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12 October 2018

Sarah Wollaston: no-deal Brexit would be “catastrophic” for the NHS

The chair of the Health Select Committee talks about defending the NHS from “the awkward corner” and not toeing the party line. 

By Will Dunn

Shortly before the 2010 general election the candidate for Totnes, Sarah Wollaston – a local GP for whom the election would be her first – was invited to meet Patrick McLoughlin, then the party’s Chief Whip. “He asked me what I would like to do if I was elected,” Wollaston remembers. “I said I would like to be on the Health Select Committee. And he looked at me and said, ‘why would we want a doctor on the Health Select Committee?’”

A quick audit of the Department of Health suggests this attitude prevails today. Not one of the six ministers in the Department of Health holds a degree in medicine, any related science, or in fact any science at all. No current health minister has worked in the NHS. 

By the time Wollaston joined the Conservative Party, she had worked in the NHS for 20 years. “I’d always been politically interested,” she remembers, “but as a junior doctor, I was working, sometimes, 120-hour weeks, which left no time to be politically involved, and then I had a young family. I thought that politics was something I would never have an opportunity to do.”

Then, one afternoon in May 2009, Wollaston was driving when she heard Anthony Steen, the MP for Totnes, telling the World at One why he had spent more than £87,000 of taxpayers’ money on the garden of his second home. “I’ve got a very, very large house,” explained Steen. “Some people say it looks like Balmoral… it does me nicely.” As Steen asked “what right” a “jealous” public had to know what he’d spent their money on, Wollaston sensed the political landscape changing quickly. 

Two months later, Wollaston was one of three people running in the UK’s first “open primary” election, in which all voters in the constituency were given a say in who would replace Steen as the Conservative candidate. The other two candidates, a mayor and a council leader, were local career politicians. The local party presented Wollaston with a pre-written election leaflet but, in the first of a series of respectful disagreements, “I said, ‘no, I’ll write it myself’. In retrospect it probably looked more like an NHS vaccination leaflet.”

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This, it turned out, was a winning strategy. YouGov data shows that the NHS was five times as important to voters as Europe in 2010 (those were the days) and almost twice as important as education. And with the expenses scandal still fresh, the people of Totnes wanted anything but another professional politician. “I was very upfront in my election leaflet that I didn’t have any political experience,” remembers Wollaston. “I think that was actually an advantage.”

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Wollaston won the primary and, the following year, doubled the Conservative majority in the seat. But while the people of Totnes welcomed a non-politician, politicians themselves were another matter. “You arrive,” says Wollaston, “and you’re expected to immediately toe a party line. When you dissent, that is seen as you being unhelpful. And once you’re put into the awkward corner, it’s very difficult to be seen as anything other than awkward.”

Wollaston had become an MP to make improved, “evidence-led” health policy. “I had strong disagreements with Andrew Lansley, and I wanted to be free to say that.” But in Westminster, the clinical perspective she offered was “positively unwelcome”. 

The party tried one more tactic to keep Wollaston’s criticisms quiet: they offered her a job, as a parliamentary private secretary (PPS), one of the most common routes by which MPs progress towards ministerial positions. Having read the Ministerial Code, she was “not tempted at all” to accept, thanks to section 3, part 9: No Parliamentary Private Secretary who votes against the government can retain his or her position.

Wollaston says the PPS position is a popular way to move MPs who are “a little bit awkward” into “the vacuum of silence”. She declined, and in a move that must have left Tory whips spluttering, wrote an opinion piece in the Guardian criticising the “creeping patronage” of the system. “It was made very clear to me,” she recalls, “that I wouldn’t be asked again.”

Instead, Wollaston chose “the select committee route” to influencing her chosen area of policy, joining the Health Select Committee in 2010 and being elected as the Committee’s chair in 2014. She was re-elected in 2015 and again last year, when she ran unopposed. 

