Cumberlege Report

Alec Shelbrooke Excerpts

Thursday 3rd February 2022 Westminster Hall

[Andrew Rosindell (in the Chair)]

Before we begin, I remind hon. Members to observe social distancing and to wear masks.

[Alec Shelbrooke (Elmet and Rothwell) (Con)]

I beg to move,

That this House has considered the Cumberlege Report.

It is a pleasure to serve under your chairmanship, Mr Rosindell. I have secured a debate about fulfilling the recommendations of the Cumberlege report because I do not feel that we are making enough progress. We had a debate on the Floor of the House in July and a written ministerial statement on 21 July. To stay in order, Mr Rosindell, I will only say that the Minister’s answer to the debate and the written ministerial statement were disappointing, in many ways. In my opening remarks, I will seek to address why I believe that to be the case and, fundamentally, ask for certain updates. We are talking about people whose lives have been destroyed. Many hon. and right hon. Members will bring their own examples about various parts of the report, whether they are about Primodos, sodium valproate or mesh, but I will focus my comments on mesh.

I will not spend too much time going over the examples I gave during the debate in July, which can be looked up in Hansard, but I will say that people were given an operation that many did not need, which many were convinced that they should have. Some people did not even know it had happened to them. It took many years for the problems that arose to become apparent, and so those people have effectively been dismissed.

Like many Members, I have constituents who have had their lives stopped, especially women, although I will mention how the issue affects men as well. One constituent, who I have mentioned before, was a physiotherapist in her 40s who had had a child. She had mild incontinence after giving birth and was told to have the mesh implant, which she went ahead and did. Her entire life has been destroyed by that. Trying to remove it was described to her as being like “trying to take hair out of chewing gum”. We should consider that image when we think about the difficulty of the operation. We must not forget that the NHS did this, and the NHS has a responsibility to deal with it. I will make that point several times.

I have been contacted by a lady who is a constituent of my hon. Friend the Member for Thornbury and Yate (Luke Hall). Her name is Paula Goss and both she and he have given me permission to talk about her case. She set up Rectopexy Mesh Victims and Support in March 2019 after she was unable to find much research or information about the meshes that she had had put in. The group now has over 1,100 members, as well as members who have sacrocolpopexy vaginal mesh and hernia mesh. She is the ambassador and advocate for rectopexy and hernia mesh on the Mesh UK Charitable Trust, which has a further 2,000 members.

She had rectopexy mesh in 2014 as she was unable to clear her bowels. She was ill-informed by the now dismissed surgeon, who, as she found out from her notes, inserted three meshes—in the bowel, vagina and posterior. She says:

“All mesh types don’t necessarily show complications straightaway. My Pre mesh insertion issues started again around 9 months after the op, in which I was passed from pillar to post by all medical professionals saying my issues were the menopause or in my head. This went on from 2015 until September 2018 when I was admitted to hospital with a blocked bowel and bladder and had to have enemas and catheters, still they would not connect this to the mesh, upon doing a CT scan at this time they also found a large ovarian tumour, it was then discussed by my gynae oncologist at the BRI and Southmead NBT to do a joint op to remove the tumour and the mesh, due to the incompetence and lack of mesh removal experience at Southmead I ended up having the ovarian tumour removal in January 2019. Thankfully, after testing it was a large benign fibroma, following up with Southmead they then stated that they wouldn’t remove my mesh but would do an op to give me a permanent stoma—again, brushed aside and fobbed off, I sought a second opinion in London privately, whilst we are by no means rich, you can’t put a price on your health...I had to pay £32,000 for my removal, it took over 10 hours and they could not get all of it…two protacks in particular sit very close to the bifurcation of the inferior vena cava on the left and the common iliac on the right. Pre mesh removal I was found to have a heart murmur and I suffered pericarditis quite a few times. My histology on my meshes showed that I was not a candidate for polypropylene and should not have this inserted again…When I discovered I had hernias again I was neglected by the local hospital who at first refused to do a scan, saying I must have an ulcer. it was thanks to my private mesh removal surgeon who contacted my GP and insisted that I was referred for a CT which then clearly showed two large incisional hernias.

The consultant at Southmead stated he would only fix my hernias with polypropylene mesh. After I told him that I couldn’t have that, there was no option but to again look down the private route. Thankfully, my colorectal mesh removal surgeon was able to do this and a date was set for 6 January 2020. However, my hernia started to strangulate and I was luckily rushed to London by my husband, and had this op done on 28 November 2019. This cost £43,000.

