretary of State for Health as well as officials in my Department, and I understand that those officials are in correspondence about his concerns with representatives of the Rarer Cancers Forum.
I hope that I have managed to go some way to reassuring hon. Members that the Government take this issue extremely seriously. Both the Department and NICE take the issue of access to new drugs very seriously indeed. As I mentioned, NICE is assessing its policy on approval of orphan and ultra-orphan drugs. We recognise that local NHS trusts are in the best position to make decisions for their local populations, particularly for the exceptional cases of individuals, because they know their needs best. However, it is important to remember that mechanisms are in place through the national specialised services commissioning group to resolve some of the issues that have been raised today.
This is an important and topical debate. We are entering difficult financial times. Many of my constituents in Shrewsbury are facing huge rises in the cost of living, the cost of food and petrol, and mortgage payments. It is important to get the tax credits system right and working properly and effectively, especially as we are entering this difficult time when the budgets of individuals who are the most vulnerable in society are being tightened up. I wrote that last part of my speech in preparation for this debate. The Prime Minister stated the same thing on GMTV today:
“We have got this credit crunch, we have got food prices rising, we have got fuel prices rising. I feel very worried about the effect of that on ordinary, hard-working families and on pensioners.”
Those were the words of the Prime Minister today.
Problems to do with the tax credit system comprise, without question, the single biggest issue facing my office today. The Minister should send my secretary, Mrs. Helen Sheppey, a box of chocolates and flowers—not just today, but every week—for the work that she does sorting out the tax credit problems. The Minister’s Department should have fixed that system a long time ago. My secretary does an enormous amount of work every day, through the Members of Parliament hotline, trying to sort out people’s tax credit problems.
This is the first time that I have spoken at any length in the House of Commons about my secretary. Helen is extremely attentive to everybody who comes to see her about tax credits. She listens to constituents and sorts things out efficiently. Many people write, but when somebody comes in off the street without making an appointment, she drops everything and prioritises somebody with a tax credit problem. I will come in a minute to why everything is dropped to sort out people’s tax credit problems and why the issue is so important.
Helen is coming under huge extra strain, as the number of cases that she has to deal with is soaring on a weekly and monthly basis. She has to deal, like many other constituency secretaries, with a great number of things: she has to manage me, which is a nightmare in itself. I sympathise greatly with her in managing my diary and my constituency engagements but, ultimately, those are the things—the main tasks of a constituency secretary—that she was hired to do. Yet we have estimated that she now spends about 30 per cent. to 40 per cent. of her time dealing with tax credits. That is astounding. I am deeply concerned about the amount of time that she is having to spend dealing with these cases. The numbers are staggering and growing.
What worries me even further is that the Government have said to us that they intend to try to clear up the mess of the 10p tax band fiasco, over which they have backed down, by using tax credits. So they are going to bring more people into tax credits. I understand that the Government are going to compensate those people who have lost out as a result of the 10p band being abolished by bringing them into the tax credit system. There will now be a huge extra strain on a system that is already not working and not operating efficiently, with even more people potentially facing chaos when trying to get their tax credits rectified and paid appropriately on time.
I come now to the most important part of my speech: not my comments as a Conservative Back-Bench MP, but the views of my secretary, Mrs. Helen Sheppey, for which I asked her in preparing for this debate because I wanted to put her words, not mine, to the Minister. In between sorting out tax credit issues, she has typed a one-page document containing some of the real problems that she faces daily in dealing with tax credits.
Helen wanted me to stress that,
“The staff on the MP Hotline are very helpful and knowledgeable”,
because she acknowledges that. I thank the Minister for the MP hotline. There is no doubt that its staff are courteous, polite, helpful and will go to the nth degree to help MPs’ secretaries try to resolve some of the problems. In fact, my secretary wanted me to put in a special plug for them, because she wants me to acknowledge just how helpful they have been to her. However, she continues:
“Constituents are very frightened when faced with a Tax Credit demand. Some constituents have told me when they receive a letter from Tax Credits they are too frightened to open it and ask a friend to come around and open it on their behalf.”
I am staggered that my constituents are receiving official communications from the Government but are too frightened to open a letter and need a friend to help them open it and give them support. What sort of a system is this that is terrorising people—I do not want to be over-melodramatic—and frightening them in this way? You will know, Mr. Pope, that these are the most vulnerable people in my constituency, and in yours, and throughout the United Kingdom.
My constituents have had to borrow money from banks to pay off the debts. Suddenly, the Government realise that they have overpaid tax credits to a certain individual and send a demand for this money. In the meantime, these vulnerable constituents have spent the money, thinking, quite rightly, that they were entitled to it and, suddenly, they have to find the money to pay the Government back. They go to relatives, friends and banks to try to borrow money. Given the credit crunch, it will be increasingly difficult for them to find the money to pay the Government back.
My secretary continues:
“Some constituents have had such a frightening experience”—
this is the most important point—
“they no longer claim Tax Credits, even though they are fully entitled.”
These are the words of my secretary, not myself as a partisan MP. What sort of system is it that leaves some of my constituents too fearful to claim something that they are entitled to, simply because of their experience?
“In the old system of Tax Codes, these problems did not exist.”
I agree with her on that point.
With regard to case problems:
“Constituents telephone the Helpline to advise them of a change of circumstances (usually an increase in income). Constituents then receive a new Award Notice which does not show the new income details. When constituents telephone the Helpline they are assured the information on the computer is correct, thus the payments they received are correct. It is only when the Award is finalised it is discovered the changes were not in fact made, and constituents have been receiving too much money. The onus is on the constituent to prove the date of their telephone call and the name of the person they spoke to.
Constituents have to return an Annual Declaration to Tax Credits at the end of the financial year to confirm the figures they have provided are correct. Constituents return the Annual Declaration and hear nothing further. Their payments later stop and they are informed the Declaration was not received.”
My secretary’s last point is that,
“If a joint claim ceases because a relationship has ended, it can be extremely difficult for the parent with care of the children. If the absent parent does not return an Annual Declaration, any overpayment is usually reclaimed from the parent with care.”
That worries me greatly.
The chaos of the system is taking a huge amount of resources out of my budget as an MP. I give the Minister three options to consider. First, I could send her an invoice. I come from business, where there was a lot of accountability in respect of finances. I can happily send her a quarterly invoice for the 30 per cent. to 40 per cent. of my secretary’s time in dealing with all these issues. Although I will not go into my secretary’s salary and remunerations, I could work it out for the Minister and send her an invoice. I genuinely believe that her Department should be sorting this matter out.
