Nurse Training

Nick Thomas-Symonds Excerpts

Wednesday 5th September 2018 Commons Chamber

[The Minister for Health (Stephen Barclay)]

I pay tribute to my hon. Friend the Member for South Dorset (Richard Drax) for his assiduous campaigning on behalf of his constituents and for securing the debate. Its importance is reflected by the fact that my hon. and learned Friend the Solicitor General and the Under-Secretary of State for Wales, my hon. Friend the Member for Eastleigh (Mims Davies), were in the Chamber to listen to the points that my hon. Friend the Member for South Dorset raised.

My hon. Friend spoke passionately about the training of nurses in England and the pivotal role of training in ensuring that we have a workforce to deliver first-class services in the NHS. With a budget in which two thirds of our spend goes, quite rightly, on our workforce, the importance of that workforce is absolutely critical. Indeed, that was reflected by my right hon. Friend the Secretary of State when he set out his three key priorities for the NHS after taking over that post. He particularly emphasised the importance of the workforce within those priorities.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I apologise, Mr Deputy Speaker, for not being here at the start of the debate. A number of constituents who have contacted me are clearly concerned about the fact that the demand for nurses is not quite being matched by recruitment at the moment, particularly in the areas of learning disability and mental health. What specifically can the Government do, in addition to what they are doing, to really focus on those two specialist areas?

NHS 70th Anniversary

Nick Thomas-Symonds Excerpts

Wednesday 16th May 2018 Westminster Hall

[Nick Smith (Blaenau Gwent) (Lab)]

I beg to move,

That this House has considered the 70th anniversary of the NHS and public health.

It is a pleasure to serve under your chairmanship, Mr Hosie. The 70th anniversary of the NHS is an important time for the country, but it is also a special time for Blaenau Gwent. Aneurin Bevan, and the health service he created, was born and bred in Blaenau Gwent—in Tredegar. Since Nye’s death in the 1960s, Blaenau Gwent MPs have followed in the footsteps of a colossus. We in the borough are immensely proud and fiercely protective of his legacy. When he said he wanted to “Tredegar-ise” the NHS, he was basing his plans on the Tredegar Medical Aid Society, a mutual and an organisation established for all, supported and funded by the people of Tredegar, whether they be miners at the Ty Trist colliery, like my grandfather George, quarry workers at Trefil or nurses at the St James Hospital. If Bevan established an NHS for the 20th century, at this anniversary it is important that we ask ourselves what sort of NHS we need for the 21st century.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I should declare an interest as a biographer of Aneurin Bevan. Before my hon. Friend moves on to talk more generally about the future, does he agree that the decision to nationalise the hospitals, and the painstaking work that Bevan did in negotiations with the British Medical Association, mean that he truly is the architect of the national health service?

[Nick Smith]

My hon. Friend has written a terrific biography of Aneurin Bevan. He absolutely captured what Nye did for us all.

On 5 July it will not be good enough just to celebrate the past, the history of this brilliant institution and its architect; we must also look to its future and the challenges it now faces. Many of those challenges have been created by eight years of Tory austerity, which has left our national health service underfunded, understaffed and underprepared. Labour would provide more doctors and nurses and provide a funding level to support the service for years to come. Other challenges cannot be put down to politics. The epidemics of old—diseases once fatal that we have almost eradicated—are being replaced with new health problems that are putting massive strains on our NHS. It is wonderful that people are now living longer, but that also means our population is an ageing one that needs support. As our society gets to grips with caring for our mental health, more people need access to these services than ever before.

Today I want to concentrate on another big challenge: rising levels of obesity, particularly among children. In this case, it is a challenge where an ounce of prevention can be better than a pound of cure. Back in Blaenau Gwent, surveys estimate that 70% of adults are overweight or obese and 11% are being treated for diabetes. Most troublingly, the latest figures from the child measurement programme reveal that last year 15% of four and five-year-olds in my constituency were classed as obese. We should all be worried by that trend, which is being replicated across our country.

--- Later in debate ---

[Nick Thomas-Symonds]

Will my hon. Friend give way?

[Nick Smith]

I am pleased to give way to my other neighbour.

[Nick Thomas-Symonds]

I join my hon. Friend in congratulating all those involved in parkrun. Will he join me in congratulating the volunteers who make parkrun possible in his constituency and in mine in Pontypool and Cwmbran, where I too have taken part in parkruns, but I have not quite reached my hon. Friend’s running level yet?

[Nick Smith]

I thank my hon. Friend for supporting parkrun. Perhaps we should have a south Wales eastern region parkrun championship at some point in the coming months. He is absolutely right about volunteers and the running club supporters who are out there at 9 o’clock on a Saturday morning, or sometimes on a Sunday morning for the junior parkrun, in parks all across the country. They do a great job in all weather. It is brilliant to see. More than 30,000 runners took part in parkruns in Wales alone last year. It is that sort of activity with cross-body support and backing from our community role models that can make a big difference to making such schemes stick.

When Nye wanted to Tredegar-ise the national health service, he wanted a service built on community where we all bought in and all had a stake. In that spirit the public health challenges we face 70 years on should not be tackled alone. To truly take care of ourselves, we need a society that sets us up for success, a system that has our backs, a public service that recognises what needs to be changed and how to do it. The Government have a real chance to honour the anniversary of the national health service in the months ahead, not with pomp and ceremony, but with the sort of action that people will celebrate another 70 years from now.

Bowel Cancer Screening

Nick Thomas-Symonds Excerpts

Tuesday 1st May 2018 Westminster Hall

[Sir Roger Gale (in the Chair)]

I apologise to Members for my late arrival; the previous debate finished early and I was under the impression that I was in the Chair only until 11 o’clock.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I beg to move,

That this House has considered bowel cancer screening.

It is a great pleasure to serve with you in the Chair, Sir Roger, and I am glad that you have taken your seat.

Bowel cancer is the fourth most common cancer in the UK. Sadly, around 16,000 people die from the disease each year. It is estimated that between now and 2035, around 332,000 more lives could be taken by this awful condition. Nearly everyone will survive bowel cancer if it is detected at its earliest stage, but unfortunately only 15% of bowel cancer patients fall into that category.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman for securing the debate. Does he agree that early-stage cancers are not only easier to treat, but less costly for a cash-strapped NHS? That is why we need an effective screening programme that includes lowering the screening age to 50 and implementing the simpler and more accurate faecal immunochemical test. That would help to get the earlier diagnosis, to stop the cancer.