This operation was by far the toughest and took a long time to get over, due to ending up with a seroma and now a hiatus hernia due to the trauma to my abdomen.

My journey has not been, and is still not, plain sailing, but I am one of thousands.

Whilst vaginal mesh gets a lot of coverage, ours does not. Rectopexy affects men, women and children…All three main types of mesh need to be included and talked about—bowel mesh, vaginal mesh…sacrocolpopexy and colporrhaphy vaginal mesh and hernia mesh...One of our rectopexy mesh ladies found out that the surgeon who put mesh in also removed her ovary without consent, she sadly committed suicide due to this event.

One of our rectopexy patients was just 15 when she had her mesh inserted. She’s early 20s now and now suffers complications and doesn’t even know if she will ever be able to have children.

We have other ladies in their 20s and early 30s suffering, who may not be able to have children.

We have many rectopexy bowel men on our sites who feel they have nowhere to go and no one who will listen to them.

This is the same for all hernia mesh victims too.

There are many real victims’ journeys that need to be listened to and taken seriously.”

That is what the report did, and why it was so appreciated by the victims, as they were finally being taken seriously. That is where the report’s value lies. Today, I once again push for it to be implemented in full as far as possible, and for recommendation 3 about redress, recommendation 4 and recommendation 5 to be reconsidered.

Recommendation 1 was for an apology. That apology was received in July 2020, given by the Government, but, as good as it was, their actions depend on whether they can justify what they are doing on recommendation 9. Recommendation 2 is:

“The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices.”

The Government accept recommendation 2, and I ask the Minister for the latest update on that appointment. On 2 December last year, in the other place, the noble Baroness Cumberlege asked Her Majesty’s Government

“when the process to appoint the Patient Safety Commissioner will commence; and when they expect the Commissioner to be in post.”

In response, the noble Baroness Chisholm of Owlpen said:

“My Lords, we are making good progress towards appointing the first patient safety commissioner for England. We expect the appointment of the postholder by spring 2022.”—[Official Report, House of Lords, 2 December 2021; Vol. 816, c. 1443.]

As I said, I would like an update on where we are in that process.

Recommendation 3 is that:

“A new independent Redress Agency for those harmed by medicines and medical devices should be created based on models operating effectively in other countries. The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals.”

The Government do not accept recommendation 3. As set out in the Government’s statement,

“We have no current plans for a redress agency…We do not believe it is necessary to create a new agency for redress as it is already possible for the Government and others to provide redress for specific issues where that is considered necessary. Neither do we believe that creating an agency would succeed in making products safer as the report suggests, or that grouping existing redress schemes through a single front door would add value for harmed patients.”—[Official Report, 21 July 2021; Vol. 699, c. 72WS.]

I do not accept that it is already possible to provide redress where necessary, because my inbox, and I am sure those of several right hon. and hon. Members, suggests that that is simply not true. It is too vague and takes too long. When I talk about recommendation five, I will discuss where that issue comes to a head.

I come back to my point, which is that the NHS did this to people. I have said it before and I say it again: the problem is very similar to the thalidomide scandal. Eventually we got justice for thalidomide victims. People are just being fobbed off—I have many examples—and that is exactly what happened with thalidomide. Mr Rosindell, can you imagine living an active life, as we all do, and the NHS recommending something that means that you can no longer take part in what you were doing? Imagine being physically and mentally restricted and unable to fulfil your life’s ambitions. A full quango might not need to be set up, but at the very least we need a ring-fenced department in the NHS to bring those areas together.

[Sir Mike Penning (Hemel Hempstead) (Con)]

Baroness Cumberlege specifically states in her report that her terms of reference prevented her from talking about individual compensation and redress. Is my right hon. Friend suspicious, like me and probably many others, that that was specifically written into the plan so that she could not do what my right hon. Friend is asking for?

[Alec Shelbrooke]

That is where we have to dig into recommendation 4:

“Separate schemes should be set up for each intervention—HPTs, valproate and pelvic mesh—to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim”.

The Government do not accept recommendation 4. That is exactly the same situation as with thalidomide. One of my earliest campaigns in 2012 was to extend the grant to victims, and my hon. Friend the Member for North Dorset (Simon Hoare) took that campaign further to make it a permanent grant. People will not recover from what happened, whether it was drug-induced or operation-induced.

