Tobacco Control Strategy

Philippa Whitford Excerpts

Thursday 17th December 2015 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The hon. Member for Harrow East (Bob Blackman) gave us a comprehensive summary of the situation, so I will bring us back to a few key points that we need to think about. What are the issues? They are not just the obvious things that people care about, or see mentioned in adverts, such as lung cancer; there is hardly a part of the body that is not affected by smoking. There are many problems that people are not aware of, such as stomach ulcers and bladder cancer. There are also the obvious ones, such as strokes, heart attacks, peripheral vascular disease and dementia—14% of Alzheimer’s is caused by smoking. Amputation is commonly due to peripheral vascular disease. Those are things that put people in a dependent situation and often result in them being in care homes. Not only does that have a direct cost for the NHS, but huge costs in our care world will become an increasing burden.

We have had quite a lot of success, but as was mentioned, 18.7% of people in England smoke. Unfortunately, while there has been a considerable drop in Scotland, the figure there is 20%. We started with the worst heart attack rates, and we still have 10,000 people in Scotland dying from heart disease every year. That number is almost equivalent to the population of Troon, where I live. That is a considerable number of lives lost every year. In England, the figure is 100,000. In addition to the question of the number of people who die, there is the painful journey to dying, and the amount of debilitation and suffering for the person and their family.

We have had success: in March 2006, Scotland was the first United Kingdom country to go for the smoking ban, so next year’s 10-year anniversary is approaching. I expect that there will be a re-evaluation of the ban’s success. We had a 17% drop in admissions for heart attack in the first year. That is a bigger effect than anyone expected. We saw an 18% drop in admissions for acute childhood asthma. Myocardial infarctions had been dropping slowly by 3% a year in the previous decade, but the rate accelerated to 17%. Childhood asthma admissions had been increasing by 5% a year until the smoking ban; there has been a 40% drop in smoking exposure for 11-year-olds. And so it goes on. We saw a much bigger impact in the first year than we could have hoped for. There has been success, and that has been UK-wide. It has all been done separately, but we were very much moving in the same direction.

We think of the debates that we have had here with the Minister with responsibility for public health on other issues, such as obesity. The whole public health agenda involves us taking radical action. It is interesting to hear about the earlier debates on banning sponsorship and banning smoking in public places, and how hard those things were to do, but look at what we and the NHS have recouped from that. We need to look at that going forward.

The impact of the cuts and changes to Public Health England has been covered in great detail. It is right that a lot of public health measures are integrated in local authorities, because they can bring about a more people-centred approach to such things as active transport, and the control of how tobacco is sold and how things are sold near schools. This is about looking at the whole person, because public health cannot always just be campaigns looking at one bit at a time. We need to challenge our whole lifestyle, and local authorities are in the best position to do that.

Unfortunately, Public Health England faced a significant cut of more than 6%, or £200 million, and it has been earmarked for significant ongoing cuts. That is a real problem. We have heard about the cuts to smoking cessation, including Manchester stopping all specialist services, and it being on a charitable or basically ad hoc basis in other places, and that just is not good enough. We need to think about how we go forward, and the lives being lost, the suffering being caused and the burden on the NHS.

In the five-year forward view, a shortfall of £30 billion was identified. Some £22 billion of that is expected to be found by the NHS. When Simon Stevens was in front of the Health Committee, on which I sit, he identified that the NHS was expecting about £5 billion to be saved through prevention, but at exactly the same time, we are talking about cutting public health funding. If that prevention does not come about, that £5 billion saving will not happen and the NHS will hit a brick wall. It is important that we look at all that local authorities do, including to prevent tobacco being sold to under-age people, and to prevent the smuggling of cigarettes and the selling of illicit cigarettes—the whole environment that people are facing.

The hon. Member for Harrow East mentioned the experience in New York, and the stalling of the drop there. That is already being seen here, with the slight increase in the prevalence of smokers, the decrease in quit attempts and the decrease in success. One of the biggest successes is an almost halving of young smokers starting. While the main drive of smoking cessation is helping people to stop, it is important that we do not create future generations who are in the same boat as ours. If we had listened to Wanless 12 years ago and got serious about public health then, we would be in a better place. He said that there would be a sudden surge of preventable and multimorbid diseases hitting the NHS, and that is exactly what we are living through.

It is timely that the debate in the Chamber is about the 1,001 critical days of pregnancy and the first two years of life. We need to invest in our children to try to have healthier, more successful generations in the future. We see odd patterns, such as the connection between smoking and people who end up in prison, and between smoking and those who have mental health problems. There has not been enough research to enable us to say that that is causal, but the fact that mental health patients smoke one third of all tobacco consumed does prompt the question: which one is the chicken, and which the egg? We need to think about our future generations; we need to ensure that pregnant women stop smoking—and do not start again as soon as the child is there, thereby exposing those young children to cigarette smoke. A lot of work has been done on smoking in cars. There has been a big campaign in our neck of the woods to try to get people to go outside the home and not smoke in the presence of children.

We have had a huge amount of success on this issue, due to the work of successive Governments who have ploughed forward, but we cannot afford to take our foot off the gas. We owe it to adults, to those who are approaching the age at which they might take up smoking, to the young, and to those not yet born to aspire to a future generation that is not burdened with the crippling diseases related to smoking. I saw this as a breast surgeon. People ask, “Why do people from deprived areas have poor success from cancer treatment?” Quite simply, I would meet someone aged 70 with breast cancer who had begun to collect morbid diseases from the age of 50. I could see straight away that they would not survive chemotherapy, and might not survive surgery. Treatment for a disease that is not related to smoking is therefore completely inhibited by their underlying disease. Smoking affects every part of people’s bodies. It affects the NHS and our society. We need to ensure that the smoking control policy we have at the moment is quickly replaced by one that is just as determined.

Conception to Age 2: The First 1001 Days

Philippa Whitford Excerpts

Thursday 17th December 2015 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

One other area we need to consider is malnutrition and micro-malnutrition. Regardless of obesity or weight, we are seeing a more malnourished diet in this country from poor quality food and reliance on food bank food. Work done has shown low levels of iodine, which increases cretinism, and low levels of folate, in girls in their late teens, which means that, as they enter the child-bearing age, they are at high risk of having children who have major disabilities.

[Bill Esterson]

I am glad the hon. Lady managed to get that point on the record. That is an incredibly important part of the picture of the damage done to brain development. I want to concentrate my remarks on the damage from alcohol and the inquiry report that the all-party group has just published, but I am grateful to her. Her point is very complementary to my remarks.

My hon. Friend the Member for Nottingham North made a powerful point on the potential of early intervention—he said it could be the biggest deficit reduction scheme of all and mentioned the figure of £17 billion. That is an important point when it comes to foetal alcohol spectrum disorders. In Canada and the US, they use the term “million dollar baby”. It refers to the lifetime costs of the damage done by alcohol during pregnancy. The hon. Member for Congleton and others have mentioned many of those costs, whether it is the inability to engage socially or hold down a job. Many end up in the criminal justice system and many of us care for children and young adults who were damaged by alcohol during pregnancy. All of these things have huge economic and social costs. It is incredibly important that we take those points on board, whether on alcohol harm or other forms of damage and deprivation caused during pregnancy and in the early years.

