4 July 2011 : Column 1331

Kate Green: Does my hon. Friend agree that it would be an important opportunity to look again at the assertion that the countries with the highest levels of inequality are also those with the least social fluidity and therefore at the role that tax could play in achieving the Government’s social mobility objectives?

John McDonnell: That is particularly important given that we are in if not a recession, a period of economic inactivity in which the economy has been scraping along the bottom. We have 2.5 million unemployed, of whom nearly 1 million are young people and 1.7 million people are in enforced short or part-time working. As Richard Wilkinson demonstrated, during the ’80s, the social psychological response was either fight or fright: fright meant depression, alcohol and drugs, and fight often meant violence on our streets and, unfortunately, an increase in violent crime.

We should be addressing those issues now, as we pass through this economic recession, which might last some time. It behoves us, as we discuss taxation and if taxation can play a role in addressing inequality, to examine the matter in detail. The amendment simply tries to emphasise that inequality is an important issue that has to be addressed and that all legislation needs to be reviewed and assessed in the light of its impact and effectiveness in addressing inequality. The amendment therefore calls for a report to be brought back to the House addressing that matter. In that way, we might at least acquire an understanding of the impact of taxation policies on inequality, even if we might disagree on specific taxation policies.

Mr Love: I associate myself with the speech made by my hon. Friend the Member for Hayes and Harlington (John McDonnell) and its focus on inequality. I want to pick up on that focus, and on the discussion we had a few moments ago about the Government’s claim that we are all in this together. I shall subject that to scrutiny through amendment 13, which was tabled by my right hon. Friend the Member for Birkenhead (Mr Field). As my right hon. Friend said, and as has been said by those on our Front Bench, the Conservative manifesto at the 2010 general election included a commitment to

“freeze public sector pay for one year in 2011, excluding the one million lowest paid workers”.

It was announced in the 2010 Budget that there would be a two-year pay freeze, except for those earning £21,000 or less, who would receive an increase of at least £250 a year. In his statement, the Chancellor went on to say that 1.7 million public servants would benefit from that and receive the £250 for two years.

In the Budget statement this year, the Chancellor had changed his tune somewhat. He said:

“I can confirm today that in the coming year all workers in the armed forces, the prison service and the NHS, and teachers and civil servants, earning £21,000 a year or less will receive a pay uplift of £250.”—[Official Report, 23 March 2011; Vol. 508, c. 963.]

That is considerably less than the commitment given in the 2010 Budget, and it is different from—and, in a sense, considerably less than—the commitment given in the Conservative manifesto. Some work has been done that shows that if the measures include only public sector workers who are under ministerial control and subject to pay review bodies—that is in essence what the

4 July 2011 : Column 1332

Chancellor is saying—that commitment is very considerably less. As I understand it, it equates to less than half the original number affected.

In supporting amendment 30, I want to ask the Minister directly whether he accepts that the Conservative manifesto misled the people of this country. Does he accept that, in his Budget statement in 2010, the Chancellor misled the House and the people of this country? Does he also accept that the present number of people who will benefit from the £250 uplift is considerably lower than the number originally envisaged? In those circumstances, and given the difficulties that we face in a debate of this nature on taxation, will he accept the thrust of the amendment? Will the Government recommit to doing something to address low pay for those earning less than £21,000 a year? Will the Minister also ensure that everyone earning under that amount will receive the £250, given that only some are doing so at present?

Mr Gauke: It is a pleasure to respond to the debate. Amendment 10 would require the Office for Budget Responsibility to report on the revenue raised by the additional rate of income tax. Amendment 14, meanwhile, seeks a report on the impact on inequality of all taxes, and amendment 30 seeks to provide a £250 reduction in the tax liability of all public sector workers earning less than £21,000.

I deal first with amendment 10. At the Budget, my right hon. Friend the Chancellor asked HMRC to assess the revenue raised by the additional rate. As I explained during the extensive debate on this clause in Committee, which the right hon. Member for Delyn (Mr Hanson) will well recall, HMRC will consider all the available evidence on the impact of the additional rate, including data from the 2010-11 self-assessment returns, which will become available next year. Data from tax returns are clearly essential in any assessment of the revenue raised, but of course they contain confidential taxpayer information and are best reviewed by HMRC. It already has the expertise in monitoring and evaluating tax measures and is resourced to do so in future. The Office for Budget Responsibility has a different remit in producing independent economic and fiscal forecasts, judging policy against the fiscal mandate and analysing the sustainability of the public finances.

Kate Green: I understand what the Minister says, but does that not suggest that one useful role that the Office for Budget Responsibility could fulfil would be to take a dynamic look at the effect of the 50% tax rates on, for example, the propensity of people to remain in the country and pay that tax and the longer-term impact on the economy?

Mr Gauke: I would not necessarily have put the hon. Lady down as an advocate of a more dynamic assessment of the tax measures, but perhaps I was mistaken in my understanding of her views. The purpose of the review that my right hon. Friend the Chancellor has announced will be to enable HMRC to see what has happened in the first year. It is right to say that there are long-term effects that will not necessarily be incorporated in that first year’s data, and I think anyone with an understanding of these matters would acknowledge that.

It is perfectly reasonable to make the point that if the 50p rate were to become a permanent feature of our tax system, it could damage the UK’s competitiveness. That

4 July 2011 : Column 1333

is a point that the noble Lord Mandelson appears to support and I believe that the right hon. Member for Edinburgh South West (Mr Darling), who introduced the 50p rate as Chancellor, saw it as a temporary measure, while Tony Blair has made it clear that he thinks the 50p rate is a mistaken policy—full stop. Our view, however, is that at this time, because of the sacrifices we are asking people to make, the 50p rate does play a role, but we want to analyse what revenue it brings in the short term and to gain an understanding of its long-term effects.

