Rickets

Tuesday 4th September 2012 Westminster Hall

13:30

[Kate Green (Stretford and Urmston) (Lab)]

I am very pleased to have been given the opportunity of and time for this debate and to introduce it with you in the Chair, Mr Hollobone. I start by acknowledging two Manchester GPs, Dr Hans-Christian Raabe and Dr Avril Danczak, who came to see me some months ago to draw my attention to the shocking rise in the incidence of rickets in this country over the past 15 years. A written answer that I received on 9 November 2011 contained figures showing that the number of reported cases of rickets had risen from 183 in 1995-96 to 762 in 2010-11. Earlier this year, it was reported that the chief medical officers of the UK had contacted health professionals to highlight the need for vitamin D supplements for at-risk groups. Therefore, the issue is clearly one of concern. I welcome the steps that the Government have taken so far to deal with it, but more needs to be done.

Rickets is a disease that affects the growing of bone in children and is associated with moderate vitamin D insufficiency. It is mainly characterised by deformed bones, bone pain, convulsions and delayed development, particularly in relation to height rather than weight. Current Government guidance is that most people can get all the vitamin D that they need by eating a healthy balanced diet and getting some sun. However, it is not at all clear that that advice is adequate. The national diet and nutrition survey found that 90% of people in the UK do not get enough vitamin D from their diets, and there is widespread confusion in the public mind about what constitutes an appropriate amount of exposure to sunshine.

Certain groups have particularly high levels of vitamin D deficiency. They include pregnant and breastfeeding women and their babies, young children, elderly people, those who are not exposed to much sun—perhaps because they cannot get out of the house or because they cover up their skin for cultural reasons—and people with darker skin pigmentations, such as those of African, African-Caribbean or Asian origin. Levels of air pollution may also have an impact on sunshine exposure levels, and there is certainly a gradient of rising incidence of vitamin D deficiency as we move north across the UK, so it is clearly a concern in the north-west region, where my constituency is located. When one member of a family has a vitamin D deficiency, it is also likely to be replicated among siblings and children.

It is therefore clear that steps need to be taken to deal with vitamin D deficiency in quite large sections of the population. I am pleased that the Scientific Advisory Committee on Nutrition is examining the issue, but it is not due to report until 2014, and it is likely that any recommendations made by the committee could take time to implement in any event. However, there are things that can and should be done now, not least in terms of informing and educating the public and health professionals.

A recent study by the clinical effectiveness unit at Stockport NHS Foundation Trust highlighted a quite surprising lack of awareness among health professionals about vitamin D. That study, across eight acute and six primary care trusts in the north-west, found quite poor knowledge among midwives and health visitors surveyed. Only 24% of health visitors and just 11% of midwives reported having had training in vitamin D supplementation. As a result, they felt less confident in discussing vitamin D with pregnant women and mothers, vitamin D was poorly promoted at the booking of appointments and 90% of the women were not provided with information about vitamin D. However, the study found that where trusts had good policies or expert personnel in place, staff reported greater confidence in discussing vitamin D and more women received verbal and written advice.

Last year, my hon. Friend the Member for Bolton South East (Yasmin Qureshi) hosted an event in Parliament, in conjunction with the Proprietary Association of Great Britain—the UK trade association for manufacturers of over-the-counter medicines and food supplements—at which it was suggested that doctors, nurses and pharmacists receive very little nutritional training at undergraduate level and that there is no obligation for health professionals to undertake such training once in practice. Therefore, I would like first to ask the Minister to comment on the steps that the Government are taking or planning to improve training, awareness and knowledge among health care professionals. I would also like to ask what steps are being taken to raise awareness among the wider pool of professionals working with families and children, and what discussions the Minister and colleagues in the Department may have had with Ministers in the Department for Education to ensure that staff in schools, Sure Start workers, child care professionals and so on are aware of the importance of vitamin D.

There are also concerns about financial incentives. I have looked at the quality and outcomes framework for GPs, and there is a lack of a clear financial incentive for GPs to address their patients’ nutritional needs. Will the Minister say what steps are being taken to develop the quality and outcomes framework to focus more GP attention on nutrition and vitamin D intake, and how she expects that that framework will be kept under review?