[Nick Thomas-Symonds]

I entirely agree with the hon. Gentleman about the need for an optimal screening programme—I will come to that in a moment.

In Wales around 2,200 people are diagnosed with bowel cancer each year. Nearly half of those are diagnosed at a late stage. Approximately 900 people in Wales will die from bowel cancer every year, but 78% of patients will survive for one year or more, and 58% for five years or more. These figures are not mere statistics; every single extra day with the people we love is a great joy.

I lost my own mother, Pamela Symonds, to bowel cancer on new year’s day this year. She lived just under two years after her formal—too late, I am afraid—diagnosis. She was one of the 10,000 people diagnosed annually at the late stage of bowel cancer. I know only too well the impact that bowel cancer has on families.

[Chris Evans (Islwyn) (Lab/Co-op)]

I pass on my condolences to my hon. Friend. With all candour, I know what he is going through: I lost my father in 2003 to bowel cancer. He was just 51. Does my hon. Friend agree that we need to start screening people for bowel cancer at the age of 50?

[Nick Thomas-Symonds]

I absolutely agree with my hon. Friend and I pass on my condolences to him, even though the loss of his father was some time ago.

Along with my father Jeff, my wife Rebecca and my mother’s many friends, I supported her through three arduous rounds of chemotherapy, helping her to achieve her goal of living long enough to meet her grandson, my son William, who was born some three months after she was diagnosed. Owing to the care and treatment she received, her inspirational bravery and her sheer determination, she lived not only to see him born but to see him reach his first birthday in September 2017, and to see her beloved granddaughters, Matilda and Florence, reach the ages of eight and five—precious moments that are now my precious memories.

For families dealing with cancer, time is everything. Those who are diagnosed with bowel cancer have the best chance of surviving—and of surviving for much longer—if they are diagnosed at the earliest stage. This is why screening is so important.

[Stephen Lloyd (Eastbourne) (LD)]

I thank the hon. Gentleman for securing this important debate. I offer him my condolences on his dear mother’s death. He will be aware of the enormous public petition—it has received 446,000 signatures—that was started all those years ago by Lauren Backler, who also lost her mother. I have supported that campaign for a long time. Does he agree that the evidence is clear that we should be screening at the age of 50, so it is surely time for an end to shilly-shallying from the Department of Health and Social Care? Will the Minister agree to at least pilot screening for bowel cancer at 50? It is obvious that the evidence from such a pilot would be irrefutable.

[Nick Thomas-Symonds]

rose—

[Sir Roger Gale (in the Chair)]

Order. The situation we are in is entirely of my making, and for that I can only apologise. Given that there are so many Members present who might wish to intervene, I am prepared to stay in the Chair for six minutes of injury time to enable the hon. Gentleman to take interventions. I am sure that is illegal, but I am willing to do it, provided that the Minister and the hon. Gentleman, who are in charge of the debate, are prepared to accept that.

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

indicated assent.

[Nick Thomas-Symonds]

I am grateful for that kind offer, Sir Roger. I am delighted to hear that we can continue for an extra six minutes.

The hon. Member for Eastbourne (Stephen Lloyd) is absolutely right. This is a cross-party issue. I believe that his predecessor spoke in favour of the system that he proposes, and the hon. Member for Hexham (Guy Opperman) contacted me to draw attention to the debate that he led back in 2011. There is broad cross-party consensus for looking at the screening age and at more accurate screening methods, which I will come on to.

Participation rates remain an issue. We should send a very simple message to people: “Please do not ignore your bowel cancer screening kit, which could save your life.” There is no doubt that we must also do more to raise awareness of symptoms. Bowel cancer is often mistaken for other conditions, such as irritable bowel syndrome. That only reinforces the point that a number of hon. Members have made about the importance of highly accurate screening.

Previously, the standard screening test was considered to be the faecal occult blood test—the FOB test, as it is known—and all men and women between 60 and 74 received a home test kit, but that has been changing across the country. The best available test is now the faecal immunochemical test—the FIT—which can detect more cancers and can be set to different sensitivity levels, enabling any traces of human blood that are found to be investigated. The Royal College of Pathologists sent me a useful briefing, in which it indicates that it would expect a 45% increase in demand on pathology if the test were set at one level, but a 480% increase if it were set at a more sensitive level. That sensitivity level is important.

The Welsh Government are introducing the FIT from March 2019. I believe that it was due to be introduced in England in April. I hope that the Minister can update the House on when that will happen. I hope that there will be a decision for Northern Ireland soon. Of course, Scotland already screens people using the FIT at age 50.

[Lady Hermon (North Down) (Ind)]

As ever, it is lovely to have you in the Chair, Sir Roger. We forgive you, of course.

My youngest sister had bowel cancer. Mercifully, she had an early diagnosis because she had a wonderful GP. The hon. Gentleman mentioned Northern Ireland. In the continued absence of a functioning Northern Ireland Assembly, will he and his colleagues, and colleagues from other parties, please support the very active campaigners in Northern Ireland who, like me, wish to see the screening age for bowel cancer reduced to 50?

[Nick Thomas-Symonds]

I am pleased to hear the good news that the hon. Lady’s sister was able to recover well. Of course Members across the House should look to support those campaigners. I am in favour of consistency across the UK. One of the great things about devolution is learning from best practice in different parts of the United Kingdom, and people in Northern Ireland absolutely should benefit too.

There are other differences in testing. In England and Scotland, people aged over 75 can obtain a screening test by calling a free bowel cancer helpline. In England, a one-off bowel scope screening is promised for those aged 55, but only around half of areas currently offer that. Will the Minister update us on how progress towards all areas being covered can be sped up?

As I indicated in answer to the hon. Member for Eastbourne, there is cross-party support for reviewing the age at which testing starts. I ask the UK Government and all the devolved Governments to look at and keep under review the age at which screening begins—that is crucial—and the sensitivity of the tests that are used. It seems to me that reducing the screening age, which many Members have pointed out, and increasing the sensitivity of tests are the two uniting themes.

[Lilian Greenwood (Nottingham South) (Lab)]

My hon. Friend is making a powerful argument. Like him, I lost my mother to bowel cancer when she was only 53—an age I am now approaching. Does he have evidence on whether there should be a lower screening age at least for those of us with a family history of bowel cancer, even if the screening programme cannot be extended to everyone under 60 or 55?