My constituent who has had mesh removed emailed me only today to say that four years down the line things are better, but they have not improved to the point where she can really live her life. She says she is mentally exhausted and does not want to go on. She had a thriving physiotherapy career that she cannot go back to. She is only in her 40s and has the rest of her life to live. The Government have a responsibility because the Government run the NHS. I interchange the words “NHS” and “Government”, but the NHS is the Government. That is where this situation falls on the Minister:

“While the Government are sympathetic to the experiences of those patients who gave evidence to the report, our priority is to improve the future safety of medicines and medical devices.”—[Official Report, 21 July 2021; Vol. 699, c. 72WS.]

Trying to prevent further catastrophe is obviously very important—that is one thing—but thousands of people will suffer for the rest of their lives thanks to this treatment.

I will draw the distinction between this surgery and breast-enhancement surgery. Many people have had that done privately and then when there have been complications, they have had the operation to sort it out on the NHS. There is often a lot of debate around whether that is right or wrong. That is not where I want to go today. However, if we are willing to do that for things that people have had done privately, why are we not willing to redress the issues of people who have had things done by the NHS?

We are talking about women from their teens all the way up. Some people think the problem is with the elderly end of the population, but we are talking about those in their teens upwards. As I said, we did recognise the situation with thalidomide. I know that costs come into it, but there is a moral responsibility to redress the situation.

[Hannah Bardell (Livingston) (SNP)]

The right hon. Gentleman is making a powerful speech. Does he agree that there is a moral responsibility? Once the Government—whatever Government that is and wherever they are—have committed to review such a profound issue, and have essentially marched people up to the top of the hill, giving them faith and hope, they must then follow through. Leaving people in a state of suspended animation for such a long time, when they have already suffered so much, is just not acceptable.

--- Later in debate ---

[Alec Shelbrooke]

I am most grateful to the hon. Lady for that intervention. She summarises the entirety of what we are trying to achieve. When I put in the application for the debate, I found no difficulty at all in getting sponsors who were one third Conservative, one third Labour and one third SNP. This is not about the colour of the Government. It is about the NHS, which will be managed through all colours of Government, and has been throughout its life. It is the responsibility of this place, and part of who we are, to do the right thing by people.

I ask the Minister to look at the thalidomide grant scheme and translate it across to those who, as a direct result of the issues raised, will not be able to fulfil their earning potential and will have to deal with physical restrictions and pain for the rest of their lives.

[Alan Brown (Kilmarnock and Loudoun) (SNP)]

As well as compensation, which I think is what the right hon. Gentleman was talking about with “redress”, the Scottish Government, at least, are now progressing with a Bill to set money aside for people to get mesh removed through private surgery, fully funded by the Scottish Government. Does he think that that should also be considered by the UK Government?

[Alec Shelbrooke]

Again, I am most grateful for that intervention, because people are having to turn to private care to get that surgery done—often by the same surgeons. There has always been a conversation about the NHS commissioning private medicine to help it, particularly when it comes to clearing the backlogs caused by the pandemic. That that is important. I will come on to that question in my comments about where we are going.

Recommendation 5 says:

“Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy.”

The Government accept the first part of recommendation 5, on specialist centres for those adversely affected by mesh. I regret to tell my hon. Friend the Minister that it is not working. I have a document that I will read from Kath Sansom of Sling the Mesh. She sent me this information. These are women’s voices, in just January 2022. An 83-year-old says:

“I am disappointed. I was expecting help but just offered pain relief and physio. And I now have red inflamed abdominal inflammation. I wanted to know if all these problems were the mesh—the answer was that they don’t know.”

A 64-year-old says:

“Not sure about anyone else, my experience hasn’t been particularly good. For me the wait goes on and on. Offered pain management, didn’t get anything only offered physio. In 14 years I have had enough physio to last a lifetime. Latest offer yet another camera in the bladder, that makes 4 now. First removal 2019, been waiting ever since for stage 2. I feel the longer it goes on, they hope I will give up having surgery at 64 years old.”

Others say:

“After a very long wait to see a specialist in the mesh centre, having scans etc. was told no real problems”—

and—

“Mesh centres are a piece of paper over a cavernous crack!”