The funding problem

Wollaston clearly prefers the even-tempered committee environment to what she calls the “yah-boo horror” of the Commons. Matt Hancock, on the other hand, might have swapped a few minutes of being yelled at by his fellow MPs for the more than two hours of quiet but insistent interrogation he

faced from the Health Select Committee, as Wollaston and her colleagues questioned how the new Health Secretary’s plans for a modernised NHS would be carried out and paid for. 

“There’s a long list of what they want to do. I know £20.5bn is a vast amount of money,” says Wollaston of the so-called “Brexit dividend” that the Prime Minster has said the NHS will receive from 2023. “But when you consider the backlog, and what it doesn’t cover – it doesn’t cover social care, it doesn’t cover public health. Those will have huge impacts on costs in the health service.”

NHS funding is now in a vicious cycle. There is no money for public health, prevention, social care or mental health, because every spare penny is spent propping up the more urgent needs of ambulances, hospitals, surgery and medication. But the fact that money isn’t being spent on public health, mental health and prevention also means more people end up in hospital, which puts more pressure on acute services, which means there is even less money for social care. 

Wollaston says this has applied “as long as I’ve been in medicine, and in politics… almost every time, the cycle repeats itself, and the money is hoovered up into the acute sector. Money heads into these acute budgets, and mental health and primary care slip further and further behind. We really can’t afford to let that happen again, this time around.” 

One example of this cycle can be found in the way the NHS treats cancer. “In this country,” Wollaston points out, “people are more likely to present with cancer in an A&E department than at their GP practice.” By the time someone presents at A&E with “later complications, symptoms that are severe enough to take you to an A&E department… you’re diagnosing too late.” As a doctor, she says, “you often hear people say ‘I’m sorry to waste your time’ – we need to change that culture.”

But that culture is expensive and difficult to change. And because people already present too late with their symptoms, the money that might have been spent on public awareness campaigns and earlier diagnosis has to be spent in hospitals, now. In 2015, a study by Macmillan found that cancer survival rates in the UK were a decade or more behind comparable European countries. 

An unequal crisis

The distribution of public health problems is not equal. Many patients face a “postcode lottery” in the treatment they receive, but for Wollaston, the most worrying health inequalities are between people on different levels of income, particularly in early life. Childhood obesity is a timebomb that will detonate mainly on the poor. The gap between the children of affluent and disadvantaged families, she says, “gets wider every year. The more advantaged you are, the more the obesity issue declines. You can put a ruler on it.”

It’s for this reason that she calls the sugar tax “a big win, particularly if they use the money from it to fund things like children’s playgrounds,” and supports the government announcement, on the day we meet, of a public consultation on banning the sale of energy drinks to children. A single 500ml can of Monster, one of the most popular brands among children, contains 25 per cent more than the maximum amount of “free sugars” the NHS says a 7-10 year old can safely consume in a day. “Children don’t need energy drinks,” Wollaston says bluntly, “and particularly not those stuffed full of caffeine as well. People will feel that it’s the nanny state,” she concedes, but “health inequality in children has such serious implications for their entire life course, that it does justify taking decisions that people won’t agree with.”

Talk of inequality from a politician whose party has imposed almost a decade of austerity on the country may seem disingenuous. When Wollaston entered parliament in 2010 the Trussel Trust, the UK’s largest network of food banks, handed out 41,000 food packs. By 2017, this number had risen to 1.2m. Over the same period, the number of people on zero-hours contracts more than quadrupled and more than 500 libraries closed. Last year, a study by the London School of Economics found that in areas of the UK most affected by austerity, suicide rates had risen by 20 per cent, and that the effect of austerity on social care for the elderly had led to the largest rise in the mortality rate for half a century. How does she reconcile the evidence of harm and inequality austerity created with her desire for greater health equality and a stronger NHS? 