[Nick Thomas-Symonds]

I absolutely agree. Although we all want a blanket reduction in the screening age across the United Kingdom, there are a number of risk factors for bowel cancer, one of which is family history, and we certainly need to look at having flexibility around the country so that screening can be done earlier where those risk factors are present.

The charities Bowel Cancer UK and Beating Bowel Cancer seek an optimal screening programme for men and women from 50 to 74. They rightly point out the importance of early diagnosis and the real opportunity to reduce the number of people who die from this awful disease.

[Julian Sturdy (York Outer) (Con)]

I pay tribute to the hon. Gentleman for bringing forward this debate at what must be a difficult time for him. My sympathies are with him. A member of my close family—my father-in-law—is suffering from bowel cancer. Thanks to the superb support of the NHS, we hope he is on the road to recovery. That has brought home to me the importance of early diagnosis. I just want to put on the record the fact that I would support the hon. Gentleman on a cross-party basis to ensure that we bring down the screening age and improve testing wherever we can.

[Nick Thomas-Symonds]

I am sure that all hon. Members would join me in sending their very best wishes to the hon. Gentleman’s father-in-law. I would be grateful if the hon. Gentleman passed those on. I welcome the cross-party support for reducing the screening age. I referred to Bowel Cancer UK, and I should point out that I have been pleased to do a number of runs to raise money for that charity through sponsorship.

I realise that we must deal with two other things to ensure that lowering the screening age and improving the screening process across the UK is effective. First, pathology capacity must be increased, because there will obviously be vastly more samples to deal with. Secondly, we need high-quality colonoscopy capacity to deal with the increased numbers of people referred on for further investigation as more sensitive tests yield further results that need to be checked out.

[Liz McInnes (Heywood and Middleton) (Lab)]

I extend my condolences to my hon. Friend on the sad loss of his mother. I worked in pathology before I became an MP, and I am grateful to him for mentioning it and the increase in capacity that will be required if it is found to be indicated clinically that we need to reduce the screening age to 50.

[Nick Thomas-Symonds]

I am grateful to my hon. Friend for her sympathy and for bringing her experience to bear on the debate. Such increased capacity will be so important.

That we need to be ambitious on pathology and colonoscopy capacity should not deter us from the ultimate goal, however; I want to see every eligible person across the United Kingdom have access to the best and most effective screening methods, so that we can finally defeat this cancer. Saving lives—giving more families more precious moments with their loved ones—should be the only incentive we need to make progress.

--- Later in debate ---

[Nick Thomas-Symonds]

I am grateful to the Minister for his tone and constructive approach. May I press him for a little more detail? He said that FIT will be introduced in England in the autumn, but when will we get closer to a precise date?

[Steve Brine]

I cannot give the hon. Gentleman the precise date today, but I know of his and other Members’ interest in the matter, and as soon as I can give that date I will tweet it and tag him. I assure Members that I will let the House know as soon as I have the date, and I have a funny feeling that Members will be watching closely for that.

On lowering the age for screening, many right hon. and hon. Members and their constituents are concerned that the age at which we invite people for bowel screening should be 50 rather than 60. Such concern is sometimes driven by personal experience of the impact of cancer on families as well as on constituents. The hon. Member for Eastbourne (Stephen Lloyd) feels particularly strongly about the issue and has worked on it for a long time—I worked with him a lot during his first iteration as an MP, and it is good to see him in his second chapter. I thank him and his constituent Lauren Backler, who sadly lost her mum to bowel cancer, for personally delivering to my Department last week a petition on the screening age with, as he said, 400,000-plus signatures. I was in my constituency; otherwise, I would have come down and got it myself. I saw him on “ITV News Meridian”, our local news, walking up Victoria Street with the petition. I thank him for that and will take great note of the petition. We will, of course, consider it carefully and respond in due course, but I hope what I will say today will give him some cause for optimism.

When the bowel cancer programme was introduced in 2006, it focused in the first instance on those aged 60 to 69, and then in 2010 it was extended to 70 to 74-year-olds. When we consider that eight in 10 cases are in over-60s, we can understand why that was the starting point, but that does not have to be the end point. It is therefore crucial that the clinician looking at the bowel following a finding of blood in a stool is as skilled an expert as possible, and the NHS has to make sure there is enough clinical capacity to follow up referrals.

The hon. Member for Torfaen rightly mentioned NHS England capacity, which is critical. To boost clinical capacity in the NHS in England, Health Education England has recently pledged to fund the training of 400 clinical endoscopists by 2021, which will significantly increase the endoscopy capacity in England and is a key part of the jigsaw.

This decision to screen from the age of 60 was also based on the fact that, as I have said, the risk of bowel cancer increases with age and people in their 60s are found to be most likely to complete a testing kit. However, that does not have to be the end of the conversation. Therefore, five years ago, in 2013, we started to introduce bowel scope screening for those aged 55. In the research that underpinned that decision, those who took up the offer of a bowel scope test and follow-on treatment reduced their chances of dying from bowel cancer by more than 40%. Those are good stats. Now, with the introduction of FIT, we have an important, evidence-supported opportunity to consider the totality of the bowel cancer screening programme and maximise the benefits of bowel cancer screening.

--- Later in debate ---

[Nick Thomas-Symonds]

One of the issues with the scope test is its geographical spread: as I understand it, at the moment only about half of England is covered. First, will the Minister comment on when it will be extended? Secondly, I would welcome his commitment to reviewing screening in its totality.

[Steve Brine]

I will indeed ask the question that the hon. Gentleman raises about geographical spread. It is a key point.

I am pleased to say that the UK National Screening Committee is now considering how to optimise bowel cancer screening using those two evidence-based testing methods, namely bowel scope screening and FIT. It will advise on the optimal strategy—the hon. Gentleman rightly used that term—for England, this summer. To inform that advice, it ran a consultation, which ended on 9 April. That focused on whether the current evidence supports a change to the current tests approved for use in bowel screening programmes. In particular, it considered whether an optimal bowel screening programme should use both BSS and FIT. Both those screening methods require significant numbers of highly trained people and significant amounts of hospital resources in the NHS. With the introduction of FIT, it is therefore timely to carry out further work to decide the best combination of tests for the English programme; that includes the issue of sensitivity. I know that there is a lot of debate in the clinical community about the range and the number of people affected. We must get that right.