As the additional rate was introduced by the previous Government, I can perfectly understand why the right hon. Member for Delyn is so interested in establishing whether it was a successful policy, but when he talks about public scrutiny of Budget measures I must ask him what public scrutiny was there when the 50p rate was introduced? To what extent was the analysis published then, and to what extent was it published when the 10p rate of income tax was doubled? What information was put into the public domain at that point? As a Government, we have done much more on putting information into the public domain by publishing our analysis. Announcements in this area will be made by the Chancellor at the appropriate time. It is peculiar, however, to hear the Opposition proposing more evidence-based policy making only to reject the notion, it seems to me, that this Government should consider the evidence before making any further commitments.

I turn now to amendment 14, which deals with the impact of tax on inequality. I realise that the hon. Member for Hayes and Harlington (John McDonnell) has his own views on inequality, some of which may not necessarily be shared by his Front-Bench team. I thank him for tabling this amendment, however, as it provides me with an opportunity to highlight the significant steps that the Government have taken in 13 months to address inequality through the tax system.

First and foremost, the Government are committed to ensuring that the income tax system gives more support to those on low to middle incomes, and rewards the efforts of those who choose to work. That is why the June 2010 Budget announced a £1,000 increase in the income tax personal allowance for those aged under 65. A further £630 increase was announced in Budget 2011. That will make the personal allowance £8,105 from next year. Together, those increases will benefit 25 million individuals, and take 1.1 million low-income individuals out of income tax—an important point that my hon. Friend the Member for Bristol West (Stephen Williams) highlighted. Basic rate taxpayers will gain by £210 per year on average. That is part of our stated objective to increase the personal allowance to £10,000, with real terms steps in that direction every year.

Income tax is not the only area in which the Government are tackling inequality. All local authorities in England have voluntarily frozen or reduced their council tax in 2011-12 and as a result have qualified to receive additional Government grant equivalent to a 2.5% increase in their band D council tax. We have committed £1.9 billion to ease the burden on motorists, including the 1p cut in fuel duty as opposed to the 6p increase under the plans of the previous Government. We are supporting pensioners through the triple guarantee of state pensions being uprated by earnings, prices or 2.5%, whichever is highest. The television licence will be frozen for the next six years.

4 July 2011 : Column 1334

Clearly, the Government have taken great strides to tackle inequality in this country.

Kate Green: What steps have the Government taken to reduce inequality by concentrating on taxation not at the bottom of the income spectrum but at the top?

Mr Gauke: As was mentioned earlier, we have increased capital gains tax rates from those that we inherited, and our income tax decreases have been focused on the low paid. That is an example of what we are trying to do. The point is how to ensure that we have a competitive tax system so that we have the growth that the economy needs and that benefits all our constituents.

Let me turn to the report requested by the hon. Member for Hayes and Harlington.

I draw his attention to the detailed analysis that the Government have published on the impact of direct tax, indirect tax, tax credits and benefit reforms, which can be found in annexe A to “Budget 2011”. The Government have gone further than any previous Government in presenting distributional analysis of how changes to taxes, tax credits and benefits affect households. We have published detailed analysis at Budget 2011, the spending review and the June Budget 2010. That analysis shows that the top decile sees the largest losses from the cumulative impact of tax, tax credit and benefit reforms introduced at Budget 2011 and previous fiscal events. In cash terms, the top decile loses more than twice as much as the ninth decile, and 10 times as much as the bottom decile. That is the case if one looks at the overall impact or in cash terms, as a percentage of net income, or across income or expenditure deciles.

John McDonnell: Will the Government publish anything with regard to the distribution of wealth—for example, the impact of such policies on the Gini co-efficient?

Mr Gauke: We will make further announcements as and when necessary, but we are publishing much more information on distributional analysis than any previous Government have. It is right to do so, and to take steps to ensure that the House and the whole country can debate such matters with as much information presented in future. A striking contrast can be drawn with regard to one policy—the doubling of the 10p rate—about which the hon. Gentleman and the right hon. Member for Birkenhead (Mr Field) had concerns. It was difficult to obtain any information on that policy’s impact, although we have learned in recent weeks that much of the information about that was available to Ministers at the time.

Amendment 30 seeks to provide a one-off £250 reduction in the tax liability of all public sector employees earning less than £21,000. In the June 2010 Budget, we announced a two-year pay freeze for public sector workers earning a full-time equivalent of £21,000. That is one of the many difficult choices that we have had to make to help put the UK’s public finances back on track, and it does not mean that we do not value the work done throughout the public sector. All Members know that those in the public sector work hard for the benefit of society. However, pay freezes of this sort save jobs. Given that we are having to constrain public spending and given that the fiscal deficit requires cuts, a pay freeze will help

4 July 2011 : Column 1335

to mitigate the effect of those cuts. Because we recognise that the freeze will be hardest on the lowest-paid public sector workers, it was announced in the June Budget that those earning a full-time equivalent of £21,000 or less would receive an uplift of at least £250 in both years of the freeze.

Both the Labour party’s manifesto at the time of the last general election and the 2009 pre-Budget report announced a 1% increase for public sector workers across the board, apart from the armed services. No distinction was made between the low paid and the high paid. Under a Labour Government, none of those earning less than £21,000 a year—including nurses, teaching assistants, police community support officers and hospital porters—would be receiving a £250 increase.

Mr Frank Field: What we said at the last general election is not very relevant, because we lost. The other side won, and made a commitment in the Budget. The Chancellor stood at the Dispatch Box where the Minister is standing tonight, and said that 1.7 million low-paid workers in the public sector would receive an increase of £250. What we now want to know is how many are being paid the £250, and, if 1.7 million are not being paid that sum, what steps the Government will take to ensure that they are paid it.