Secondly, I can collate all the inquiries from people who are frightened and frustrated, and send to them the Minister’s e-mail address and personal telephone number so that she can deal with them herself.
Thirdly, the Minister could ask the Exchequer to give MPs money for a full-time assistant to deal just with tax credits, because if the system continues as at present MPs will need one staff member—I am not being melodramatic—to deal just with tax credit problems. Those are the three options for the Minister.
I have three questions. First, why is the system not working, and why is it so chaotic? The Labour party believes that supporting the most vulnerable people in society is important, and is determined to redistribute wealth in this country, so why is its flagship and pivotal policy of helping the most vulnerable not working? Is it because of the system, or because of the computers? I do not know.
Secondly, what plans does the Minister have for reform? Does she acknowledge that there is a problem? I do not know, but I would like to hear from her, now that she has heard about the problems that we face in Shrewsbury. If she acknowledges that there is a problem, what plans does she have for reform?
Thirdly, what extra resources will the Minister secure from the Treasury to deal with the extra work involved in processing many new claims as a result of the 10p fiasco? Many more people will come into the system in the coming months and years as a result of the 10p fiasco, so what extra resources will she secure from the Exchequer to deal with the huge increase in demand when the system is buckling under the strain and is not fit for purpose?
My only party political comment—[Interruption.] My neighbour, the hon. Member for Telford (David Wright) is snorting at that. The cynical part of me believes that the Government are happy to allow this mess to continue because MPs are tied up with the problems. I have spoken a great deal about my secretary, but I also spend a great deal of time on Fridays and Saturdays dealing with people’s tax credits. If the system was working effectively, I could spend that time campaigning for extra resources for infrastructure projects in Shrewsbury, scrutinising the Government, thinking of debates, and so on, but I cannot do that at the moment because I spend hundreds of hours every month dealing with tax credits, which should be working smoothly and purring along like a Rolls-Royce engine without MPs having to involve themselves. The cynical part of me believes that the Government are happy about the matter because it allows us less time to scrutinise them.
Until this mess is sorted out, we are very happy to help constituents. Some people may ask why this MP is whingeing about having to deal with tax credits. I am not. I am more than happy to deal with any tax credit problem for any constituent. I go further and urge any constituent in Shrewsbury and Atcham who has a problem with tax credits immediately to get in touch with my office. Until the problem is sorted out, I or my secretary will be happy to help. They can get in touch with me at my office in Harlescott lane, Shrewsbury—most of my constituents know where my office is—where we are more than happy to help them. I will do everything that I can to help them. Why should they have to pull their hair out in frustration? Their MP is there to help them, and I want to get that message across, but I have a duty at the same time to raise my concerns about a system that is not working. I want to scrutinise the Minister to find out what will happen to make it work more efficiently.
At the end of the day, what angers me most is that many of my constituents are treated as numbers, unlike me. The MPs’ hotline purrs along beautifully, and when a Member of Parliament telephones the service is first class and the problem is rectified, but when a member of the public telephones, they must listen to music for hours on end, no one comes back to them, and they pull their hair out with frustration. People come to see their Member of Parliament because they are frustrated by their interaction with the system.
I do not believe that Members of Parliament should be treated differently from those whom we represent, and I want the excellent service that the Minister has provided for me through the MPs’ hotline to be universal for all my constituents so that they can sort out their tax credits on time and receive the appropriate money. I very much look forward to hearing the Minister address some of the issues that I have raised.
I see you smiling, Mr. Pope. You and I have had a number of conversations about tax credits, and this is a problem.
I congratulate the hon. Member for Shrewsbury and Atcham (Daniel Kawczynski) on securing this debate. I am grateful to him because it allows me to address the genuine problems that he is raising, and to explain some of the work that we are doing on an effective policy that is made difficult by its administration. I shall deal with one or two of the points that he raised.
I am grateful to the hon. Gentleman and to Helen Sheppey for their complimentary remarks about the MPs’ hotline. The staff will also be grateful to have them recorded publicly. I acknowledge the work that Helen is doing. She, like probably one member of staff in almost every MP’s office, has an almost personal relationship with staff of the MPs’ hotline. There is a high degree of awareness of the problems in the system, but as for sending her a box of chocolates every week—
Just once. It certainly sounds as though she deserves it. I was surprised to hear that she spends 30-40 per cent. of her time dealing with tax credit problems. I do not disagree that, although we have made great strides in improving performance, a great deal more needs to be done. Her Majesty’s Customs and Revenue and I are working hard to improve the experience of our customers, not so that MPs receive the Rolls-Royce service that the hon. Gentleman described, but, as he suggested, so that anyone contacting the tax credit offices receives a quality service.
I know from meeting staff who work in tax credits how committed they are to that high quality service, and how disappointed they are if there are problems in the system or with the computer that prevent them from delivering that service. There is a real and serious intention among staff to provide a good service, and they will be particularly pleased to hear that some aspects of their work are happily acknowledged.
I do not have the details to hand and it would not be proper to talk about individual cases, but I receive monthly operational statistics from the tax credit office. I instituted that to monitor its work, and I assure the hon. Gentleman that the level of complaints and disputes that it receives is falling, although not as quickly as I would like, but progress is being made.
I was interested and disappointed to hear Helen’s description of the impact on some constituents of receiving communications from HMRC. It would be disappointing if there was a widespread sense of fear when an HMRC letter comes through the letterbox. In the House—although often only in the few moments that we have at Question Time—I have described how we are working hard with regular customers who renew every year and every year have problems with their renewal. The renewal is part of the annual system by which we make sure the tax credit support that families get is appropriate and is exactly their entitlement. The renewal is a necessary part of the system and tax credit offices and call centres are now instituting work through which they proactively contact customers over the period of renewals, particularly those we know have got into difficulties in previous years, not only to remind them to renew, but to assist them in the process. If errors have been made because they have not understood the form, which is complicated, or if they are unaware that details of their personal incomes need to be included, staff can talk people through the difficulties. Therefore, we hope the number of customers who get into difficulties as a result of renewing will be reduced.
I was interested to hear the hon. Gentleman mention a case in which a family had renewed as requested and then did not receive anything at all. I want to go away and study everything that he has said in today’s debate. I have a number of sources of information about the subject—not only colleagues such as you, Mr. Pope, but my staff and friends of mine who are debt counsellors in Liverpool and who work with people in such circumstances. I am kept aware of where the rubbing points are, but as I have said, the overall number of complaints and disputes is falling. I was concerned about and am interested to learn the extent to which people find the process so difficult that they decline to renew and let their claim lapse. The statistics that I have seen—and I have asked for more detail on this—do not indicate that that is widespread. I appreciate that to decline to renew is an expression of frustration, but for many families, particularly those in the lower income groups, tax credits are so important that people do, nevertheless, renew. Tax credits are an integral part of a family’s income.