I come now to the question of vitamin supplements, which the Department of Health recommends for at-risk groups—the groups I mentioned in my opening remarks—and which are available free of charge to certain low-income families via the Healthy Start programme. However, that targeted approach has resulted in only very limited uptake, which unpublished PCT data suggest could be as low as 2% to 4%. Clearly, many at-risk families are missing out on the recommended vitamin D supplements; and although some families may obtain supplements, from over-the-counter sources, that can be expensive and the dosage may be inappropriate. I would be interested in the Government’s attitude to allowing food supplement manufacturers greater freedom to develop and market a wider range of vitamin D products, targeted at different population groups. I would also welcome the Minister’s view on how the European Food Safety Authority might make it easier for manufacturers to make legitimate claims about the role of vitamin D in good bone health.

I particularly hope that the Minister will consider a report published online, on 21 August, by the British Medical Journal that considers an initiative by the Heart of Birmingham PCT to provide universal vitamin D supplementation to all children from the age of two weeks to five years and to all pregnant and breastfeeding women. That provision of supplements was supported by a programme of continuing professional education of health staff, including GPs, health visitors, midwives, pharmacists, paediatricians and obstetricians and by a public communications campaign. In that initiative, uptake of vitamin D supplements rose year on year to reach 17% among children and pregnant women. That was still low, but considerably higher than the 2% to 4% achieved under Healthy Start. Public awareness of vitamin D also rose from just over 60% to nearly 90%, and a 59% fall was recorded in the number of cases of vitamin D deficiency.

Clearly, there are some important lessons to be learned from the Birmingham initiative. Although some problems were experienced with distribution through the NHS supply chain, limited opening hours at pharmacies and so on, and with the availability of trained staff, the initiative was very successful overall in reaching a considerable number of families who might be at particular risk of vitamin D deficiency by virtue of ethnicity, skin pigmentation or lifestyle, but would not be eligible for free supplements.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Lady on bringing this matter to Westminster Hall today. I am of an age group, and others in the House may be of a similar age, that can remember that when we went out to play at school lunchtime, the milk was on the table when we came in. Is there a role for the Department of Health in the education of children to ensure that children’s health is better monitored and supervised?

[Kate Green]

I absolutely agree with the hon. Gentleman. Health professionals, and other professionals from across different disciplines, have pointed to the absence of a holistic approach that draws different practitioners and professionals together to ensure that the message is promoted and the education of children and families is pursued coherently.

The absence of trained staff was certainly seen as a factor that limited the effectiveness of the Birmingham initiative, but overall it was very successful in improving vitamin D uptake in families who would have been at risk. I am keen to invite the Minister to look carefully at the Birmingham experience. Is she willing to analyse the costs and benefits of a universal approach based on the study’s findings?

On food fortification, relatively few foods are naturally rich in vitamin D, and consumption of many of those that are, such as full-fat dairy products, eggs and oily fish, has fallen in recent years. Yet in the UK, we fortify relatively few foods, such as margarine, some processed cheeses and breakfast cereals. We do not fortify milk, which has been fortified in Canada and the US for many years. Finland, Jordan and the Irish Republic have all taken recent steps to introduce food fortification. Will the Minister indicate the Government’s attitude to statutory food fortification? There seems to be scope for a more robust approach. Can she confirm whether the work of the Scientific Advisory Committee on Nutrition will look at the experience of other countries? Will the committee’s report reflect an analysis of the effectiveness of food fortification measures in those countries?

Finally, there appears to be scope to make greater use of the public health outcomes framework, to focus attention on vitamin D. I looked at the framework, and, with the exception of some quite vague indicators on diet and hip fractures, there appears to be nothing specific to highlight the need for action to tackle vitamin D deficiency and its consequences, including the risk of rickets. I welcome the Government’s focus on public health, but we must ensure that the framework and the new health structures being put in place more widely achieve the best possible outcomes.

This is a crucial and, I have to say, challenging time of transition. We are settling into the new public health infrastructure against a backdrop of far-reaching changes in the NHS more widely. Although I appreciate that the public health outcomes framework will be kept under regular review, I would like very specific and early attention to be given to the issue in the framework and by the new health and wellbeing boards. I would welcome the Minister’s comments on that.

[Jim Shannon]

I thank the hon. Lady for giving way again. She is being very gracious. Is she aware of the statistics and figures that show a greater problem in the United Kingdom—England, Wales, Scotland and Northern Ireland—with not only rickets, but osteoporosis, from the lack of vitamin D? Is there a need not only for a pilot programme, such as the one she mentioned in Birmingham, but for a programme for the whole UK, working with all the regions?

[Kate Green]

The hon. Gentleman is quite right. The impact of vitamin D deficiency is felt in not only rickets and diseases in children, but osteoporosis and other diseases. Vitamin D deficiency inhibits the absorption of calcium, for example, which is important for bone health and growth.