Mr Gauke: The policy advocated by the Labour party when they were in government would have resulted in none of these public sector workers receiving £250.

We will ensure that the policy on pay increases for low-paid local government workers is applied across the civil service and to work forces with pay review bodies. That will include civil servants, NHS staff, teachers, members of the armed forces and those working in prisons. Many civil servants, nurses and prison officers, and the armed forces, have already received the £250 increase this year and can expect a further £250 increase next year, but other work forces have responsibility for negotiating their own pay deals. Decisions on the pay of local government work forces are for local government employers, rather than central Government, to negotiate. Provision was made in the local government settlement for local authorities to pay the £250 increase, but the fact remains that the decisions are made by local authorities. We gave them the opportunity to pursue the policy that we are pursuing at national level, but it is ultimately for them to decide how to pay their employees.

Mr Field: At the Dispatch Box, the Chancellor said that 1.7 million low-paid workers in the public sector would receive increases of £250 this year and next year. Will the Minister please tell the House how many of those 1.7 million have received the promised sum—promised by the Chancellor, not by me?

Mr Gauke: Where it is within the Chancellor’s control because the money is paid through central Government, those low-paid public sector workers will receive the £250. For those who work in local government, which is not within the control of central Government, we have provided local authorities with the funding to be able to meet that policy objective.

4 July 2011 : Column 1336

Mrs Mary Glindon (North Tyneside) (Lab): My own Tory council totally ignored the Chancellor’s directive to give that money, and in the debate on the budget refused to give the £250 to our low-paid workers and said it had put in place a balanced budget that was in line with the Chancellor’s requests. What does the Minister think of that?

Mr Gauke: It is for local authorities to determine what they pay their employees, but we have given them the extra money to fund this, and we would like local authorities to fulfil the objective that we are achieving at national level. We do not control local authorities, but we can provide them with the funding, and we did that. Our intention was that all low-paid workers would receive the £250, but we do not—and should not—have the ability to mandate local authorities to pay their workers, and that is currently up to them.

John McDonnell: When the Chancellor made his statement, there were no caveats; it was a straightforward commitment to pay 1.7 million workers the £250. The Chancellor gave a moral commitment; it therefore behoves the Government to intervene to ensure the Chancellor’s pledge is fulfilled to all 1.7 million workers, without any caveats.

Mr Gauke: As I said, where this is within our control, public sector workers earning less than £21,000 are getting the £250. Where it is not within our control, we have funded local authorities; they are funded to make this payment, but it is ultimately for them to decide.

Nic Dakin: As a former council leader, it occurs to me that Governments were for ever putting conditions on how money for local government should be spent, so surely that could be the case in this respect as well?

Mr Gauke: This Government believe in localism. I do not know whether the hon. Gentleman wants to return to the days when local authorities were highly prescribed as to how they could spend money and everything was ring-fenced, but that is not how we want to operate.

Kate Hoey (Vauxhall) (Lab): The Minister said earlier that the Government had specifically given this money to local authorities. If we are now hearing that authorities—of all political persuasions, perhaps—such as that of my hon. Friend the Member for North Tyneside (Mrs Glindon) have not been paying it as they should, will the Government take that money back?

Mr Gauke: No. The funding settlement with local authorities was made on the basis that the money would be available for them to pay to low-paid public sector workers, but it is ultimately their decision.

Returning to the amendment of the right hon. Member for Birkenhead, I understand that it is intended to help enforce the Government’s policies, and I am sure he intends to be helpful. However, we do not believe that using the tax system is the right way to address this; we do not think that will be practical. It would add complexity to the tax system, and I therefore urge him to withdraw the amendment, especially as I know he will return to this subject at a later date.

Mr Frank Field rose—

4 July 2011 : Column 1337

Mr Gauke: I have given way to the right hon. Gentleman on a number of occasions, and I think it is time to conclude.

I have explained why the assessment of the additional rate of income tax requested by my right hon. Friend the Chancellor must be prepared by Her Majesty’s Revenue and Customs. I have explained that the analysis the hon. Member for Hayes and Harlington seeks already exists, and I have explained why the Government’s approach to assisting the lowest-paid public workers is the right one. There is no need for these amendments, so I ask for them to be withdrawn.

Mr Hanson: What is clear is that my right hon. Friend the Member for Birkenhead (Mr Field) has exposed completely the fact that the Chancellor of the Exchequer promised one thing at the election and one thing in his Budget, and has not delivered on that promise completely. I know that we will return to that issue during the next few weeks and months.

On the issue of the Office for Budget Responsibility, I wish to press amendment 10 to a Division and I urge my right hon. and hon. Friends to support me in the Lobby.

Question put, That the amendment be made.

The House divided:

Ayes 229, Noes 298.

Division No. 313]