I totally agree with the Minister: it is extremely important to ensure that people renew. In Shrewsbury, we have had some cases in which people have felt unable to renew because of the problems that they have had. May I write to her with the names? I will not inundate her, but I would like to provide a sample. Will she look at some of the worst cases and get back to me?
Yes. I was going to suggest that the hon. Gentleman might wish to do that. I would be interested to look at those examples as case studies. Officials would be grateful to learn from the circumstances that he is describing. I do not wish in any way to diminish the pressure that he has described his secretary being under, but the information that I have, shows that during the past 12 months, he and his staff have made 34 calls to the hotline about 20 different customers. That is a large number, but it would be wrong and would distort the picture to allow people to assume that that represents the majority or a significant number of tax credit customers. In fact, 9,600 families benefit from tax credits in the hon. Gentleman’s constituency. I do not offer that figure as a way of saying that he is taking a party political position; I know that he not. However, 9,600 is a significant number of his constituents. The families of 15,900 children benefit from tax credit support. Out of those 9,600, the relative number of people who come to him are small, but I accept that those who find their way to a Member of Parliament are often a small, but determined group. That is usually indicative of a problem that we, as Members of Parliament, need to take account of and be aware of. I, as a Minister, ought to be listening to such problems.
On that point, I appreciate that, as an efficient Minister, the right hon. Lady obviously has the details of the cases with which we have been officially involved and that we have raised through the MP’s hotline. I am sure that she will appreciate that because of the experience that my secretary is getting in dealing with these matters, much work is done on other cases, about which we do not necessarily phone the MP’s hotline. Some of the problems are in certain cases very small and we do not need to approach the MP’s hotline because, after three years, my secretary has experience of the issue. Although the figures that the Minister quotes are correct, they are just the tip of the iceberg of the other issues that my secretary is involved with.
The hon. Gentleman makes a fair point and I take on board what he says. As I have said, I accept that there have been serious difficulties and that in the early days, they were very serious indeed. I hope he accepts that matters have improved since then. Her Majesty’s Revenue and Customs now provides a much better, if not good, service—although I am the first to recognise that there is always room for improvement. The improved performance of the tax credit system has meant that fewer overpayments are caused by IT or administrative errors. Again, that is demonstrated by improvements to the accuracy in processing and calculating awards, which increased from 78.6 per cent. in 2003-04—during the opening days when the systems were being set up—to around 97 per cent. in 2006-07.
There have been a number of significant changes in the past year, and I would like to mention briefly two important developments. One development that the hon. Gentleman might know of was the reform of code of practice 26, which is the policy that defines how HMRC should respond to disputes and complaints about recovery of overpayments. Previously, an overpayment was written off if there was an official error but it was reasonable to expect the customer to believe that their award was correct. That allowed for a huge area of disagreement between HMRC and the staff. I know that the reasonable belief test caused concern because people’s perception of what is reasonable can vary greatly. Before I was the relevant Minister, I saw many tax credit cases involving my constituents, but when answering letters to Members of Parliament as a Minister, I bear in mind, as I always do, that what I see is the smallest wedge of complaints, and I ask myself, “Does HMRC’s response feel reasonable to me?” Out of that discussion, work that was already under way with HMRC to review the reasonable belief test and code of practice led to a more straightforward set of questions and responsibilities, some of which HMRC also took on board. From the end of January this year, we replaced the reasonable belief test with a clearer test that sets out the responsibilities of HMRC and the customer for checking factual information.
Although we may not all be very good at doing it, if we are paid through pay-as-you-earn, we accept without question the responsibility that we have as taxpayers to ensure our pay slip is correct and to check our end of year tax statements and codes. We have a responsibility in relation to that and that is carried through into tax credits. The tax credits transformation programme, which started in 2006, aims to improve the service that families receive. Often, when I get the opportunity at Question Time, I mention the changes that are being introduced as a result of the work of this excellent group of HMRC officers. As I said, one change that has been made regards contacting customers at some of the most difficult times in their lives. When a family breaks down, we now have a system that is spread throughout the administration of tax credits. In the past, if a customer contacted the office to tell someone that their relationship had broken down, their joint claim would have been cancelled, a new form would have to be sent out, and it would have taken about six weeks to renew and get the person back into receipt of valuable tax credits at a time when the family needed it most. Now, we make the change during the phone call, so that the customer should not see a break in their receipt of payments. That is important to maintaining the confidence of our customers in the service.
I hope that the hon. Gentleman agrees that the service is getting better and that he welcomes our plans to improve the service further. I would be grateful to receive some of the detail of what he has mentioned if it is available, and I thank him again for securing the debate.
Commonwealth Immigration Visas
I am grateful for this opportunity to raise two issues relating to Commonwealth migration. The first is the proposal to curtail the visa-less period during which tourists coming on holiday, visitors and people coming for family reunions can stay in this country from the current six months to three months. I do not know whether the British Tourist Authority was consulted on the proposal, but that is the aim of the immigration and nationality directorate.
The second proposal is to abolish ancestral rights—the ability of people from Australia, New Zealand, Canada and South Africa to enter the country and be eligible for settlement after five years and to work. That is a remnant of the old patriality situation. People could claim British citizenship if they had a grandparent who was born in this country. Incidentally, that still seems to be the case in Ireland. I hope that my hon. Friend the Minister can comment on that. People with Irish grandparents can still claim Irish citizenship, whereas we are curtailing that right in this country.
On both issues—curtailment of the visa-less period from six months to three and abolition of ancestral rights—there has been a consultation or a consultation is in progress. The first has finished and the second will be completed in mid-May, but to my mind “a consultation” is what we might call Blair-speak for getting rid of those provisions. People do not hold a consultation unless they want to get rid of the provisions. People have a consultation to show that they have listened and then do what they wanted to do in the first place, after the consultation. That is a very British way of doing things—polite and meaningless consultation.
I want to make it clear that I oppose both proposals, because they weaken a Commonwealth tie to which I and many other hon. Members are strongly attached, to which the Government say that they are strongly attached and to which a large section of our population is attached. I am referring to people with relatives or other ties, particularly to the old Commonwealth—people, incidentally, who vote.