I am pleased that as part of its deliberations, UKNSC will also consider the most appropriate age at which FIT screening will start. It would be wrong of me, however, to pre-empt its recommendations or, as the hon. Member for Eastbourne said, to announce an exclusive from Westminster Hall. However, it is being considered and Ministers, including the Secretary of State, take a close interest. That is as clear as I can be. We are clear that recommendations must be achievable, so the availability of high-quality follow-on tests—colonoscopy and pathology—will be central to ensuring that we can turn the benefits of a better test into thousands fewer people getting and dying from bowel cancer. I am asking NHS England to consider that carefully. It knows of my clear interest in the matter.

I am thankful that survival rates are improving year on year, with about 60% of bowel cancer patients now surviving for five years or more, compared with about 25% 40 years ago. That is a significant change. As hon. Members have said, early diagnosis is vital—for all cancers, but certainly for bowel cancer—which is why the independent cancer taskforce included driving a national ambition to achieve earlier diagnosis among its six strategic priorities in the cancer strategy for England, which I am passionate about implementing. We remain on track to deliver that priority and to deliver every one of the 96 recommendations in the strategy by 2021. We are, of course, thinking about post-2021 as part of the long-term vision for the NHS, which the Prime Minister spoke about at the Liaison Committee recently.

We hope that the introduction of FIT as the primary test in the bowel cancer screening programme later this year will further enhance the drive towards early diagnosis and ensure that we catch more cases of bowel cancer early and allow for better treatment outcomes.

NHS Blood Cancer Care

Nick Thomas-Symonds Excerpts

Wednesday 17th January 2018 Westminster Hall

[Henry Smith (Crawley) (Con)]

I beg to move,

That this House has considered blood cancer care in the NHS.

Mr Wilson, it is a pleasure to serve under your chairmanship.

Like many people in this room today, I have lost a family member to blood cancer. Five and a half years ago, my mother died from acute myeloid leukaemia, also known as AML, an extremely short time after diagnosis. I have been touched by the many stories of families in Crawley and nationwide who have contacted me to share their own experiences of losing a family member to blood cancer. With conditions such as AML, there is an incredibly short time—sometimes just a matter of days—between being diagnosed and this form of blood cancer taking a life.

It was with those stories in mind that in 2016 I was pleased to set up the all-party parliamentary group on blood cancer. I place on the record my thanks to all colleagues, including those who left Parliament last year, for their work in getting the group up and running and in starting our inaugural inquiry on NHS blood cancer care. While the inquiry, held last year, and the report, to be launched in the Palace of Westminster right after the debate, focus on the implementation of the cancer strategy for England, we are keen to learn from examples of good practice in Scotland, Wales and Northern Ireland and have made approaches to the devolved Administrations accordingly.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I would like to talk about a Welsh example: my young constituent Emily Clark, who was diagnosed at 16 and subsequently sadly passed away. During the period of her illness, her work in setting up the RemissionPossible initiative resulted in 4,000 more people joining the stem cell donor register. Will the hon. Gentleman praise Emily, and her mother Donna Dunn, who is continuing the work?

[Henry Smith]

My condolences to Emily’s family. There are all too many examples of young people passing away from blood cancer. I pay tribute to Emily’s mother for a fine legacy. It is sad that a young life has been lost to this condition, but wonderful that so much good work has been done as a result. I would be grateful if the hon. Gentleman passed on my best wishes to them.

--- Later in debate ---

[Henry Smith]

The hon. Gentleman is entirely correct. I am sorry to hear of his family’s experience. The symptoms can often be confused with others, which is why it is important, as was said in an earlier intervention, to stress that GPs should be given the support and the backing to raise awareness of the symptoms. A simple blood test should be offered to assist with early diagnosis for people displaying one or more of these signs, and GP education and training needs to be improved to increase knowledge of blood cancer symptoms.

As was said in an earlier intervention from my hon. Friend the Member for Henley, unlike solid cancer tumours, blood cancer cannot be surgically cut out, and the experience of blood cancer patients is therefore very different from that of those with other forms of cancer. Blood cancer patients are not currently receiving the treatment and support they deserve, which is one of the key points that I hope the Minister will take from the debate.

[Nick Thomas-Symonds]

Does the hon. Gentleman agree that one of the keys to treatment is having as many people as we can on the stem cell donor register? There are 660,000 selfless individuals on it at the moment. We should thank them and also encourage those between the ages of 16 and 30 to sign up.

[Henry Smith]

The hon. Gentleman is again absolutely correct. The stem cell register is vital to our addressing this condition going forward and beating blood cancer in the future. We would all do well to echo his message.

Medicines Regulation

Nick Thomas-Symonds Excerpts

Tuesday 21st November 2017 Westminster Hall

[Helen Goodman (Bishop Auckland) (Lab)]

I beg to move,

That this House has considered the future of medicines regulation.

What a pleasure it is to see you in the Chair, Mr Davies. I am very pleased that you have been elevated to the Panel of Chairs. Yesterday, the European Parliament agreed to move the European Medicines Agency from London to Amsterdam. Today, we are asking the Minister to tell the British Parliament what will happen to medicines regulation in this country after we have left the European Union. My concern arises from the fact that I have a GlaxoSmithKline plant in Barnard Castle in my constituency that employs 1,200 people. Winston Churchill decided that production should take place in the middle of the Durham countryside, so it would not be hit by Hitler’s bombs; I certainly hope that it will also survive the Government’s Brexit.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I congratulate my hon. Friend on securing this timely and important debate, and declare an interest as the chair of the all-party parliamentary group on off-patent drugs. Does she agree that, irrespective of what happens with the Brexit negotiations, the Government should guarantee that any patient who needs access to drugs will not wait any longer as a result of Brexit?

[Helen Goodman]

In one sentence, my hon. Friend gets to the nub of the issue; I will probably take 20 minutes to reach it. He is absolutely right. The problem is that the Government did not make a plan, and as yet have not resolved how they will regulate medicines from 1 April 2019. I have been asking about that for a year. We have had no clear explanation, no policy statement, and no impact assessment. The Government refused to debate the matter in the course of the legislation for triggering article 50. We have not been able to debate it properly as part of the scrutiny of the European Union (Withdrawal) Bill, which is in Committee today, in parallel with our debate.