[10 pm


Abbott, Ms Diane

Abrahams, Debbie

Ainsworth, rh Mr Bob

Alexander, rh Mr Douglas

Alexander, Heidi

Ali, Rushanara

Allen, Mr Graham

Ashworth, Jon

Austin, Ian

Bailey, Mr Adrian

Bain, Mr William

Balls, rh Ed

Banks, Gordon

Barron, rh Mr Kevin

Beckett, rh Margaret

Begg, Dame Anne

Bell, Sir Stuart

Benn, rh Hilary

Benton, Mr Joe

Berger, Luciana

Betts, Mr Clive

Blears, rh Hazel

Blenkinsop, Tom

Blunkett, rh Mr David

Bradshaw, rh Mr Ben

Brennan, Kevin

Brown, rh Mr Gordon

Brown, Lyn

Brown, rh Mr Nicholas

Brown, Mr Russell

Bryant, Chris

Buck, Ms Karen

Burden, Richard

Burnham, rh Andy

Byrne, rh Mr Liam

Campbell, Mr Alan

Campbell, Mr Ronnie

Caton, Martin

Chapman, Mrs Jenny

Clark, Katy

Clarke, rh Mr Tom

Clwyd, rh Ann

Coaker, Vernon

Coffey, Ann

Connarty, Michael

Cooper, Rosie

Cooper, rh Yvette

Corbyn, Jeremy

Crausby, Mr David

Creagh, Mary

Creasy, Stella

Cryer, John

Cunningham, Alex

Cunningham, Mr Jim

Cunningham, Tony

Curran, Margaret

Dakin, Nic

Danczuk, Simon

Darling, rh Mr Alistair

Davidson, Mr Ian

Davies, Geraint

De Piero, Gloria

Denham, rh Mr John

Dobson, rh Frank

Docherty, Thomas

Donohoe, Mr Brian H.

Doran, Mr Frank

Dowd, Jim

Doyle, Gemma

Dromey, Jack

Dugher, Michael

Durkan, Mark

Eagle, Ms Angela

Eagle, Maria

Edwards, Jonathan

Efford, Clive

Elliott, Julie

Engel, Natascha

Esterson, Bill

Farrelly, Paul

Field, rh Mr Frank

Fitzpatrick, Jim

Flello, Robert

Flint, rh Caroline

Flynn, Paul

Fovargue, Yvonne

Francis, Dr Hywel

Gapes, Mike

Gardiner, Barry

Gilmore, Sheila

Glass, Pat

Glindon, Mrs Mary

Godsiff, Mr Roger

Goggins, rh Paul

Goodman, Helen

Greatrex, Tom

Green, Kate

Griffith, Nia

Gwynne, Andrew

Hain, rh Mr Peter

Hamilton, Mr David

Hamilton, Fabian

Hanson, rh Mr David

Harman, rh Ms Harriet

Healey, rh John

Hendrick, Mark

Hepburn, Mr Stephen

Heyes, David

Hillier, Meg

Hilling, Julie

Hodge, rh Margaret

Hodgson, Mrs Sharon

Hoey, Kate

Hopkins, Kelvin

Hosie, Stewart

Howarth, rh Mr George

Irranca-Davies, Huw

James, Mrs Siân C.

Jamieson, Cathy

Jarvis, Dan

Johnson, rh Alan

Johnson, Diana

Jones, Helen

Jones, Mr Kevan

Jones, Susan Elan

Joyce, Eric

Kaufman, rh Sir Gerald

Keeley, Barbara

Kendall, Liz

Lammy, rh Mr David

Lavery, Ian

Leslie, Chris

Lewis, Mr Ivan

Lloyd, Tony

Llwyd, rh Mr Elfyn

Love, Mr Andrew

Lucas, Caroline

Lucas, Ian

MacNeil, Mr Angus Brendan

Mactaggart, Fiona

Marsden, Mr Gordon

McCabe, Steve

McCann, Mr Michael

McCarthy, Kerry

McClymont, Gregg

McDonnell, John

McFadden, rh Mr Pat

McGovern, Alison

McGovern, Jim

McGuire, rh Mrs Anne

McKechin, Ann

McKinnell, Catherine

Meacher, rh Mr Michael

Meale, Sir Alan

Mearns, Ian

Michael, rh Alun

Miliband, rh David

Miliband, rh Edward

Miller, Andrew

Mitchell, Austin

Morden, Jessica

Morrice, Graeme


Morris, Grahame M.


Mudie, Mr George

Munn, Meg

Murphy, rh Paul

Murray, Ian

Nandy, Lisa

Nash, Pamela

O'Donnell, Fiona

Onwurah, Chi

Osborne, Sandra

Owen, Albert

Pearce, Teresa

Perkins, Toby

Pound, Stephen

Raynsford, rh Mr Nick

Reed, Mr Jamie

Reeves, Rachel

Reynolds, Emma

Reynolds, Jonathan

Riordan, Mrs Linda

Robinson, Mr Geoffrey

Rotheram, Steve

Roy, Mr Frank

Roy, Lindsay

Ruane, Chris

Sarwar, Anas

Seabeck, Alison

Sharma, Mr Virendra

Sheerman, Mr Barry

Sheridan, Jim

Shuker, Gavin

Skinner, Mr Dennis

Slaughter, Mr Andy

Smith, rh Mr Andrew

Smith, Angela

Smith, Nick

Smith, Owen

Spellar, rh Mr John

Straw, rh Mr Jack

Stringer, Graham

Stuart, Ms Gisela

Sutcliffe, Mr Gerry

Tami, Mark

Thomas, Mr Gareth

Thornberry, Emily

Timms, rh Stephen

Trickett, Jon

Turner, Karl

Twigg, Stephen

Umunna, Mr Chuka

Vaz, rh Keith

Vaz, Valerie

Watts, Mr Dave

Weir, Mr Mike

Whiteford, Dr Eilidh

Whitehead, Dr Alan

Wicks, rh Malcolm

Williams, Hywel

Williamson, Chris

Wilson, Phil

Winnick, Mr David

Winterton, rh Ms Rosie

Wishart, Pete

Woodcock, John

Woodward, rh Mr Shaun

Wright, David

Wright, Mr Iain

Tellers for the Ayes:

Graham Jones and

Lilian Greenwood


Adams, Nigel

Afriyie, Adam

Aldous, Peter

Alexander, rh Danny

Amess, Mr David

Andrew, Stuart

Arbuthnot, rh Mr James

Bacon, Mr Richard

Baker, Norman

Baker, Steve

Baldry, Tony

Baldwin, Harriett

Barker, Gregory

Baron, Mr John

Barwell, Gavin

Bebb, Guto

Beith, rh Sir Alan

Bellingham, Mr Henry

Benyon, Richard

Beresford, Sir Paul

Berry, Jake

Bingham, Andrew

Binley, Mr Brian

Birtwistle, Gordon

Blackman, Bob

Blunt, Mr Crispin

Boles, Nick

Bone, Mr Peter

Bottomley, Sir Peter

Bradley, Karen

Brake, Tom

Bray, Angie

Brazier, Mr Julian

Brine, Mr Steve

Brokenshire, James

Brooke, Annette

Bruce, Fiona

Bruce, rh Malcolm

Buckland, Mr Robert

Burley, Mr Aidan

Burns, rh Mr Simon

Burrowes, Mr David

Burstow, Paul

Burt, Lorely

Byles, Dan

Cable, rh Vince

Cairns, Alun

Campbell, rh Sir Menzies

Carmichael, rh Mr Alistair

Carmichael, Neil

Carswell, Mr Douglas

Cash, Mr William

Chishti, Rehman

Clappison, Mr James

Clark, rh Greg

Clarke, rh Mr Kenneth

Clifton-Brown, Geoffrey

Coffey, Dr Thérèse

Collins, Damian

Colvile, Oliver

Cox, Mr Geoffrey

Crabb, Stephen

Crockart, Mike

Crouch, Tracey

Davies, David T. C.