Professionals have identified the lack of joined-up advice—for example, telling a woman recovering from a cancer operation and having chemotherapy that there could be an impact on her bone health and the steps that she could take to address it. It is right that professionals have expressed an interest in the development of a strategic approach, both geographically and across health conditions. Perhaps the Minister will comment on how the Government might react to that.

Rickets is a largely preventable disease that many of us thought had been left firmly in the past. Its resurgence is not in question, yet the distress and pain it causes are preventable, and we know what steps we need to take. What is more, the solutions are mainly systemic—within the control of public policy and health care practice. Although I acknowledge that some gaps in the evidence remain, the importance of vitamin D for at-risk groups—children, pregnant women and mothers—has been understood for many decades, as has the need for effective supplementation where intake is inadequate. There is therefore no need to delay working on and developing appropriate systems and a programme of public and professional education to maximise vitamin D intake. I hope that today’s debate raises public and professional awareness of the issue.

13:47

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to serve under your chairmanship this afternoon, Mr Hollobone. I congratulate the hon. Member for Stretford and Urmston (Kate Green) on securing the debate. She is right that these are important opportunities to raise awareness. Although we sometimes underestimate our impact, such debates are sometimes picked up by the media, and anything is useful.

As the hon. Lady eloquently set out, with vitamin D, we are talking about children, strong and healthy bones, and bone health generally. Often, rickets occurs because a child is born without enough vitamin D due to the mother’s deficiency in pregnancy. Alternatively, it can be a post-natal condition due to a poor diet or lack of sun exposure. That is why successive Governments have long recommended that young children and pregnant and breastfeeding women take a daily supplement of vitamin D.

As the hon. Lady says, most people would imagine that rickets is something from the Victorian era. The incidence of rickets fell dramatically in the 1920s, and, in the past, several public health policies have helped to reduce its incidence further. The law now requires the addition of vitamin D to all infant formula, and vitamin supplements containing vitamin D are made available for pregnant women free of charge and to young children from low-income families via the Healthy Start scheme.

Unfortunately, we do not have good data on the national prevalence of rickets in the UK. The hon. Lady has been provided with data on episodes of rickets recorded by hospitals in England, but sometimes a problem when we produce data is that they are about episodes, not people. I believe that she was given that information through an answer to a parliamentary question. The figures appear to be slightly higher, and looking at the percentage increases, the statistics are startling, but episode data do not represent the number of patients, because a person may be admitted more than once in a year. The number of patients diagnosed with rickets is therefore a better measure, and that has increased from 134 to 395 in 2010-11. It is important to consider those figures in the context of increased population size and improved reporting and recording. Those numbers appear quite low when compared with other diseases, but rickets is still a problem, particularly since hospital episode statistics do not show the number of children who may have been treated as outpatients or those diagnosed by a GP. We are aware that over the past few years there have been several reports of clinically apparent vitamin D deficiency and rickets in children from doctors in Manchester, London, Glasgow and Burnley. That is not an exhaustive list; there will be other places.

As the hon. Lady pointed out, the tragedy is that rickets is preventable. That is why it is so important that at-risk groups such as pregnant women, babies and toddlers take those vitamin D supplements. As she also rightly pointed out, that is particularly important for women of south Asian, African, Caribbean or middle eastern family origin, because people with darker skin do not produce as much vitamin D in response to sunlight. It is also important for women who are not exposed to much sunlight, either because they cover their skin for cultural reasons or because they do not spend much time outdoors. The hon. Lady referred to older people who might, due to immobility problems, not be able to get out.

Our national infant feeding survey tells us that about half of mothers across the UK reported taking some form of vitamin or mineral supplement other than folic acid during their pregnancy. On the one hand, that is encouraging but on the other it means that 50% do not. There is a problem and clearly more needs to be done.

[Kate Green]

The Minister is right that we should worry about the 50% that may not be taking the supplements that they may need, but another concern is the lack of clarity among pregnant women and others about what supplements they should be taking and in what dose.

[Anne Milton]

The hon. Lady is absolutely right. A huge amount of data and confusing information are given to women. That is one thing we need to tackle in our public health changes. She also talked about joining up services and having a strategic approach. Given the many different information sources, particularly on the internet and some very reputable websites, it is hard for women to know exactly what to do.