Another person says:

“I feel mesh centres are giving us false hope—and then the realisation that it’s all been pointless. They actually admitted at Nottingham that they would watch Leicester removing my mesh so that they could learn how to remove a TOT mesh! They looked disappointed when I said there was no way I was thinking of having it removed. I feel like I would have been an experiment. I’m scared.”

Another says:

“I waited 12 months from referral by GP for my first appointment, then it has taken 3 years of various tests and appointments to get on the surgery removal waiting list. I have been on that list for 15 months so far. In that time, I lost my job that I’d had for over 16 years due to sickness record, I’ve been on the waiting list for pain management for over 12 months, and I am gradually able to do less and less due to the constant pain.”

Someone else says:

“Nottingham mesh centre same pro mesh surgeons that put in mesh in charge of centre referring patients to nearby Leicester Hospital for operation—what’s all that about!! It’s OK having Specialist Mesh Centres, but these doctors need to be trained by surgeons that are doing good jobs.

I’ve been hurt once by these surgeons that put mesh in, I’m not letting anyone near me unless they have done lots of successful removals. the sad thing is, because only 4 or 5 great surgeons do removals, you have to pay private, because their waiting lists are so long.”

Others say:

“Kath, can you highlight the LONG waiting times please and referral to pain management, which has a long waiting list—we are talking years overall when all we want is this damned mesh removing sooner rather than later”

and

“Mesh centres, what mesh centres? Same doctors been under for years. No faith at all. Only know how to put it in, not take it out.”

Another person says:

“Been waiting 15 months, and still no appointment. Was referred to UCHL, which I have heard nothing from, even though the hospital referring has resent the referral a couple of times. Been told I have to go to my local now, which is Southampton which I have heard not one positive outcome from, so basically, funding it myself with credit cards as can’t put up with the pain anymore”

while another says:

“Suffered for years before I found out what it was. My GP referred me five years ago—doctor yawned in my face & denied it was plastic. Told me it was tape. Sent me round in circles for lots of tests and visited 8 different hospitals for mainly painful procedures before I was finally sent to St Mary’s (Manchester) 3 years ago for a translabial scan.

Was sent to Wythenshawe then back to St Mary’s & told I had to see pain management clinic before I could be offered a full removal.

Covid cancelled all appointments in 2020 then I had an SNS trial implant at Northern General Christmas ’21 for bowel control (it failed) & spinal fusion L4/5 year ago for stenosis then got wound sepsis, so back in DRI for two weeks in lockdown last March. Sure the mesh damage caused all this!”

Somebody else says:

“There is a stark contrast between NHS and private, it shouldn’t be like this. I saw Professor Hashim on 1st October, he examined me, confirmed issues and said he could offer me full or partial removal. If I had been able to cough up the money I would probably be getting removal February or March. I am in his area for the Bristol mesh centre so my consultant referred me straight to him after reading his report. I have not had any communication from Southmead Bristol yet, everything I am hearing about Bristol now is that I am going to have to go through the pain clinic and try steroids etc first. Why do we have to jump through these hoops with the same surgeon just because we can’t afford…£15,000”?

Another says:

“Gynaecologist was dismissive and stated that women like me are depriving other women from benefitting from it.”

[Caroline Nokes (Romsey and Southampton North) (Con)]

My right hon. Friend has made that point a number of a times during his speech, and it is worth highlighting. I know that my hon. Friend the Minister will do some great work on the women’s health strategy, but time and again my right hon. Friend has said that women’s voices are being ignored and dismissed. They are told that they are imagining things and that it is in their heads. It is not good enough.

[Alec Shelbrooke]

I completely agree with my right hon. Friend. In fact, I will later make a couple of points on what I have discovered about women’s health. The way women are treated is quite appalling.

Another person says:

“I had my TVT in Exeter 12 years ago. Exeter consultant in 2020 told me I couldn’t be referred to Bristol. He said he would refer me to UCLH but I never heard from them, I rang in 2021 to be told UCLH hadn’t received any referral but they then put me on their wait list from when I’d been told the referral was made. I then heard nothing from them for ages so I paid for a private consultant at Bristol to be told I could have been referred to Bristol on the NHS in the first place. Bristol requested NHS tests in Exeter which were done in August 2021 and they referred me back to Bristol in October, so I am now on Bristol NHS list for removal”.

Somebody else says:

“Took 4 years to be referred to specialist mesh centre, after a lot of pushing and pushing for it, referred to Royal Victoria Hospital in Newcastle upon Tyne. The mesh centre was no better, more lies, gaslighting and a really appalling treatment and total indifference, lots and lots of mistakes, cancelled appointments and no regard for any pain or suffering.”