Davies, Glyn

Davies, Philip

de Bois, Nick

Dinenage, Caroline

Djanogly, Mr Jonathan

Dodds, rh Mr Nigel

Dorrell, rh Mr Stephen

Doyle-Price, Jackie

Drax, Richard

Duddridge, James

Duncan Smith, rh Mr Iain

Ellis, Michael

Ellison, Jane

Elphicke, Charlie

Eustice, George

Evans, Graham

Evans, Jonathan

Evennett, Mr David

Fabricant, Michael

Featherstone, Lynne

Field, Mr Mark

Foster, rh Mr Don

Francois, rh Mr Mark

Freeman, George

Freer, Mike

Fullbrook, Lorraine

Fuller, Richard

Garnier, Mr Edward

Garnier, Mark

Gauke, Mr David

George, Andrew

Gibb, Mr Nick

Gilbert, Stephen

Gillan, rh Mrs Cheryl

Goldsmith, Zac

Goodwill, Mr Robert

Gove, rh Michael

Graham, Richard

Grant, Mrs Helen

Gray, Mr James

Grayling, rh Chris

Greening, Justine

Grieve, rh Mr Dominic

Griffiths, Andrew

Gyimah, Mr Sam

Hames, Duncan

Hammond, rh Mr Philip

Hammond, Stephen

Hancock, Mr Mike

Harper, Mr Mark

Harrington, Richard

Harris, Rebecca

Hart, Simon

Harvey, Nick

Haselhurst, rh Sir Alan

Hayes, Mr John

Heald, Oliver

Heath, Mr David

Heaton-Harris, Chris

Hemming, John

Henderson, Gordon

Hendry, Charles

Hinds, Damian

Hoban, Mr Mark

Hollingbery, George

Hollobone, Mr Philip

Holloway, Mr Adam

Hopkins, Kris

Horwood, Martin

Howarth, Mr Gerald

Howell, John

Huhne, rh Chris

Hunt, rh Mr Jeremy

Huppert, Dr Julian

Hurd, Mr Nick

James, Margot

Javid, Sajid

Jenkin, Mr Bernard

Johnson, Gareth

Johnson, Joseph

Jones, Andrew

Jones, Mr David

Jones, Mr Marcus

Kawczynski, Daniel

Kennedy, rh Mr Charles

Kirby, Simon

Laing, Mrs Eleanor

Lamb, Norman

Lancaster, Mark

Lansley, rh Mr Andrew

Latham, Pauline

Laws, rh Mr David

Leadsom, Andrea

Lee, Jessica

Lee, Dr Phillip

Lefroy, Jeremy

Leigh, Mr Edward

Leslie, Charlotte

Letwin, rh Mr Oliver

Lewis, Brandon

Lewis, Dr Julian

Liddell-Grainger, Mr Ian

Lilley, rh Mr Peter

Lloyd, Stephen

Lopresti, Jack

Loughton, Tim

Luff, Peter

Lumley, Karen

Main, Mrs Anne

McCartney, Jason

McCartney, Karl

McCrea, Dr William

McIntosh, Miss Anne

McLoughlin, rh Mr Patrick

McPartland, Stephen

McVey, Esther

Mensch, Louise

Menzies, Mark

Metcalfe, Stephen

Miller, Maria

Mills, Nigel

Mitchell, rh Mr Andrew

Mordaunt, Penny

Morgan, Nicky

Morris, Anne Marie

Morris, David

Morris, James

Mosley, Stephen

Mowat, David

Mulholland, Greg

Munt, Tessa

Murray, Sheryll

Murrison, Dr Andrew

Neill, Robert

Newmark, Mr Brooks

Newton, Sarah

Nokes, Caroline

Nuttall, Mr David

O'Brien, Mr Stephen

Offord, Mr Matthew

Ollerenshaw, Eric

Ottaway, Richard

Paice, rh Mr James

Parish, Neil

Patel, Priti

Pawsey, Mark

Penning, Mike

Penrose, John

Percy, Andrew

Perry, Claire

Phillips, Stephen

Pincher, Christopher

Poulter, Dr Daniel

Prisk, Mr Mark

Pugh, John

Raab, Mr Dominic

Randall, rh Mr John

Redwood, rh Mr John

Rees-Mogg, Jacob

Reevell, Simon

Reid, Mr Alan

Robathan, rh Mr Andrew

Robertson, Hugh

Robertson, Mr Laurence

Rogerson, Dan

Rudd, Amber

Russell, Bob

Rutley, David

Sanders, Mr Adrian

Sandys, Laura

Scott, Mr Lee

Selous, Andrew

Shapps, rh Grant

Sharma, Alok

Shepherd, Mr Richard

Simmonds, Mark

Simpson, David

Simpson, Mr Keith

Skidmore, Chris

Smith, Miss Chloe

Smith, Henry

Smith, Julian

Smith, Sir Robert

Soames, Nicholas

Soubry, Anna

Spelman, rh Mrs Caroline

Spencer, Mr Mark

Stephenson, Andrew

Stevenson, John

Stewart, Bob

Stewart, Rory

Streeter, Mr Gary

Stride, Mel

Stuart, Mr Graham

Stunell, Andrew

Sturdy, Julian

Swales, Ian

Swayne, Mr Desmond

Swinson, Jo

Syms, Mr Robert

Teather, Sarah

Timpson, Mr Edward

Tomlinson, Justin

Tredinnick, David

Turner, Mr Andrew

Tyrie, Mr Andrew

Uppal, Paul

Vara, Mr Shailesh

Vickers, Martin

Villiers, rh Mrs Theresa

Walker, Mr Charles

Walker, Mr Robin

Wallace, Mr Ben

Ward, Mr David

Watkinson, Angela

Weatherley, Mike

Wharton, James

Wheeler, Heather

White, Chris

Whittaker, Craig

Whittingdale, Mr John

Willetts, rh Mr David

Williams, Mr Mark

Williams, Roger

Williams, Stephen

Williamson, Gavin

Willott, Jenny

Wilson, Mr Rob

Wollaston, Dr Sarah

Wright, Jeremy

Wright, Simon

Yeo, Mr Tim

Zahawi, Nadhim

Tellers for the Noes:

Bill Wiggin and

Mr Philip Dunne

Question accordingly negatived.

4 July 2011 : Column 1338

4 July 2011 : Column 1339

4 July 2011 : Column 1340

4 July 2011 : Column 1341

Ordered, That further consideration be now adjourned. —(Mr Newmark.)

Bill to be further considered tomorrow.

Business without Debate



That Mr Chuka Umunna be discharged from the Treasury Committee and Tom Blenkinsop be added.—(Geoffrey Clifton-Brown, on behalf of the Committee of Selection.)

4 July 2011 : Column 1342

Musculoskeletal Diseases

Motion made, and Question proposed, That this House do now adjourn.—(Mr Newmark.)

10.16 pm

Graham Stringer (Blackley and Broughton) (Lab): The genesis of this debate was four reports into musculoskeletal disorders from about two years ago. The first was from the National Audit Office, one was the King’s college report, there was another from the umbrella organisation, the Arthritis and Musculoskeletal Alliance, and the final one was the clinical advice from the National Institute for Health and Clinical Excellence. Those four reports led to an excellent debate in Westminster Hall on 19 January 2010 at column 1WH of the Official Report. I advise the Minister to take a look at that hour and a half debate in which many more points were made than—[ Interruption. ]

Mr Speaker: Order. I apologise for interrupting. There are Members behind the Chair making a frightful racket and it should not happen. They should leave the Chamber and show some courtesy to the Member who is developing his speech. I apologise to the hon. Gentleman who should now resume.

Graham Stringer: Thank you, Mr Speaker.

Many more points were made in that debate than it is possible to make in a half hour debate in this Chamber. What the then Government were essentially being asked was to take action to ensure better clinical outcomes for the money being spent on musculoskeletal disorders. The real ask from the community was for a clinical director or so-called tsar. In a sense, however, the most important ask is not that, but that there is an outcome strategy that improves the outcome for people suffering from musculoskeletal disorders. In many ways, in spite of those four reports and the debates that have taken place since, the situation nationally remains much the same. The statistics are worth going through in some detail. The amount of money spent on musculoskeletal disorders is large—£4.76 billion, which is the fourth-largest category spend within the NHS. That money is spent on 25% of the population as one in four people have a musculoskeletal disorder. That is 9.6 million adults and 12,000 children. Many people think that arthritis and rheumatism affect only older people, but that is not true. They can affect people of any age, as is perfectly illustrated by the fact that 12,000 children suffer from it. In terms of costs, the magnitude of the issue is that one visit in every four to a general practitioner concerns musculoskeletal disorders and 10.8 million working days are lost because of such disorders.

Those are the statistics. The problem is that there is no equality of outcome and no sense that when money is put into the system outcomes improve. About two years ago, partly in response to the reports, the previous Government put £600 million more into the system, but there was no noticeable improvement in outcomes. The NHS atlas of variation shows a threefold difference in spending in different parts of the country, but it does not relate to differences in incidence, prevalence or severity of the problem; nor does it necessarily relate to better outcomes. Although there is a threefold difference generally, the difference for rheumatoid arthritis is five

4 July 2011 : Column 1343

times, for hip replacements 14 times, cemented hips 16 times and for uncemented hips it is 30 times. Clearly something unusual is happening in that area of the service and it requires examination.

Quite simply, current services do not ensure swift treatment of arthritis, which in many cases is vital. I shall give an example from one category of disorder: rheumatoid arthritis. People think it is the same as any other arthritis but it is not; it is an auto-immune disease and few people suffer from it. Many GPs see only one new case every year or so, which is surprising but true. Because GPs do not see such cases regularly, patients often have to visit their GP about three times before they receive treatment, but early treatment is vital. The time before treatment means not only pain but also that the rheumatoid arthritis is not cured. Since a third generation of drugs—the biologics—has been developed, the disease is curable in a large number of cases if treatment is given quickly enough. Even if the disease is not curable, what matters is getting the patient to a multidisciplinary team of physiotherapists, consultant surgeons, doctors and community nurses as quickly as possible.