That Commonwealth attachment works both ways: the other countries are attached to us as well, and New Zealand, which I want to concentrate on today, is more attached than most. It is a relationship from which we all benefit—both the Commonwealth country and we in Britain. In fact, we benefit more than most. I would like to remind the House of the contribution made to this country and this economy by New Zealanders. One goes back to people who could have claimed the same patrial rights and the same ancestor rights. I am thinking of Katherine Mansfield, Ernest Rutherford, Dan Davin, Sir Geoffrey Cox, Len Cook—the former national statistician—and hundreds of lawyers, teachers, accountants and doctors, from McIndoe downwards, all of whom have made a big contribution to this country. Do we want to close off that free market in people, from which we and the other countries benefit?
Let us consider New Zealand literature. Practically everybody I find on the Wikipedia list of great New Zealand writers—I also have a long list of great New Zealand artists; of course, those lists are subject to revision, like everything else on Wikipedia—has spent a period in this country learning their craft, working with British authors and perfecting their skills, because London has been a focus for writers from New Zealand, Australia, Canada and so on, from Janet Frame downwards.
Do we want to curtail that type of contact? Should we not be strengthening those ties, rather than weakening them? IND officials—Home Official officials—seem to me to want to weaken the ties, because they have been saying to Commonwealth diplomats who have been consulted on the proposals, “The concepts of immigration and Commonwealth that this visa”—the ancestral visa—“route is linked to are outdated.” I do not think that they are outdated. They are important, they are living and they are vital. However, Home Office officials claim that their Ministers periodically ask them why those visas remain and they say that, when they are asked, they do not have “a robust answer” on the unique value added for the UK. That is more a comment on the IQ or the experience of the officials than it is on reality.
First, I declare an interest as someone who, like many of us, has relatives in Australia. Does not this measure show, as my hon. Friend is rightly explaining, a lack of understanding of history? Both Australia and New Zealand have always been there for this country when we have been under threat. It also shows a lack of understanding of the real dynamic of the current relationship at all levels—he has mentioned culture, business and sport. It goes right the way through the economy and is growing even further under the excellent premiership of Helen Clark in New Zealand and as a result of the very welcome election of Kevin Rudd as Prime Minister of Australia.
I am most grateful to my right hon. Friend. Both those Prime Ministers, but particularly Helen Clark, are concerned about this development. A robust answer to Ministers’ questions would involve not only the contribution that people make in that two-way trade, but the flexibility, skills and adaptability that people who come here from Australia and New Zealand contribute to our work force.
That contribution does not seem to be recognised by Home Office officials. It is reported that diplomats were “left in no doubt that neither officials nor Minister Byrne considered themselves bound to New Zealand by any historical ties.” It is clear that none of them was at the opening of the New Zealand war memorial in 2006 by our then Prime Minister, Mr. Blair, and by the Prime Minister of New Zealand, Helen Clark, which affirms those strong emotional ties. I find it appalling that such a comment can be made in the process of the discussions, because there are ties not only of ancestry and history but in the form of the contributions made by Australia, New Zealand, Canada and even South Africa in two world wars and in other wars since. That may be felt more strongly by an older generation. I represent the “wheeze” generation, whereas the Minister represents the whizzkid generation—I am a “wheeze” kid. The feeling that I have described may appeal more to an older generation, but it is still strong and still important and it is still felt across the board in this country, but each of the proposals is an affront to that feeling.
Let me examine first the proposal to reduce the visa-less period for visitors from six months to three. We must not forget that the New Zealand visitors who will be affected by that come a long way. It is a journey of 13,000 or 14,000 miles; it is not a day trip with a pensioner’s pass, such as the ones that I am now beginning to make around the country. It is a long journey and it merits a long stay. For many people it is often a retirement journey—a renewal of roots and contacts, a renewal of family connections.
Above all, those who come here are paying for themselves. They are not coming here to live on the system. When I first came back from New Zealand with a New Zealand wife, we were deluged with streams of visitors who all said, “Don’t worry, I’ve brought a sleeping bag. I’ll sleep on the floor.” Clearly, there is a great deal of living on the land, but there is no living on social security. After all, they are paying for themselves and they will want to go back to their home country. They are visiting this country, and it is unnecessary to curtail those visits from six months to three.
There has been no indication of problems being caused by New Zealanders staying for the full six months. Are they growing and selling illicit kiwi fruit on some sort of black market? Are they preparing and merchandising their own brand of Spates beer? That beer was always labelled as “Man of the South”, a tough image, but calling a beer “Man of the South” in this country would make it seem effeminate: it should be “Man of the North”.
There is no indication that they have been indulging in that kind of illicit activity. They are not even going underground, hiding from the authorities and fomenting discontent by telling people that there is a better land. It certainly is a better land far, far away—so why should they stay here? A certain degree of disgruntlement is justified, but there is no indication that those people are a threat or abusing their time here. No evidence has been produced to that effect, and there is every indication that they want to go back to that better land because it is indeed better.
The length of visit seems not to suit the convenience of the immigration and nationality directorate. However, if it is curtailed it is certain to produce retaliation on British tourists in New Zealand and Australia. There is no indication of a problem, but there is every indication of huge benefits resulting from the relationship.
I turn to the ancestral visa, which produces the same kind of benefits. Descendants of British citizens have the right to come here, the right to work and, after five years, the right to become citizens. Again, there is no indication of a problem, so why is it being reviewed—unless it is a kind of administrative tidying up?
When one considers the number of such visas being given, nine out of 10 go to white Commonwealth citizens. That cannot be fair. It rests on the old patriality clause, which ensured that white Commonwealth citizens were spared the rigours of increasing immigration enforcement. A provision that indirectly allows white Commonwealth citizens rights that black Commonwealth citizens do not have is not fair.
Those are our ancestral rights, and they are quite specific. I agree with my hon. Friend on equality; it is unfair, but there has always been an ancestral right. I am asking for its maintenance, but it is already attenuated. It is a right to work, and a right to citizenship after five years, and I want it to be maintained. I am talking about our relationship with the older Commonwealth, and particularly the benefits that we get from such countries as New Zealand.
I have to point out that one cannot speak of being swamped by ancestral visitors; there were only 8,490 of them in 2006, a 3 per cent. increase on 2005. Admittedly, those figures were prepared by a New Zealander, but that does not detract from the figures given by Len Cook. I do not see how it can detract from their accuracy. The figures may be small, but in terms of long-standing Commonwealth relationships they have an enormous emotional impact.
