From GP to MP: How to lose friends but try to influence people
Sarah Wollaston, MP for Totnes, Devon, spoke at the 2018 HealthWatch Annual General Meeting on Wednesday 31 October 2018. It had already been an eventful week. Our AGM took place the day after the House of Lords Science and Technology Committee had published the results of their inquiry: Research integrity: clinical trials transparency. Earlier that week, the Chancellor of the Exchequer had presented his 2018 Budget to Parliament. The following text is adapted from her presentation and the question and answer session that followed.
There is a real challenge ahead of us about how we present evidence within our politics, and value evidence. Something that I have noticed in my role chairing the Health and Social Care Select Committee, is how within politics you have to find a balance between the idea that everything should be based on popular demand, and presenting the evidence.
Nowhere is this more evident than in public health. When you go out and consult the public about where they would like to spend investment within the health service, public health is always at the bottom of the list. Yet the evidence shows that if you really want to tackle health inequalities and make a difference, that’s where the money should be going. But I’m afraid it always tends to get deprioritized, as we’ve seen over the last 24 hours, as we unpick what the Budget numbers mean. There’s been a bit of smoke and mirrors, in that some of the funding for NHS England is actually going to come out of public health budgets, which I think is a tragedy because it’s through public health that we’re going to really tackle the issues that governments all pay lip service to, about burning injustices, and reducing inequalities.
My point is that you’ve got to look at the evidence about how you’re going to achieve those aims. And in a week when we’ve got the Chancellor talking about how he wants to reduce the tragedy of lives lost to suicide, while we would all agree that’s extraordinarily important, you shouldn’t at the same time delay implementing evidence based policy around reducing gambling addiction because you’re caving into industry lobbying that is fighting the introduction of the maximum £2 fixed-odds stake for betting terminals. We absolutely need people in Parliament to make the case relentlessly for evidence and how you actually make a difference, rather than what the lobbying industry says makes a difference, or what is popular. And right now we are in the midst of the fight of our lives, against the “Trumpification” of politics, the downgrading of evidence, the ridiculing of any expertise, and I think nothing has exemplified that more than the referendum campaign and the way it was conducted.
That’s my job in parliament, to be rattling a few cages and to keep doing that! But there’s something you in HealthWatch can do. Never underestimate the effect of going to see your MP in person. If you write an e-mail, send a postcard, or re-tweet, you’re not actually going to shift the dial. And it doesn’t help for us to be talking to people who already agree with us. What we need to be doing is talking to the people that don’t agree with us, and having somebody actually turn up in your constituency surgery makes an MP think, I have to look at this. Tomorrow I’m launching our committee’s report into prison health care, and that for me came out of a grandmother coming to talk to me in tears about the death of her grandson in prison, and the authorities’ failure to follow up on reports that had been coming out from inspectors about circumstances that had led to that avoidable tragedy.
So, going to see your MP really has an impact. I hear time and again from colleagues that it is the person who takes the trouble to make that appointment that makes the lasting impression. Encourage your members to get out and talk to your MPs and talk to them about the importance of evidence and science.
Q: The Science & Technology Committee have done two reports on research integrity, but if you read them, nearly all the concerns are about medical research - I gave evidence to that committee, and it’s entirely about medical research. Should the Science and Technology Committee co-ordinate efforts more with other areas of research?
SW: Increasingly committees are doing joint enquiries where something is of mutual interest, for example, the report we recently published on anti-microbial resistance follows up on many of the points from previous committees. So we do try.
Q: At a meeting today at the Royal Society we heard about TARGIT (TARGIT IORT is targeted intraoperative radiotherapy treatment for breast cancer, see ), a well-researched innovation that has been reviewed and recommended by NICE, that would save NHS money, and which offers huge benefits to patients, yet has not been adopted by Public Health England. How can we free NICE so that their recommended good practice actually gets implemented?