Nic Dakin (Scunthorpe) (Lab): My hon. Friend is setting out his stall powerfully. It is a difficult subject. Does he agree that early intervention is good not only for the patient, because they can recover faster or get to grips with the condition, but also for the economy, because the person is more likely to be able to continue active employment, and for the health service because early intervention is likely to cost less in the longer term?

Graham Stringer: Precisely. I mentioned the total number of lost days. In the vast majority of cases of rheumatoid arthritis, people stop working two years after diagnosis, but if diagnosis and treatment are earlier it is most likely that even if the person is not cured they could continue working for longer.

The Arthritis and Musculoskeletal Alliance—ARMA—is calling for a number of things, but before I put its case I note the following points. The fact that there are unsatisfactory differences in inputs and outcomes is not completely an accident. By and large, the services have not had the attention they deserve. I am not making a party political point; the situation has been going on for a number of years and unfortunately it continues. The quality and outcomes framework contains no indicator for musculoskeletal conditions. Why not? The musculoskeletal services framework of 2006 lacked leadership and was largely ignored by the centre in the NHS, GP training in musculoskeletal conditions remains poor, despite the evidence I have just given about the importance of GPs recognising precisely what form of musculoskeletal disorder a patient has, and only two of the NICE policy standards announced so far relate to musculoskeletal conditions—for hip fractures and osteoarthritis—out of the vast range of some 200 conditions covered by this generic term.

ARMA is calling for an outcomes strategy as a vital first step in addressing the current failures in provision of treatment and care for people with these disorders. What would that strategy look like? It would cover a number of areas, including outcomes, demonstrating

4 July 2011 : Column 1344

how high-quality musculoskeletal services can deliver improvements in the outcomes measured in the NHS outcomes framework, particularly gaining independence and returning to work, as my hon. Friend the Member for Scunthorpe (Nic Dakin) pointed out.

The useful slogan, “no decision about me without me”, should also be a guiding factor, enabling patient involvement and shared decision making at all points in the patient pathway and, in particular, encouraging better self-management and at the same time improving general public awareness of musculoskeletal conditions. The information revolution is also relevant for setting out and making public the key sources of data on the performance of and expenditure on musculoskeletal services and improving our understanding of outcomes beyond hip and knee replacements, which account for only 20% of expenditure. There must be co-ordinated service delivery, joining up delivery across the NHS and social care services. Commissioning should describe the measures of success that will be used to assess clinical commissioning groups and set out the support that will be provided to commissioners. Training for GPs in musculoskeletal medicine is also important. We must enhance the currently small component in training to support GPs in providing effective and timely treatment and care to patients, as well as informing their commissioning decisions.

ARMA’s request of 18 months ago for a direct musculoskeletal service was reasonable. Even if there is to be no service director, ARMA’s requests are quite reasonable, because surely the Minister cannot be satisfied with how services are being delivered across the country, with different inputs and massively different outputs.

I finish by quoting Professor Emery of Leeds university. He was talking about rheumatoid arthritis, but this applies to any of these conditions. He said that it is the “most common treatable disability”. Essentially, it is not treated as well as it should be and the disability could be removed. I look forward to the Minister’s response, and hopefully he will respond positively to what should be a reasonable way forward.

10.29 pm

The Minister of State, Department of Health (Paul Burstow): I congratulate the hon. Member for Blackley and Broughton (Graham Stringer) on securing the debate and bringing to the House’s attention an important issue. He has rehearsed the statistics, but behind them are people with real lives, in some cases suffering in agony and having difficulty getting on with their lives as a consequence of musculoskeletal disease.

Let me make it clear from the outset that the Government fully recognise the impact that musculoskeletal disease has on individuals and society as a whole and that, although there are excellent services in some parts of the country, there is still far too much variation in the availability of services and the outcomes they secure for people. This debate is about how we will respond to that evidence and to the concerns that the hon. Gentleman has brought to the House tonight, and about how we will deliver the change on the ground that we all want to see as constituency Members.

The hon. Gentleman argued for a national outcomes strategy on musculoskeletal conditions. He made some important points and I will try to address directly some

4 July 2011 : Column 1345

of the concerns that sit behind them. The 34 organisations in the Arthritis and Musculoskeletal Alliance, which he has spoken on behalf of this evening, make some important points. They have been in discussions with the Department of Health about their concerns over how we will ensure that the differences between services around the country are addressed so that people get access to the right services at the right time.

On 19 April, officials wrote back to the alliance to confirm that we would

“ask the National Quality Board to look at this area as a potential topic for a national outcomes strategy”.

By that, we mean that it will consider whether there are problems in our approach to these conditions that go wider than the NHS. It is important to understand that an outcomes strategy produced by the Department of Health looks out from the NHS to wider impacts on health and considers how those might be influenced to improve health outcomes for people. It will also look at what needs to be done about efforts that are already in hand, to ensure that the NHS is more responsive to patients’ needs and that there is an uptake of good clinical practice.

I do not believe that the case has been fully made for such an outcomes strategy, and I want to explain to the hon. Gentleman, and through him to members of the alliance, why that is. A number of steps have been taken in the past 12 months that have moved us on significantly from the debate that the hon. Gentleman spoke about at the beginning of his remarks. I understand that the National Quality Board will consider its future work programme at its meeting this month. It will decide whether it is appropriate to commission the necessary work to look at the case for a Department-led outcomes strategy. I assure the hon. Gentleman that I will ensure that not only this debate but the debate that took place in 2010 are cited by the members of that board.