Another person says:

“Told too dangerous to remove…left in agony...self-catheterising, lost job, pain management referral but they are behind 12 months …invisible and invalid is how I feel…is this my life at 54?”

Somebody else says:

“I went for a consultation for removal in 2020 had a scan then asked to contact his secretary when I’d had an MRI which I did in December 2020. Now still waiting for them to contact me. I leave messages and nothing happens.”

I could go on and on and on, and I am sure that many other right hon. and hon. Members will be raising similar cases. What I want the Minister to comment on in today’s debate is this. There is now, from the relevant royal colleges, the “Purpose Statement for the Mesh Complications Management Training Pathway”. That statement outlines several areas, but I will highlight just the “Mesh Complication Management credential”. Its subheading is “Professional Identity: Clinical Expert” and it states:

“The doctor has the knowledge, skills and attitudes required for clinical assessment of patients presenting with suspected mesh-implant complications…The doctor is able to investigate mesh complications, and interpret the results of tests, appropriately…The doctor is competent in non-surgical management of mesh complications…The doctor is competent to undertake mesh removal surgery as part of a multidisciplinary team”.

This is progress, but I think we can all understand that there is going to be a long time around that, so I say this to the Minister. Can the House please have regular updates on how this training process is going, within the royal colleges, for surgeons, because we need to understand what the process is and how long it is taking to try to deal with the main issue?

That brings me to the other parts of recommendation 5 in the report of the independent medicines and medical devices safety review. The written ministerial statement in response said:

“Recognising the need for enhanced data collection on pelvic mesh, the Government in 2018 announced the provision of £1.1 million for the development of a comprehensive database of urogynaecological procedures, including vaginal mesh, to treat pelvic organ prolapse and stress urinary incontinence. I can update the House that the pelvic floor information system has started to receive live data, including historical data from July 2017 onwards, with an initial focus on supporting specialist services to report every pelvic floor and comparative procedure to this national database.

The report of the IMMDS review also recommends that the information system is accompanied by a retrospective audit of mesh procedures, and by the development of a patient reported outcome measure (PROM) or patient reported experience measure (PREM). I am pleased to announce to the House today that the Government accept both these recommendations. NHS Digital has been commissioned to scope and deliver the retrospective audit. Subject to receiving high quality research bids, a new validated PROM for pelvic mesh procedures will be commissioned through the National Institute of Health Research in 2022.”—[Official Report, 21 July 2021; Vol. 699, c. 73WS.]

Again, I ask the Minister whether she can update us on progress in these areas and, after today’s debate, could she speak to her Department about ensuring, even if it is just through a written ministerial statement, that there is a regular update on the progress being made?

I will give a summary of the points that I have made. GPs are unaware of mesh complication centres and the referral process. Many patients are denied access and offered physio and pain management instead. They pay thousands of pounds for private care. They experience extremely long delays for appointments. Many women end up seeing their implanting surgeons, who then dismiss them. That leads to further deterioration in their physical and mental health. There is a lack of experience, particularly in mesh removal. There are only around four to five surgeons in the UK who can do mesh removal. There is no post-op aftercare.

More positively, on recommendations 6 and 7, the Government announced that the MHRA

“has initiated a substantial programme of work to improve how it listens and responds to patients and the public, to develop a more responsive system for reporting adverse incidents, and to strengthen the evidence to support timely and robust decisions that protect patient safety.”

Recommendation 7 was:

“A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation. This can be linked to specifically created registers to research and audit the outcomes both in terms of the device safety and patient reported outcomes measures.”

The Government accepted both recommendations. Again, I ask the Minister for an update.

Recommendation 8 states:

“'Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors' particular clinical interests and their recognised and accredited specialisms. In addition, there should be mandatory reporting for the pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians.”

The Government said that they accepted the recommendation in principle:

“We agree that lists of doctors’ interests should be publicly available, but we do not think that the GMC register is the best place to hold this information”,

so “publications of interest” should be held by healthcare providers. Having approved the recommendation, how is that progressing and how easy is patient access?

Finally, we get to recommendation 9:

“The government should immediately set up a task force to implement this Review's recommendations. Its first task should be to set out a timeline for their implementation.”

The Government accepted the recommendation in part.