What is the reason for the proposals? My answer—I hope that the Minister will comment on this—is that this piece of what I might call perfidious Albion, or perfidious pommery, is happening because the poms are scared that immigration is becoming a major issue. The number of immigrants, particularly from the European Union, which now has 25 member states, is rising rapidly. In 2005 there were 117,000 immigrants, and in 2006 there were 145,000. That was not expected. The numbers were underestimated. It is clearly causing problems and concerns. However, those problems and concerns have arisen because of pressures on social services, education and the health service. It is an indication that we are not spending enough locally, not an indication of major problems with immigration.
Local authorities, particularly, complain that they have not been provided with adequate funds to cope with that influx. However, we have a Government who need to show that they are doing something. They want to do something but cannot do anything about the major component because they cannot stop it—it is caused by people with European citizenship—so they are going to deal with it by taking it out on old and new Commonwealth countries. That will lead to a number of problems. For instance, with Pakistani and Indian doctors and ethnic restaurant cooks all being controlled, the two problems that I have raised today will occur. The proposals are totally unreasonable. The problem is caused by European immigration. I do not criticise such people. Poles are hard-working. We even have a Polish chief executive in Grimsby; we, too, move rapidly with the times.
It is as if the middle of the dam has broken and collapsed and the tide is coming in, and the Government propose repairing the side walls by trying to exclude Commonwealth citizens. I hope that I am wrong. I hope that the Minister can explain why it is being proposed. I hope that he will disown those views on the Commonwealth that I cited, and that he will tell us that, after consultation, the two policies will be rejected and will not go ahead.
The Government pride themselves, particularly under their brilliant new phalanx of Home Office Ministers, on firm and effective immigration control. However, for such control to be acceptable, it has to be fair—and, specifically, it must not be race-based. My hon. Friend the Member for Great Grimsby (Mr. Mitchell)—he is an hon. Friend—said that we have always had ancestral rights. We have not. I remember with some clarity the patriality clause being introduced, mainly because I used to work for the Home Office. It was brought in when the Government sought to bear down on Commonwealth immigration.
It seems to me that the sweeping away of the clause is long overdue. I do not believe that it would survive legal challenge. If we look at the figures, we will see that in 2004, out of 9,397 visas issued, more than 8,000 were to people from the white Commonwealth, and most of the rest were from Zimbabwe. In 2005, out of 10,143 visas issued, nearly 10,000 were to people from the white Commonwealth; in 2006, out of 9,741 visas, more than 9,000 were to people from the white Commonwealth; and the most recent figures show that out of 8,380 visas issued, 8,083 went to people from the white Commonwealth.
The clause has provided a route by which members of the white Commonwealth gain rights and access that are denied to members of the non-white Commonwealth. It is archaic, but not in the sense that it goes back hundreds of years—it is one of the many indefensible and incoherent aspects of immigration control. I welcome the fact that Ministers, in seeking to revise, improve and make immigration control more coherent, are eliminating the clause. I believe that if persons from the rest of the Commonwealth—Africa, the Caribbean and Asia—realise how disproportionate the figures for the handing out of the visas are, they would understand the nature of the clause.
I should begin by expressing my gratitude to my hon. Friend the Member for Great Grimsby (Mr. Mitchell) for securing this debate this afternoon. This is the first debate that we have had on one part of the Green Paper, “The Path to Citizenship”, which the Home Office published earlier in the year.
The House knows that 2008 is a big year for immigration reform. We are comprehensively changing how the system is policed and how we judge who has the right to come to this country and who has not—we debated the points system at length in the House last week. As those two sets of changes will come into force this year, I personally felt that it was time that the House turned its attention to the unfinished business of migration reform in the past 30 or 40 years.
Any student of immigration legislation since the second world war will know that the busiest periods of change in legislation for immigration reform were, first, in response to decolonisation in the 1950s and 1960s and, secondly, in response to the asylum crisis that we inherited from the Conservatives in the late 1990s. Since 1945, Governments and the House have never applied themselves systematically to thinking from first principles about who should be able to come and stay, and what we should ask of people to whom we grant the great privilege of British citizenship. The Green Paper attempts to do just that. Many of the ideas will be wrong or will need to be revised, and plenty of them will benefit from the House’s attention, which is why they were published in a Green Paper.
Before I deal with the detail of my hon. Friend’s remarks, I should put on record my thanks and gratitude to my right hon. Friend the Member for Warley (Mr. Spellar), who has bent my ear for some weeks and months about some of the proposals on immigration reform and more generally. My hon. Friend the Member for Great Grimsby touched on some of the changes that we are proposing for tourist visas. That is part of the proposed reform to how we judge who is allowed to come to the UK in the first place—I shall not detain the House with another discursion into the iniquities of the points system because my hon. Friend raised the point about how we are changing short-term visas.
My starting point for that reform is an analysis that says that the visa system was invented for the 1970s, which was a different era, and I do not believe that it works any more, so it should be changed. It does not work for business people who want to come to do business in the UK, or for family visitors, many of whom come to see me at my advice bureau in Birmingham each month. There is a strong argument for reforming how we offer tourist visas to the world, simply because something like 1.1 per cent. of people who apply for such visas stay for longer than three months.
We cannot think about the question in isolation from the changes that we want to make to youth exchange and youth mobility schemes. That has been an issue on which there have been enormously important exchanges between Britain and Australasia. I should declare my first interest at this stage: when I finished my A-levels, I spent four or five months working my way around Australia. At the tender age of 18, it taught me a great deal about life, and it certainly gave me an enormous love for Australia. When the Government publish some of the changes to the youth mobility schemes under the points system later this year, the House will see how clearly determined we are to ensure that there is a continued opportunity for people from Commonwealth countries, but in particular from Australia and New Zealand, to come to the UK and spend a bit of time learning about the country from which many of their ancestors came.
I am delighted to give my right hon. Friend that absolute assurance. I was able to meet the Australian high commissioner shortly before he returned to Canberra recently. Such people are important friends of the United Kingdom; we have enormous regard for, and pay attention to, their advice and counsel. I urge my hon. Friend the Member for Great Grimsby not to see changes to the tourist visa system in isolation from the wider changes that we are making on youth mobility, but the picture will become clearer in the next month or two when we publish relevant proposals.
My hon. Friend’s second point, which I believe was the substance of his remarks, was about Commonwealth visas. Again, I welcome his comments. By publishing the Green Paper, the Government were attempting to go back to first principles and to set out a coherent story on the values and attributes that we want newcomers to sign up to if they want to become British citizens for the long term. I could not profess to have many of the answers to those questions, so I spent three or four months going around the United Kingdom to talk to people from all over the country about what values we think are important in the country, what values we want newcomers to sign up to, and what is the British deal that we want migrants to buy into if they want to make the United Kingdom their long-term home. Four values or standards were paramount across the United Kingdom: the ability to speak English to a certain level, the aptitude and attitude of hard work and paying tax, obeying the law, and making an effort to integrate with the wider community.
