Tobacco and Vapes Bill

Dan Poulter Excerpts

2nd reading
Tuesday 16th April 2024 Commons Chamber

[The Parliamentary Under-Secretary of State for Health and Social Care (Dame Andrea Leadsom)]

I want to start by thanking the many lung cancer and asthma charities, particularly ASH, for their advice, research and support. I personally pay tribute to the chief medical officer for England for his commitment to making the strongest possible case for this life-changing legislation, and to Health Ministers across the UK for their collaboration in what will be a UK-wide solution for future generations.

I was very disappointed with the hon. Member for Ilford North (Wes Streeting), who opened for the Opposition. I have said it before and I will say it again: I like the hon. Gentleman. He once said on air that that was death to his career! Why would he have said that, Madam Deputy Speaker? But I am really disappointed today, because he was not listening. My hon. Friends had some very sensible questions about consultation, and they raised very serious points about flavours for vapes and how they might help adults to quit. He was not listening; he was making party political points. In fact, he barely said anything sensible about the legislation. All he did was talk politics. I appreciate the fact that Labour Members have been whipped to support the Bill. On my side, colleagues are trusted to make their own decisions on something that has always been a matter for a free vote. [Interruption.] He sits there shouting from a sedentary position, political point-scoring yet again.

The hon. Member for Birmingham, Edgbaston (Preet Kaur Gill) raised a very serious question about stop smoking services. I can tell her that the Government have allocated £138 million a year to stop smoking, which is more than doubling. The Government’s commitment to helping adults to stop smoking is absolutely unparalleled.

I thank the hon. Member for East Renfrewshire (Kirsten Oswald) for her support for the Bill, and for the collaborative approach of the Government in Scotland in their work bringing forward this collaboration among all parts of the United Kingdom.

I pay particular tribute to my hon. Friend the Member for Winchester (Steve Brine), the Chair of the Health Committee for his excellent speech and his strong case for long-term policies that will prevent ill health and thereby reduce the pressures on the NHS, which is so important. He asked when we will see the regulations and the consultation on vaping flavours, packaging and location in stores. It is our intention to bring forward that consultation during this Parliament if at all practicable.

I thank my right hon. Friend the Member for Bromsgrove (Sir Sajid Javid) for his tribute to Dr Javed Khan for his excellent report into the terrible trap of addiction to nicotine. My right hon. Friend made the point that it is simply not a free choice, but the total opposite.

I thank the Liberal Democrats and their spokesman, the hon. Member for St Albans (Daisy Cooper), for saying that they will support the Bill on Second Reading. I am not quite sure where they are going on the smoking legislation, but I am grateful for their support on vaping. I hope to be able to reassure them during the passage of the Bill.

The case for the Bill is totally clear: cigarettes are the product that, when used as the manufacturer intends, will go on to kill two thirds of its long-term users. That makes it different from eating at McDonald’s or even drinking—what was it?—a pint of wine, which one of my colleagues was suggesting. It is very, very different. Smoking causes 70% of lung cancer cases. It causes asthma in young people. It causes stillbirths, it causes dementia, disability and early death. I will give way on that cheery note.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I thank the Minister for giving way. I draw the attention of the House to my entry in the Register of Members’ Financial Interests as a practising NHS consultant addiction psychiatrist. Does my right hon. Friend share my concern that what we have heard from the libertarian right today is a false equivalence between alcohol and bad dietary choices, and smoking, and that moderate alcohol and moderate bad eating are very different from moderate smoking, because moderate smoking kills. It means that people live on average 10 years less and it means less healthy lives. Does she agree that this is not about libertarianism but about doing the right thing, protecting public health and protecting the next generation, and that is why we should all support the Bill?

[Dame Andrea Leadsom]

I am grateful to my hon. Friend, who makes such a powerful point and speaks with such authority. Similar points were made by my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson), who as a paediatrician spoke with great expertise on this matter. It is absolutely true: it is a false choice. It is not a freedom of choice; it is a choice to become addicted and that then removes your choice.

Every year, more than 100,000 children aged between 11 and 15 light their first cigarette. What they can look forward to is a life of addiction to nicotine, spending thousands of pounds a year, making perhaps 30 attempts to quit, with all the misery that involves, and then experiencing life-limiting, entirely preventable suffering. Two thirds of them will die before their time. Some 83% of people start smoking before the age of 20, which is why we need to have the guts to create the first smoke-free generation across the United Kingdom, making sure that children turning 15 or younger this year will never be legally sold tobacco. That is the single biggest intervention that we can make to improve our nation’s health. Smoking is responsible for about 80,000 deaths every year, but it would still be worth taking action if the real figure were half that, or even a tenth of it.

There is also a strong economic case for the Bill. Every year, smoking costs our country at least £17 billion, far more than the £10 billion of tax revenue that it draws in. It costs our NHS and social care system £3 billion every year, with someone admitted to hospital with a smoking-related illness almost every minute of every day, and 75,000 GP appointments every week for smoking-related problems. That is a massive and totally preventable waste of resources. For those of us on this side of the House who are trying hard to increase access to the NHS and enable more patients to see their GPs, this is a really good target on which to focus. On the positive side, creating a smoke-free generation could deliver productivity gains of nearly £2 billion within a decade, potentially reaching £16 billion by 2056, improving work prospects, boosting efficiency and driving the economic growth that we need in order to pay for the first-class public services that we all want.

I know that hon. Members who oppose the Bill are doing so with the best of intentions. They argue that adults should be free to make their own decisions, and I get that. What we are urging them to do is make their own free decision to choose to be addicted to nicotine, but that is not in fact a choice, and I urge them to look at the facts. Children start smoking because of peer pressure, and because of persistent marketing telling them that it is cool. I know from experience how hard it is, once hooked, to kick the habit. I took up smoking at the age of 14. My little sister was 12 at the time, and we used to buy 10 No. 6 and a little book of matches and —yes—smoke behind the bicycle shed, and at the bus stop on the way home from school. [Interruption.] Yes, I know: I am outing myself here.

Having taken up smoking at the age of 14, I was smoking 40 a day by the age of 20, and as a 21st birthday present to myself I gave up. But today, 40 years later—I am now 60, so do the maths—with all this talk of smoking, I still feel like a fag sometimes. That is how addictive smoking is. This is not about freedom to choose; it is about freedom from addiction.

There is another angle. Those in the tobacco industry are, of course, issuing dire warnings of unintended consequences from the raising of the age of sale. They say that it will cause an explosion in the black market. That is exactly what they said when the age of sale rose from 16 to 18, but the opposite happened: the number of illicit cigarettes consumed fell by a quarter, and at the same time smoking rates among 16 and 17-year-olds in England fell by almost a third. Raising the age of sale is a tried and tested policy, and a policy that is supported not only by a majority of retailers—which, understandably, has been mentioned by a number of Members—but by more than 70% of the British public.

Physician Associates

Dan Poulter Excerpts

Wednesday 7th February 2024 Commons Chamber

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I draw the attention of the House to my entry in the Register of Members’ Financial Interests as a practising NHS consultant psychiatrist.

The UK has a severe shortage of healthcare professionals, amounting to more than 110,000 in England alone, coupled with a growing ageing population with an ever-increasing need for a strong and responsive health service. To address the shortage, the Government in England have introduced the NHS long-term workforce plan, with additional proposals also set out in the devolved nations.

NHS England’s plan sets out a wide range of mostly unfunded workforce measures, including doubling the current number of medical student places to potentially add 60,000 doctors to the workforce by 2036-37. Controversially, it also includes plans to increase the number of physician associates from approximately 3,250 to 10,000, an increase of over 300%, and anaesthesia associates from approximately 180 to 2,000. That is not to say that physician and anaesthesia associates should not have an important role in the future NHS workplace. However, at this time, serious regulatory and safety concerns relating to associates need to be addressed before the NHS seeks to expand their numbers and roles. Furthermore, standardised high-quality training pathways and a properly defined scope of practice are essential.

Physician associates, anaesthesia associates and surgical care practitioners are collectively known as the medical associate professions, and I may use the terms interchangeably. Physician associates and anaesthesia associates currently complete a two year postgraduate course and are employed in a variety of settings in the NHS, including GP surgeries, emergency departments, and medical and surgical settings, and they have also been introduced to mental health settings.

[Jim Shannon (Strangford) (DUP)]

I commend the hon. Gentleman for securing the debate. The issue is massive—it is massive for me back home, as well—so I thank him for his reasoned and knowledgeable speech, as well as his contribution to the NHS over the years. Without an increase in the number of GPs and doctors, does he agree that the healthcare crisis we face will become an abyss? In small countries such as Northern Ireland, students cannot get places in our small medical schools and are training, working and living in other countries, which is a real loss to future stability. Does he agree we need to do more to keep our young medical staff rather than let them head to greener grass in far off fields?

[Dr Poulter]

I completely agree with the hon. Member. He advocates strongly for his constituents, as always, and for the need to better retain our medical workforce in general, our junior doctors in particular. The Government will have heard his comments. I am sure that things can be done to improve the current offer to junior doctors in England. Indeed, things can be looked at in Northern Ireland, too, with the restoration of political arrangements.

An agreement could be put in place that will properly renumerate junior doctors, and also look at the other terms and conditions of employment that are important in respect of retaining the medical and healthcare workforce. These situations are not always about pay; it is also about wider terms and conditions. The Government could certainly look in more detail at student debt, for example, as the Times Health Commission outlined this week, which may incentivise people to stay in medicine for longer.

We have diverged slightly into the broader healthcare challenges, so I will return to physician associates, which was the point of this evening’s debate. There are concerns about the regulation and training of this particular group in the medical workforce. Physician associates and anaesthesia associates are not currently regulated. There have been a number of recent high-profile cases of patient harm as a result of being seen by medical associate professionals, including, sadly, some deaths. We know, for example, of the tragic case of Emily Chesterton from Salford who died of a pulmonary embolism having been seen twice and had her deep vein thrombosis misdiagnosed as a musculoskeletal problem by a physician associate at her local GP practice.

Anybody who watches the TV programme “24 Hours in A&E” may have seen some fairly enlightening scenes in respect of the clinical skills of some medical associate professionals, including physician associates. There are many examples of poor clinical diagnosis and judgment, including, for example, making initial decisions to send patients with compound fractures home without an X-ray when the patient actually required surgery.

In my own clinical practice, I have worked alongside some very competent physician associates, but there is a high degree of variability in their training and skills. Only last year, I was forced to directly intervene to prevent patient harm following a paracetamol overdose by a patient who attended A&E. The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose. Of course, at that time, the patient’s liver function tests were normal, but they would not have been for very long. The consequences of that diagnostic decision by the physician associate could have been fatal. The key issue for me is that many physician associates do not know or have the self-awareness to understand the limits of their knowledge and practice, but this is perhaps understandable in a health system that fails to adequately regulate and indeed define its scope of practice.

There are many other areas of concern that have been highlighted in a recent British Medical Association survey of 18,000 doctors, an overwhelming majority of whom work with physician associates. In November 2023, due to severe concerns around patient safety, the BMA called a halt to the recruitment of medical associate professionals to allow proper time for the extent of patient safety claims to be investigated and the scope of the role to be considered.

When the physician associate role was introduced, it was clearly seen as part of the solution to a shortage of doctors, which currently stands at in excess of 8,500. By freeing up doctors from administrative tasks and minor clinical roles, it allowed them to see more complex patients and get the training required to become excellent consultants or GPs.