Having probed the recommendations to open the debate, I ask the Minister whether she and her Department are able to say positively that they are meeting recommendation 9. Are the recommendations being implemented properly and is she revisiting the recommendations rejected by the Department initially? We can all recognise from the examples that I have given that the mesh centres are not working, that people’s lives have been destroyed and that they will need to support throughout their lives. We cannot just draw a line, have a year zero and say that we hope such things do not happen again. We have to move forward.

Drawing on what my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) said and on my research, it is clear to me that the NHS is constantly failing women. During the pandemic, I read a report—unfortunately, I have not been able to reference this since, so it is open to challenge—stating that gynaecological surgeons were taken off their operating theatres for longer than any other surgeons, being kept on the frontline of the covid wards.

That says exactly where the problem in the NHS lies. That comes up not just in this debate, but next week, in another debate, on problems with endometriosis. It seems that the NHS is—I do not say this in a positive way—gender-blind to the needs of women and the complications that occur. It is an attitude, a built-in psychology, that we will have to address, and we can only start to do so if we take all the aspects of this report seriously.

Although men have mesh issues too, this debate is dominated fundamentally by women’s health. It speaks to that wider assessment of NHS priorities on women. We have to start doing something about that. We must stand up and say that we are not afraid to criticise areas of the NHS, because I am sure that as we go through the debate we will have example after example from which we can draw only one conclusion: women are being failed.

My hon. Friend the Minister, as a practising nurse, will know the importance and vocation of patient care. With her professional eyes, will she allow the NHS to ignore the plight of people who are suffering every day? To be blunt, her predecessor appeared to. I ask her to apply her considerable and dedicated professional expertise to get the Government to direct the NHS to adopt the recommendations, or at least to mirror them. That is the least we can do for the terrible and horrific damage that the NHS has caused to so many people. To finish: the NHS did this, so the NHS must fix this.

--- Later in debate ---

[Mrs Theresa May (Maidenhead) (Con)]

As others have said, it is a privilege to serve under your chairmanship, Mr Rosindell. I add my congratulations to my hon. Friend the Member for Elmet and Rothwell (Alec Shelbrooke) on having secured this important debate. We are here for a significant reason, which is, frankly, to hold the Government’s feet to the fire and press them on why they have not made more progress on this issue. As others have said, it was debated some months ago in the Chamber of the House of Commons, and the cross-party support for Government action was absolutely clear, as the presence here shows, yet we have had to come back to ask the Government why they are not making more progress.

The independent medicines and medical devices safety review was absolutely clear about the damage done by the three medical devices and medicines that it considered: Primodos, mesh—not only vaginal mesh—and sodium valproate. As my hon. Friend the Member for Elmet and Rothwell—

[Alec Shelbrooke]

Right honourable.

[Mrs May]

I am so sorry; that must have changed after my time. My right hon. Friend set out very clearly how people’s lives have changed. The hon. Member for Blaydon (Liz Twist) has just done that as well.

Lives have been not just changed, but significantly damaged. People have suffered physically, mentally, socially and, in many cases, economically. As well as suffering the direct impact of what was done to them and, in the case of Primodos, to the babies born with defects as a result of their mothers taking it, they suffered constant rejection by the state—by the NHS and the Government, the very bodies that should have been there to protect and support them. The longer it takes the Government to fully implement the recommendations of the Cumberlege report, the more rejection these people suffer. Every week that goes by is a further rejection, because the report was very clear: action needs to be taken.

I was pleased to set up the report, and I commissioned it largely out of the concern I had about Primodos, which had been raised with me by my right hon. Friend the Member for Hemel Hempstead (Sir Mike Penning), but also by our former colleague Seema Kennedy, who took up this issue as well. The aim of the review was not just to get to the truth, but to identify what needed to be done to redress the problems that had occurred, to provide support to those who had suffered, and to ensure that it could not happen again.

There are two glaring aspects to these issues. The first is that the natural reaction of the NHS and the medical establishment was—and, I fear, continues to be—to defend themselves, rather than to admit to mistakes, ensure that those who suffered were given the support they needed, and take action to ensure that those mistakes could not happen again. That is still happening.