The all-party group took evidence from a great many experts: Martin Clarke of the Adolescent and Children’s Trust; the consultant psychiatrist and nationally renowned expert on FASD, Dr Raja Mukherjee; Sir Al Ainsley Green, now President of the British Medical Association; SABMiller from the drinks industry; the British Pregnancy Advisory Service; Public Health Research; a midwife; and parents and carers, as well as young adults living with foetal alcohol spectrum disorders. We heard heartrending examples of damage done, difficulties faced and the life-limiting effects of alcohol during pregnancy.

I want to pay tribute to and thank the Foetal Alcohol Spectrum Disorder Trust for the secretariat support, and other organisations such as the National Organisation for Foetal Alcohol Syndrome, which has for many years attempted to improve the education of professionals in health, education and other sectors on what is needed to prevent the disorder and to support people who care for children and young adults; and Mencap, which advises GPs.

There have been some puzzling changes over the past 20 or 30 years, something the hon. Lady touched on. In the 1970s, alcohol consumption in the UK was one of the lowest in the western world. From that low base, however, there has been a steady increase. There is a remarkably strong correlation between the increase in alcohol consumption and the increase in the incidence of mental health problems, attention deficit hyperactivity disorder, autism, Asperger’s, and many different kinds of learning and physical disabilities. The remarkably close correlation suggests causality. Brain damage is not reversible and is clearly significant. As the hon. Lady said, the World Health Organisation estimates that 1% of people born today are affected by FASD. Even at 1%, that is 7,000 children born every year. That is 7,000 too many.

For anyone new to this subject, there is a widely shared video of the effect of a small drop of alcohol on an embryo, which is compared with an embryo that does not experience the ingestion of a small drop of alcohol. The difference is stark. For two hours, the embryo stops moving altogether. We can only wonder at the damage done at that very early stage of pregnancy. International evidence suggests that the damage is done in the early days and weeks in particular.

As the hon. Lady said, the advice is far from clear. On the one hand, people are told not to drink. That seems clear. From the evidence heard by the all-party group, that is the right advice. However, the advice also says that if a woman chooses to drink, she should drink only one or two units. The advice appears inconsistent and contradictory. We took evidence from health professionals, the vast majority of whom do not appear to be aware of the real level of risk and danger. They do not appear to be passing on advice to women planning to conceive or who are pregnant. That is why our inquiry recommended it be made clear that the best thing for mother and baby is for the mother not to drink at all.

I hope that the Minister—I am sure he will—and all who are interested will read the report and carefully consider its recommendations. It is only an initial report—we plan to continue our work—and I hope that he or one of his colleagues will come to one of our meetings to discuss this matter in greater detail. As my hon. Friend the Member for Nottingham North said, early intervention gives us a fantastic opportunity not only to improve the life chances of many people but to save a lot of money. When it comes to the damage done by alcohol during pregnancy, the 7,000 figure, which, from the evidence we received, might well be on the low side, suggests that there is a huge opportunity. I hope that, as a result of the work we have done and the fine work of those Members responsible for today’s report, progress can be made and that the Minister will agree to commission the prevalence study, so that we can start to reduce the number of children damaged every year in this country.

Victims of Contaminated Blood: Support

Philippa Whitford Excerpts

Wednesday 16th December 2015 Commons Chamber

[Jane Ellison]

That point is well made and very much on my mind. When I can say more about the shape of our proposed reformed scheme, I hope my hon. Friend will see that we have tried to respond to her concerns and those of many other right. hon. and hon. Members.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The Penrose inquiry was held in Scotland—there has not been a UK inquiry—and, in response, the Prime Minister made his statement about the £25 million transitional payment. These people are awaiting a final settlement and compensation for what the NHS did to them, but their suffering goes on. We were told that the transitional payment would be made this financial year to help people get to that settlement. The consultation is on the final arrangement, but we need some action now and people need access to the new hep C drugs. The Scottish Government have written about support for fuel payments, but we need the transitional money now. It should not be kicked into the long grass.

[Jane Ellison]

This certainly has not been kicked into the long grass. As I have told the House, it is my intention to consult in January. I have said before, but it is worth repeating, that although we are working to establish a fair resolution, liability has not been established in the majority of cases, so it is not appropriate to talk about compensation payments, particularly on the scale that some campaigners and colleagues envisage. I have been open about that for many months. The hon. Lady is right to make the point about treatments, and all those things will be considered. I can confirm to the House that, although the £25 million was allocated to be spent in this financial year, it will be carried forward. The money that the Prime Minister announced in March was to support the transition of the scheme, which we envisaged beginning next spring, following the consultation. The money will support that, and it will be carried forward.

ACCESS TO MEDICAL TREATMENTS (INNOVATION) BILL

Philippa Whitford Excerpts

Wednesday 16th December 2015 Public Bill Committees

[George Freeman]

I do not. I am politely winding my way round to saying that. However, the reasons are important. It is not that I object to amendments at all—I hope the Bill will be heavily amended in Committee to reach that nirvana of all the parties—but, because the clause is important and helps to clarify the Bill’s intention, I suggest that the amendments should not be pressed. However, we might work on a package of amendments on Report that tackle giving clinicians access to information about innovative medicines and the important points made by the hon. Gentleman.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

My concern about the Bill is that it seems to create a parallel system for something that we already have. We already have clear structures around litigation, defence and informed consent, which the Bill seems to bypass. If a doctor finds one other doctor who agrees with them, they can do what they like to somebody—they can go out and clip their privet hedge and give it to them: they are at the end of life and desperate, so they will try anything. That is really concerning.

The database would create a second information system that is not just about people reporting something. Someone might go to it in desperation, read about privet hedges and try that. That creates a separate system from the research system that has been developed over many years.

When I was a young doctor—sadly that was quite a long time ago—there was a paternalistic approach, in which the patient did exactly what the doctor told them. The thing is, when people are at the end of life or suffering from something for which we do not have an easy treatment, they are incredibly vulnerable, so we have a duty to protect them.

Part of the problem with the Bill is that it would create separate systems. Why should a doctor go through the entire system of pre-clinical research phases 1, 2 and 3, getting permission and getting things passed when, whatever their idea is, they can talk some wee lady into it and give it to them without any cover? That is quite frightening and would undermine our trials process.

There are things that could be improved. I agree with the Minister that some institutions have become rigid and defensive, thinking, “We don’t want you using that for anything else.” Out of the Bill we could get, as the Minister said, a database that talks about research that is going on that we could collaborate in, and what the findings and trial results are. Busy, front-line clinicians are often unaware of trials. In Scotland, we have the Scottish Breast Cancer Trials Group so that we flag up trials to people. There could be merit in that, but the idea that putting on a database something that I do to a patient, just randomly, somehow gives it credence is actually quite frightening.

We have Bolam. We have a system and a definition of negligence and litigation. Creating these two parallels undermines the patient. How can they give informed consent if we are talking about something that has no work-up, no safety profile and no phase 1 trials? How do we ensure that we are not encouraging people to do that across the country? There are things that could be done with the Bill but, as it stands, I have grave concerns, as many other doctors do.