Unfortunately, physician associates and anaesthesia assistants have been employed in the NHS in roles that stretch far beyond that original remit, and in many cases that were reported in the recent BMA survey that I mentioned, they appear to be working well beyond their competence. That has raised serious patient safety concerns—I gave some examples earlier—and led to calls to review the role, limit the scope of practice, and protect training for the doctors that the NHS desperately needs. When consultant time is taken by supervising physician associates, that is to the detriment of training and supervising junior doctors. That has not yet been addressed or even considered in the NHS England workforce plan.

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful to the hon. Member for introducing this evening’s debate. I sat on the Committee that considered the Anaesthesia Associates and Physician Associates Order 2024. He is drawing out several issues. One is competency; another is patient literacy. A lot of new roles are emerging—technicians, assistants, associates, and advanced practitioners—and to the public this is now becoming a blurred space. People do not understand the competences that individuals possess, their scope of practice, and where they fit into the medical family, or indeed professions allied to health. Does he agree that we need to define those roles clearly, and that associate roles should be around professions allied to health, rather than associated directly with the medical profession?

[Dr Poulter]

I fully agree with the hon. Lady, and I will expand on that a little later. There is certainly confusion among the public about what a physician associate is. Many members of the public assume them to be doctors or other healthcare professionals. They therefore lack a much greater degree of competence. Given that it is envisaged that the role will be significantly expanded, the public understanding and awareness of it, and people’s expectations when being treated by somebody in that role, are really important. That needs to be better addressed through the current proposals for regulation, which I will come to in a moment.

I will talk briefly about general practice and the additional roles reimbursement scheme. Through the ARRS, the Government have provided funding to GP practices that can be used to pay for physician associates and other clinical staff, but not for hiring additional doctors and nurses. That is quite extraordinary, and results in GP practices having physician associates rather than fully qualified GPs. Currently, most physician associates in general practice are funded through the additional roles reimbursement scheme: an NHS scheme that funds primary care networks to support recruitment across a very limited set of eligible roles. The current rules for ARRS funding are causing inefficiencies as they are not flexible enough to respond to locality needs for healthcare staff. In particular, the rules do not allow practices to hire primary care nurses, practice nurses, or indeed GPs, as I mentioned.

Over the past year, there have been many developments in how the Government and the profession view the roles of physician and anaesthesia associates, but it seems extraordinary that when we are talking about supporting general practice in developing the right skills and competences, and delivering the right service for patients, one of the key funding schemes does not allow for the hiring of the GPs and practice nurses that are needed, and is skewed towards physician associates. I wonder whether the Minister might take that away, look at the scheme, and help to provide additional flexibility, which general practice would like and which seems eminently sensible, to allow recruitment at a local level, in line with patient need.

There are significant concerns connected with the roll-out of the anaesthesia associates project. While the GMC addressed some of those issues in its recent letter to NHS England, a number of concerns remain. In particular, the NHS long-term workforce plan suddenly projected a huge expansion in the number of anaesthesia associates, but no expansion in the number of doctors in anaesthesia—or, as we are talking about position assessments, in the number of doctors in other specialities. To many, that looks like a replacement of doctors with anaesthesia associates, rather than anaesthesia associates being employed to complement the anaesthesia team, which was the idea previously portrayed.

There are many examples of medical associate professionals in the wider sense working in ways that have caused concern, as we have discussed in this debate, particularly with regard to their scope of practice. Anaesthesia provision in the UK must continue to be led and delivered by doctors, who are properly trained and properly regulated. Anaesthesia associates are valuable members of the anaesthesia team in addition to doctors, but they are not a solution to the challenges of low workforce numbers in anaesthesia and growing waiting lists.

The answer is to expand consultant numbers, an expansion in training scheme places for doctors in anaesthesia, and the development of the large number of speciality doctors and locally employed doctors already in post. Creation of speciality and specialist doctors and consultants via the General Medical Council’s new portfolio pathway could result in our having many more independent doctors in anaesthesia and other medical disciplines. It seems extraordinary that we are not looking at that first, given that we have a properly regulated and properly trained profession, rather than at expanding a workforce that is not subject to proper regulation to date, does not have a certified training pathway, and has been associated with a significant number of adverse patient outcomes and incidents.

Regulation ensures consistent standards for training, and for the practice of physician associates and anaesthesia associates. It maintains standards and, critically, contributes to patient safety. As per the recent Anaesthesia Associates and Physician Associates Order 2024 laid before the UK and Scottish Parliaments, those associates will be registered with the General Medical Council. However, there are increasing concerns that that could further blur the distinction between doctors and anaesthesia associates.

In response to those concerns, the GMC has said that physician associates and anaesthesia associates will be issued with a registration number format that distinguishes them from doctors. That is to be welcomed. However, it must go further and present doctors on a separate register from physician associates and anaesthesia associates, whether we are talking about a register online or in print—that aligns with the point that the hon. Member for York Central (Rachael Maskell) made—so that it is very clear that the different professions are regulated under separate registers. That is important for both accountability and transparency, and it is important that patients understand that.

There should be a clear distinction between the register of doctors and other registers. That is necessary to provide absolute clarity for patients and others who wish to access the registers, and it is essential to protect everyone from accidental or deliberate misrepresentation. With modern information technology systems, there is no legitimate reason why that cannot be done. It would be simple, and it is about transparency, openness and patients better understanding the difference between the responsibilities of doctors, and those of physician associates and anaesthesia associates. I hope the GMC is listening to this debate and will ensure properly separate registers. That does not cost much, but is very important.

Perhaps the crucial point in this debate is the scope of practice. There should be a national scope of practice for physician associates and anaesthesia associates, both on qualification and after any post-qualification extension of practice. Any future changes to scope of practice should be developed in conjunction with the regulator and should be agreed at national level. I understand that currently the GMC will not regulate extended scopes of practice, which is very regrettable. For example, we are aware of whether a doctor is on the GP register or a specialist register, or just has a licence to practise. Those levels of expertise are part of the regulatory framework. It seems extraordinary that although the GMC has been asked to look at regulating physician associates, there is no understanding of the scope of a physician associate’s practice. That needs to be properly mapped out and explored.

[Rachael Maskell]

I am grateful to the hon. Gentleman for making those points. It is particularly concerning that a prescribing nurse, say, could become a physician associate, but perhaps without the ability to prescribe. That would create even greater confusion. Does he agree that we need clarity and distinctions to be drawn on those kinds of issues?

[Dr Poulter]

I fully agree; the hon. Lady is absolutely right. I was going to address that very point about prescribers a little later. There is clear agreement on the challenges. Those issues should be thought through before a workforce plan is brought forward, and before there is a significant expansion of the workforce, for reasons of patient safety, particularly as concerns have consistently been raised about the scope of practice and adverse incidents. It is rather putting the cart before the horse to say, “We want to expand the workforce without dealing with the important issues of how that workforce is trained, how it can properly be regulated, and what its scope of practice is.” That is unfortunately a regrettable failing of NHS England’s plan, which I hope it will consider.

If the GMC cannot regulate extended scopes of practice, they should be devised according to a national framework. There needs to be an understanding of what that should be. It is unacceptable for employing organisations in the NHS to devise their own extended scopes of practice without reference to at least some national framework—one that has the confidence of regulators and standard setters—so that we know and understand what good practice looks like.

Doctors should be directly involved in devising any changes to the scope of physician associate and anaesthesia associate practice, whether on qualification or at extended level. There should be no extension of roles beyond the scope of practice on qualification until national guidance is issued. Where organisations are planning such an extension, it should be paused for reasons of patient safety. Where physician associates or anaesthesia associates are already working in an extended role, it should be recorded on the healthcare organisation’s risk register, and the organisation should ensure that it has full confidence in its standards of supervision, access to support, indemnity of the anaesthesia or physician associate and the supervising doctor, and patient information and consent. Anaesthesia associates have a role to play as part of the wider anaesthesia team, but it is important to ensure that it is a complementary role as an addition to the workforce, not as a replacement for doctors and nurses, as the hon. Lady rightly underlined. Expansion in the number of anaesthesia and physician associates should not be at the expense of expansion in the number of doctors in specialist posts.

Let me come briefly to assessment, which is another area that has not been well thought through. It is important that assessment for anaesthesia associate roles is standardised at national level. The Royal College of Physicians does a national exam for physician associates, but a national body needs to be established to undertake the assessment process for anaesthesia associates if we are to ensure confidence in their competencies. It may be possible for that to be delivered locally, if there are stringent controls in place to ensure consistency. However, before the anaesthesia associate workforce is expanded, there needs to be some process for assessing competency.

On indemnity, which was also addressed by the hon. Lady, further information is needed around indemnity cover for both physician associates and anaesthesia associates, as well as for any doctors supervising them. “Good medical practice” expects all doctors to ensure that they are fully indemnified. The same standard should apply to physician associates and anaesthesia associates. Many doctors in anaesthesia, in general practice and in emergency departments are already worried about medicolegal liability when working with physician associates, and clear guidance is urgently needed. Although reference is made to accountability, more information is required in this area, given the challenges that we know have arisen.

The hon. Lady mentioned prescribing rights. Some physician and anaesthesia associates—for example, those with a nursing background—may already have those rights from their parent profession. The Commission on Human Medicines is responsible for deciding which professions are able to prescribe, and it is important that it is clear in its guidance and reasoning in respect of physician and anaesthesia associates before there is a wider roll-out of those roles.

I draw the Minister’s attention to key findings from the British Medical Association’s recent survey, which sought the views of over 18,000 doctors about the role of the medical associate professions. Almost 80% of respondents—that is well in excess of 15,000 doctors—had worked with or trained medical associate professionals, which means that contact with those professionals is widespread throughout the NHS. Medical associate professionals are currently unregulated and have a poorly defined scope of practice. The BMA survey respondents were very concerned about that, as well as about the fact that MAPs have been employed in the NHS in a variety of roles, which go well beyond what was originally envisioned as an assistant role. A staggering 87% of doctors surveyed believed that the way that physician and anaesthesia associates work in the NHS is a risk to patient safety. For the Minister’s benefit, that is the best part of 18,000 doctors who work with this workforce raising concerns about working practice and patient safety.

[Rachael Maskell]

Once again, I am grateful to the hon. Member for giving way. Doctors in training need a very clear career pathway, but because of the rise in anaesthesia associates in particular, but also in physician associates, the pathway to many more senior roles will be blocked. As a result, people will stagnate as doctors in training, as opposed to getting a consultancy. Does he agree that that is highly problematic, and that the career pathway needs working through before there is any increase in the number of physician and anaesthesia associates?

[Dr Poulter]

That is absolutely essential. At the moment, the prerequisite appears to be a biomedical science degree, which is incredibly variable—depending on whether a person went to Hull, Newcastle or a London university, a biomedical science degree could be very different—and then two years of study. A physician associate would then have to pass an exam set by the Royal College of Physicians, but when a person passes that exam, it does not necessarily mean that they had standardised or good training; potentially, it just means that they prepared well to pass their exam. The difference with doctors in medical school—and indeed the difference with nurses going through nursing school—is that they are consistently assessed, all the way through their undergraduate training. When they graduate at the end of that training, they are consistently assessed as they progress.

None of that exists in the training pathway for physician or anaesthesia associates; in fact, as we have discussed, there is not even an exam for anaesthesia associates at the end of the process. It is absolutely essential that those issues are addressed as a priority, and it is little wonder that patient deaths and adverse incidents are occurring on such a scale. Perhaps when the Minister is suffering from insomnia late at night, he may wish to watch old episodes of “24 Hours in A&E”. He will see the huge variability in the expertise of physician associates. Some are very good, but some are not, and we should not be dealing with variability in the British health system. That is what we are trying to address, so the hon. Member for York Central is absolutely right in everything she has said.