Some values, such as those of blood and history that my hon. Friend highlighted, would not necessarily have emerged from that survey of British citizens, but there is a good argument for putting them centre stage in immigration reform, which is the point at which I should declare my second interest: I am the great-great-grandson of someone who was born in Australia—they were born in Kulpara in South Australia. My other grandparents are Irish, so I would be able to apply for Irish citizenship in due course. There is a good case for saying that when we revise the values that we want to put centre stage in immigration and citizenship reform, those values, ties and historic bonds that my hon. Friend talked about should be part of the deal. I listened carefully to what he said this afternoon.
My hon. Friend the Member for Hackney, North and Stoke Newington (Ms Abbott) was absolutely right to say that the policy dates back to 1971. If one reads Hansard reports of the debates on the Immigration Act 1971, one will see that they were contentious and, in parts, coloured by the language of race. It is true that, overwhelmingly, people who take that route to settlement are from Australia, New Zealand, South Africa and Canada—something like 80 or 90 per cent. Our ambition is to listen to the debate on the Green Paper before bringing back a comprehensive Bill to consolidate all immigration reform back to 1971. That will involve a lengthy debate in the House and in Committee, and provide an opportunity to fix a number of historical wrongs in our immigration system. However, I hope that it will also provide a chance to reinforce and ensure that the values that my hon. Friend the Member for Great Grimsby talked about are part and parcel of the wider set of values that we have heard about from the British public, which we will seek to consolidate in the form of citizenship.
As I said, this is unfinished business, and it is down to this Government to finish the job. I hope that we will be able to do so in the next 18 months.
Bromley Hospitals NHS Trust
I raised the issue of Bromley Hospitals NHS Trust in a debate last July, and I want, through the Minister, to thank the Secretary of State—it is the same Secretary of State—for his written response to the points that I made. I make no apology, however, for returning to the subject today, because the issue is of great importance to my constituents, as the Minister will appreciate. The situation remains extremely unsatisfactory, and important decisions will be taken soon, so it is vital that the Government make the right decisions and have the appropriate input. What I have to say, however, is no reflection on the trust’s clinical staff, who do a heroic job of keeping the ship afloat. I continuously hear that much good medicine is being practised in the trust, but the situation in which staff have to work is very difficult.
The trust consists of two hospitals, both of which, as it happens, are in my constituency. The Princess Royal university hospital at Farnborough is a district general hospital with full accident and emergency facilities. It was built under the private finance initiative and is now seven years old. Orpington hospital is an older and smaller hospital, but it, too, received an infusion of capital five years ago, with £8.8 million being spent on new theatres and wards for elective surgery—hips, knees and that kind of thing. As hon. Members will understand, Bromley residents thought themselves lucky to have such excellent new facilities available to them, but serious problems have emerged.
The first problem is financial. The trust has operated at a loss every year. It now has debts totalling £100 million and it will lose more than £18 million in this financial year—2007-08—despite a cost-cutting regime. The interim chief executive forecasts that the trust will break even next year, but that is extremely unlikely given the present lack of progress, so the debt will continue to mount. Under the PFI scheme, payments of about £25 million a year are made to the owners of facilities, and that includes not only interest on private finance initiative borrowings, but payments for building maintenance and supply and support services. The trust’s financial performance is among the worst in the whole of England and Wales. The other day, the local newspaper—the News Shopper—quoted the interim chief executive as saying that repaying the debt would take between 50 and 100 years, which is quite an astonishing admission.
There are also problems on the medical side. The Healthcare Commission served the Princess Royal university hospital with an improvement notice after an inspection found blood stains on the walls and dust on the surfaces. According to the commission, the hospital is now off the sick list, but these events were a warning. Infection rates for methicillin-resistant Staphylococcus aureus and clostridium difficile are also a problem. Recent figures show an improvement, but the fact is that we are talking about a new hospital where there are still problems with cleanliness and infection.
The performance with audiology is among the worst in the country. I have had a succession of agonised letters from constituents over many years complaining of their inability to get a digital hearing aid in less than two, three and often four years, which is quite astonishing. Many of these people are in their 70s. In addition, the hospital’s maternity ward came out badly in a recent survey, and the hospital has had problems meeting its waiting time targets—both the four-hour accident and emergency target and the 18-week referral-to-treatment target.
The Minister might also be aware of the disgraceful treatment of local fundraisers, who, led by Mrs. Mary Spinks, have collected £500,000 for the Primrose centre for breast cancer care. I shall write to him shortly about that separate issue.
Another important point is that the management at the top level seems always to be interim, acting or short term. The present CEO is there for only six months and will leave in June. His predecessor was there for a year, while his predecessor’s predecessor was there for only a few weeks, which is ridiculous. Needless to say, all these people are on vast salaries.
In addition, there has been a positive frenzy of reorganisations, reports and consultations. The previous chief executive, who was there for only a year, has been taken away to head an interim executive team for the four local hospitals in outer south-east London. The team has been set up to see whether co-operation between the four hospitals could achieve economies of scale. Many people suspect—indeed, this has been talked about officially and privately—that this is a precursor to a merger between all four hospitals or between two or three of them.
The trust’s chief executive is heading a reorganisation exercise in south-east London called “A picture of health”—the Minister may be familiar with the consultation document. It is not easy to consult on such difficult issues, and anyone would have difficulty drawing up such a document. None the less, many of the options were pretty banally stated, with no real attempt to define the costs or alternatives. In the case of Bromley, it was almost pointless to answer the consultation, because all the options related to the hospital in Lewisham, not to the Princess Royal university hospital or the Orpington hospital in Bromley, where the options seemed to be taken as given. On top of that, of course, we have “Healthcare for London”, the document produced by Lord Darzi, who is now a Minister at the Department of Health, which has had a big impact in London. The situation is therefore not only bad financially, but dizzyingly complex, which makes it far more difficult for the trust’s management to make decisions. As a result, confusion is widespread and morale is low. The suspicion throughout is that decisions are financially, not medically driven.
What should be done? First, the primary and overall driving objective should be to put the medical staff in a position where they can deliver the quality of health care that I am sure they can. Secondly, a management team should be put in place that is committed to the trust and which can at least take a five-year view. I appreciate that it is difficult to attract people to management in the trust because of the uncertainties surrounding the positive plethora of consultations and rumours about mergers. However, the Government have helped to create the situation with their endless plans and should assist in resolving the issues so that committed, longer-term managers can be put in place. In that respect, we should also say no to mergers. In my experience as a former business man, mergers are often a distraction for management. It would be much more sensible for managers to focus on putting right what is wrong in the trust.