[The Chair]

Before I call the Bill’s promoter, I have allowed quite a lot of latitude but it is important in Committee to focus specifically on the amendments that we are deliberating, which the hon. Lady did without referring to them. That is the way forward and that is our system.

--- Later in debate ---

[George Freeman]

I thank and pay tribute to the hon. Member for Torfaen for his persistence and patience in working with all parties on this matter. Similar to the Bill we are discussing, his Bill touched on an ambition shared by colleagues across the House to promote greater off-label use of medicines. I have encouraged him and my hon. Friend the Member for Daventry has welcomed his commitment to try to work through this Bill to see whether we might be able to tackle some of the same objectives, which is an ambition I strongly support.

In this Bill, my hon. Friend the Member for Daventry has repositioned a much stronger focus on the database being a registry not for capturing innovations that medics might or might not think are reasonable to record, but for the provision of information to clinicians on licensed, unlicensed and off-label uses for innovative medicines that are currently being developed. That represents a powerful opportunity for us to strike a blow for getting clinicians access to drugs that are in development, in trials or in an early access to medicine scheme and to off-label drugs currently in use of which clinicians might be unaware.

I dream of the day when a clinician can talk to a patient, click on their electronic medical records to see their history, click on available treatments for patients of that profile and see, at the click of a mouse, what clinicians around the country are doing, including the numbers. That could then be used to help intelligent prescribing, using their best clinical judgment and their knowledge of the patient. There is an interesting opportunity for us to do something here.

Let me turn to the amendments. Amendment 7 seeks to make it explicit in the Bill that “treatments” includes access to off-patent drugs. I actually support that ambition. Lawyers at the Department of Health will tell me that it is otiose—a legal term meaning that it is not strictly necessary—but, as a pure democrat, I think that it would be helpful if we could find a way to make it clear that that is specifically what we want to achieve. I can list the reasons why a lawyer might say it is not a good use of legislation because it is already covered by the existing definition, which it is. I think it would be helpful to send a message that we explicitly want the database to promote off-label use. As the Minister responsible, I would happily take instruction in whatever mechanism from the House to go away and come back with a proposal on it.

Amendment 8 seeks to provide for the establishment of an arm’s length body to assist those seeking regulatory approval for off-patent drugs in a new indication. As the hon. Member for Torfaen is aware, we have talked about that at length. Although I understand the thinking behind it, I do not accept it. For those colleagues who have not been following this debate closely, the thinking is broadly that because an off-label indication does not have an applicant company with a patent and a commercial interest, there is nobody to promote its case, and to put together the data package, lobby for it and advocate for it through the system, and to ask NICE to look at it. Word has got round that, because of that absence of a commercial interest, those uses are not being properly looked into, and that if it had a licence clinicians would use those off-label indications.

I understand it, but I think that the logic is profoundly flawed for two or three reasons. First, the evidence is that even where off-label indications are well evidenced and even recommended by NICE, in which case there is clearly no barrier, uptake is patchy and in some places slow. That is not because of the absence of recommendations and data. In the example of the use of Tamoxifen as a preventative treatment for cancer, in fact, patients and clinicians decide not to use it, in many cases because of the side effects or because women prefer to have surgery. It is not due to the lack of a licence; it is because it is an off-label use and has different impacts on different patients, and patients always want to reserve the right. It is the same with the use of bisphosphonates. There are off-label treatments that are well evidenced and well supported and recommended by NICE. It is not about the absence of a licence.

Most profoundly, I worry that if we expected all off-label uses to have a licence we would inadvertently create a situation in which those off-label uses that did not have a licence would suddenly become questionable. I totally understand that is not the intention of the hon. Member for Torfaen. We might actually undermine our objective and end up in a situation in which we have to license every single off-label use in order to keep it legitimate, which would be the complete opposite of what my hon. Friend the Member for Daventry wants to achieve. I will come later to why the Secretary of State and I do not want to become the licensors of medicines.

[Dr Whitford]

I accept the Minister’s point about Tamoxifen. There are certainly other reasons why patients do not take it. As we move into an era of more and more non-medical prescribers—nurses and professions allied to medicine—those people are going to be a lot less comfortable prescribing unlicensed drugs that are not in the “British National Formulary”. Those people are made to sign a liability form and they are simply not going to do that. We are moving patients out into the community. The idea that they will come to a specialist every eight weeks for a prescription is not practical.

Southern Health NHS Foundation Trust

Philippa Whitford Excerpts

Thursday 10th December 2015 Commons Chamber

[Mr Hunt]

I will do that, and I am very grateful to my hon. Friend for giving me the opportunity to do so. We see this situation all too often. There was a story in the Sunday newspapers about a family being shut out of a very important decision about the unexpected death of a baby. It is incredibly important to involve families, even more so in the case of people with mental health problems or learning disabilities. The family may be the best possible advocates for someone’s needs.

We need to change the assumption that things will become more difficult if we involve families. More often than not, something like litigation will melt away if the family is involved properly from the outset of a problem. It is when families feel that the door is being slammed in their face that they think they have to resort to the courts, which is in no one’s interests.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I echo what the Secretary of State said about family involvement, which should be routine in investigating an adverse event. It definitely takes the heat out of the situation.

There are two issues here. One is the shocking difference between 30% of adult deaths being investigated, and just 1% of deaths of people with learning disabilities, and Connor represents the human face of that, which is frightening. The second issue is about individual trusts being left to decide what and how much they investigate, and what they produce, because a much more systematic consideration of the data is required. NHS England publishes annual mortality figures. Strikingly, 16 trusts that were identified with higher than expected mortality levels also had higher than expected mortality the year before, yet it appears that no action was taken. The benchmark appears to be “average”, but if we have poor performance, that average is lower. We should set our aspirations higher than that.

[Mr Hunt]

The hon. Lady is absolutely right. The 30% figure was for people with mental health conditions, not for all adults, but I question why we are investigating only 30%—the highest figure at Southern Health NHS Trust—of unexpected deaths. These were not just deaths; they were unexpected deaths, and it is the duty of medical directors in every trust to satisfy themselves that they have thought about every unexpected death. We must reflect on these serious matters.

The hon. Lady is right about the need to systematise processes when there is an unexpected death, so that we do not have a big variation between trusts. The exercise that Sir Bruce Keogh is doing, going around all the trusts, is about trying to establish a standardised way of understanding when a death is or is not preventable. The hon. Lady has been a practising clinician, so I am sure she will understand that at the heart of this issue is the need to get the culture right. Clinicians should not feel that a trust will take the easy route and blame it all on them, rather than trying to understand the system-wide problems that may have caused a clinician to make a mistake in an individual instance, and that is what we must think about.

Sugary Drinks Tax

Philippa Whitford Excerpts

Monday 30th November 2015 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Thank you, Mr McCabe. I am actually Dr Whitford; Eilidh Whiteford—my hon. Friend the Member for Banff and Buchan (Dr Whiteford)—is the other one, whom I always get mixed up with.

Like the hon. Member for St Austell and Newquay (Steve Double), I am clearly not skinny. I was not overweight as a child; it was the usual comfort eating later on, middle age, lack of exercise and all the rest of it. I know what it is like to move through a world where everything shouts “eat me” all the time. We live in a totally obesogenic environment. The idea that it is easy to resist things is simply not true. Everything is geared towards making people eat unhealthily. We spend a little more than £600 million on obesity prevention, but £256 billion is spent on advertising unhealthy foods. It is David and Goliath. It is difficult for people to make the right choices.