That highlights the last point I am going to draw to the House’s attention from the BMA survey of 18,000 doctors. Some 75% of respondents said that the quality of training among medical associate professions—physician and anaesthesia associates—was woefully inadequate; 84% said that the quality of their supervision when they are at work was inadequate; 91% outlined the fact that they work outside their competence; and 86% of respondents confirmed that the public would confuse them with doctors, as the hon. Lady outlined. This is not just a few hundred doctors; this is 18,000 doctors saying in a survey that they have serious patient safety concerns due to the variability in training of anaesthesia associates. There have been far too many adverse incidents where things have gone wrong, and it is time for the Government to give NHS England some clear direction that this area needs to be looked at, and some proper planning and consideration of the expansion of this workforce put in place.

These are the asks I have of my right hon. Friend the Minister. First, we should ensure there is a standardised and quality assured training programme for physician associates, anaesthesia associates, surgical care practitioners and all other medical associate professionals, and indeed that there is ongoing training and supervision to a nationally standardised level when that group is in the workplace post qualification. Secondly, we should ensure that the General Medical Council sets up a register for the regulation of medical associate professionals, separate from the register for doctors. Thirdly, as is the case with all other healthcare professionals, we should ensure that the scope of practice of physician associates is clearly set out to make sure that we can develop appropriate training pathways and supervisory pathways, but, more importantly, to ensure patient safety. Finally, the Government should support the introduction of a system with greater flexibility to hire GPs and general practice nurses using the ARRS funding. I thank the House, and I look forward to the Minister’s response.

[The Minister for Health and Secondary Care (Andrew Stephenson)]

I congratulate my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) on securing this debate. He spoke knowledgeably, both as a serving NHS medic and as a former Health Minister.

Let me begin by making a very important point. I addressed it in the Delegated Legislation Committee on 17 January, but it is worth repeating. The role of a physician associate is to work with doctors, not to replace them. Improved patient safety and care is at the heart of the NHS long-term workforce plan, which, backed by significant Government investment, shows our determination to support and grow the workforce. As set out in the plan, roles such as physician associates, who remain supervised by doctors, play an important part in NHS provision, and it is therefore right that we include a range of roles and skills in our multi-disciplinary teams that can offer personalised, responsive care to patients.

It is important to note that the NHS long-term workforce plan commits to doubling medical school degree places to 15,000 a year by 2031-32. That compares with 1,500 physician associate places. In turn, this will mean a major expansion of specialty training, on which we are committed to working with the royal colleges. We have accelerated this expansion by allocating 205 additional medical school places for the 2024-25 academic year, with the process for allocating 350 additional places for the 2025-26 academic year already under way. This demonstrates our commitment to the medical profession, and reaffirms that we absolutely do not see physician associates as replacements for doctors. There are currently 139,200 full-time equivalent doctors working in the NHS in England, which is over 42,100, or 43.4%, more than in 2010. Patient safety remains of the utmost importance, and regulation will help bring further clarity to patients and healthcare professionals on the nature of these roles and their remits.

Physician associates are qualified and trained health professionals. They undergo a three-year undergraduate degree in a health, biomedical science or life sciences subject, followed by two years of postgraduate training, gaining significant clinical experience. Alternatively, some universities now offer an undergraduate degree PA course that includes an integrated master’s degree in physician associate studies. Those courses take four years to complete. Training involves supervised practice with real patients, with at least 1,600 hours of clinical training. It also includes 350 hours in general hospital medicine, and a minimum 90 hours in other settings, including mental health, surgery, and paediatrics. The dedicated medical supervisor is responsible for the supervision and management of a student’s educational process throughout the clinical placement of the course.

[Dr Poulter]

Earlier, in response to the hon. Member for York Central (Rachael Maskell), I made the point about the variability of biomedical science degrees from different institutions. The GMC would not recognise a biomedical science degree as being adequate for a doctor in training as part of their preclinical studies, because of that variability. Will my right hon. Friend raise that issue directly with NHS England, with regard to putting in place a standardised training pathway for physician assistants?

[Andrew Stephenson]

My hon. Friend makes a valid point, and that is one reason why regulation is so important. The GMC has assured me that although draft regulations are out there, it will be consulting further on them later this year, so my hon. Friend, the BMA and various others can make strong representations about how the training framework should be provided. With that introductory regulation, the GMC will be responsible for setting, owning and maintaining a shared outcomes framework for physician associates, which will set a combination of professional and clinical outcomes. The outcomes framework will help to establish and maintain consistency, embed flexibility, and establish principles and expectations to support career development and lifelong learning. While at the moment there is significant variability in the system, I hope that the regulations we passed in this House on 17 January will help to provide that clarity and give the GMC the powers it needs to ensure that the training provided to physician associates is of the appropriate quality for the roles we are expecting them to undertake in our NHS.

Physician associates can work autonomously with appropriate support, but always under the supervision of a fully trained and experienced doctor. As with any regulated profession, an individual’s scope of practice is determined by their experience and training, and will normally expand as they spend longer in the role. That must be coupled with appropriate local governance arrangements to ensure that healthcare professionals only carry out tasks that they have received the necessary training to perform. Statutory regulation is an important part of ensuring patient safety, but that is also achieved through robust clinical governance processes within healthcare organisations, which are required to have systems of oversight and supervision for their staff.

NHS England is working with the relevant professional colleges and regulators, to ensure that the use of associate roles is expanded safely and effectively. That includes working with the GMC, royal colleges and other stakeholders to develop appropriate curriculums, core capabilities and career frameworks, standards for continual professional development, assessment and appraisal, and supervision guidance for anaesthetist and physician associates. NHS England will also work with colleges, doctors’ representative organisations, AAs and PAs to identify areas of concern. Specifically, the NHS has committed to working with the Academy of Medical Royal Colleges and individual professional bodies to develop and implement recommendations as a result.

Regulation will give the GMC responsibility and oversight of AAs and PAs, in addition to doctors, allowing it to take a holistic approach to education, training and standards. That will enable a more coherent and co-ordinated approach to regulation and, by making it easier for employers, patients and the public to understand the relationship between the roles of associates and doctors, help to embed such roles in the workforce. Indeed, regulation addresses many of the concerns that we have heard in the debate last month and today. The GMC will set standards of practice, education and training and operate the fitness to practice procedures, ensuring that PAs meet the right standards and can be held to account if serious concerns are raised. GMC guidance sets out the principles and standards expected of all its registrants, and that will apply to PAs once regulation commences. Those standards will give assurance that PA students have demonstrated the core knowledge, skills and professional and ethical behaviours necessary to work safely and competently in their areas of practice and in a care context as newly qualified practitioners.

[Andrew Stephenson]

In many ways, it will be the same as with many medical professionals. Once we have the situation clarified in regulation, it will not be any different from the personal liability of a doctor or others working in an organisation. Those are the kind of things that the GMC will be consulting on and discussing with stakeholders in the coming months, and is important that all these points are clarified. The hon. Lady was in the debate we had in January, where the tragic case of Emily Chesterton was raised. In that case, unfortunately we saw a PA move from one practice to work in another, and we need to ensure that there is a proper, robust fitness-to-practice regime so that any medical professional can be held to account in such cases for what has happened and, if necessary, struck off the register and no longer able to practice.

[Dr Poulter]

The Minister is being generous in giving, and we are taking advantage of the slightly extended time we have for this Adjournment debate, but it is an important issue, because it is about patient safety. On that point, he is putting a lot of faith in the GMC doing things quickly, when we know there are existing patient safety issues. Would it not be more sensible to wait for the GMC to put in place the proper regulatory framework, the proper scope of practice and the other pieces of work that are being done before we commit to an expansion of a workforce when we know there is variability and patient safety concerns?

[Andrew Stephenson]

I feel that I am being criticised from both angles on this point. Some people are saying we are going too fast, and other people are saying we are going far too slow. A number of years ago, we consulted on regulating these professions. We are now moving forward. Those regulations have passed through the UK Parliament and the Scottish Parliament. The GMC has had a long time to prepare. In my meetings with the GMC, it has reassured me that it is ready to go. It will want to consult to ensure that any further concerns that people wish to raise are reflected in the regulations. It wants to ensure that it gets the regulations right, but it has known that they have been coming for some time. We consulted on who was best placed to regulate physician associates and anaesthetist associates back in 2019, so the GMC has had some time to lay the groundwork.

Under the long-term workforce plan, there is a much more significant expansion of doctors, as opposed to physician associates or anaesthetist associates. The number of extra doctors we are bringing in to the health service, as compared with physician associates, is of a magnitude of five to one. I hope I can reassure hon. Members that this is not in any way about replacing doctors. Doctors are still absolutely pivotal to patient care and will be heavily involved in overseeing physician associates, who are not doctors and need to be overseen in clinical practice.

The role of physician associates is in no way a replacement for that of any other member of the general practice team. They work in conjunction with and are complementary to an existing team. Physician associates can help to broaden the capacity and skills mix within a practice team by helping to address the needs of patients in response to the growing and ageing population, but let me be clear that the employment of PAs does not mitigate the need for more GPs, nor does it remove the need for other practice staff.

There will be a wide range of clinicians, such as PAs, who are well suited to providing care in general practice as part of a multidisciplinary team, but GPs remain at the heart of general practice and primary care, and that is not going to change. As we develop and progress with changes to the NHS workforce, it is vital that the expansion of physician associates and their role is delivered safely. GMC regulation is a positive step forward in the safe expansion and further integration of AAs’ and PAs’ roles within the NHS.

I thank my hon. Friend the Member for Central Suffolk and North Ipswich for once again bringing the House’s attention to this important issue. I look forward to continuing to work with him and other right hon. and hon. Members to ensure that we get this right.

Question put and agreed to.

Dental Services: East of England

Dan Poulter Excerpts

Tuesday 16th May 2023 Westminster Hall

[Mr Richard Bacon (South Norfolk) (Con)]

I beg to move,

That this House has considered dental services in the East of England.

It is a pleasure to serve under your chairmanship, Sir Mark. I am particularly pleased to have the opportunity to introduce this debate on dental services in the east of England, as I have been applying to Mr Speaker for a debate on the subject for several months. I am sure that I am not alone among hon. Members in finding that the subject of access to a dentist is one of the largest in my constituency postbag and inbox. It has been the topic of numerous Back-Bench debates in recent times. I pay particular tribute to the efforts of my hon. Friend the Member for Waveney (Peter Aldous) and the hon. Member for Bradford South (Judith Cummins), who have jointly sponsored a trio of debates in the last year or so, most recently on 27 April. My hon. Friend the Member for Broadland (Jerome Mayhew), who is also present, led an Adjournment debate on the need to establish a dental training college in East Anglia on 11 October last year. I will not say much more about that, but I ask the Minister to reconsider the Government’s position on it, because my hon. Friend made some very good points in that debate.

There have been many other interventions on many occasions by many hon. Members from both sides of the House. Indeed, another of my parliamentary neighbours, the hon. Member for Norwich South (Clive Lewis), secured question No. 1 in Prime Minister’s questions last week and asked about dentistry. He also managed to include a rather third-rate joke—something to do with rotten teeth and rotten Governments—but before he is tempted to repeat that, should he grace us with his presence, I point out to the House that I have a fourth-rate joke just for him. Colleagues may have noticed that the debate was scheduled to start, and indeed did start on time, at tooth-hurty pm.