We are therefore extremely interested to hear what the Minister will say, especially as two months ago there were leaks from the Department of Health that the Secretary of State was flirting with the idea that we should leave the EMA and join the American Food and Drug Administration. I was particularly surprised that that was being floated, because the Association of the British Pharmaceutical Industry has said consistently that it thinks that we should be aligned with EMA standards. Alignment with Europe on regulation of medicine does not simply mean having the same rules on exit day; it means having a mutual recognition agreement with the EMA, and continued alignment of future regulations as they change, which they inevitably will.

Mental Health Units (Use of Force) Bill

Nick Thomas-Symonds Excerpts

2nd reading: House of Commons
Friday 3rd November 2017 Commons Chamber

[Mr Steve Reed (Croydon North) (Lab/Co-op)]

I beg to move, That the Bill be now read a Second time.

Seni Lewis was a young graduate embarking on his life, aged 23, and living with his parents in Thornton Heath, when he suffered his first ever mental health episode. His parents recognised what was happening and took him to their local hospital. Seni ended up in the Bethlem Royal mental health hospital in Croydon. His parents stayed with him all day, but had to leave at 8 o’clock in the evening. Seni became very agitated when he realised they had gone, and he tried to leave, too. According to the coroner, the staff lacked the training to deal with him, and although there are no allegations that he attacked anyone, they called the police. Eleven police officers took Seni into a seclusion room and, using pain compliance techniques—the kind used against violent criminals—they took it in turns to hold him face down on the floor for 30 minutes in total. His hands were cuffed behind his back, and his legs were in restraints. They held him like that until he could no longer breathe, and he suffered a heart attack. He went into a coma, and four days later Seni was dead.

The coroner criticised Seni’s treatment as “disproportionate and unreasonable”. No patient entering a hospital for care should suffer and die in the way that Seni did. But the family’s agony did not end there. It took seven years of struggle by Seni’s grieving parents until an inquest was finally opened only this year. The coroner found severe failings by the police and the mental health services, and she gave the stark warning that

“there is a risk that future deaths will occur unless action is taken.”

That action is this Bill. What happened to Seni Lewis is not an isolated incident. According to the Independent Advisory Panel on Deaths in Custody, 46 mental health patients died following restraint between 2000 and 2014.

[Nick Thomas-Symonds (Torfaen) (Lab)]

I am grateful to my hon. Friend for bringing forward this very important Bill. Many families in my constituency have contacted me, including some affected by autism, and they are very concerned about the kind of face-down restraint that he has described so movingly in talking about this case. Does he agree that it is very important to have boundaries on the use of this restraint, and that families have some certainty about what can and cannot happen in such facilities?

[Mr Reed]

I completely agree, and I am delighted that the National Autism Society fully supports the Bill and its provisions.

I was talking about the number of patients who have died following the use of restraint, and the many more who have been seriously injured. Government guidelines say that face-down restraint is so dangerous it should not be used at all, but it was used over 9,000 times in the last year alone, including 2,500 times against children as young as seven. People who have been restrained talk about the experience with horror. They say that it is frightening, painful and humiliating, and they feel stripped of their dignity. In the words of one woman:

“It made me feel like a criminal, like I had done something wrong, not that I was ill and needed to get better.”

Statistics from the campaign group Agenda show that women are more likely to be restrained face down on the floor than men. Up to half of all women in mental health hospitals have been physically or sexually abused by men. Subjecting these women to face-down restraint by groups of men adds to the trauma that in many cases led to their mental illness in the first place.

It is difficult to understand clearly from the existing data what exactly is going on. There is no standardised way of recording why, when or how restraint is used. However, from their own data, there appear to be wide discrepancies between mental health providers. Some restrain as few as 5% of patients, while others restrain over 50%. There is no good reason for that variation.

Pompe Disease

Nick Thomas-Symonds Excerpts

Tuesday 31st October 2017 Commons Chamber

[Nick Thomas-Symonds (Torfaen) (Lab)]

I am delighted to have secured this debate to raise awareness of the very rare condition known as Pompe disease. I hope that the very holding of this debate will contribute to that, and I look forward to the Minister’s response, and hope that he will set out some constructive suggestions on what we will do going forward to deepen knowledge and understanding of this awful disease.

My journey towards an involvement with Pompe disease and securing this debate began when I was visited in my constituency surgery by my constituent John Foxwell. He is a polymath. He is an award-winning author and publisher, specialising in communication technology. He worked for his community, too. He lives in my constituency at present, but he previously lived in Devon where he was both an elected councillor and served as mayor, and was also a trustee and director of his local food bank.

Drawing widely on his experience as a teacher and headteacher, John Foxwell has contributed to UK Government policy over the past 20 years. He has managed national educational projects including the first education action zone and the Building Schools for the Future project, and contributed to education White Papers. His reports on education have been drawn on by international companies. Prior to that, he worked in buying and merchandising for a multinational cycle and auto retailer. Knowing the importance of communication, he also founded companies that assisted those who come to the UK from other countries, developing translation tools and assisting community cohesion.

Now, however, John Foxwell has had to leave that remarkable career behind him. He has to spend up to 15 hours a day on a mechanical ventilator to enable him to breathe, as his diaphragm is paralysed. He cannot walk far, or lift or bend or lie flat—if he did, he would struggle to breathe—and he falls easily. A common cold could cause him to go into respiratory failure and die. His life expectancy is significantly reduced. His wife has had to give up her own job to look after him. She is one of an army of carers across the country whose work needs to be recognised right across the House.

John Foxwell is one of only about 150 people in the UK who have Pompe disease. The condition is named after a Dutch medic called Joannes Cassianus Pompe. Given that he was Dutch, his surname was probably pronounced “Pompa”, but the disease has become known as “Pompey” disease. He was born in Utrecht in September 1901, and later studied medicine at the city’s university. His breakthrough came in December 1930, when he carried out a post-mortem on a baby girl who had died at the age of just seven months. He discovered that her heart had become enlarged and that the muscle tissue in the heart had become like a mesh. He thought that a substance build-up was causing that to happen to the heart muscle and came to the conclusion that that substance was glycogen. In other words, the sugar strings that store energy in cells had not broken down as they should have done, due to a faulty gene inherited from the little girl’s parents.