Obviously the debate is about the sugar tax, but as Members have said, the issue goes much wider than that. The hon. Member for Totnes (Dr Wollaston), who is the chair of the Health Committee, talked about the sheer scale of the problem. One third of children leaving school are obese or overweight and a quarter are obese—that is the reason for the differing figures mentioned earlier. It is predicted that 70% of the population will be overweight or obese by the mid-2030s. That is an astronomical number. Our health service will not cope with all the directly obesity-related problems such as type 2 diabetes, cancers and heart disease. We have heard figures about the cost of that from other members of the Health Committee, but it is estimated that the societal costs are £27 billion. We all know someone who was overweight or obese as a child, and we know about the bullying, exclusion and self-contempt that occurs and the impact that that has on schooling, and therefore on jobs, which leads to another generation of deprivation. People say that a tax might be regressive, but it would be no more so than duty on cigarettes or alcohol. It is important to see it in that light.

We have discussed evidence from Mexico, which we heard in the Committee, but other countries such as Norway, Hungary and Finland have taken the same approach. Although not all the evidence has been peer-reviewed, published and assessed, all the details of the national experiments point in the same direction. Cochrane reviews coming up in the next year to 18 months will be able to put that information in a solid position based on experiments and data. At that point it will not be possible to ignore the issue, but we need to be thinking now about our options and what we will do.

Although this is a debate about sugar tax, the Health Committee made nine recommendations. Sugar tax is the one that the media are interested in, because it catches the light, but it is part of a whole package and a sugar tax is not even in our top three recommendations. The first is about promotions, because 40% of food bought in our shops is on promotion, and that is heavily weighted towards unhealthy foods. We need to look to rebalance that. One Member who has scuttled off said that we would come up with other rules such as getting rid of discounting, or we would suggest portion control—darn tootin’ we will!

We need to realise what we are fighting, because we are talking about something deeply shocking and very dangerous. The argument is that people who are less well off save money if they can buy one for £1 or two for £1.50. However, the evidence we heard is that, if that means they buy two packets of biscuits, one will not be put in the cupboard for next week; both will get eaten this week, and the same mum or dad will be back the following week to shop for another packet of biscuits. Therefore they have not only eaten far more unhealthy food and sugar but spent more money. Promotions of unhealthy foods in multi-buys are not helping anyone.

We also see a change in portion sizes. Packets are getting bigger, and there is the bottomless cup at McDonald’s or wherever. There is the end of the aisle, the pester power and the stuff at the till. Every mum and dad out shopping at the supermarket with their wain—that is Scottish for child—will know what it is like: they can see the light at the end of the tunnel, then their child hangs out of the trolley and grabs something. They may put it in their mouth, which means the mum or dad is obliged to pay for it. Some supermarkets have been good at taking that opportunity away, but not all of them. My local supermarket still has sweets right at the till.

Promotions have a big impact and should be tackled. So should marketing, because of the sheer scale of the budgets for and against obesity. It is not just about asking for advertising to be put after 9 o’clock; it is particularly about what is emerging on the internet in social media and advergames, as the hon. Member for Totnes mentioned. Things keep wriggling around, so we need a strategy broad enough to cover that.

Reformulation is almost the holy grail. We have seen its success with salt, but it took a long time. We have taken about 40% of the salt out of the British diet, and by and large people have not noticed. However, we do not have 10 years to do that. Reformulation is also much harder to do with sugar, because it has an impact on the structure and texture of food, but we need to get on with it. The reason why we are spending so much time talking about sugary drinks is because, as the hon. Lady said, they are one product where reformulation is easy: we can replace sugar with sweeteners.

We also need to reformulate to drive down sweeteners. We need to reset our sweet tooth—we have all seen someone washing down a big slab of sticky cake with a diet soft drink—because the craving remains. Even those who choose diet soft drinks will find that their craving for sugar remains, so when they cook they will add more sugar and they will eat more cake and biscuits. Sweeteners can really help us to speed up the removal of sugar, but we still need them to be on a downward journey. That must be done with industry, which has done a lot. Many soft drink manufacturers provide a choice, so if a sugar tax is introduced, hopefully that should nudge people across to less sugary drinks, as the hon. Member for Totnes said. It would be ideal if there was no tax collected at all, because that would suggest that the policy was working. At the moment, however, the traditional product is still absolutely packed with sugar.

[John Glen]

The hon. Lady is speaking with her customary authority on the subject. Does she agree that the industry has the potential to go a lot further so that we can make more progress before a sugar tax, which has attracted all the attention, is instituted? It is a matter of providing choices, and a lot of consumer power could be harnessed to help us make that progress.

[Dr Whitford]

As the hon. Member for Totnes mentioned, the people who make such choices tend to be those who are more oriented towards a healthy diet anyway. It is about trying to teach people in the mire of deprivation, and often in the mire of despair, who smoke more, use more alcohol and take more sugar. They are the very people who are hit by all our measures to try to bring about health improvement.

All the industries are making efforts, but they are afraid of being out there on their own and seeing their competitors mopping up their business. That is why we need regulation. In our inquiry, that came out from the retailers in particular, who said they wanted a level playing field. Whether it is through a sugar tax or regulation, they want to feel that everyone has to move forward.

We also need leadership. The Food Standards Agency was important in leading on salt reformulation, so we need to work out who will be the leader on this, because we need a focused project to get not just sugar but fat and calorific intake out of our diet. As has been mentioned, there are also hidden sugars, particularly in tomato products such as baked beans, tomato sauces and bolognese sauces in which it is easy to hide sugar. When we start to look at that, we see that it is quite scary.

That is where labelling and education comes in. The traffic light system has been helpful for a broad range of foods. When we are looking for a sandwich in a rush, we can spot the green and amber on the label as opposed to the red and red. However, that will not help with sugary drinks, which get a red light and two green lights because they do not contain salt and fat. Therefore, someone who picks that up might think, “Two greens— that must be quite good.” That is why the labelling of teaspoons of sugar is important. The industry could be applauded as it took every single teaspoon of sugar out of a drink.

We have heard talk about the nanny state and people having the freedom to do what they like, but as a doctor for 33 years I heard that about seatbelts and crash helmets. People want to feel the wind in their hair, but they do not look so good if they have come off their bike. We talk about the challenge of cigarettes and alcohol, and sugar is the same. All Governments have a responsibility to look at the report and all the measures it suggests, and to bring them in as a full package, because we need to tackle this, and we need to start now.

--- Later in debate ---

[Barbara Keeley]

As I was saying, we should look at the whole range of options. I want to talk about health campaigns. The Public Health England campaign Change4Life is an excellent example of providing families with information about small changes they can make to improve their health, as well as with advice on healthy recipes, diet and exercise. However, I fear that the announcement of a 25% cut to the non-NHS part of the Department of Health’s budget will have a significant impact on Public Health England. I want public health bodies to be able to continue campaigns to tackle obesity, but I am worried that their ability to do so will be damaged by these significant cuts. I am concerned that we will not in future be able to fund campaigns such as Change4Life, and that they may just not happen.