Given the—[Laughter.] It got there eventually. That is Lincolnshire for you, Sir Mark. Given the enormous cost of dealing with the pandemic, and the inevitable financial consequences and constraints that it imposed, I think that the Government have done rather well, but that is not to say that they cannot do better. We all expect them to do better, as do our constituents. The Commons Health Committee has studied the reform of dental services and noted concerns that the Government have

“transferred financial risk from the NHS to dentists”,

adding:

“The fixed-term contract may make dentists reluctant to make long term investments in their practice.”

The Committee observed that the chief dental officer appeared in evidence to argue that if commissioners and dentists

“acted more flexibly and used common sense and good will the new arrangements would work”,

but it concluded that

“we see little evidence that this will happen.”

The Committee also reported that the total number of dentists working for the NHS and the activity that they have provided has fallen, and that the total number of patients seen by an NHS dentist has fallen by 900,000. The conclusion of the Health Committee was that the contract was

“failing to improve dental services measured by any of the criteria.”

If hon. Members find any of those conclusions eerily familiar, it would not surprise me, because they are from the Health Committee’s report in July 2008, when the Committee had a Labour majority and a Labour Chair, and there was a Labour Government. I hope that we can all agree that this is a long-standing problem that is not confined to any one Government or party.

There is widespread agreement that the dental contract introduced in 2006 lies at the root of many of the problems that we see today. The old item of service method that existed prior to the 2006 contract may have had some issues, but as one dentist said to me:

“It was a system that allowed you to be entrepreneurial”.

A dentist could set up a dental practice, put a sign outside and get on with it. Under the old NHS contract, dentists were paid for each item of treatment that they provided—an examination, a filling, a crown or a denture. Now they are paid per course of treatment, irrespective of how many items are provided, thus a course of treatment involving one filling attracts the same fee as one containing five fillings, a root treatment and an extraction. As the Duke of Norfolk is rumoured to have said about the rhythm method of contraception, there is only one problem: it “doesn’t bloody work”. We have had this problem since 2006. We have a contract that is, effectively, not fit for purpose.

In fairness, the problems go back beyond 2006. Indeed, my hon. Friend the Member for Waveney said in his last debate on the subject on 27 April:

“The fundamental causes of the collapse of NHS dentistry”

—I do not like saying that as a supporter of the Government, but I do not think the “collapse of NHS dentistry” is too extreme when we see what is happening; I hope that the Minister notes that—

“go back over 25 years with a gradual withdrawal of funding by successive Governments and the poorly thought-through 2006 NHS contract.”

My hon. Friend added:

“Covid was the final straw that brought the edifice crashing down.”—[Official Report, 27 April 2023; Vol. 731, c. 995.]

The problems in NHS dentistry have been so well canvassed in so many recent debates that I do not want to rehearse them again. I will, however, reprise one story from my constituency. The Manor House dental practice in Long Stratton in South Norfolk was run for many years by a respected and successful dentist called Dr Mark Ter-Berg, who, after many years of service, retired and sold his practice. After a period, the new managers of the practice got into financial difficulty and the business went under, owing money both to its corporate owners and the NHS. Dr Ter-Berg offered to come out of retirement and take over his old practice. He was quoted as saying in a local newspaper:

“You would have thought that”—

NHS England—

would have bitten my hand off”.

After months of making the offer and getting nowhere, I intervened on his behalf with NHS England, but it did not make much difference.

Dr Ter-Berg finally gave up waiting and decided instead to set up an entirely separate new dental practice in Long Stratton. I drove past it the other day, and there was a sign that read, “Open from 4 May”. I spoke to him yesterday and he is now very busy. He does not have an NHS dental contract; it is all private work and he is extremely busy—and Long Stratton is not by any means the most prosperous part of my constituency.

As Allison Pearson wrote on 10 August 2022 in The Daily Telegraph, which is not a notable bastion of left-wing journalism:

“I can’t think of a better example of a two-tier NHS than the one that currently exists in dentistry.”

Indeed, I understand that the providers of dental plans—for example, Practice Plan, which styles itself

“the UK’s leading provider of practice-branded dental membership plans to help you leave NHS dentistry or switch providers”—

are so busy that they are rushed off their feet.

Colleagues will have seen the British Dental Association briefing for this debate, which references a much-reported BBC investigation showing that no dental practice in Norfolk, Suffolk or Cambridge was taking on new adult NHS patients, and that this was also true of nearly all dental practices in Hertfordshire, Bedfordshire and Essex. At the end of March, Bupa announced that it will close many dental practices across the country; 85 practices were to be affected, with 38 set to close immediately. That includes two in Norfolk, with one in Harleston in my South Norfolk constituency—although I understand that Bupa is hoping to sell that practice to a new owner and that it will not close on 30 June as previously expected. The truth is that successive Governments have made NHS dentistry a place where dentists increasingly do not want to work. We need to focus on that, and we would all like to know what the Minister will do about it.

Let me say a word about money. The thing that struck me most in preparing for this debate was how little money the NHS spends on dentistry—indeed, how little is spent on dentistry at all compared with what it spends on other things. The figure is currently about £3.2 billion a year—that fluctuates a bit—and about 20% to 32% of that is actually paid through patient charges, paid by the patients themselves.

A recent National Audit Office study showed NHS spending rising from £123.7 billion in the financial year that ended in 2020 up to £151.8 billion—more or less £152 billion—at the end of the financial year that just finished. Further big rises are expected and planned—going up to £162.6 billion—by the end of the financial year 2025. Those are huge sums. In comparison, the annual cost of dentistry is tiny. I tend to compare anything under £3 billion with the NHS national programme for IT in the health service—one of the less successful parts of the last Labour Government. The Health Committee and the Public Accounts Committee studied that extensively at the time, and showed that the electronic patient record element, which cost £2.7 billion, had achieved basically nothing. The Public Accounts Committee’s report—this was its third report on the issue—from around August 2011 stated:

“The Department is unable to show what has been achieved for the £2.7 billion spent to date on care records systems.”

In other words, that nearly £3 billion achieved precisely nothing. I know that this is not quite comparable, being an annual number, but talk of a few hundred million or a couple of billion pounds means a few failed Government computer projects, in terms of the quantum. Compared with the £124 billion or £152 billion or £160-something billion that we are talking about, £2 billion or £3 billion here or there is of very little account.

I am sure that the Minister will refer to the fact that the Government are aware they need to reform NHS dentistry and that he is working on a plan. Some hon. Members might press him for a date on that plan, but I will not do that. I am much more concerned about ensuring that, when he gets the plan, it is right. I do not think it is any one Government’s responsibility that this has gone wrong. In fairness to the Labour Government of the mid-00s, in 2006, they were trying to correct what they thought was a big problem—that the item of service method led to a bill that was difficult to control. It was more akin to annually managed expenditure in the social security Department.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

My hon. Friend is making some very good points, and I congratulate him on securing the debate. He will recognise that there is a tension between payment by activity, which is not necessarily a desirable way to manage health—be that dental or physical health—and moving towards a more preventive model, which was the aim, if not the reality, of the changes to the 2006 contract and subsequent changes. What does he think about finding a way to lock in dentists to the NHS for maybe five years, post-graduation, to ensure that they pay back some of the training that cost the taxpayer many hundreds of thousands of pounds?

[Mr Bacon]

My hon. Friend makes several good points. We did payment by activity for acute hospitals, and we got a huge amount of activity in acute hospitals. Mental health was then the Cinderella service, with what little was left. Of course, there are tensions, and my hon. Friend, as a practising hospital doctor, will know that better than most. How that needle can be threaded to get the desired results has confronted Governments for many years.

On my hon. Friend’s specific point, having gone through medical school or dental school and come out the other end, junior doctors and, I am sure, junior dentists are at the moment struggling in the way that many others are—including young professionals—to afford anywhere to live. We have hundreds of thousands of acres of public land, including Ministry of Defence land, NHS land, railway land and church land, which has a quasi-public flavour to it. Norfolk County Council alone owns 16,000 acres of land. I would say to these people, “Come and work for the NHS for a few years full time. Commit yourselves completely to this, and we will help you design, build and rent from us at a decent rent. And then, depending on the calibrated loyalty package, which I am sure we can easily work out, you will get the chance in future to buy the house that you have designed for yourself.”

To go back to the point that my hon. Friend the Member for Broadland has made, getting people to stay in a particular area has proved difficult, not least because we do not have a dental training college. However, this is also about people understanding that the area they are going to work in is particularly attractive. That is true of much of the east of England, except people do not realise it because not enough of them, certainly in dentistry, are educated there. There is a huge opportunity for the Government to get this right, and I am more concerned about ensuring that the plan that comes from the Minister in the next few weeks or months is correct.

The fear I have is the potential downside. My constituent who, before Christmas, booked an appointment for her children for 9 May but found out recently that it was cancelled in a text message from the Harleston Bupa practice—she has been phoning to find out what is going on—will not care or know about the interstices of the 2006 dental contract, which was perhaps well intentioned but is deeply flawed and has led to many of the problems we are grappling with. She will just care that she cannot get an appointment.

Although the Opposition have not been particularly fleet of foot in recent years, even they can see that this will become a very salient issue at the next general election. We have our five points: halving inflation, growing the economy, reducing the national debt, cutting NHS waiting times and stopping the boats. Those are fine, but they are not a programme for Government. We need to do those things to restore confidence after the events of last autumn and—it might be best if I quote Mark Twain—to try and draw a veil and hope that not too many people remember them. However, the fact is that we need a better programme for the election, and I am sure we will have one.

The hon. Member for Denton and Reddish (Andrew Gwynne) will be sitting there with his chums, thinking, “What are our five points going to be?” If we do not get this right—mark my words, Sir Mark—the Opposition parties will say, “They have had 13 years to talk about it. It started with the 2006 dental contract, but they have had long enough and have not yet sorted it.” It will then become one of their five points. We are talking about such piffling sums of money compared with the overall cost of the NHS that it is simply incomprehensible that we would not deal with this properly.

The issue of dental care has been of growing concern to our constituents for many years, and the concern has only grown as successive Governments have failed to grapple with the issues properly. On present trends, it will continue to get worse—much worse—unless the Government make a decisive step change and match that decision with the right resources in the right places within a contractual framework that incentivises the right behaviour. That is what the Government need to do.

Performance-enhancing Drugs and Body Image

Dan Poulter Excerpts

Tuesday 21st February 2023 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Neil O’Brien)]

It is a pleasure to serve under your chairmanship, Mr Mundell, and to listen to my hon. Friend the Member for Bosworth (Dr Evans). I knew as soon as he secured the debate that he would bring us something special, and he did not disappoint—it was a fascinating speech. Without wishing to spoil the impact of my response, there were so many good questions and important ideas in it that I will not be able to bottom all of them out this afternoon, but we should see this as the start of a conversation that I am keen to pursue with him. Likewise, there were many important and interesting observations from other hon. Members, including about the issue of roid rage, which was raised by the hon. Member for Rutherglen and Hamilton West (Margaret Ferrier), and about the position of young men in society, which was raised by my hon. Friend the Member for Don Valley (Nick Fletcher). I was sorry to hear about the tragic case of Matt, which was raised by my hon. Friend the Member for Rochford and Southend East (Sir James Duddridge), and I am sure our hearts go out to his parents and family.

I will touch on the positive steps we took last week in the substance misuse and recovery strategy—the 10-year drugs strategy. My hon. Friend the Member for Bosworth mentioned that the strategy has a heavy focus on alcohol, heroin and crack, and the reasons for that are obvious. Indeed, as part of the launch, I met my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), who will appreciate that there is a big focus on those drugs because they drive about half of all acquisitive crime. Alcohol is one of the big killers and addictions that causes so many problems. As part of that 10-year drugs strategy, we have created a ministerial working group across Departments of exactly the kind that my hon. Friend the Member for Bosworth talked about creating. There is every reason to look, through that group, at what we can collectively do, particularly on the illegal sale of some of these drugs.