Thirdly—this is the point that I particularly want to address to the Minister—not only should there be a management that is committed to the hospital and to making it work, but that management should be given a workable financial situation. Here the Government have a plain responsibility. They signed off a bad PFI deal, which has now clearly come unstuck. The Government acknowledged that when they gave the trust a £6 million a year subsidy. They have now withdrawn that, admittedly step by step and not all at once; but the fact that they ever gave it shows that they were concerned that the PFI deal was a poor one. Now that the subsidy has been withdrawn, the costs of the PFI are coming home to roost. The situation is still bad. The PFI charge for the hospital is 10.4 per cent. of its annual income, which is nearly double the average charge of 5.8 per cent. That is the handicap under which the hospital starts.
The Government also precipitated the crisis that is affecting the hospital. They changed the regime governing all hospital trusts, away from the old-fashioned borrow and broker, by which hospital trusts could at the end of the year broker an arrangement so that even if they made a loss it would be worked out with surpluses from other trusts and so on. Two years ago, when there was a deficit in NHS funds nationwide, that was scrapped, and we now have a transparent and accountable system. I welcome that, but it led to the exposure of the difficulties into which the trust had fallen, and the Government precipitated that.
The Government have in addition brought in a national payment-by-results scheme. The problem with it is that the tariffs are based on average costs throughout the country, whereas the trust, because of its difficult PFI agreement, has higher than average costs. It is reckoned that the gap between the high-cost trust and an average-cost trust is between £7 million and £12 million a year, and that is a further disadvantage for the operation of the hospitals trust in Bromley.
The Government have some money: as a result of the tightening of the regime for all NHS trusts throughout the country, compared with two years ago, when there was a £500 million deficit, they now boast of a £1.8 billion surplus. Therefore there is money to deal with such difficulties, which are fallout from the action taken by them. Whenever I talk to the people who run the London NHS, they always say money is not a problem. The Government should take that into account.
If the interim chief executive officer of a hospitals trust can say quite openly that it will take between 50 and 100 years to pay off its debt, that is a ludicrous situation. Clearly, something must be done before then, and quickly; otherwise there will be an overhang that will destroy the hospital’s morale and ability to act. I therefore want a debt write-off in some form. That is necessary so that the hospital can be placed in a position where it can take decisions on medical grounds, not purely driven by financial requirements.
A fourth matter that I should like taken into account in the discussions that relate to the Bromley hospitals trust and all the reviews and consultations is the idea that we should use the facilities that we already have. There are proposals in the document “A picture of health” to move elective surgery from Orpington, and day surgery from the Princess Royal university hospital, somewhere else. However, both those facilities are new and work well. Why spend money to close them and move them elsewhere? That does not seem economically sensible. As the trust said in its evidence in relation to the document, with respect to the day surgery unit:
“The DSU at the PRUH consists of 6 operating theatres that are supported by 40 patient spaces. This is therefore the largest stand-alone DSU in OSEL”—
outer south-east London. The evidence continued:
“Indicative figures for a proposed ISTC at QMS quoted costs of £30 million...In addition...we consider that expanding the PRU DSU to 3 lists per day would mean that all the population could be treated without any added capital expenditure”.
That is the view of the hospitals trust, and I support it. It seems stupid to spend money when facilities exist and work well.
On the waste front, let us not waste money on big ideas that do not work locally. Lord Darzi’s health care for London strategy would mean, if applied to Bromley, that having spent £120 million on new hospital facilities, we would take income from them by diverting business to specialist hospitals and polyclinics. Of course, neither the specialist hospitals nor the polyclinics exist; it will cost money to build them. Therefore, we would be reducing the chances for the district general hospital to make money; it would make further losses and the Government would spend taxpayers’ money on building new facilities. As Professor Harrison of the King’s Fund said:
“There has been a complete failure to bring the elements of policy together...When they started PFI 10 years ago they were just blithely modernising hospitals and the ideas which are now prominent about centralising specialisation and shifting care into the community weren’t strong policy commitments. So the policies are now out of sync. It’s a mess.”
It is indeed a mess.
My conclusion is that modern facilities exist in the Bromley hospitals NHS Trust and there is an excellent medical staff. Therefore, the opportunities to provide good health care for the people of Bromley exist. The Government have a responsibility, for the reasons that I have given, to put the trust in a position to deliver that, but the Government can do so only if they take sensible decisions along the lines that I have described. Having taken them, they should let local people get on with it. There is no time to lose.
I congratulate the hon. Member for Orpington (Mr. Horam) on securing the debate on Bromley Hospitals NHS Trust. I congratulate, too, the health staff in his constituency on their hard work to improve services and performance. The hon. Gentleman will be pleased to know that the figures on the issues that he raised about accident and emergency and hospital-based infections are moving in the right direction, and millions of people—not just in his constituency but around the country—receive high-quality, safe services every day. However, he is aware, as I am, of the serious challenges that have confronted health care provision in south-east London for some time now. They go back several years.
In spite of record investment in the NHS—Bromley primary care trust received a 30 per cent. increase in funding for the three years between 2003 and 2006, and a 17 per cent. increase for the two years between 2006 and 2008—Bromley Hospitals NHS Trust, along with the three other outer south-east London NHS trusts, continues to report a deficit, and the Bromley trust was designated as one of the financially challenged trusts at the end of 2006-07, reporting a forecast year-end deficit of £18.5 million for 2007-08. The financial problems of that trust resulted from poor financial management over several years, but the new executive team is tackling the issues, and, as the hon. Gentleman acknowledged, although he expressed some scepticism, their plan is to break even in the financial year 2008-09.
As a result of some of the challenges, what to do about health care in south-east London has been hotly debated now for a considerable time, but at long last the health service in the area has come together with proposals that have gone out to consultation. The hon. Gentleman, being very interested in the subject, will I am sure be aware of the details of the proposals, and I do not want to go through them in detail now, but I want to highlight the fact that the Princess Royal hospital in Farnborough, the main part of the Bromley Hospitals NHS Trust, has been proposed as a major admitting hospital under all three options subject to the consultation. Indeed, under all the options, his hospital’s services would be enhanced.
Enhancements would include improvements to maternity, including more options for mothers, midwife-led and home births and 98-hour consultant cover; an enhanced critical care facility with improved quality for patients; and improved specialist rotas for medically ill patients, allowing them to be admitted under a doctor who specialises in their condition.