The 2005 infant feeding survey found that only 7% of infants aged eight to 10 months were given any type of vitamin supplement. The hon. Lady talked about raising awareness, which is indeed what we need to do. We need to ensure that GPs, midwives, health visitors and other health professionals—she talked about schools—are fully aware of the need for those groups of the population to take vitamin D supplements. That is why in February all four of the UK’s chief medical officers wrote to GPs, health visitors, practice nurses and community pharmacists to reiterate the Department of Health’s recommendations. I would put particular emphasis on the role that pharmacists can play in informing the public, as they have quite a lot of contact.

The chief nursing officer for England also highlighted the issue in her February newsletter bulletin for all nurses and midwives in England. The Department of Health is liaising with the Royal College of Midwives to explore how we can work with them to spread advice further. It was also encouraging to hear that the Royal College of Obstetricians and Gynaecologists welcomed the CMOs’ letter and that it, too, promotes the importance of daily vitamin D supplement during pregnancy.

The National Institute for Clinical Excellence’s public health guidance on maternal and child nutrition, and clinical guidance on antenatal care—quite a mouthful—also support the Department of Health’s advice on vitamin D, reiterating the importance of consistent messages. We have also asked NICE to develop public health guidance on how to improve implementation of the advice on vitamin D and on safe sunlight exposure for the UK.

As the hon. Lady alluded to, there have been issues concerning the availability of prescribable vitamin D preparations. The NHS London Medicines Information Service has produced a document that lists the preparations with appropriate levels of vitamin D for different age groups, so health professionals know exactly what to prescribe. That list was sent to pharmacy organisations in March.

Healthy Start vitamins are not available on prescription, but the Department encourages NHS organisations either to sell the vitamins or consider supplying them free of charge to target groups who are not eligible for the scheme. I was pleased to see the positive effect of the CMOs’ letter—I do not know whether the hon. Lady is aware of this—on the number of orders placed. Orders for the children’s drops have increased from around 72,000 bottles in quarter 4 of 2010-11 to more than 97,000 bottles in quarter 4 of 2011-12. That is a significant increase, which demonstrates, although we are starting from a low base, that we can have an impact. Similarly, orders for the women’s tablets have increased from around 58,000 to more than 105,000 in the same period—an 80% increase.

We all need to keep up our efforts. The hon. Lady raised the issue of awareness and training, which, I suggest, should apply to all the professions. There would be no harm in the person who takes blood from a pregnant woman also reiterating some of the simple advice.

The Department of Health has produced a leaflet entitled “Vitamin supplements and you” as part of its Start4Life campaign. That contains up-to-date advice on the importance of vitamin D. Health care and child care professionals can download it. On top of that, in May we launched what I think will be one of the most significant initiatives, the new NHS information service for parents. Through regular e-mails, online videos and texts, it gives parents information and advice as they progress through their pregnancy and beyond. The service is very new. About 47,000 parents have already signed up, and I would urge those who are reading or listening to this debate to encourage the people they know to do so, too. Members of this House can have a significant impact by raising the issue in their local press and getting people to sign up. This is about trusted advice from the Department, cutting across a lot of the confusion.

We have also asked the Scientific Advisory Committee on Nutrition to undertake a comprehensive review of the scientific evidence on vitamin D and health. That will include a review of the existing dietary recommendations on vitamin D for all population groups, as well as looking at the options to improve the amount of vitamin D we get as a population. The risk assessment is due to be completed in 2014. In the meantime, it is important to ensure that the existing recommendations are put into practice, which is what this debate is all about.

The hon. Lady raised a number of other issues. I probably cannot give them the time they deserve today but I am happy, if she would like to know more detail, to talk to her on another occasion. We strayed a little into EU legislation—worthy of a three-hour debate—about health claims of vitamin supplements. She also asked about universal access and food fortification. Some of those issues are quite tricky. One needs to be sure that what is done has the desired impact. There is also quite a lot of resistance to fortification of food from another quarter.

In the final minutes, I would mention the public health outcomes framework, which she mentioned, the health and wellbeing boards and the opportunities that lie ahead. To some extent we now have an opportunity we have not had before, with public health moving into local authorities. Local authorities will have a remit to do a lot more work in this area. The hon. Lady mentioned schools. I think we will see an opportunity for local areas emerging, particularly when the joint strategic needs assessment reveals some of the issues. There may be opportunities, for example, where there is a high proportion of people who may be at risk from low vitamin D, for local areas to take action. That can be across the board, involving not just GPs and midwives, but schools. We will see changes. We will keep this under review; we know how important it is. The numbers might be relatively small but the increase is significant.

Question put and agreed to.

13:59

Sitting adjourned.