I spoke to a constituent earlier this week who had an operation a number of years ago, and is still having operations to correct problems that arose from a mistake made in that operation. My constituent Hugh Whitfield, a former consultant surgeon who runs the Independent Medical Negligence Resolution, spoke to me before Christmas about the large sum of money the NHS spends on litigation and on trying to defend cases in court, when a better system would be to just accept that mistakes were made. I have constituents who just wanted an apology. They just wanted to know that somebody had accepted that something had gone wrong, and to be shown that it would not be allowed to happen again. Instead, the NHS spends significant sums of money trying to defend itself in court cases when there is a better solution. That is slightly aside from the main point I want to make about the Cumberlege review, but it shows that the NHS’s attitude is to defend itself, rather than accept that mistakes were made.

I want to pick up on a point made by the three Members who have spoken. Sadly, when we look at the three issues that the Cumberlege review considered, we see a patronising attitude towards women—a pat-you-on-the-head attitude. “There, there. This is the sort of thing you can expect. You’re in pain? Oh well. You’re a woman.” I am afraid that that was the attitude taken on some of these issues—and it was not just that: it was a female doctor, Isabel Gal—a woman who had survived Auschwitz—who first identified the problems with Primodos, but she was dismissed and ignored, and sadly her career was damaged as a result. She eventually left the medical profession. What comes through in the report is that there is an attitude of not being willing to listen to women’s voices, and of not accepting it when women say, “Actually, what you have done to me is causing me extreme pain and difficulty.” Instead of saying, “You know what? I do this, and I get it right. Go away, dear,” professionals should say, “Let’s look into this and find out exactly what happened, and whether we made a mistake.”

I come to three of the specific recommendations, one of which is to appoint a patient safety commissioner. Reference has already been made to this, and it is good that the Government have accepted the recommendation, although they needed a bit of a nudge in the House of Lords to do so. What concerns me is the need to ensure that this patient safety commissioner is not in hock to the Department of Health and Social Care.

My right hon. Friend the Member for Elmet and Rothwell spoke about the NHS. Yes, these are the actions of the NHS, but behind it lies the Department of Health and Social Care, which consistently resisted properly looking into these issues over a significant period. I do not want a patient safety commissioner to be taken over by the Department of Health and Social Care. It has to be somebody who can be independent and can genuinely give patients a voice.

On the recommendation to establish a redress agency, my right hon. Friend the Member for Hemel Hempstead is right that under its terms of reference, the Cumberlege review was not able to look at compensation for individuals, but it was asked to look at wider redress measures, and it proposed the redress agency—a proposal that, sadly, the Government have not been willing to accept. I know the Treasury will have heard the proposal as, “Ding, ding, ding! Pounds!”—I have dealt with the Treasury, and we all know what happens—but the agency would have a wider remit than that. The Treasury often thinks these things are just about funding and monetary compensation, but people who have suffered as a result of these issues need other sorts of support given to them—for example, support for children with special educational needs. Redress is wider than monetary compensation, which is often what Government think about.

Recommendation 9 is to set up a taskforce. The patient reference group is a good idea but, as the hon. Member for Blaydon (Liz Twist) said, where now? The taskforce would have the job of gripping this issue and pressing down on the accelerator for action. I ask the Minister: who in Government is gripping this issue and pressing the accelerator for action? As I am sure she will gather, most of us here think that nobody is doing that, and that the issue is being allowed to drift. It is important that these recommendations be followed up on.

My final thought is about levelling up—a term that some of us in politics like to use at the moment. The victims of these three issues need to have their lives levelled up with those of people who did not suffer as a result of this. Above all, NHS treatment given to women needs to be levelled up with that given to men, to ensure that women are not just patted on the head and told to go away.

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[Maria Caulfield]

I want to reassure my right hon. Friend that changes have already been made. When women were experiencing these problems, particularly with sodium valproate, compensation was mainly run by NHS trusts and individual organisations, which was very difficult and cumbersome.

We have introduced the duty of candour, which a number of Members have raised this afternoon. That duty means that when a mistake happens, hospital trusts and GPs have to be up front, own that mistake and explain it to patients. Very often, women did not realise that the problem was the sodium valproate or the Primodos; they thought something else had happened. The duty of candour means that hospital trusts and GPs are up front, that that apologise and that the process of redress is started as soon as possible.

Now that NHS Resolution has been set up, the process is as easy as possible for anyone with a claim of clinical negligence to come forward. As a result of the new system, between 70% and 80% of claims—I will correct the record if I am wrong—are now settled out of court, which is quicker and helps patients get the compensation they need. They have a fundamental right to that if clinical negligence has happened.