We must also be careful that the huge cuts to the public health grant given to local authorities do not reduce the advice and support available to those wanting to lose weight. At many community events in Salford, I have seen health improvement staff working with community groups and running all kinds of sessions. I fear that we will not have that in future.

Although the debate is about a sugar tax, I want to mention the importance of increasing physical activity among adults and children. I was a member of the all-party commission on physical activity, which published its report “Tackling Physical Inactivity—A Coordinated Approach” in 2014. We have discussed various aspects of our children’s health, but inactivity is a key factor, which is why a number of Members have referred to it. It is important that we encourage children to maintain active lifestyles from an early age.

[Dr Whitford]

May I draw the hon. Lady’s attention to a novel approach that has come out of St Ninians primary school in Stirling, called the daily mile? A teacher got the children to go out and run round the field. That seems to have made a huge difference at the school. Obviously, it costs absolutely nothing, and it seems to help the kids to concentrate, because they have been outdoors in the fresh air and—in our neck of the woods—probably in the rain as well.

[Barbara Keeley]

That type of initiative is wonderful, but fewer and fewer children are walking to school, and an awful lot more are being taken there by bus or by their parents. The Health Committee report reminds us that the latest figures show a fall in physical activity. In 2012, only 21% of boys and 16% of girls did enough exercise to meet the Government’s physical activity guidelines. That is a fall from four years earlier, when the figures were 28% for boys and 19% for girls. We are therefore going in the wrong direction, and we are all becoming couch potatoes. We might worry about this for ourselves, but it is a great concern when children are involved.

I am a former member of the Health Committee, and it is a pity that little emerges from the report, which simply reiterates and endorses the findings of its predecessor Committee’s inquiry, in which I was involved.

--- Later in debate ---

[Jane Ellison]

I am going to come on to teaspoons, and I do not want to run out of time before I do so. I will make a bit more progress and then see how we are getting on for interventions.

The Government cannot tackle obesity alone. I welcome the fact that we have consensus across the House on that, and the Committee draws that point out in its report. Businesses, health professionals, schools, local authorities, families and individuals have a role to play, as my hon. Friend the Member for St Austell and Newquay (Steve Double) brought out.

I want to talk about some of the industry action that has been taken. There has been progress in recent years on reducing sugar consumption. The focus under the voluntary partnership arrangements, which have been discussed, has been on overall calorie reduction, of which sugar can form a part. Billions of calories and tonnes of sugar have been removed from products and portion sizes have been reduced in some areas. Some major confectionery manufacturers have committed to a cap on single-serving confectionery at 250 calories, which is an important step.

We have to be realistic about consumer relations, which are important. Before I was an MP, I worked for the John Lewis Partnership—John Lewis and Waitrose—and I know only too well the important role that retail relationships play in an average family’s life. We need to involve those partners. Some retailers have played a part, for example by removing sweets from checkouts. Interestingly, they did so after asking their customers in surveys what support they wanted, as family shoppers, from industry to help them to make healthier choices. Much of the action that retailers have taken was in response to that.

I was very interested in the point that my hon. Friend the Member for Salisbury (John Glen) made in an intervention about consumer power. There is much greater consumer power to be unleashed, but the challenge to the industry to make further substantial progress remains. Like the Chair of the Health Committee, I have had some encouraging conversations in that regard, but we need to make more progress.

Providing clear information to consumers to help them make healthier choices is important, as a number of hon. Members have set out. The voluntary front-of-pack nutrition labelling scheme, introduced in 2013, plays a vital part in our work to encourage healthier eating and to reduce levels of obesity and other conditions. The scheme enables consumers to make healthier and more balanced choices by helping them better to understand the nutrient content of foods and drinks.

I turn to the issue of teaspoons of sugar, which has come up a lot in the debate. It is more complicated than something so simple should be; “teaspoons” sounds straightforward, but labelling is an EU competence, so member states cannot mandate additional forms of expression, such as spoonfuls of sugar, for pre-packed food. Under EU legislation, it would be possible for companies to represent sugar content in the form of spoons of sugar or sugar cubes on a voluntary basis, as long that met a number of EU criteria—I will outline what some of them are. It would sit alongside front-of-pack nutrition information, which I remind the House is voluntary, not mandated, in order to meet the same criteria.

[Dr Philippa Whitford]

For the public nowadays, “teaspoons of sugar” is more helpful than “sugar cubes”, because very few people use sugar cubes.

[Jane Ellison]

I am aware of that; the point has been made to me a number of times.

Let me mention a few of the criteria that would apply if we were to move in that direction. There would be a requirement to consult, and we would have to ensure that any measure was supported by scientific evidence and did not constitute a barrier to trade. Any such form of labelling would need to be agreed with the Commission before it was implemented, to avoid future infraction proceedings.

I have heard the strength of feeling in the House and I understand the point being made, but references to sugar cubes are quite powerful; last year’s Sugar Swaps campaign proved that they can be made meaningful. However, I will ask my officials to look carefully at the issue, because I have heard a great deal of interest in it being expressed today, and I know that the Health Committee took evidence on it. I wanted to underline the point that it is not as straightforward as it might seem, but we will look closely at it again in the light of the interest in it.

[Dr Whitford]

Did the same apply to cigarettes? Were we not allowed independently to add the warnings and so on that we put on cigarettes in this country? Did that have to be EU-wide?

[Jane Ellison]

As we approach the transposition of the new EU tobacco directive, the hon. Lady will see that the measures being taken are EU-wide, but those are two slightly different things. I am happy to come back to her in more detail after the debate, but generally speaking, packaging and labelling are EU competences.

I was delighted to hear so many hon. Members say that front-of-pack labelling was important. The scheme is popular with consumers. It provides information on calories and levels of specific nutrients in an easy-to-read, intuitive format. Businesses that have adopted the scheme account for two thirds of the market for pre-packed foods and drinks. Within the Change4Life programme, front-of-pack colour-coded nutrition labelling will continue to be included as a key message whenever there is a campaign focused on healthy eating. We use that in all the Change4Life materials, across a wide range of formats.

I want to reassure the hon. Member for Worsley and Eccles South (Barbara Keeley), who spoke from the Opposition Front Bench, that there will indeed be a physical activity strand in our childhood obesity strategy. I agree with the balance that the Health Committee struck on tackling childhood obesity, which is an important strand of the work. The great news about physical activity, as the Committee’s report underlined, is that it is good for everyone, whatever their weight. There is no downside to being more physically active, so of course we will want to reflect that.

This has not been touched on much this afternoon, but there is also a significant role for the family of health professionals in giving advice and supporting families to make changes to their lives. That relates particularly to families in more deprived communities. Only this morning I was talking about the role of health visitors, for example, in family education and family support. Again, a strand of our strategy will develop that.

Junior Doctors Contract

Philippa Whitford Excerpts

Monday 30th November 2015 Commons Chamber

[Mr Hunt]

I thank my right hon. and learned Friend for his robust support. I seem to remember that when he was Health Secretary posters were put up all over the country saying, “What do you call a man who ignores doctors’ advice”, with a picture of my right hon. and learned Friend. He knows exactly what this is all about. It is not just Conservative Health Secretaries: Nye Bevan and Alan Milburn went through this.