I will spend a little time describing what is happening now. The hon. Gentleman referred to the musculoskeletal framework that the Department published in 2006. He spoke about the impact of that strategy, and I will say more about that in a moment. The document was developed in collaboration with a wide range of patient and professional organisations. It set out a vision for services based on the concept of an integrated care pathway—exactly the sort of pathway that the hon. Gentleman talked about. The clear aim was to help the NHS to organise services so that patients could access a variety of primary and secondary care services according to their need, including physiotherapy, clinical psychology, specialist rheumatology and surgery, and have a seamless transition from one service to another.

The model proposed depended on the idea of a multidisciplinary clinical assessment and treatment service, or CATS, for musculoskeletal services. That would bring together clinicians from primary and secondary care, assess patients’ needs, treat them locally where possible, and where necessary refer them on for specialist hospital care. The document recognised that different health communities would implement the framework in different ways, and that it should be possible in some circumstances to offer patients a choice of pathways.

Three years after the publication of that document, in spring 2009, the British Institute of Musculoskeletal Medicine held a symposium to review progress in implementing the framework. Today’s debate echoes

4 July 2011 : Column 1346

the frustration that was felt there. Although the symposium found that a number of excellent services had been developed, incorporating the vision of services integrated around the needs of patients, which this Government strongly endorse, interestingly it also found that those services were very different from one another. Some were still based in hospitals, some were in the community. Some were a see-and-treat type of service, but others had triage-based systems to refer people on to the most appropriate service. However, as the hon. Gentleman identified, there was still a patchiness to the provision.

The hon. Gentleman touched on the need to integrate services, which the Government are determined to drive forward in order to deliver better results for patients. We need to do that at the same time as acknowledging that people want to be able to exercise the maximum possible control and choice over their treatment. We set out our course clearly last year in the White Paper on the NHS, and just recently in the response to the NHS Future Forum we made it clear that we would be placing explicit duties on clinical commissioning groups to promote integrated services for patients. We will also further strengthen existing duties planned for the NHS commissioning board. We will amend the proposed duty of Monitor to make it clear that its core duty is to promote and protect the interests of patients, rather than to promote competition as an end in itself.

We intend those amendments, taken together, to create a strong incentive for local commissioners to take forward more integrated services, which I think all of us in the House wish to see delivered for people with musculoskeletal disorders and other patients. However, we have to go beyond just health integration and ensure that we achieve integration across health and social care. The hon. Gentleman was right about the concept of “no decision about me, without me”. We need to ensure that it is hard-wired into the way the NHS works.

Nic Dakin: The Minister has spelled out the Government’s position carefully. Will they publish a response to the Public Accounts Committee’s report, which responded to the National Audit Office, in taking forward the matter of musculoskeletal disease?

Paul Burstow: As ever, there is a clear obligation on us to respond to reports and recommendations of the Public Accounts Committee, which we happily fulfil. I am sure that we will do that if we have not already done so, and I am grateful to the hon. Gentleman for asking.

I turn to the specific issue of outcomes. The Government believe that a focus on outcomes is key to how we can drive improvements in the NHS. It is also how we can hold the NHS to account. That was why we published the NHS outcomes framework, to which the hon. Member for Blackley and Broughton referred, in January. It has five key domains that are populated by measures that will be used to judge outcomes. They are preventing people from dying prematurely; enhancing quality of life for people with long-term conditions; helping people to recover from episodes of ill health or following injury; ensuring that people have a positive experience of care; and treating and caring for people in a safe environment and protecting them from avoidable harm.

The second domain, improving the quality of life of people with long-term conditions, is clearly the most relevant to the debate. It includes an instrument known

4 July 2011 : Column 1347

as EQ-5D, which is to measure people’s quality of life in a number of respects including mobility, pain and the ability to carry out the usual activities of daily living. The inclusion of that measure was the result of feedback from the public consultations last year on the outcomes framework. It is clear from the analysis done by the Department’s economists that almost half the total burden of disease, as measured by that instrument, is due to musculoskeletal disease.

In other words, the inclusion of that instrument in the NHS outcomes framework highlights clearly the importance of musculoskeletal conditions to the population, and why commissioners and clinicians need to focus their efforts on designing and delivering care pathways of the type outlined in the framework in 2006. It shows how that can have a significant impact on the aggregate score in the outcomes framework on enhanced quality of life for people with long-term conditions. It will not be possible to achieve success, as set out in the framework, without making progress in that way. There is a powerful new lever in the system as a consequence of the outcomes framework.

The hon. Gentleman talked about the atlas of variation, which is also a powerful tool for identifying outliers and allowing the appropriate challenge of commissioners

4 July 2011 : Column 1348

and others on the decisions they have made. We intend it to be used by commissioners in that way, to drive improvements in the service.

I welcome the fact that the hon. Gentleman sees quality standards as a useful tool. NICE has already developed a quality standard for osteoarthritis, and we are looking at the scope for the development of a quality standard in pain management. We are about to see a further consultation on a range of subjects for the next batch of clinical quality standards. We have the hon. Gentleman’s suggestions on a musculoskeletal condition standard in mind.

This short but timely debate has highlighted an important area of health policy in which we need significant improvements on the ground. The evidence and clinical advice to provide excellent services is there, but we need clinicians to use their leadership role in the NHS to drive change, and we need to take the opportunities of changes in clinical and commissioning leadership to drive forward those reforms. I shall certainly ensure that the debate is referred to those who need to take such decisions, and I thank the hon. Gentleman for bringing the matter to the House tonight.

Question put and agreed to.

10.41 pm

House adjourned.