Dr Pompe became a pathologist at the Hospital of Our Lady in Amsterdam in June 1939, and after the German invasion of the low countries in the second world war, he became a part of the Dutch resistance. He was involved in finding places for Jewish people to hide from Nazi persecution. His laboratory at the hospital housed a radio transmitter that was used to send messages from the Dutch resistance to the United Kingdom. He was eventually arrested by the Nazis in February 1945, after the transmitter was detected. On 15 April 1945, he was executed as part of a reprisal for the Dutch resistance blowing up a railway bridge. The discoverer of this disease seems to have been a very brave man indeed.

Dr Pompe had discovered what came to be known as the first category of the disease, the infantile variety that presents in small babies who fail to thrive, and that often leads to death from heart failure in the first year of life. Life expectancy in those case is, alas, less than two years. The second category is “late onset” where, as the name suggests, symptoms do not become apparent until later on in life. As is the case with my constituent John Foxwell, progression is generally slower, but it is characterised by skeletal muscle wasting that causes mobility issues and breathing problems.

Those who suffer from the disease receive support from Muscular Dystrophy UK—I put on the record my thanks to it for sending a briefing in advance of this debate—and the Association for Glycogen Storage Disease (UK), which also provides support to sufferers here. The standard treatment for Pompe disease is enzyme replacement therapy. The faulty gene that is inherited from sufferers’ parents stops the creation of an enzyme called acid alpha-glucosidase—I will refer to it as GAA from here on—that breaks down the sugar strings of energy in muscle cells. The enzyme replacement therapy involves a genetically engineered enzyme that assists with regulating glycogen—the sugar strings— and is received into the body by regular infusions. The trade name for the enzyme is Myozyme, which is available from the pharmaceutical company Sanofi Genzyme.

The availability of Myozyme differs slightly around the country. In England, it is directly commissioned by NHS England under specialised criteria. In Wales, where my constituent lives, the All Wales Medicines Strategy Group recommended to the Welsh Government that Myozyme should be endorsed within the NHS in Wales for the treatment of Pompe disease, but there is a specific restriction in that it is not endorsed for late-onset Pompe disease on grounds of insufficient evidence of clinical effectiveness.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on presenting such a wonderful account of the gentleman involved in the history of the disease. Like others, I have been contacted by Muscular Dystrophy UK, and rare diseases come up here often and are a particular interest of mine. This is ultimately a question for the Minister, but does the hon. Gentleman agree that the Department of Health must ensure that there is adequate support for the centres across the UK that provide highly specialised care for patients with this rare muscle-wasting disease? I think the Minister will respond to that, but the hon. Gentleman’s speech encapsulates what we are all trying to achieve here.

--- Later in debate ---

[Nick Thomas-Symonds]

I am grateful to the hon. Gentleman. I entirely agree that support for the different centres across the country is absolutely vital. While we all know that health is a devolved matter, awareness is so important and is something that we can still promote across the United Kingdom.

My constituent’s particular issue with accessing treatment is that he falls into a category that does not have general commissioning for late-onset Pompe disease, meaning that he would be left having to make an individual funding request, only some of which are successful. However, the reality is that nobody has a chance of accessing the treatment if the disease is not diagnosed in the first place, which was the real challenge facing John Foxwell. His diagnosis took over seven years. Many consultants told him that his diaphragm was paralysed—that was pretty obvious—but they made no link to the disease that was causing the paralysis. John went through some incredibly difficult periods of low appetite, when he was living only on jelly and milkshakes. Unable to function and to continue with the wonderful career that I described, he moved back to Wales, where he was originally from, to die.

Then the diagnostic break came. Nevill Hall Hospital, Abergavenny, is in the constituency of the hon. Member for Monmouth (David T. C. Davies), but none the less it serves a number of my constituents in Torfaen. A respiratory consultant at the hospital gave my constituent a mechanical respirator, which helped him significantly. In addition, he was advised to see a neurologist, who conducted a series of tests, including a genetic test that finally identified late-onset Pompe disease.

Pompe disease is incredibly complex, and it requires a multi-disciplinary approach. The medical disciplines required include geneticists, pulmonologists, neurologists, cardiologists, respiratory therapists, physiotherapists, dieticians and clinical psychologists. Conditions that cross the medical disciplines in that way are, of course, a challenge for our NHS across the country, but it is a challenge that we can and must meet.

I will conclude with an email that my constituent sent to me, which shows where he is at the moment:

“Now I am almost a recluse as I find that leaving the house is extremely challenging. I don’t know the future, but I do know, from statistical testing in other countries, that there are many more people with Pompe Disease out there that are needing to be diagnosed and that I want to be able to assist…in understanding the disease and supporting them when they need help. I am creating Pompe Wales, a Pompe Disease specific charity, to be able to help others who have Pompe, to be able to make the medical professionals aware of Pompe and its symptoms and to link with other Pompe organisations around the world”.

That shows that those who suffer from the disease, named after Dr Pompe, share characteristics with him—they are determined and courageous. But, for them to be able to fight this disease, it must first be identified. The only way to do that is to raise awareness across the medical professions. Nobody should suffer unduly because of falling victim to a disease that is extraordinarily rare.

[The Parliamentary Under-Secretary of State for Health (Steve Brine)]

I congratulate the hon. Member for Torfaen (Nick Thomas-Symonds) on securing this debate. I often think this about Adjournment debates, but this shows how excellent the House of Commons is in that it can debate a Finance Bill and then discuss a condition like Pompe disease.

I read the hon. Gentleman’s article in The Times this morning. The article was well written, and it set out very clearly the heart-breaking impact that this disease has had on his constituent’s health. I am sure his constituent appreciates very much the way he has taken up the issue. Well done for getting an article in The Times!

I hope my response will go some way to reassuring the hon. Gentleman and his constituent that the importance of understanding how to recognise and treat rare diseases such as Pompe disease is increasingly recognised by policy makers and healthcare service providers, not just in England but across the UK and internationally.

The hon. Gentleman spoke movingly about the subject, and he is of course right to praise the army of carers in our country. Carers Week is a big deal in my constituency, as I am sure it is in his, and he is absolutely right to praise the work of Muscular Dystrophy UK. When I was a Back-Bench MP, I was a member of the all-party parliamentary group on muscular dystrophy, which was chaired by a now former Member. Having grown up with friends who suffered with muscular dystrophy, and who ultimately lost their fight, I have a lot of time and respect for Muscular Dystrophy UK.