My right hon. and learned Friend is absolutely right: we will all be delighted if the strike is postponed. Incidentally, it begins at 8 o’clock tomorrow morning, not midnight—I must correct that. He is right: the Government’s focus is unremittingly on improving patient care. We have made it clear that any settlement has to be within the current pay envelope. The great sadness is that the vast majority of doctors are passionate about doing something about seven-day services. If only we had had the chance to negotiate from June, we could have avoided the situation we are in.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, welcome the fact that the Secretary of State has been to ACAS and made the change to plain hours that would have resulted in hours between 7 o’clock to 10 o’clock on a Saturday being counted in the same way as the equivalent period during the week. That would particularly punish people who already work at weekends such as acute medical staff and doctors working in accident and emergency—the very people we need.

I welcome the fact that the Secretary of State has made that change. I should be grateful for clarification of whether the threat of imposition is there or not. The statement says that it has been removed, but in his reply to the shadow Secretary of State he implied that it has not been removed. It would be helpful if he clarified the position.

We keep talking about more people dying at the weekend. May I again stress that it is not excess deaths at weekends, implying that hospitals look like the Mary Celeste? It is excess deaths of people admitted at the weekend, who may die on any day of the week. Junior doctors already cover weekends. It is the additional services to diagnose and get people on their journey that we are discussing. We need to focus on that. Unfortunately, the Secretary of State, in previous statements, has moved from talking about excess deaths to talking about the consultant opt-out clause, which applies only to routine work—I am sorry, a toenail clinic on a Sunday will not save lives—but he needs to focus on strengthening the seven-day service for urgent cases, in which people are ill and where existing provision leads to excess deaths. Hopefully, we can make progress. I join the Secretary of State and everyone in the House in hoping that there is not a strike tomorrow.

[Mr Hunt]

The hon. Lady is right that this is about the excess mortality rates of people admitted at the weekend—not of people who are already in hospital at the weekend. I am afraid that she is mistaken in her characterisation of the rest of the Government position. Clinical standards are clear: people admitted at the weekend, or at any time, should be seen by a consultant within 14 hours, but that is true in only one in eight hospitals across seven days of the week, which is why sorting out the consultant contract for urgent and emergency care matters. Although the opt-out in the consultant contract applies only to elective work, half as many consultants are available in A&E on Sunday as are available during the week, although Sunday is one of the busiest days of the week, so it is not just about junior doctors. However, if we are going to make life better for junior doctors, we need to make sure that they have more senior cover and do not feel clinically exposed, which is what independent studies have said they feel.

Governments of any party must have the right to set the terms and conditions of an employment contract. That is a right that no part of the public sector has moved away from, and it is a vital right for all employers. I have simply said that I will not move towards any new contract while negotiations are happening during this time-limited period. That was what my statement clearly said, and the BMA for its part has said that if this agreement is honoured, it will remove the threat to strike during that period.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 17th November 2015 Commons Chamber

[Mr Hunt]

I absolutely give my hon. Friend that reassurance. There are no preconditions, and this morning I wrote again to the BMA to reiterate that point. Of course, if we fail to make progress we have to implement our manifesto commitments, but we are willing to talk about absolutely everything. I agree strongly with my hon. Friend that it will be difficult to avoid harm to patients during those three days of industrial action. Delaying a cancer clinic might mean that someone gets a later diagnosis than they should get, and a hip operation might be delayed when someone is in a great deal of pain. It will be hard to avoid such things impacting on patients, and I urge the BMA to listen to the royal colleges—and many others—and call off the strike.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is 40 years since the last junior doctor strike—before I even started medical school. Given the ballot tomorrow, does the Secretary of State regret the antagonistic approach that he took before the summer towards senior and junior doctors? Should he instead have worked with them and not threatened to impose a contract so as to reach a stronger emergency seven-day service?

[Mr Hunt]

I do not know what the hon. Lady thinks is antagonistic about holding reasonable discussions with doctors for three years to try to solve the problem of seven-day care. Those discussions ended with the BMA, after two and a half years, walking away from negotiations last October. We made a manifesto commitment to have a seven-day NHS and to do the right thing for patients, and we simply asked the BMA to sit round the table and talk to us about it. I am confident that we can find a solution.

[Dr Whitford]

Claiming in July that senior doctors do not work outside 9 to 5 was perhaps felt to be antagonistic. Contrary to the figures quoted by the hon. Member for Dudley North (Ian Austin) last Monday, A&E figures for NHS England are 5% below those in Scotland. With such disappointing figures before we even get into winter or face a work-to-rule, and in the presence of eye-watering deficits, how does the Secretary of State plan to support hospital trusts through the winter?

Off-patent Drugs Bill

Philippa Whitford Excerpts

Friday 6th November 2015 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I was interested to hear the hon. Member for Torfaen (Nick Thomas-Symonds) mention the research into zoledronic acid. I took part in the AZURE study, which indeed means that this bisphosphonate, which strengthens bone, will help bone to avoid getting invaded in the first place. We already use it in breast cancer for patients who have bone metastasis, but it provides a perfect example of where a second use can be found.

The hon. Member for Newton Abbot (Anne Marie Morris) expressed concern about prices going back up, but that simply does not apply. These drugs have been through the whole process, so we know about their safety and their side-effects; they are now cheap and generic. They are made by lots of different companies, and the reason they do not get licences is that it is simply not worth while because the companies cannot put the price back up. If a formulation is changed—if it was a tablet and is now an injection, or if it was an injection and is now a tablet—it is possible to apply for a new patent. If it is exactly the same drug, even with a new use, the company cannot get a new patent. It is not willing to spend the money on sponsoring it.

I have heard people say, “It is in the guidelines”—and believe me, many of these drugs are in NICE guidelines. NICE guidelines say exactly what was said at the beginning of the debate, which is that tamoxifen should be made available to patients who are at high risk of breast cancer. However, it is not licensed for them.

I am a breast cancer surgeon, and in my practice we carry out an operation called sentinel node biopsy. Instead of taking all the lymph nodes out of a woman’s axilla and giving her lymphedema—which some Members will have seen, either in their families or in their constituents—we try to remove only one or two, and we use dyes to target them. One is a blue dye called patent blue dye. It is so old that it is not even made in this country any more, and it literally costs pennies, but it is unlicensed. One of its possible side-effects is anaphylactic shock. That is very rare, thank goodness, but there it is. According to all the UK guidelines, that is the approach that must be taken to breast cancer patients.

I used to have to sign a form before every case that I handled, stating that I accepted personal financial liability if the patient suffered. Eventually I said, “Wait a minute: I am not putting my house on a piece of paper for every case when I would be in trouble if I did not handle that case.” Thankfully, my health board was eventually willing to underwrite it.

The idea that guidelines give us protection is unfortunately not true. When guidelines were introduced, the medical profession was reassured that they did not handcuff a clinician, and if a patient was treated off-guidelines, because patients do not fit in cubbyholes, there would not be an issue. Similarly, following guidelines slavishly does not give any protection. Doctors carry legal responsibility for any drug that they prescribe. So the specialists will prescribe off-patent drugs, and we will be using them.