SW: It’s a huge challenge in many areas of the NHS where you see good evidence based practice and it’s not being effectively rolled out. I would advise you (1) to go to your MP and try and get them to stand up and talk about it in Parliament; (2) there are all party parliamentary groups within parliament, for example there is one on breast cancer specifically, you could raise it with them; (3) although the Health and Social Care Select Committee tends not to look at single disease issues, we do hold regular accountability session with bodies like NICE, so there’s the possibility we could use a session to raise such an issue and ask whether we could help if their recommendations aren’t being implemented. You are very welcome to write to me, and although we wouldn’t hold a specific enquiry I might be able to raise in correspondence or queries issues that people raise with me.
Q: Do you have any thoughts on the matter of a people’s vote?
SW: Who would want to be wheeled into the operating theatre on the basis of a consent form we had signed two years ago, or in the case of younger voters, one their parents signed, and if you didn’t even know which operation you were going to have! And the surgeons are still arguing amongst themselves, and there is no majority for anything. The implications of Brexit will last for generations.
Q: At our recent HealthWatch symposium on debunking false health information, one of the issues was the level of confidence people have in their source of information – how do you and your committee decide whether a group or individual presenting you with evidence is credible or not?
SW: There are some markers for not being credible, for example, people who write to you with a sample size of ten to support a view that something is important should be implemented straight away. Essentially in an inquiry we publish everything, but we choose the witnesses we then hear from selectively. Unfortunately there are always more fantastically credible witnesses we’d like to hear from than we have time, so we have to prioritize based on what they write to us in their evidence. And we also try and get out of London and meet as many people from different areas as we can.
Q: The Science and Technology Committee report on clinical trials reported yesterday on Research Integrity; the govt now has two months to respond to this report, is there anything we can do to tip the scales towards a favourable response? Secondly, looking at the various NHS foundation trusts that sponsor clinical trials, the reporting rates are bad, and there’s now going to be a lot of inefficiency as each individual trust tries to figure out how to improve their clinical trial reporting – how can we ensure economies of scale to do this? Who is responsible in each trust and can they nominate someone to do it?
SW: Some people have got considerable expertise already – it is encouraging that Matt Hancock has appointed Ben Goldacre to be chair of his advisory panel, who has done fantastic work in this area and is not afraid to hold Public Health England to account. But it is not easy to identify who is responsible. When asking government to respond to a report, you can put in a recommendation to the government to identify who is responsible and who to hold to account.
Q: Part of the problem is that the Science and Technology Committee have put this back to UKRIO (the UK Research Integrity Office), the UK universities, who have consistently failed to self-regulate, and who have a concordat that only 30% of them adhere to, and none of the hospitals where human research is conducted are part of the concordat, so the committee has come up with a solution that has failed in the past and doesn’t anyway apply to medicine.
SW: It would be worth speaking to Norman Lamb MP about that. (Questioner's reply: “I have!”)
Q: Would you agree to introducing clear guidelines on minimum staffing levels for the NHS?
SW: I would agree that in an ideal world we would have minimum staffing levels, but the trouble is, there is overall a workforce staffing shortfall. If you were to impose a minimum staffing level on wards, if there was limited flexibility to move staff around you might find unintended consequences, such as you might not be able to transfer people out of ambulances into the emergency department, and end up with people being cared for in corridors or in ambulances. The workforce challenge across the NHS and across social care is extraordinary. In my area, there is a 8% vacancy rate in social care, and 7% of the workforce are from the EU, of the nursing workforce in Devon it is nearly 30%. What is going to happen if we make it much more difficult to recruit and people don’t feel welcome here?
Q: Granted, you can’t say, if you’re understaffed you’ve got to shut the doors and stop. But are there halfway houses? Supposing an acute hospital trust had to be on amber, so that if something goes wrong we can’t blame the person on the coalface?