To mention a bit about the strategy, this is a £421 million investment over the next two years to improve the number of recovery and treatment places. Perhaps I can cheekily use this opportunity to thank everyone working in the drug and alcohol treatment sector for all the fantastic work they are already doing, and there are many other things we want to extend out to, which my hon. Friend the Member for Bosworth has raised today.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I draw Members’ attention to my declaration in the Register of Members’ Financial Interests—I am a practising addiction psychiatrist. I thank the Minister for the focus he is bringing to bear on this area and for the fact that the Government have put in place a comprehensive strategy for the next 10 years that focuses on alcohol, crack cocaine and opiate use, which is absolutely the right focus. I also thank him for the fact that the strategy is backed up with substantial investment, which is very much needed and which I am sure will make a big difference over time.

However, we do not have good data collection for steroid misuse. A good way of collecting data about drug use in the general population is through the crime survey for England and Wales. I wonder whether the Minister might be able to take that away from the debate and collect some more robust data to ensure that steroid use is properly captured in that crime survey. Perhaps he might have conversations with colleagues in other Departments because that will give us a much stronger basis to work from, and an evidence base is important in drug and alcohol treatment.

[Neil O’Brien]

My hon. Friend brings huge expertise to the debate. He and my hon. Friend the Member for Bosworth are right that we need better data. Perhaps one route is through the CSEW, as he says. It may be that there are other routes for getting better data on prevalence. There are limits to how much people will report some of these crimes when it is something they are taking, rather than a case of stealing to fund that, but there may be different ways we can get the right data.

In terms of what we know, a small cohort of people—only 0.2% of people aged between 16 and 59—use steroids. However, these individuals, as my hon. Friend and other Members have pointed out, may not be fully aware of the health risks associated with the drug or the impact it can have on their mental or physical health. As Members present certainly know, anabolic steroids are prescription-only medicines that help patients gain weight and rebuild tissues that have become weak because of serious injury or illness—that is their clinical use. These drugs are sometimes taken without medical advice to try to improve muscle mass or athletic performance. Anabolic steroids are a class C drug under the Misuse of Drugs Act 1971. Although it is not illegal to possess them for personal use, possession, importation and exportation are illegal if deemed to be with the intent to supply others. So people who are involved in these issues need to be extremely careful.

Lots of work is under way across multiple Departments on this important issue, and I want to talk about just some of the actions the Government are taking, notwithstanding the need to do more on a range of fronts. The Government are committed to stopping the illegal trade in human medicines. The majority of IPEDs are sold online through illegal trading websites based overseas. The Medicines and Healthcare products Regulatory Agency works with private sector partners to try to reduce the presence of such websites and, with the Home Office Border Force, to intercept and seize medicines entering the UK.

We are also taking action in the Online Safety Bill to prevent criminal activity, including the illegal sale of steroids. The intention is that companies that fail to comply with the Bill when it has been enacted will face stiff financial penalties or, in the most serious cases, have their sites blocked by the independent regulator, Ofcom. I hope that that addresses some of the concerns about the frightening-sounding websites that the hon. Member for Croydon Central (Sarah Jones) mentioned.

Of course, we know that preventing the trade in steroids is not enough to tackle the problem. As my hon. Friend the Member for Bosworth rightly said, the wider issue lies with the increased prevalence of body dysmorphia and the societal preference for young men to look a particular way. The rise of social media has undoubtedly increased this pressure in recent years, as young people have greater access to platforms promoting often unrealistic and digitally altered body images.

Schools play a really important role in helping young people to make positive choices about their wellbeing through their compulsory relationships, sex and health education curriculum. The Office for Health Improvement and Disparities has worked with the Department for Education to create quality teaching resources for teachers in order to help prevent substance abuse and to address some of the issues with young people feeling that they should look a certain, completely unrealistic. To pick up on some of the horrifying stories that the hon. Member for Croydon Central shared about the young Scouts she met who were all fans of Andrew Tate, that is also something that we need to address in education in schools.

As well as informing students about the risks associated with harmful substances—this goes to the point that my hon. Friend the Member for Bosworth made about harm reduction as well as prevalence reduction—schools have an important duty to protect pupils from harm and to provide mental and physical health support. Through statutory health education, secondary school pupils are taught about the similarities and differences between the online world and the physical world, including how people may curate a particular image of their life online, how information is targeted at them, and how to be a discerning consumer of information online. I am always interested in how we can improve what is taught in schools, because the world facing young people is so different from the world that the generation of people represented here experienced when they were young.

I am proud to highlight that the Government have committed to offer all state schools and colleges a grant to train a senior mental health lead by 2025. That will enable schools to introduce effective, whole-school approaches to mental health and wellbeing. Backed by £10 million in 2022-23, over 8,000 schools and colleges have taken up the offer so far.

We are also taking significant steps to tackle body image issues. On 2 February, the Government responded to the Health and Social Care Committee’s important report on the impact of body image on mental and physical health. We welcomed the Committee’s report and recommendations, and we agree with the Committee that image and performance-enhancing drugs are a significant public health issue. However, we know that prevention is better than cure, and when it comes to harmful substances, it is crucial that we ensure the public have access to sufficient information to inform them of the harms associated with substances such as steroids. The Government-commissioned website Talk to FRANK provides detailed information on the mental and physical health risks of taking steroids, and it is updated on a regular basis.

Additionally, UK Anti-Doping already has an outreach and communication programme that is run in partnership with ukactive, which has been live since 2018. The partnership aims to improve education and awareness around image and performance-enhancing drugs in gyms and leisure centres because, as my hon. Friend the Member for Bosworth rightly pointed out, such places are a focus for these issues. They are the right places to target, and we need to work with sporting bodies, gyms and the like to try to tackle the problems where they are most concentrated.

I draw Members’ attention to the investment that we are making in mental health services. The Government will have invested £2.3 billion a year by 2024 in expanding the services available in England, including for people with body dysmorphic disorder. An additional £54 million is being invested in children and young people’s community eating disorder services in 2022-23. That investment is alongside the development of a major conditions strategy, which will address prevention and treatment for mental ill health, with an aim of producing an interim report in the summer.

I once again thank my hon. Friend for securing this debate on an important issue, and for his many, many ideas. He set out a whole suite of things that we need to be doing. It was a fascinating speech. I commend his work in this area, including his image campaign last year, which achieved national media coverage and will no doubt have had a beneficial impact.

The Government are taking significant steps to protect the mental health of the nation, and particularly young people, and we are ensuring that the right support is in place for those suffering or at risk of body dysmorphic issues. Although a review is not currently planned, the Department of Health and Social Care, the Department for Education and the Department for Digital, Culture, Media and Sport will continue to work closely on tackling the use of anabolic steroids, educating the public on the risks associated with them and ensuring that mental health support is available for all those who need it.

Draft Mental Health Bill 2022

Dan Poulter Excerpts

Thursday 26th January 2023 Commons Chamber

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I first draw the House’s attention to my entry in the Register of Members’ Financial Interests as a practising NHS psychiatrist.

The Joint Committee on the Draft Mental Health Bill was formed on 4 July 2022 to scrutinise this important and urgently needed reform of mental health legislation. Our Committee has been working hard since that date. We held 21 meetings in just over 12 sitting weeks, spoke with more than 50 witnesses, received more than 100 submissions of written evidence, and engaged with affected communities through surveys, roundtables and a visit to the mental health unit at Lambeth Hospital. We are grateful to everyone who took time to contribute to our inquiry, to the officials and Ministers at the Department of Health and Social Care for their engagement with our work, and to our specialist advisers and secretariat.

Working on the Joint Committee was a collaborative process as we worked together through this complex topic and learned from each other’s expertise. There were differences of opinion, which may be reflected in later debates in this place. However, the fact that we felt it important to agree the report unanimously is testament to the Committee’s dedication to getting this once-in-a-generation piece of legislation on to the statute book. Our work was supported by an excellent team of officials and Clerks from both Houses. The Committee is grateful for their expertise and support in our work and in compiling the report.

The Mental Health Bill has been much anticipated. Detention rates under the Mental Health Act are rising. A disproportionate number of people from black and ethnic minority communities are detained. Our attitude as a society towards mental health has changed and reform is needed. We welcome the principles contained in the draft Bill, which introduces important reforms to improve patient choice, bring down detentions and reduce racial inequality. In our inquiry we heard concerns about implementation, resourcing and possible unintended consequences of the proposed legislation. Our recommendations address those concerns and are intended to make this important Bill stronger and more workable.

However, the process of mental health reform cannot stop or even pause with this Bill; there needs to be further consideration of fusion legislation of the mental health and mental capacity laws. During our evidence it became apparent that someone needs to drive mental health reform on behalf of patients, families and carers. We have recommended the creation of a mental health commissioner to oversee that process and to challenge the stigma that still exists around serious and enduring mental illness.

Proper resourcing and implementation will be crucial for the changes to work. Mental health services are under enormous pressure, and significant changes and improvements are needed to provide high-quality community alternatives to in-patient care, particularly ensuring that there will be a sufficient workforce to deliver the proposed changes. We welcome commitments from the Government to increase spending on health and social care, but most people we spoke to, including mental health providers, were still unconvinced that current resourcing or workforce plans are adequate. The Government must publish a detailed plan for resourcing and implementation on introducing the Bill, including the implications for the workforce. They should report annually to Parliament on their progress against that plan.

The independent review structured its work around four key principles that should shape care and treatment under the Mental Health Act. Those principles were: choice and autonomy, least restriction, therapeutic benefit and the person as an individual. These principles should be included in the Bill to ensure that they endure and become a driver of cultural change.

Tackling racial inequalities in the use of the Mental Health Act must be at the core of the reform. Black people are four times more likely to be detained under the Mental Health Act than white people, and 11 times more likely to be given a community treatment order. Those figures are rising. There has been a collective failure to address this issue. We now feel that the time has come for that to be addressed. Understanding of racial inequality must be included in the Bill. There must be a responsible person in every health organisation to monitor data on inequalities and oversee policies for change. We heard evidence that community treatment orders are ineffective for most patients and disproportionately used for black patients. We have therefore recommended that they are abolished for civil patients and reviewed for use with forensic patients.

On the important issue of the detention criteria, the draft Bill makes changes to the grounds on which someone can be detained for assessment and treatment, with the intention of moving away from a risk-based model and ensuring that detention will benefit the patient. Accountability is welcome, but we heard that it may lead to people being denied the help they need when they most need it, particularly patients with psychotic illnesses and those with chronic and enduring mental illness. We recommend some changes to the criteria and greater guidance in the code of practice to prevent that.

Too many autistic people and those with learning disabilities are detained in inappropriate mental health facilities, and for too long. Change to the way the Mental Health Act works for patients with learning disabilities and autism is long overdue. The Government’s intention to address that, by removing learning disabilities and autism as conditions that can justify long-term detention under section 3 of the Mental Health Act, may lead to benefits in the longer term. However, we heard that without proper implementation, those changes could make the situation worse, and potential displacement of people with learning disabilities into the criminal justice system could occur. There must be improvements in community care before people with learning disabilities and autistic people can be supported to live in the community. It is vital that reforms are not implemented until that is achieved.