[Kit Malthouse]

I am slightly confused. Doctors are absolutely responsible for what they prescribe, but only if they do so negligently. The hon. Lady would not expose herself to litigation if she had, for instance, used the dye on a patient who then suffered from anaphylactic shock if that had been an appropriate and responsible thing to do given the patient’s condition at the time.

[Joanna Cherry (Edinburgh South West) (SNP)]

There is a risk.

[Dr Whitford]

There is indeed a risk, as my QC expert has muttered. Part of the case would be that the doctor had prescribed an off-licence drug.

Experts in the field will prescribe many drugs that are off-patent for the treatment of secondary cancers. We are aware of the evidence, and we will use such drugs when we have the experience, but general practitioners will not. If a drug is not in the British National Formulary, they cannot check the dose, which might be different from the dose for the other usage.

We are seeing more and more non-doctor prescribers. We are seeing nurse prescribers and physio prescribers. We do not want to limit the use of future drugs that may be discovered by not sorting out the present position. It should not be beyond the wit of man. The NHS is surrounded by organisations, such as quangos, that could surely be used to deal with it.

[The Minister for Community and Social Care (Alistair Burt)]

Given the hon. Lady’s experience in this area, her presence in the House provides me with an opportunity that is too good to miss. Let me ask a question that goes to the heart of the reason for the Government’s concern about the Bill.

If I understand the hon. Lady correctly, it is not impossible to prescribe off-label if there is an indication that, say, the prevention of breast cancer may be aided by the use of tamoxifen. There is nothing to preclude that, although it may be difficult in the circumstances that she has described because of possible considerations of liability. Is she arguing that there should be no off-label prescribing because everything should be licensed, or not? I do not know whether it should be one or the other—[Interruption.] It is not a stupid question. We believe that if it is possible to prescribe off-label, the Bill is not necessary, but if it is not possible because of the difficulties that the hon. Lady has identified, perhaps that should not happen. Her experience is vital in this regard.

[Dr Whitford]

As I was trying to suggest, someone who is an absolute expert in a field will be comfortable prescribing off-label, because they are using the drug every day, and they know exactly what it does and how to use it. But our patients spend the majority of their time in primary care, and a GP, who is unable to look up and check the dose or indication, will be a little more uncomfortable. People who are non-consultants—those at staff grades, who are at other grades—will be less comfortable. We see that exactly in the prevention of breast cancer; this drug has not come on stream at the speed that would have been expected, because people are uncomfortable. There is certainly not enough protection to mean that nurses are going to prescribe a drug that is not licensed, and the vast majority of drugs do not have guidelines, so what the Minister describes is not a protection.

[Alistair Burt]

I just want to be sure about this. If I understand the hon. Lady correctly, that hesitation could apply to any off-label prescribing now, but off-label prescribing goes on—doctors and GPs do find the information and do it. I would not want to take the implication from her that off-label prescribing is wrong. It just needs the appropriate amount of information to make sure that it is right—otherwise, we do have to license everything.

[Dr Whitford]

When a drug is proven and is going to be in common usage, it should be licensed—otherwise, we are suggesting, “Why bother with licensing any drug?” We are talking about drugs that could make a big impact, but they will do that only if they are in common usage. Expecting doctors to face any potential that they are signing away their mortgage on their house by prescribing something is simply bizarre. Of course there is off-label prescribing as a drug develops, but once we have something with rock-solid evidence behind it, which we expect everybody of every grade and every profession within the NHS to use, we should give them the reassurance of licensing.

[Joanna Cherry]

My hon. Friend speaks knowledgeably about the treatment of breast cancer, but a number of my constituents who are living with multiple sclerosis have also written to me about this Bill. Scotland has one of the highest incidences of multiple sclerosis in the world. Can she confirm that the Bill will be of particular benefit to patients with multiple sclerosis in Scotland?

[Dr Whitford]

Yes, absolutely; a drug called simvastatin is simply used for lowering cholesterol but it has been shown significantly to reduce brain atrophy in patients with a certain type of MS.

We do not know what is in the future. Other drugs will be found to have a second use, so why would we not take this very practical Bill through and allow ourselves to deal with a bizarre anomaly? As I say, this is not beyond the wit of man. Let us pick one of the quangos around the NHS and get this job done.

--- Later in debate ---

[Alistair Burt]

Because if the message that goes out from this debate is that there is only one way to get these drugs, and if people feel that they cannot get them because of what has been said here, that would be darkness indeed. That is not the truth. That is not the position.

[Dr Whitford]

I find it bizarre that the right hon. Gentleman says that we must not bring in this change because it would undermine access to other drugs, because that tends to suggest that we should not have any licensing at all. Why is he happy to have drugs licensed but also feels that we should have unlicensed drugs?

[Alistair Burt]

Because current medical practice appears to be that drugs are available on licence for indications that are already there, but it may then become clear that some drugs are also useful for things that were not previously indicated. If the patent position is as we have discussed, then no licence process is put forward and people can prescribe off-label, as they do in many cases. Accordingly, the system works with both. The Government’s worry about this Bill is that, because of the attention paid to what is being said, it will be suggested that there is some sort of prevention mechanism that does not enable people to get the treatment they need. I am very anxious to state that that is not the case, as I think the hon. Member for Central Ayrshire also said. These drugs can indeed be prescribed. That has to be the message.

[Dr Whitford]

rose—

[Alistair Burt]

I will give way, but then I want to set out what the position is rather than what it is believed to be.

[Dr Whitford]

As I said, there is still an implied risk to people, and those who are distant from the research will not do this. The only reason these drugs are not licensed is that it is not worth the company’s while. Surely letting the Bill go into Committee would allow us to iron out all the issues to the satisfaction of the Government.

[Alistair Burt]

The issue about licensing could apply to any off-label prescribing. What we are talking about for some would, in theory, have to apply to all, because there is a risk to everything. That suggests a provision of licensing for all, which is not where we are going. This matter is not closed—let us be quite clear about that. If this measure does not go through today, the matter is not closed.

--- Later in debate ---

[Alistair Burt]

In that case, I am more than happy to again let the message go out from the Chamber today that these drugs are available and can be prescribed. Where it is clinically appropriate, they should be prescribed. Seeking this legislation will not change that availability.

Members of the House are doing a highly effective job of bringing their constituents’ concerns to the attention of Ministers and asking our help to resolve this issue. We are not aware of colleagues bringing examples of people who have been refused treatment. It is vital to know if there is evidence of people being refused treatment. As I said, the clinician’s letter that the hon. Member for Torfaen read out was wrong. Unless there is a clinical reason for not supplying the drug, there is nothing to prevent the doctor from doing so.

[Dr Philippa Whitford]

I simply make the point that we are now not just talking about doctors prescribing. It is unrealistic to expect physiotherapists and nurses to prescribe drugs off licence. It just will not happen.