The number of rare disease patients can be very small. For example, Pompe disease has an estimated prevalence of one in every 40,000 births, but collectively some 3.5 million people in the UK alone are affected by what we term, in policy terms, rare diseases. To put this in context, one in 17 people will therefore suffer from a rare disease at some point in their lives. As we have heard, patients with Pompe disease are deficient in or completely lacking the activity of an enzyme that affects the ability of cells to degrade glycogen, causing its build-up in the body cells, which impairs their ability to function normally. Pompe disease often affects neonates—newborn children—and becomes apparent from within a few days to a few months after they have been born. Sadly, affected infants often require long periods in paediatric intensive care units, with many going on to require long-term mechanical ventilation, as the hon. Gentleman said.

[Nick Thomas-Symonds]

I thank the Minister for that positive introduction to his speech. One issue that my constituent raised with me was that because this disease is genetic it can be picked up by a blood test from birth. He has asked whether such testing could be done on a more regular basis. I understand that this is difficult because the disease is so extraordinarily rare, but I flag it up for the Minister’s attention.

[Steve Brine]

The hon. Gentleman makes a good point, and I know my officials will be listening carefully to what he says. I may come to touch on that point, if I do not deal with it specifically, but I am sure he will remind me.

Some patients with Pompe disease are treated with an enzyme replacement therapy called Myozyme, which is a direct replacement of the missing enzyme via infusion therapy. Myozyme dramatically alters the natural history of the disease in infants, but many patients still require complex long-term follow-up, as the hon. Gentleman’s constituent does.

NHS England commissions its service for patients with Pompe disease from eight national centres; five of these are for adults and three are for children. The centres provide an inclusive, holistic, multi-disciplinary service—the point the hon. Gentleman rightly makes—for patients with lysosomal storage disorders. That is the wider term for these conditions, including Pompe disease. The centres provide rapid diagnosis, an assessment of disease burden, provision of disease-specific therapy, advice on symptom control and palliative care, where this is, sadly, necessary for patients with untreatable disorders. In conjunction with patient advocacy groups, the centres also provide support for affected families. We of course support these centres utterly—that point was put on the record so well, as usual, by the hon. Member for Strangford (Jim Shannon).

As the hon. Member for Torfaen says, late-onset Pompe disease may not become apparent until later in childhood, adolescence or most commonly, as in the case of his constituent, Mr Foxwell, in adulthood. Although late-onset Pompe disease is usually milder than the infant forms of the condition, patients can experience progressive muscle weakness in the legs and trunk—the main body—and it can affect the muscles that control breathing, which is why the mechanical ventilation becomes necessary. As we have heard, as the condition progresses, breathing problems can become more serious and often prove fatal.

We know more can be done to diagnose rare conditions earlier. Currently, the average rare-disease patient consults five doctors, can receive up to three misdiagnoses and waits four years before receiving their final diagnosis. These delays in diagnosis often mean that opportunities for timely interventions can be missed and/or that patients may be given unsuitable or harmful treatments to treat their misdiagnosed condition; more than half of patients wait for more than one year after the first symptoms and some have waited over 20 years. Although not a great term, I am reliably informed that this is called a “diagnostic odyssey”, which causes uncertainty and distress for those affected, as well as considerable costs for health and social care budgets. We should remember that.

The 100,000 Genomes Project—

[Nick Thomas-Symonds]

rose—

[Steve Brine]

I was going to touch on that project, but before I do I shall give way to the hon. Gentleman again.

[Nick Thomas-Symonds]

I am grateful to the Minister for giving way again. Before he moves on to the genomes project, I just wanted to touch on the issue of the diagnostic odyssey. My constituent’s diagnostic odyssey was seven years, and clearly although the symptoms, particularly the issue involving the diaphragm, were very apparent and were picked up, this was about making the link from there to the rare disease. Clearly, one always has to take into account statistical probabilities—there is no direct criticism of any medic or anything like that here—but part of trying to reduce that diagnostic time must be about increasing awareness among the medical profession of many of these rare diseases.

[Steve Brine]

Yes, I absolutely agree. I also have ministerial responsibility for cancer—if only I had a pound for every time I heard early diagnosis mentioned in the office. I shall explain how I think the rare diseases strategy can help with that. Of course, it is important not just for rare diseases, but what the hon. Gentleman says is absolutely right.

The 100,000 Genomes Project addresses parts of the unmet diagnostic need I have described. It focuses on patients with a rare disease and their families and on patients with cancer. The sequencing of an individual’s genome is increasingly utilised as a diagnostic tool in cases where an individual has unrecognised signs and symptoms and to support the diagnosis of a rare disease. I am pleased to say that around 25% of patients whose genome is sequenced through the project now receive a diagnosis for the first time. In addition, despite their often chronic and progressive nature, the associated long-term complications of some rare diseases can be targeted and addressed early if they are diagnosed as such. That is clearly the holy grail. The UK rare diseases policy board has been tasked with looking at the diagnostic issues—the odyssey that I mentioned—and I look forward to it reporting its initial findings to me. I am told that they will come in early 2018, so I shall look out for them.

I assure the hon. Gentleman that the Government are and remain dedicated to improving the lives of all patients with rare diseases. The publication of the UK strategy for rare diseases in 2013 represented a significant milestone for all patients with rare diseases, and it is now being implemented throughout the country. The strategy set out our strategic vision and contains 51 commitments, concentrating on raising awareness, better diagnosis, which has been touched on, and patient care. It also has a strong emphasis on the importance of research in our quest to better understand and treat rare diseases. Research is so important. The Government are committed to implementing the strategy in full by 2020, and we know that the real test of success will be when patients and families affected by rare diseases experience real improvements.

The Minister of State, Department of Health, my hon. Friend the Member for Ludlow (Mr Dunne), announced in a 28 March Westminster Hall debate on the implementation of the strategy that NHS England will produce an implementation plan for the commitments in the strategy that it has lead responsibility for, and I shall hold NHS England to account ministerially. The Department of Health is now working collaboratively across stakeholders to produce the implementation plan for all those commitments that fall outside NHS England’s remit. Both NHS England and the Department are aligning the publication of those complementary plans, and I want them on my desk by the end of the year.