Another pressing risk is that those communities may be detained, instead, under different legal powers, and possibly criminalised. That would be the opposite of what the change is intended to achieve. The Government must address that risk before the changes are implemented. We have therefore recommended the introduction of a tightly defined power to allow for longer detention periods in exceptional circumstances, with strong safeguards in place to prevent that happening unnecessarily.

On patient choice, patients should be able to make choices about their care and treatment. The draft Bill makes welcome changes in this area but does not follow through on a White Paper commitment to give patients statutory rights to request an advance choice document. We heard almost unanimous evidence supporting an advance choices document, and made a recommendation that advance choices should be a statutory right.

The number of children and young people experiencing mental distress has risen dramatically since the covid-19 pandemic. Children and young people continue to be placed in adult wards or in hospitals far from home due to the lack of appropriate care placements. The draft Bill misses a crucial opportunity to address that. We also believe that children should benefit from stronger protections in the draft Bill to support patient choice. This is a complex area and the Government need to carefully think through their proposals, consulting further where necessary about this Bill and how it will interact with the Children Act 2004.

In conclusion, it is 40 years since the Mental Health Act 1983. This draft Bill is needed. If the Government are willing to address our concerns in the ways that we have suggested, the Bill can make an important contribution to the modernisation of mental health legislation. Given our suggested amendments, we hope that the Government act swiftly to introduce the Bill to Parliament in this Session, so that it can be further scrutinised and improved.

[Dr Rosena Allin-Khan (Tooting) (Lab)]

I thank all those patients, campaigners and experts who provided evidence to the Joint Committee. I give special thanks to Alexis Quinn, whose account of her own lived experience with autism touched many Committee members. I also thank the Committee members for what was an incredibly valuable experience and a true example of when cross-party working goes really well.

I am honoured to have worked on a once-in-a-generation opportunity to improve the rights of patients experiencing a mental health crisis, and to tackle the health inequalities enshrined in current legislation. For years the Government kicked updating this legislation into the long grass, and now the draft Bill still does not go far enough to tackle the health inequalities and racial disparities of those detained under the Mental Health Act. I hope the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) will agree that the Government should put patient voices at the heart of this legislation and take the Joint Committee’s recommendations on board.

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[Dr Poulter]

On behalf of the Committee, I thank the hon. Lady for all her work. We were lucky that we had her professional expertise as a frontline clinician, which added to our important scrutiny work. Given that it has been 40 years since there were any changes to the Mental Health Act, I certainly agree that the time has come to make those changes through a Bill. We urge the Government to take on board our well-intentioned recommendations and concerns to strengthen the Bill, and I hope we will continue to see a cross-party, collaborative process to improve mental health care for the patients who most need it.

[The Minister of State, Department of Health and Social Care (Will Quince)]

I sincerely thank my hon. Friend and the Committee for all the work that has been put into this constructive and important report, and I also thank all those who gave evidence to the Committee. The Government are now considering the Committee’s recommendations on how we can further improve the Bill and modernise the Mental Health Act. The Minister for mental health, my hon. Friend the Member for Lewes (Maria Caulfield), gave evidence to the Committee in November, alongside the Minister for prisons, parole and probation, my right hon. Friend the Member for East Hampshire (Damian Hinds).

I am grateful to see that the final report reflects the support that these reforms have on both sides of the House. The Committee has clearly engaged fully with the complexities involved in this work. It is the Government’s intention to take the next steps in getting this legislation right, so that people with severe mental health needs get the help and support when they need it, with their rights and dignity better respected. It is vital that we continue to progress the work we have started with NHS England and others to address the racial disparities that have for too long been associated with the use of the Act. Does my hon. Friend agree that the reforms proposed in the Mental Health Bill provide for an improved framework in which people experiencing the most serious mental health conditions will have far more choice and influence over their treatment?

[Dr Poulter]

I agree with the Minister. He is right to suggest that this is an important step forward and this piece of legislation will make a significant difference to patients, but it is part of a process, not the end of the journey. In particular, I draw the Government’s attention to the potential unintended consequences of some of the well-meaning changes being proposed in relation to patients with learning disabilities and autism and to changing the grounds for detention; for example, it might be harder to detain patients who are the most unwell, with chronic and enduring mental illness and psychotic conditions. I hope the Government will take on board those concerns and ensure that what comes back to this place is a stronger Bill that works in the best interests of patients.

[Fleur Anderson (Putney) (Lab)]

I welcome this report, and in particular the section on racial inequalities, which have been highlighted in my constituency by organisations such as the Wandsworth Community Empowerment Network for many years. Is the hon. Member optimistic after hearing all the evidence from organisations that the inequalities affecting black and minority ethnic groups, especially in terms of culture and policy, will be improved?

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[Dr Poulter]

I am optimistic that if the Government adopt the recommendations we have made, we will have a much stronger Bill that recognises that we need to improve the care that is available to all patients and, in particular, that will deal with some of the racial disparities we currently see in the implementation of the Mental Health Act. We know that black people—particularly black men—are disproportionately detained under the Mental Health Act and are disproportionately likely to receive a community treatment order, or a CTO, as I would term it in professional jargon. There is also a disproportionate use of depot medication for black men. That has caused challenges in building therapeutic relationships and building trust with black communities across London and elsewhere, and it has to be put right.

We have made several recommendations. For example, we believe that the evidence for CTOs is weak for all patients, and there is a disproportionate use of CTOs among the black community, so we have said that we think community treatment orders should not be applied in the civil part of the Bill. We have also recommended greater monitoring of how mental health legislation is used in each mental health provider, to ensure that providers, be they in London or elsewhere, have a proper understanding of how mental health legislation is used. Hopefully, that will start the process of rebuilding the trust of communities—particularly the black community—with mental health providers where it has been lost in the past.

[Dr Ben Spencer (Runnymede and Weybridge) (Con)]

I draw the House’s attention to my range of interests in this area, which were declared as part of the Committee’s report. I thank my hon. Friend for his statement and join him in thanking all those involved in the Committee, in particular the Clerks and the staff, who were fantastic in supporting us as we put this report together.

Every 20 years or so, we go through a process of reviewing our mental health legislation. I am delighted at the work that has been done over the past few years through the Wessely review panel and driven by the Government, to make real changes in this very important area of law. Notwithstanding the huge step forward that the Bill will hopefully make in this area, does my hon. Friend agree that this is the beginning of a journey of continuous reform, rather than the end point?

[Dr Poulter]

The Committee was very lucky that we had the professional expertise of my hon. Friend, the hon. Member for Tooting (Dr Allin-Khan), a former president of the Royal College of Psychiatrists and some distinguished lawyers. I know that my hon. Friend has taken a great interest in this issue for many years, and he is right: this is the beginning of a process, not an end in itself. The Committee recognised that much needed to be done by a future Government to bring fusion between mental capacity law and mental health law, of which I know he was a great advocate throughout our work.

[Jim Shannon (Strangford) (DUP)]

I thank the Committee for its recommendations and the hon. Gentleman for his presentation of this report. Each and every one of us recognises the importance of these recommendations, which are for both patients and staff, and they should be commended to all the devolved Administrations—in particular the Northern Ireland Assembly, as health is devolved. Will that happen, and if not, could he make sure that it does?

--- Later in debate ---

[Dr Poulter]

I thank the hon. Member for his question. As part of our work, we looked at elements of reform that are being considered across the devolved Administrations. The fusion of mental health law and mental capacity law is already well under way in Northern Ireland, so it may be a question of the UK Parliament learning from the Northern Ireland Assembly, rather than the other way round. We in this place will continue to watch with interest how the proposed changes to legislation in Northern Ireland progress, as they may improve what we do when we look in the future, I hope, at a fusion of mental health law and mental capacity law.

[Madam Deputy Speaker (Dame Rosie Winterton)]

I thank the hon. Member for his statement and all colleagues who participated.

Aortic Dissection: Patient Pathways and Research Funding

Dan Poulter Excerpts

Tuesday 13th December 2022 Westminster Hall

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I pay tribute to my hon. Friend’s bravery in bringing this debate to the Chamber. I know that she has been through a lot personally. As she says, no parent would want to experience the death of a child as a result of aortic dissection and her subsequent and recent work to bring this debate here and her work with the charity is commendable. I am sure that it will lead to many lives being saved in future.

On the point about diagnosis, I remember from my days in the emergency department that fast scanning, which is a simple technique that uses an ultrasound scan to check for free fluid in the abdomen, was a very important tool that we could use to detect aortic dissection. It is a simple thing to train ED doctors to do, but that training is not available in the way that it should be. Will my hon. Friend join me in pressing the Minister to ensure that the focus is not always on service delivery in ED? If we are going to have good clinicians, we need to have the right training for them and this is an area that would save lives. Can the Minister put some funding aside specifically for that purpose?

[Mrs Latham]

I thank my hon. Friend for his intervention, knowing as he does what it is like to work in an emergency department. A lot of people come through the department, but the study he refers to about the abdominal aortic aneurysm was only for men of a certain age. This affects people from 17, or even younger, to 90. Although that sounds like a good idea, I am not sure that it would work in practice. We need more CT scanners used more frequently in emergency departments, and that is what is missing in part from emergency medicine settings.

The next phase in the patient pathway for those who have been correctly and speedily diagnosed is treatment. As I mentioned, 80% of those diagnosed survive. That is not enough and research is ongoing into better methods of treatment. However, one area where we can certainly improve is long-term treatments that do not require further medical interventions. There is currently a call for research proposals into that from the National Institute for Health and Care Research. That is excellent news and I encourage the Minister to make as much money as possible available for this area of research.

After treatment, it is imperative that the follow-up treatment for aortic dissection patients and their families is of the highest quality. Two thirds of survivors of aortic dissections have some kind of post-traumatic stress disorder. They need specialist treatment by somebody who understands their conditions. Furthermore, aortic dissection survivors have a long-term condition that places them at risk of future complications. They need to be monitored by specialist teams and currently, that provision is highly variable. Teams exist in some specialist hospitals, but not all patients are reliably followed up, and too often that is a failure to take a holistic approach to follow up. The employment of specialist nurses in every aortic centre, similar to those in cancer and palliative care, would greatly strengthen follow-up.

The massive improvement in the patient pathway would not be expensive. Although I understand that every penny is being counted in the current situation, to provide a specialist nurse in each of the 29 NHS centres in the country that deal with aortic dissection, for two days a week, would cost less than £400,000 in total per year. The charity has explored the replication of the Macmillan nursing model for aortic nurses and, with funding, would be well positioned to support the design and roll-out of that initiative. Given the enormity of the NHS budget, I hope that is something that the Minister will confirm that she will look into.

The final stage of the patient pathway is genetic screening. About a third of patients who suffer an aortic dissection have some sort of genetic predisposition to the condition. That is why I welcome funding. Screening relatives of sufferers can detect those at risk and proactive treatment can significantly reduce their risk. However, that requires specialised clinical genetics input, access to which is, again, very variable. The technology exists to do that, and it would certainly save lives every single year.

There are two steps the Minister could take to improve this stage of the patient pathway. First, the employment of the specialist nurses I mentioned would be of great assistance. They would lead on the patient’s follow-up plan, part of which would include screening for their relatives. The second step would be for the Minister to facilitate a series of meetings between the relevant professional societies and appropriate NHS staff, to agree and implement a set of NHS guidelines for genetic screening for those suffering aortic dissection and for their relatives.

As I have set out, there are improvements to be made all along the patient pathway, which would go a long way towards saving many of the 2,000 patients every year who would otherwise die from aortic dissections. If nothing is done, that number will only increase in the coming years, so it is crucial that we act now.