I am also aware of the representations that the hon. Gentleman mentioned about the future of elective services at Orpington hospital. They will be considered in the round as part of the consultation, but I assure him that whatever the outcome of the final consultation, Orpington hospital will continue to provide a valuable outpatient and diagnostic service to his community.
We all know that it is natural for concerns to be raised when changes are proposed to how health care is organised in a particular area, but changes are not made for change’s sake or to save money, although waste and duplication in public services should be deprecated. The reason for the proposals affecting south-east London is that doctors there tell us that the current pattern of care delivers a substandard service to the public and even puts lives at risk. The four medical directors of the hospitals involved said:
“We have looked at the best way to provide hospital services for the whole population. We have not been talking about which site provides the service, but rather how we can best meet the hospital needs of the 1 million people in the area as a whole. There is a high level of consensus amongst colleagues about the recommendations we are making. It has taken a lot of work to get this far, and everyone is very excited about the opportunity for those who deliver the service to take advantage of this opportunity to provide better care for our patients.”
Professor Sir George Alberti, the country’s leading expert in service design and in emergency care in particular, said:
“It has been obvious for some time that safe, high quality services will not be possible in the future unless services in outer south-east London are redesigned.”
The Minister may be aware of other papers produced by substantial numbers of consultants, such as those at Queen Mary’s hospital in Sidcup, which state the contrary opinion that although some of the change is certainly necessary, some is not, and that to close down new facilities that work well in favour of facilities not yet built is complete madness.
I am sure that the hon. Gentleman will acknowledge that it is also in the nature of consultations on service reorganisation for some consultants at hospitals that do not expect to come out as well as others to have a different view. It is the job of health care professionals and the management of primary care trusts in south-east London to sift through all the proposals and work out in consultation and in a transparent and open way what the best outcomes are for the public in the area, rather than bowing to special pleading on behalf of some professionals.
I would never do that. They very rarely are on a process such as this.
To continue, George Alberti said:
“Many good ideas are included in the current proposals…we were impressed by the enthusiasm for making tangible improvements…None of the Emergency departments are adequately staffed with consultants. It is recommended by the College of Emergency Medicine that there should be eight to 12 consultants per Emergency department, with the aim of having a consultant presence in the department from 8.00 am to 12 midnight, 7 days per week. None come close to this.”
Similarly, the outer south-east London surgery and critical care group said:
“Some patients require ‘critical care’ in the Intensive Care Units—either as the result of an accident or emergency…There is considerable evidence to show there is a better chance of survival in a larger unit”.
The outer south-east London maternity group said that the Royal College of Obstetricians and Gynaecologists recommends that the consultant presence on labour wards be increased from 40 to 98 hours a week. The group agreed recently that
“the…standards for 98 hour consultant cover, which will provide safer maternity care, can be achieved if services are reconfigured across the four hospitals”.
I admit that clinician support for one or another of the options on the table is not unanimous, but it is strong.
Formal consultation on the proposals ended on 13 April. I am informed that about 9,500 responses have been received. They are being collated and will be independently reviewed by Imperial College’s Centre for Health Management. I understand that the team in charge of developing the proposals expects to make the consultation results publicly available in June this year, and that the primary care trusts aim to take a final decision at the meeting of their joint committee this summer.
To respond to the hon. Gentleman’s points about finances, I referred earlier to the fact that Bromley is one of a small number of financially challenged trusts. Most of the financially challenged trusts with which we had to contend some years ago have reached solutions to their problems. Indeed, most of the 17 announced last year have now agreed solutions with their strategic health authorities that will help resolve their problems. The four in south-east London are slightly behind the curve because of the seriousness and complexity of their problems and the connection with reorganisation. However, I understand that NHS London’s provider agency continues to work with each trust to develop a range of options for solving indebtedness while maintaining standards of patient care and value for money.
I cannot promise the debt write-off requested by the hon. Gentleman, as that would not be fair to other trusts that have been through serious problems and taken difficult decisions to get themselves into financial balance. We have managed to find solutions for trusts in other parts of the country, enabling them to agree long-term recovery plans so that services are not negatively affected and they can get on with planning patient care without constant concern for a long-standing debt hanging over them. I assure the hon. Gentleman that my Department is working closely with the London strategic health authority to identify solutions for the trusts in his area similar to those that we have implemented in other parts of the country.
Within the course of this year, I hope, as we proceed with the consultation and the outcome of the consultation as a package. I hope that the strategic health authority will be able to reach an arrangement with the trust similar to the arrangements reached by other SHAs with the small number of remaining financially challenged trusts around the country. I cannot give the hon. Gentleman a categorical assurance of that, but it is my hope.
The hon. Gentleman raised local issues about audiology waits, which I know have been a problem in his area. I am told by Bromley hospital that it currently reports no waits of more than six weeks for audiology assessments. In January 2008, Bromley Hospitals NHS Trust received an extra £250,000 from Bromley PCT to meet the increased demand for audiology services. The funding has allowed the trust to appoint an additional audiologist to work with the team and to send a significant number of patients to Guy’s for treatment. On the Primrose centre, I am advised that the trust is willing to reach an agreement and confident of reaching one that will satisfy him and his constituent about the problem. If he writes to me about it, I will send him written clarification that he might find helpful.
I am sure that the hon. Gentleman recognises—I think that he acknowledged it in his speech—that the status quo is not an option for the NHS in south-east London. It has gone through a difficult period for historical reasons, but it is now coming through and has finally developed a vision of the area for the future. I hope that after the consultation is over, the PCTs can agree on a forward strategy behind which we can all unite. The health service in his area has made huge progress in the past few years despite the difficult backdrop, thanks to the hard work and dedication of its staff. With increased funding, that has enabled the provision of better care for patients.
When we talk about reorganisation, we are not talking about cost-cutting, although in a situation such as Bromley’s where there are historical financial difficulties, it is always difficult to attempt any reorganisation without people claiming that it is about cutting costs. However, I hope that I have illustrated with views taken from leading doctors and other clinicians in the hon. Gentleman’s area that we intend to reorganise to provide better, safer services for his constituents, better outcomes for patients and better safety and quality of care. That is what is driving change.
I hope that the hon. Gentleman is reassured that whatever happens—this is not necessarily the case for some of his fellow south-east London MPs—the hospitals in his constituency have a very positive future indeed. They will enjoy an enhanced future, whatever option is decided on. I appreciate his role and interest in expressing his constituents’ concerns about the future of health services in his area, and I encourage him to continue to engage locally with the NHS to help it improve services.
Question put and agreed to.
Adjourned accordingly at one minute to Two o’clock.