[Alec Shelbrooke]

I am listening closely to what my hon. Friend is saying. Is that data independently audited, and will it be made available? The reality on the ground is that although these things are in place, there are plenty of examples of people who feel that that is not the case, and that doctors and professionals are carrying on doing the same thing and not feeding back in. I welcome what she has said, but could an auditable trail be published to show what is happening and those who perhaps are not taking any notice?

[Maria Caulfield]

There are absolutely processes in place, including bodies such as the Care Quality Commission, which audit and inspect to ensure that the processes that have to be in place are being used. NHS Resolution is clear about the work it does, and its chief executive also gave evidence to the Select Committee this week on how the process should work. Of course, if patients feel that it is not working for them, we need to hear about it. We set up these mechanisms specifically to make compensation easy, quick and representative of the needs of those who are claiming, to make sure that they get the compensation they need as quickly as possible. That has not happened in the past; we fully acknowledge that.

The Secretary of State will announce a consultation on wider reforms to clinical negligence very soon, because we recognise that the system has not worked for people. It has been too bureaucratic, and the legal position and fear of going to court has put many people off. It does not need to be like that. We want to make it as easy as possible for people, whatever their clinical negligence claim.

--- Later in debate ---

[Alec Shelbrooke]

I thank all hon. Members who have contributed this afternoon. Even though many Members have given me apologies for not being able to be present, we have covered the wide-ranging aspects of the review concerning Primodos, sodium valproate and mesh. I thank and congratulate the Minister, who showed in her response that she understands her brief. I will come on to some of the issues we disagree on, but she did not just read out what has been written for her. She has taken the issue seriously and has taken the debate on board. That is a refreshing change from her predecessor.

Let me move on to some of the specific comments. I welcome the hon. Member for Chesham and Amersham (Sarah Green), with whom I have not had the privilege of being in a debate before. She made an important point when she said that we need to listen to victims. That is the point of the report: the need to listen to victims. We have to be very careful about how we proceed. The report was trusted because the victims felt that they were finally and properly listened to. That is why it matters so much.

Let us be blunt: it does not matter which side we are on, we in this place are all getting a bit of a bad press at the moment. The report is an opportunity to show people that they can have faith in this place and trust it. When we go out, listen to victims, take their views on board and, as a Parliament, say, “The adversarial side of politics can be parked over there, because on these really important issues, we all get together and we can make things happen,” we can do things. I thank the Minister for the progress that she is making on the recommendations, and for giving us the update.

The hon. Member for Livingston (Hannah Bardell) gave us a shocking revelation. Records were destroyed, rather than people admitting the mistakes that had been made. That is why redress, the databases and all the other things that we want to introduce are so important.

We come back to this point. I thank my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) for her reference to the analogy I gave her about the aircraft industry. The Minister used the word “whistleblower”, and that is the wrong word. We are talking about cultural change, and it follows on from what the hon. Member for Livingston and my right hon. Friend the Member for Romsey and Southampton North said. We have to develop a culture in which it is natural for anybody working in a system to feed in, “This is going wrong” or “There has been some evidence of this.” There should be no blame for anybody and no comeback for their careers.

I am a great fan of the TV programme “Air Crash Investigation”—my wife cannot watch it—especially as I spend my life in the air. It is absolutely clear when people watch that programme how the airline industry is now at a point at which it is really unusual for a plane to drop out of the air, because of the no-blame culture. If somebody leaves a spanner somewhere, that gets reported. The tiniest things are reported, which is how that industry’s safety has improved.

[Mrs May]

Will my right hon. Friend give way?

[Sir Graham Brady (in the Chair)]

Order. I am terribly sorry to interrupt the right hon. Lady, but we cannot have interventions during what should be a very brief winding-up speech.

[Alec Shelbrooke]

Thank you, Sir Graham. The most important point that I want the Minister to take away today is the following. I do not want compensation for people; it is not compensation that I am seeking. I want there to be grants, like the thalidomide grant. People will be subject to these injuries for life, and compensation is not going to cover it. We have a responsibility to deal with the problem, so I hope that my hon. Friend takes that away today. I say this to the Minister: we will keep coming back and keep coming back, and eventually there will be a votable motion on the subject on the Floor of the House and I do not think it will be able to be whipped.

Question put and agreed to.

Resolved,

That this House has considered the matter of implementation of the recommendations of the Cumberlege Report.