Turning to the opportunities for investment in research, which would make a huge difference to the diagnosis and treatment of aortic dissection.

NHS Dentistry in England

Dan Poulter Excerpts

Wednesday 22nd June 2022 Westminster Hall

[Derek Thomas]

I appreciate that intervention. In my case, NHS England, and commissioners for the south-west have been fairly good and engaged with the challenge. However, it is a tale of woe, as my right hon. Friend says. Perhaps we can all commit to coming back to this place in a year or two to commend the Minister and celebrate the fact we have a new contract that addresses exactly the challenges that we are all quite rightly highlighting today.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing this debate. He is right to highlight this national challenge. We have substantial challenges with access to NHS dentistry in Suffolk. Part of that, as our right hon. Friend the Member for Epsom and Ewell (Chris Grayling) said, relates to the quality of the commissioning and monitoring of contracts by the local commissioner. Will my hon. Friend join me in urging the Minister to put pressure on local commissioners to take this issue seriously? Also, does he agree that we need to ensure that dentists who are commissioned to perform NHS services do actually provide the services that they are commissioned to provide? Some of them are not doing so at the moment.

[Derek Thomas]

I thank my hon. Friend for that intervention. He is right to say that there are commissioned units of dental activity that are not being delivered. There are all sorts of reasons for that, which I hope to cover in my speech. Ultimately, however, we need to look at the contract itself and consider whether it actually works for patients. The contract was introduced by the Labour party in 2006. We know that it does not work today and is in urgent need of reform, which I will come on to in my remarks.

--- Later in debate ---

[Peter Aldous (Waveney) (Con)]

It is a pleasure to serve under your chairmanship, Mr Stringer. I congratulate my hon. Friend the Member for St Ives (Derek Thomas) on securing the debate. Access to NHS dentistry remains an enormous problem right across England, from his constituency, which is the most westerly, to the Waveney constituency that I represent, which is the most easterly. There is not only a so-called perfect storm, but also a perfect symmetry, which hits the most vulnerable hardest.

The Government have brought in measures to address this crisis, which have had some partial success; but what is needed is a long-term strategic plan for NHS dentistry, which I would suggest should meet the following criteria. First, a secure long-term funding stream. Secondly, a strategic approach to recruitment and retention. Thirdly, replacement of the dysfunctional NHS dental contract. Fourthly, a prevention policy, promoting personal oral healthcare. And fifthly and finally, transparency and full accountability, through the new emerging integrated care systems.

The issue on which I wish to focus falls in the last of those categories. It is the procurement of NHS dentistry, which at present is opaque and has, over a long period, led to some outcomes that are not in the best interests of local residents and do not meet the standards of probity that one is entitled to expect in the award of public contracts.

In 2009, the late Dr David Johnson, a much-loved local dentist with a thriving practice in the high street of Lowestoft, was refused a contract to continue to offer a service that he had provided to the local community for many years. That happened in highly unsatisfactory circumstances, which caused much personal upset and ultimately led to units of dental activity being taken away from Lowestoft, where they were much needed, and reallocated elsewhere.

More recently, approximately two years ago, a contract was awarded for the out-of-hours service in Norfolk. The company that won the contract still does not have either regular dentists or premises, and does not work anywhere near the hours stipulated in the contract.

[Dr Poulter]

My hon. Friend is absolutely right when he speaks of the challenges that patients face throughout Suffolk in accessing NHS dentistry. Does he agree that there is availability of emergency out-of-hours dentistry, but that some companies are not taking the correct steps to provide it—and that some dentists are not opening up the number of slots that they are contractually obliged to, to provide it?

[Peter Aldous]

I thank my hon. Friend and neighbour for that intervention. He is correct, and the example I have just provided illustrates that point.

On the issues with the probity of procurement arrangements, I will move forward to the present. It is welcome that a new, long-term NHS dentistry contract has been awarded for the Lowestoft area, and the locally based Dental Design Studio will deliver the contract to a high standard for the benefit of local people. However, before DDS was awarded the contract, it was initially won by a limited company with no local presence, no dentists and no premises. That company then offered the contract to local practices, seeking bids, initially of £400,000, which it then reduced to £250,000. When it was unable to sell on the contract, it withdrew from the process.

Procurement arrangements that allow such blatant profiteering are quite clearly not fit for purpose. There is also a worry that the process is skewed against partnerships, which have been the traditional means of providing primary healthcare in local communities. Only single legal entities and limited companies are able to tender for NHS dental contracts, with partnerships excluded from doing so. The feedback that I am receiving is that the tender documents are far from straightforward and discourage some local NHS dentists who remain in practice from bidding for contracts.

The transfer of responsibility from NHS England to the new integrated care systems, which will start operating in just over a week’s time, provides an opportunity to carry out root-and-branch reform of the procurement and oversight arrangements for NHS dentistry. We need to ensure that they are fair, transparent and in the best interests of local people. It is vital that we seize this opportunity.

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[Maria Caulfield]

I am very happy to meet MPs. Once we get through the contract announcements before the end of recess, it has to be a priority to look at how we increase the number of dentists in specific parts of the country, whether in York or in coastal or rural areas. I am very willing to do that. Many parts of the country do have enough dentists, but they do not want to take on NHS work, so we are also going to look at the procurement and commissioning of services. That is where the ICSs will come into their own. At last, local commissioners will be accountable for commissioning dental work. There is no ring-fenced budget for dentistry. We spend about £3 billion a year and the work can be commissioned at a local level. The problem up until now is that no one has taken responsibility for that, so the ICSs will be a key change to make that happen.

[Dr Poulter]

I want to clarify one point. Does my hon. Friend anticipate the new dental contract being a sticking plaster, or does she think that it is here to stay that it will put right these challenges?

There is a real problem with the commissioning of dental services. I am afraid that I do not have faith that ICSs will be a panacea to sort things out, because local CCGs, some of which were not good commissioners of a number of services, have simply been cut and pasted into the same posts on the ICSs. Will my hon. Friend reassure me that she will personally look at the commissioning process and hold those commissioners to account, to ensure that they deliver proper dental services?

[Maria Caulfield]

Absolutely. The whole point of the ICSs is that the commissioning service has not worked up until now. Some commissioners are very good at commissioning dental services, while others do not have anyone with dental experience on their boards and are not so good. ICSs will be accountable, which is the difference from what we have now. I will meet ICSs to ensure that they understand the responsibilities.

Health and Care Bill

Dan Poulter Excerpts

Consideration of Lords amendments
Monday 25th April 2022 Commons Chamber

[Margaret Greenwood (Wirral West) (Lab)]

Amendment 29B goes much further than the Bill’s current provisions on workforce reporting, which are extremely weak. It would require the Government, at least once every three years, to lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of health, social care, and public health services in England. What could be more reasonable? One has to wonder why the Government do not support amendment 29B. Surely any Government who were committed to running the NHS as a public service would see these provisions as crucial.

The Royal College of Physicians has pointed out that clause 35

“will not set out how many health and social care staff are needed to meet demand”

and has stated that, without long-term projections, which amendment 29B would provide, there is no way to assess how changes in workforce trends, such as retirements or working part time, will impact the delivery of healthcare. The Royal College of General Practitioners has spoken of unsustainable pressures driving GPs out of the workforce and threatening to destabilise general practice.

Just a few weeks ago, the Royal College of Nursing said that nursing staff are exhausted and that staff shortages are undermining their efforts to give safe and effective care—a sentiment reflected by a nurse I met on bank holiday Monday. That is hugely concerning. As the RCN has said, there is a clear evidence base showing that staffing levels have a direct impact on the safety and quality of patient care. When I met members of the RCN last year, they made clear to me the increased stress levels that nurses are experiencing as a result of staff shortages and the impact that is having on the care they so desperately want to deliver.

According to the Health Foundation:

“In the next 25 years, the number of people older than 85 will double to 2.6 million”

in England, so demand for social care is increasing and we need to know that there will be enough doctors, nurses and social care workers to meet people’s needs. The “Strength in Numbers” campaign, a coalition of more than 100 health and care organisations, says that we must put

“measures to adopt a sustainable long-term approach to workforce planning on a statutory footing.”

Without credible, up-to-date numbers, the system cannot plan.

I support Lords amendment 29B. I urge the Government to think about those NHS staff who are working so hard and are so stretched by the amount of stress they are under because they do not have enough colleagues around them, and to listen to the clinicians who are calling on the Government in this regard.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I draw the House’s attention to my declaration in the Register of Members’ Financial Interests as a practising NHS doctor. I welcome the Government’s concessions on modern slavery and procurement and on the reconfiguration of NHS services. However, I remain concerned about two issues: the care cap and independence in the staffing assessment process.

To touch briefly on the issue of the care cap, a number of years ago I took through this House the Care Act 2014, as a Minister in the coalition Government. We based that Act and the care cap on the Dilnot proposals. I continue to be concerned that the current proposals deviate from the Dilnot proposals, in that those with lower or more moderate net assets will be asked to pay disproportionately more than those with greater assets. That is something I find very difficult to accept. It deviates from the principles of the 2014 Act and the Dilnot proposals, and I hope that even at this late hour the Government will reconsider their position on it.

I rise in particular to speak in support of Lords amendment 29B and the comments by my right hon. Friend the Member for South West Surrey (Jeremy Hunt). It is undoubtedly the case that we cannot have safe staffing in the NHS if we do not have the right number of staff. We cannot meet the increasingly complex care needs of patients with not just one, two or three but sometimes four comorbid conditions if we do not have staff with the right skills and in the right numbers to meet those care needs.

We talk often of building new hospitals and of our programme of capital investment in hospitals, but unless we have the right numbers to staff those hospitals, we will not be able to deliver safe care. In every constituency represented in this Chamber, we recognise that there are staff shortages in the local NHS. We recognise particular challenges in the medical workforce among fully qualified GPs—over the past seven years the number of full-time equivalent GPs has fallen. We recognise challenges in the midwifery workforce, which were brought tragically to our attention by the Ockenden report, and we recognise challenges in areas such as intensive care and paediatrics and throughout the health service.

The problem with health workforce planning is that Governments see the NHS in electoral cycles, but workforce is much more complicated than that. From starting medical school to becoming a consultant it takes perhaps 15 years, and to become a fully qualified GP takes about 10 or 11 years. It is important that we have a genuine independence to the process of workforce planning. I have great faith in Health Education England and I am sure it will produce a good report and assessment, but unfortunately it will be doing so with one hand tied behind its back, because it must do so within the confines of the financial envelope in which it is working, and it lacks the genuine independence to say what the NHS really needs.

If we care about patients and about the future of the NHS and its needs, true independence in a report on workforce is required. That is in the best interests of patients, of the health and care workforce and of the future of our health service. I hope the Minister will reconsider.

Allergy Research and Treatments: Government Support

Dan Poulter Excerpts

Wednesday 9th March 2022 Westminster Hall

[The Minister for Care and Mental Health (Gillian Keegan)]

It is a pleasure to serve under your chairmanship, Sir Charles. I thank the hon. Member for City of Chester (Christian Matheson) for securing this debate on this important issue and the hon. Member for Dagenham and Rainham (Jon Cruddas) for his comments. In my short few months in this role, we have already talked about this important topic on a number of occasions. I take it very seriously and I appreciate the tone in which this debate is taking place.

Allergies affect around 20 million people in the UK. Thankfully, most allergic reactions are mild and people can manage their symptoms effectively. However, for some people, as we heard from the hon. Member for Bolton South East (Yasmin Qureshi) when she spoke about her niece, management of allergies can be complex and reactions to allergens can be severe and cause much distress, and can even, sadly, be fatal on some occasions.