SW: People make comparisons with airline safety but this is different in that you can ground an aircraft, but you can’t close a hospital - although there is a precedent even for that in critical areas - or you end up with people being cared for in sub-optimal conditions. I agree with the suggestion of a very clear amber alert where a hospital is understaffed, though if we imposed such measures too rigidly I would have concerns.
Q: Mass cancer screening – why don’t we have proper standards of informed consent in cancer screening? And how can we improve decision-making so that we can stop doing something that doesn’t work? On screening, there are also concerns over vested interests and charities running awareness campaigns that create fear and havoc and end up sending healthy people to add to their GPs workload?
SW: Margaret McCartney has done some amazing work highlighting this, and my congratulations to her for highlighting the losses and harms resulting from the rise of the private screening industry, with the costs falling back to the NHS, and harms to people who are persuaded to have these tests. Just yesterday I asked the Care Quality Commission what they are doing to ensure these clinics are operating in an ethical manner. Certainly there’s more that can be done. Drop me a line.
Q: Do you feel reassured about the provisions for medicines supply after we leave the EU?
SW: There has been a phenomenal amount of money diverted into contingency planning, which is going to feed back into the cost of drugs and healthcare. When you look at the amount of time it can sometimes take even now to source medicines – for example, my daughter is a junior doctor in pediatrics at the moment, and she recently spent two hours trying to source an epipen for a patient - I can’t begin to imagine what it will be like if these problems occur on an industrial scale after we leave the EU. The public is used to being able to take a prescription to the pharmacy and expect the medicine to be there. What is going to happen when the medicine is not there and no-one can find it for you? When my constituents get cross with me for banging on about Brexit, I say to them, when we are three months on after a hard Brexit, and these issues are still ongoing, I want to be able to look you in the eye and say that I tried my best to present the evidence of what would happen as a result. I hope these problems won’t happen, I hope I’m wrong, but even if I am, it’s been a most tragic waste of resources.
Q: Has the NHS become a religion? We are spending £150bn a year on the NHS alone, about a quarter of all public spending, yet it’s nothing like enough? Where is this going?
SW: There’s a huge success story we shouldn’t forget - we’re helping people live longer. Yes, we’re living with more years of ill health and multiple morbidity, so it’s a success story not a disaster. But did we adequately plan for this? For generations people have failed to take the long view and look at what longer life means for the health workforce, and people’s readiness to put money in. The trouble is, we promised people they can have all this for free. This week’s budget was an opportunity to say to people, honestly, this extra commitment has to be paid for somehow. But what we’ve seen is talk about Brexit dividends, and giving people a tax cut a year early, rather than being straight with people and saying that if we value our NHS we’re going to have to pay more. When something is a religion, criticism is not very welcome, and you can be vilified for it. We should guard against treating the NHS like a religion, because we should be able to challenge bad practice.
Q: A lot of what I do as a GP only results in marginal gains, we are given the impression we are saving lives, but in practice we are throwing money at the end of life.
SW: The biggest gains in healthcare have resulted from public health measures. If you were going to start somewhere, start with the first 1000 days of life – it is the subject of our current inquiry. Look at education, housing, dealing with poverty, the things that make the biggest difference to health.
Q: How do you cope with being an MP in Totnes?
SW: It is a wonderful and interesting place, but let’s take just one issue, that of vaccination. Totnes has the lowest vaccination rate in Devon, and there is a very strongly held belief by many people in town that homeopathic vaccines are the way to go. There are many children there who have not been vaccinated against anything at all, not even tetanus. This can be a challenge, because some people can become very cross if I point out that some of the claims made against vaccination are untrue, and they may say I have no business to represent Totnes when I do not support the alternative community. But my view is that it is absolutely my job, to speak the truth it as it is. The rise of the anti-vaccination movement and the resulting resurgence of measles is deeply worrying. Fortunately Totnes is much happier about my stance on Brexit.
Based on Sarah Wollaston’s presentation at the HealthWatch 2018 AGM, adapted by Mandy Payne.