We appreciate the fact that any specific rare disease is, by its nature, very rare, so we should be honest about the fact that there is often a scarcity of patients and expertise in any single country. The diagnosis, treatment and management of rare diseases strongly benefit from cross-border collaboration. Through an EU initiative on patients’ rights in cross-border healthcare, European reference networks were set up throughout European countries earlier this year. These virtual networks act as centres of knowledge, skills and expertise in the field of rare diseases and complex conditions, and provide a platform to create partnerships between healthcare providers here in the UK and throughout Europe.

The UK is already a key player, leading six ERNs—more than any other member state—and participating in 23 of 24 networks, including what is known as the Metab ERN, which covers rare hereditary metabolic disorders such as Pompe disease. Six NHS trusts participate in the Metab ERN, which aims to ensure a joined-up approach to care by bringing together paediatric and adult metabolic physicians throughout the EU. That is really important. The ERNs are a cornerstone of the UK rare diseases strategy, and the Government are committed to ensuring that no patient should be put at a disadvantage through the UK’s exit from the EU—and that is a priority for me. Therefore, an important element of our future plan will be to continue to play a leading role in promoting and ensuring public health—I am also the Public Health Minister—both in Europe and around the world. Hopefully, that will further strengthen the long tradition of international collaboration, which our clinicians and scientific community have in this country, and often lead across Europe and the world.

Let me touch further on research. The full potential for improving our knowledge of rare diseases and our work towards better treatment and, hopefully, prevention can only be realised by continued research into rare diseases. That is why the National Institute for Health Research has established 20 biomedical research centres that develop new groundbreaking treatments, diagnostics and care for patients with a wide range of diseases.

The centres enrolled patients across 60 NHS trusts and, in partnership with Genomics England, led a pilot for the rare diseases element of the 100,000 Genomes Project that has delivered the sequencing of whole genomes of more than 12,000 bioresource participants.

[Nick Thomas-Symonds]

rose—

[Steve Brine]

I think that I can anticipate the hon. Gentleman’s intervention. Go for it.

[Nick Thomas-Symonds]

I am very grateful to the Minister for his generosity in giving way. My constituent has been unable to demonstrate the exceptionality required to access the treatment through an individual funding request. In reality, there is only this one standard treatment. One thing about the research into rare diseases that the Minister has referred to is the need to discover more options for treatment rather than having only one realistic one, as is the case so much of the time.

[Steve Brine]

I completely agree with the hon. Gentleman. That is why I said that research is absolutely central to this. Let us be honest: this country has led the world in this field. We have an absolutely fantastic record and long may that continue, because people’s lives benefit and depend on that. Once again, he is spot on. Let me conclude my point. In 2016-17, the NHIR research infrastructure supported studies into Pompe disease across nine of its centres and facilities.

The hon. Gentleman referred to national variations in access to Myozyme treatment for Pompe disease across the UK. In England, NHS England funds this treatment for all patients, regardless of age or the form of the disease. In Scotland, the Scottish Medicines Consortium does not accept Myozyme for routine use, but it is funded for children and adults by its ultra-orphan drugs risk scheme. NHS Scotland also provides any patients with particularly complex needs access to highly specialised services in England. In Wales, I understand that the treatment is funded for children and adults with late onset of the juvenile form of the disease, but not the adult form where the symptoms are less severe.

As the hon. Gentleman will be aware, healthcare in Wales is a devolved matter, but I am sure that he will raise any concerns with the Welsh Government. I was delighted to hear about the setting up of Pompe Wales, which he talked about in his speech. It sounds really interesting. Obviously, it is in Wales, so perhaps he could send me details of it when it becomes available.

[Nick Thomas-Symonds]

The Minister is entirely right. It is commissioned in Wales for the infantile aspect. There is no general commissioning for late onset. There has to be what is called an individual patient funding request, where a patient has to demonstrate certain things, including exceptionality.

[Steve Brine]

The hon. Gentleman has put that clearly on the record.

Finally, it is worth noting that the rare disease landscape has been greatly transformed since the UK strategy was published in 2013, especially considering Brexit, the evolving legacy of the 100,000 Genomes Project and new emerging technologies such as genome editing. The recent independent chief medical officer’s report “Generation Genome”, which I said at Health questions was a landmark piece of work, and the “Life Sciences: Industrial Strategy” make it clear that genomics has an important role to play in future healthcare delivery, including the treatment of rare diseases. The House of Commons Science and Technology Committee is also currently engaged in an inquiry into genomics and genome editing in the NHS, and I look forward to seeing its report in due course. I can assure the hon. Gentleman that we will harness the remarkable prospects that these new developments present for the benefit of our rare diseases patients. The NHS has always harnessed new technology to lead the world, and it will continue to do so in this field.

I thank the hon. Gentleman once again for highlighting these issues in this debate and in today’s media for his constituent and for all those who suffer from Pompe disease and other rare diseases. I hope that I have helped to reassure them a little that the Government and the NHS are working hard to tackle these conditions and to help to improve the lives of people suffering from Pompe disease and other rare diseases because, ultimately, that is what we are here for.

Question put and agreed to.

Autism Diagnosis

Nick Thomas-Symonds Excerpts

Wednesday 13th September 2017 Westminster Hall

[Bambos Charalambous (Enfield, Southgate) (Lab)]

I beg to move,

That this House has considered a waiting time standard for autism diagnosis.

It is a pleasure to serve under your chairmanship, Mr Howarth. During the last general election campaign, I attended a hustings in Enfield, Southgate organised by the local branch of the National Autistic Society. Following that meeting, and after further discussions with constituents and others on issues related to autism, I decided to request a debate on the matter. During this debate, I will briefly describe the effects of autism and explain the National Institute for Health and Care Excellence’s diagnostic assessment standard. I will also question why that standard is not being adhered to, explain the impact of late diagnosis and propose a way forward to the Minister.

As some people may be aware, autism is a lifelong developmental disability that affects how a person communicates with and relates to others and makes sense of the world around them. It is a spectrum condition and affects individuals to varying degrees.

[Nick Thomas-Symonds (Torfaen) (Lab)]

All my constituents who contacted me about this issue are very concerned about the time taken for diagnosis. Does my hon. Friend agree that it is important to have a consistent approach right across the country—like in Wales, where last year the Welsh Government introduced a national autism strategy?

[Bambos Charalambous]

My hon. Friend makes a valid point: consistency is required across the range.