Wollaston maintains that “it really was necessary that we got a grip” on the economy in 2010, but she says too that a turning point has been reached. “The elastic,” she says, “is stretched to the limit. You have to look at the evidence, and to my mind, local authorities now need to have a relaxation of the austerity they’ve had, in order for them to be able to contain future costs. Look at what’s happened to prison services – we cut too far, and now it’s costing a lot more. The public doesn’t want to see these important public services stretched to the extent that they are.”

Informed consent

The single clearest example of Wollaston’s “evidence-led” politics has been her position on Brexit. She began as what she calls a “Eurosceptic soft-Leaver” but listened to evidence from across the NHS and the wider health system until, uniquely, she changed her mind. 

Wollaston says that while she initially supported the Leave campaign, “I wouldn’t get on their bus”; again, she offered helpful criticism, and again, it wasn’t welcome. Of the infamous £350m claim for NHS funding, Wollaston says she “spent some time trying to persuade them to change it, and very senior people within the Vote Leave campaign kept saying to me ‘it doesn’t matter… people will just remember the big number.’ They knew, absolutely, that it was the wrong number. They didn’t care.”

At the same time, however, the Health Select Committee was taking evidence. “I can’t think of anyone who came forward and said that this was going to be a great opportunity… researchers, patient groups, the ‘qualified persons’ who do batch testing… a nurse from Spain, who had worked here for ten years, almost in tears, talking about how she no longer felt welcome. It left me feeling ashamed.”

As the scale of the supply problem became apparent, Wollaston was reminded of her time as a GP. “Every so often, all hell would break loose, because there would be a fire in a warehouse somewhere, or a batch would be withdrawn, and there would be a supply issue. You would sometimes waste half a day trying to track down where you could find one particular medicine. I can see that happening on a grand scale, if we have no deal and no transition. And I think that would be an absolute turning point. If people found they couldn’t get medicines or diagnostic tests, there would be an extraordinary level of anger.”

The dangerous lie currently emanating “from Rees-Mogg and Boris”, she says, “is that this is about tariffs. NHS issues have almost nothing to do with WTO rules. It’s about complex, decades-long integration from the research bench to the product arriving on your pharmacy shelf. Take insulin, for example, or medical radio isotopes – 700,000 diagnostic tests a year rely upon those. They can’t be stockpiled, and none of them are manufactured here. It’s not about WTO rules. It’s about how we physically get them in, if we’ve got friction at the borders.”

Contingency plans are being made to try to cope with the sudden change in the British border, including stockpiling of medicines and importing them via air freight. “How much is that going to cost,” asks Wollaston, “and who’s going to pay? Ultimately, it will be reflected in charges to hospitals.”

At the same time, she predicts, hospitals will be trying to cope with a huge reduction in staff. While Wollaston acknowledges the reassurances the government has offered the 65,000 people from the EU currently working in the NHS, the referendum result dealt a huge blow to recruitment. In 2015, the UK had a net gain of 3,000 nurses from the EU, but by 2017 this had dropped to a net loss of more than 1,000 nurses per year. The slump exactly coincides with the referendum and is not mirrored by non-EU countries. With domestic input into the nursing workforce also declining by more than 1,000 per year overall, Britain faces a catastrophic shortage of nurses. This is another self-reinforcing cycle; as the NHS spends heavily on agency nurses to cover the shortfall (the temporary nursing bill for 2017 was £1.46bn), there will be no money for long-term solutions. 

As a doctor, Wollaston has a long acquaintance with the principle of “informed consent”. Any patient about to undergo an operation, she says, would “expect to know what the operation is going to be, the risks and benefits. What you wouldn’t do is consent someone to an operation two years in advance, without them knowing what the operation involved”.

This, she says, is why she has joined the campaign for a second referendum. “If, in two years’ time, there are serious unintended consequences, I don’t want people writing to me asking ‘what did you do?’ I want to be able to point to the things that I did try to do. Not because I want to block Brexit, but because I want to check we’re prepared. To proceed without informed consent would be a catastrophic mistake.”

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