For people living with allergies, everyday activities can be challenging and navigating the world can be an anxious experience. The Government recognise the challenges faced by people with allergies and are committed to ensuring that all children and adults living with allergies are well supported.

As has been mentioned, investing in research is a key component in supporting people living with allergies. It plays a vital role in providing those working in the NHS, public health and social care with the evidence they need to better support parents and families, and supports access to pioneering treatment, diagnostics and services.

The Department of Health and Social Care funds research through the National Institute for Health Research. In the past five years we have provided the NIHR with over £14.1 million in funding for research into allergies. We would welcome funding applications for research into allergies, including potentially into more unusual types of allergies, as more funding is available but on an application basis. There has been a wide breadth of research across the life course on a range of allergic conditions, from hay fever, eczema and allergic or atopic asthma, to food and drug allergies, which can cause severe anaphylaxis, as has been mentioned.

In addition to directly funded projects into allergies, the NIHR clinical research network also supported the recruitment of participants into 79 studies of allergies over the past five years. In 2020-21 alone, the NIHR biomedical research centres had 56 active projects related to allergies, and those projects can make a real difference to people’s lives.

One trial of a new peanut oral immunotherapy treatment in children showed a high rate of desensitisation, with many of the participants able to consume a very small quantity of peanuts following the treatment. The families involved in the trial said that oral immunotherapy had transformed their lives, reducing anxiety and allowing them more freedom in terms of food choice.

Further research is being carried out into the effectiveness and safety of immunotherapy to see whether it can be used to help others. For example, there is a project looking at peanut oral immunotherapy in adults and another investigating cow’s milk oral immunotherapy in babies. I know those will be welcomed by many people. I am very much struck by the stories of Monty and Arlo, which I took to heart, and by the anxiety felt by the children having to deal with this on a daily basis. I am also struck by the maturity with which they both approached it.

In terms of new treatments, in December last year NHS England announced that children in England will be the first in Europe to receive Palforzia, a life-changing treatment for peanut allergies, after NHS England secured the first deal of its kind in Europe. The National Institute for Health and Care Excellence published its final guidance on Palforzia in February 2022, so it is very recent. Up to 600 children aged four to 17 are expected to benefit from the treatment this year, with that number rising to as many as 2,000 in 2023.

It is important that, while we continue to look for treatments, we also consider how best we can support families living with allergies.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

My hon. Friend is right to highlight the advances in allergy treatment. I congratulate the hon. Member for City of Chester (Christian Matheson) on securing this debate and the hon. Member for Dagenham and Rainham (Jon Cruddas) on his work in this area over a number of years.

May I push the Minister on one point? The key challenge for many families is access to diagnostics and the link between primary and secondary care. As well as highlighting many of the successes, will she outline what more can be done to improve timely access to diagnostics for families?

[Gillian Keegan]

I appreciate my hon. Friend’s intervention and will go directly to that point. General practitioners are responsible for ensuring that their own clinical knowledge remains up to date and for identifying learning needs as part of their continuing professional development. I am sure he is aware of that. That activity should include taking into account new research and developments in guidance. All doctors are expected to meet those standards, and the Royal College of General Practitioners has developed an allergy e-learning online resource to support continuing professional development and revalidation, which aims to educate GPs about the various presentations of allergic disease to aid with diagnosis. We appreciate that that has to go through a large number of GPs.

I was talking about families living with allergies. Other NIHR-funded research at the University of East Anglia is developing a psychological toolkit that aims to help parents to learn skills to manage their own anxiety around their child’s food allergy, as well as addressing children’s anxiety. We know that people with allergies are often advised to avoid the substance that they are allergic to, but we also know that that is not always easy or practical, and we have seen tragic examples of where that has not been the case—indeed, Natasha was mentioned. The Government are taking steps to protect those with allergies and intolerances. That includes the introduction of Natasha’s law, named after that sad case, which came into force on 1 October 2021, making it a legal requirement for all food retailers and operators to display full ingredient and allergen labelling information on every food item they sell that is pre-packed for direct sale.

Additionally, food hypersensitivity, which includes food allergies, is a strategic priority for the Food Standards Agency. As an evidence-based organisation, the FSA has been at the forefront of world-leading research, which has had a significant impact on our understanding of food. The FSA is currently undertaking a programme of work to improve the quality of life for people living with food hypersensitivity and provide support to make safe, informed food choices to effectively manage risk. The Medicines and Healthcare products Regulatory Agency is also planning next steps to support the wider availability of adrenalin auto-injectors in public spaces. We have had debates on that here as well. That is a medicine used for the emergency treatment of severe acute allergic reactions. We know there is more to consider about how we might protect people further.

I know that this issue matters to many Members, and to many constituents. I thank all hon. Members for the points they have made and the continued discussion we have had on this topic. I hope they will accept that real progress is being made. I hope I have been able to assure them that we will continue to support people living with allergies through NIHR research and exploring and investing in new treatments. With the engagement and involvement of patients and the public across the country, I hope we can improve the lives and outcomes for everyone living with allergies and their families.

Question put and agreed to.

Access to GP Appointments

Dan Poulter Excerpts

Wednesday 12th January 2022 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Mr Robertson. I thank my right hon. Friend the Member for Chipping Barnet (Theresa Villiers) for bringing the debate to the Chamber. I echo much of what she says, and the Government are delivering on much of it, so perhaps this is an opportune moment to update Members on the progress we are making.

We owe a huge amount of gratitude to general practice staff for their efforts throughout the pandemic, stepping up to run vaccination programmes, continuing with flu vaccinations, looking after house-bound patients and continuing their day-to-day work. They have been absolutely outstanding. Since 30 November last year, more than 52 million covid vaccinations have been delivered by general practice, which is an amazing achievement. They are incredibly busy and have been throughout the pandemic, as reflected in appointment data. In November, general practice delivered an average of 1.39 million appointments nationally per working day, an increase of 6% compared with November 2019. Once covid vaccination appointments are factored in, the increase is greater than 20%. GPs and their teams have been working incredibly hard.

The focus on the booster programme has meant some patients experiencing delays in getting an appointment, but that does not mean that general practice has been closed. GPs and their teams will always be there for patients, alongside NHS 111 and community pharmacy teams. It is important that people do not delay coming forward. We saw patients stay away during the first lockdown, and so unfortunately there was a delay in starting some of their treatment, so it is important that we all get out the message that GP practices are open for business. In my right hon. Friend’s constituency, under North Central London CCG, excluding covid-19 vaccinations, approximately 16% more appointments took place in November last year compared with November 2019, of which 57% were face to face. The crux of the matter that we hear from many constituents is around face-to-face appointments. That is why, in October, the Secretary of State launched the winter support package to tackle many issues my right hon. Friend mentioned. I will just touch on several.

First, we are improving telephone access, because sometimes the problem is that patients cannot get through by phone, rather than their not being able to see a GP. My hon. Friend the Member for Southport (Damien Moore) touched on that. Part of the package is a cloud-based telephony system to help increase that capacity for GPs, who may only have one or two receptionists and a couple of phone lines that get busy pretty quickly as soon as 8 o’clock hits. The improved functionality has the potential to free up existing telephone lines for incoming calls and will be available at no additional cost to practices. We will require GP practices to sign up to this cloud-based telephony system, which will be up and running pretty soon. All those that expressed an interest have been contacted, and we expect many to go live fairly soon. Some practices are already tied into existing contracts, so there may be a slightly delay in roll-out there, but where we can get them up and running, we absolutely will.

Secondly, we are encouraging GPs to offer face-to-face appointments. However, it will not always be a GP that a patient sees. There are a range of healthcare professionals in primary care, from nurses—they do an amazing job, if I say so myself—to paramedics, pharmacists and physios, and the GP is not always the best person for a patient to see. Face-to-face appointments are available, and our message to patients is that they will not always see the GP face to face, but that does not take away from the care that they receive.

On finance, £250 million was announced in the winter support package, which can be used by GPs in a range of ways—whatever suits their local area. For some, it will be a physical expansion of their practice so that they can see more patients. For others, it may be to take on locums, where they are available—that is also a pressure point—or other healthcare professionals or an extra receptionist, or to extend opening times. The money can be used on whatever will help GPs to expand their ability to see patients.

My right hon. Friend touched on bureaucracy and red tape, which is a massive ask for GPs. We have made some temporary changes during the omicron vaccine roll-out period to free up capacity, including extending the sickness self-certification period for people accessing statutory sick pay and suspending requests for medical information from bodies such as the Driver and Vehicle Licensing Agency. We are bringing forth secondary legislation to allow other healthcare professionals to do some of those checks—statutory instruments are going through the system as we speak—and having discussions with other Departments about moving away from always expecting GPs to do medical reports, whether for the Department for Work and Pensions, the Department for Transport or for schools. Patients can do a lot for themselves and a medical report from a GP will not always be required. We are also improving digital technology so that handwritten letters and reports, which take so much time for GPs, can be digitised and made much easier.

One of the most exciting innovations in the package is the promotion of pharmacists, which my right hon. Friend touched on. We have a community pharmacist consultation service whereby patients who phone 111 or contact their GP can be referred direct to pharmacists, who are taking on prescribing skills so that they can prescribe as well as dispense. We are looking towards a more pharmacy-first model as in Scotland and Wales, where patients can go direct to pharmacists without necessarily going first to the GP, opening up primary care and making it much more accessible. I hope that, through a number of the points that I have addressed, it can be seen that we are moving at pace.

Workforce was touched on, and I am pleased that we are making progress on that. We have already recruited 10,000 of an additional 26,000 staff who will be working in general practice by the end of 2023-24. In the North Central London CCG area, 327 additional staff have been recruited to date, with a further 114 anticipated.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my right hon. Friend the Member for Chipping Barnet (Theresa Villiers) on bringing the debate to the Chamber and draw attention to my entry in the Register of Members’ Financial Interests as a practising NHS doctor. In 2015, the then Secretary of State said that we would recruit an extra 5,000 GPs to the workforce. Can the Minister update us on how many extra full-time equivalent GPs are working in the NHS?

Pensions is also a real issue that is stopping the current workforce extending their careers as they face punitive tax penalties. Will she please commit to addressing that and raising it with the Treasury?

[Maria Caulfield]

Absolutely. I was going to come to the number of GPs. I am pleased, as is my right hon. Friend the Member for Chipping Barnet, that we have 4,000 doctors in GP training places this year, which is an increase from 2,671 back in 2014. We are getting more GPs through the training process. However, in terms of GPs in place, there were 1,841 more full-time equivalents in September 2021 compared with September 2019, so we are seeing increases coming through.

However, there are issues with retention as well as recruitment. I think my right hon. Friend touched on issues with the Home Office and GP trainees once their visas expire. We met Home Office officials just before Christmas and there is better working now between the NHS and the Home Office to help facilitate those who come on a visa and need help to get into the workforce, get their visas extended or their training finished before their visa expires.

My hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) made a very valid point about GP pensions. We have discussed that, and we are setting up a meeting with Treasury teams to look at that in more depth. There is no doubt that that is a disincentive to stay in practice, and we will certainly be looking at that further.

I will finish by asking all colleagues to support local GPs. They have had a very tough time. We are taking a zero-tolerance approach to any abuse they receive. That also applies to pharmacists. They have had a difficult time and continued to stay open during the pandemic. Face-to-face appointments were a challenge. We are doing everything we can to support them with the asks to break down some of those barriers. I am optimistic that we will see progress and that patients, who are the most important people in this debate, will see improved access to services in primary care.

Question put and agreed to.