Access to Medical Treatments (Innovation) Bill (Money)

Philippa Whitford Excerpts

Tuesday 3rd November 2015 Commons Chamber

[George Freeman]

My hon. Friend makes a good point. That is the premise on which the Bill introduced by Lord Saatchi in the other place earlier in the year in the previous Parliament was predicated. My hon. Friend is right that it is a controversial proposition that fear of litigation for medical negligence is putting clinicians off innovating. The evidence that the Government received through the consultation was that some clinicians do feel that that is a problem, but very few saw it as the principal problem or the principal obstacle. A number of clinicians made the point that several factors have acted in recent decades to slow down the rate of innovative prescribing and other procedures in surgery and elsewhere, not least increasing central control of procurement from NHS England, which puts in place very tight procurement guidelines, as well as a general sense of an increasingly litigious society, which is just one of a number of factors cited in an extensive range of barriers to innovation.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Does the Minister not recognise the concern of the Association of Medical Research Charities and many within the profession about what the Bill opens up? The position when I started 30-odd years ago was that doctors could do what they liked. We have spent decades protecting people, slimming down the ethics paperwork to run trials, and I do not see that the Bill is necessary. I think it is dangerous. The problem is that people think it is about access to new drugs. It is not. Any drug that is licensed we can prescribe. This says that doctors can try what they like. That is quite scary.

[George Freeman]

The hon. Lady makes a series of interesting points. Her criticisms would perhaps apply more to the Bill introduced by Lord Saatchi in the other House. Let me confirm that this Bill has nothing at all to do with clinical research. It is to do with clarifying the freedoms that she is right to say that clinicians enjoy today. Clinicians are free to prescribe any treatment for their patients that they feel is appropriate on the basis of the clinical evidence.

The specific problem that the Government recognise, whether or not this Bill is the appropriate mechanism to deal with it, is that in order for clinicians to feel confident in making an innovative prescription or adopting an innovative procedure, the biggest barrier is the lack of information on what innovative procedures are out there already and being used by other clinicians. It was with that in mind that the registry was originally proposed in the Bill introduced by Lord Saatchi. It was originally intended as a registry of innovative practices that clinicians adopted under the procedures in the Bill, which merely clarify the existing protections already afforded by medical negligence law. It was felt that that registry would be a helpful innovation in itself.

The Government’s view is that, as we build an infrastructure for the provision of information to clinicians to support off-label use of medicines and access to the latest information on innovative treatments, that registry could provide a much more interesting function of providing to clinicians, at the click of a mouse, an up-to-date registry of innovative medicines that are available and off-label and other treatments that other clinicians are already using. I want to stress that this Bill, which has a very different structure from the original Bill introduced by Lord Saatchi, has nothing to do with research at all. It is purely to do with supporting innovative prescribing by clinicians by providing them with information on innovations that they might consider.

[Dr Whitford]

Does not this undermine our existing structures of clinical research? Those protect the patient through ethics and research being reviewed, whereas this allows a couple of doctors to say, “We’re going to give you liquorice for your cancer”, and that can get put on to a database. Many in the profession are anxious about this.

[George Freeman]

I want to make two things absolutely clear. First, this Bill, in law, would have no impact at all on clinical research. We in the Department have been very clear about that. If it in any way changed the basis on which clinical research is regulated, it would be a very serious matter, because we lead the world in terms of our ethical and regulatory controls on research, and it is vital that we do not affect that.

Secondly, it would be a matter of very serious concern if this Bill were to undermine patient or public trust and confidence in our NHS, our research medicine and our clinical trials infrastructure. I flagged up on Second Reading the fact that I do have some concerns. Some of those relate to the way in which this debate is conducted, although I am not making any comment about the hon. Lady’s intervention. It is very important that we explain to people what this Bill does and does not do. If we mislead them, it is not surprising that we will get a lot of unnecessary fear. It is very important that we clarify that this has nothing to do with clinical research.

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

There are many ways for a surgeon to share their experience if they have carried out an operation in the heat of the moment to save someone’s life. The BMJ publishes things on a weekly basis and can share interesting cases. The danger of the Bill is that the database is being used as a fig leaf to make it sound like access to innovative treatments. The hon. Member for Daventry (Chris Heaton-Harris) said that a doctor would have to prove that something was safe, but the first person prescribing liquorice for cancer has no method of proving that it is safe. That is the basis of research.

Phase 1 trials involve a small group of patients who fully consent to undergo treatment and know what they are taking on, based on pre-clinical research. Phase 2 is larger, and phase 3 involves multiple hospitals. We have that process to avoid a couple of doctors in a canteen saying, “That’s not a bad idea. I’ll back you if you back me”, and patients being given something dangerous. The Bill would not, of itself, undermine research in some way, but if patients and the public feel that they are guinea pigs for any old treatment that someone wants to have a bash at, that will undermine research.

It has taken decades to get to our current level of safety, checks and balances. That has been streamlined, and single ethical permissions are carried out once for the whole country, and then recognised in all health boards and areas. That has made things a lot easier, but it is crucial that patients who sign up to a treatment know that there has been a degree of rigour before they are given that drug.

If someone is bleeding to death in the middle of the night, of course a surgeon can innovate because every operation is slightly different, but we are talking about access to medical treatment that will predominantly involve drugs that have not had sufficient pre-clinical work. That is of concern to research charities and the royal colleges—I am a member of the Royal College of Surgeons—because of patient safety. The absolute concern is not even the secondary impact on research; it is the impact on patient safety and people finding that they are being given something totally unproven.

[Andy Slaughter (Hammersmith) (Lab)]

The hon. Lady is making a good point, and I agree with everything she says. As a lawyer rather than a doctor, I think the problem with the Bill is that—unintentionally, I am sure—it also undermines carefully constructed jurisprudence on clinical negligence, and it is dangerous for that reason.

[Dr Whitford]

Of course the Bill is well intentioned, and its title will attract support from people who think that it means getting access to drugs to which we do not currently have access. It is not that any doctor can prescribe anything—we cannot. We can prescribe drugs that are licensed and recognised, and have a basic safety profile. In Westminster Hall we often debate access to expensive, innovative, brand-new treatments, but that is not about our right as a doctor to prescribe them; it is about who will pay for them because some of those drugs are expensive. As the Minister has said, that would still be an issue. In what sense would a commissioning group have evidence to allow a doctor to prescribe a drug that has absolutely no basis, but that would have to be funded?

The Bill is basically a bit of a mess. What problem is it trying to answer? People think it means that they will get earlier access to new drugs, but drugs should be taken forward on the correct path to protect patients and doctors. Doctors need to know that what we are doing is right, and not some random thing that has been on a database after somebody tried something once and it seemed to work. We know that there are placebo and random effects.

[Maria Caulfield (Lewes) (Con)]

I support everything the hon. Lady has just said. I was a research nurse in cancer care for more than 10 years. We observed good clinical practice standards, and the standards of the Medicines and Healthcare Products Regulatory Agency and the FDA, because mistakes happened. Those safeguards are in place for a reason. The No. 1 reason is to protect the patient.

[Dr Whitford]

I did my MD thesis in the late ’80s on the use of monoclonals in breast cancer, which was then totally blue-sky thinking. What became Herceptin was found at that time. I remember speaking at a conference in America where people presented their research. At that time, they thought they had to put a toxin on the back of an antibody to make it work. They were using ricin, which was used in the Bulgarian umbrella murder, and—surprise, surprise—almost all their patients died. They got around that in America by going to Mexico and to prisons. It is not the case that everything a doctor thinks might work will be good for patients. We have developed a safe system over decades and we give it away at our peril.