NHS: Fracture Liaison Services

Baroness Bull Excerpts

Monday 8th November 2021 Lords Chamber

[Lord Kamall (Con)]

I very much agree with my noble friend that the prevention of illness is as important as the cure. In conversations I have had with the NHS and other healthcare professionals, there is a focus on prevention. Some noble Lords may remember the debate we had a couple of weeks ago, focusing on the prevention of obesity rather than treating its symptoms. The NHS is prioritising FLS and similar services when it comes to prevention, understanding that this benefits not only patients but taxpayers.

[Baroness Bull (CB)]

My Lords, I declare my interest as an ambassador for the Royal Osteoporosis Society. Vertebral fractures are the most common osteoporotic fractures, but with 70% of these going undiagnosed, the opportunity for early identification of osteoporosis is missed. Does the Minister support the recommendation of the Royal Osteoporosis Society that all diagnostic imaging services should be required to routinely look for and report on vertebral fractures in any spinal imaging they undertake, whatever its primary purpose? Does he agree that this reporting should be unambiguous and actionable, via the FLS where possible, so that patients are put on the right pathway for osteoporosis assessment and care as soon as possible?

[Lord Kamall (Con)]

The department and the NHS continue to work with interested groups to expand the understanding of the wide-ranging needs of people across the country. One example is NHS England’s Covid-19 MSK—musculoskeletal—stakeholder group, which is advising on the impact that lockdowns have had on the physical and mental health of those with MSK conditions. Collaborating with NHS England were the British Orthopaedic Association, the British Society for Rheumatology, the Chartered Society of Physiotherapy, the Arthritis and Musculoskeletal Alliance, and Versus Arthritis. Self-managed resources for patients are being developed. I will write on the specific question that the noble Baroness asked.

People with Learning Difficulties and Autism: Detention in Secure Settings

Baroness Bull Excerpts

Thursday 28th October 2021 Grand Committee

[Baroness Bull (CB)]

My Lords, I am very grateful to the noble Baroness, Lady Hollins, not just for her comprehensive introduction to this important debate, but for her work over so many years for people with learning disabilities and autism. I also pay tribute today to Professor Sir Michael Rutter, who died this week and whose work in this area gave hope to so many families, including one known to me. It was Professor Rutter who diagnosed their four year-old son and offered them hope of a life in which, with the right support, he would be able to flourish, despite his challenges. As that young man turns 30, that same hope is in painfully short supply. He is among the 2,085 people with a learning disability and/or autism currently confined in an in-patient setting—a number that has risen by 40 over the past month. The average stay is 5.4 years. He has been detained since 2011, with around one-third of that time in locked seclusion.

As we have heard, many of these people are not there because they need in-patient mental healthcare; they are there because the right kind of community support is simply not available. For some, these settings are not only inappropriate; they are deeply triggering environments in which they can be subjected to profoundly damaging practices that compound existing trauma, including segregation, restraint and seclusion. The environment can be horribly reminiscent of the extreme deprivation suffered in early years: no furniture, no personal belongings, no family contact except through an intercom, treatment delivered through a small Perspex window, no activities, no stimulation, no choice.

The NAO has estimated that in a single year, 2012-13, the NHS spent £557 million on in-patient services for people with learning disabilities whose behaviour can challenge. These are vast amounts to spend on keeping people in situations that, far from helping, are causing untold harm. There are perverse financial incentives underpinning this. While responsibility for community provision typically rests with local authorities, in-patient care costs are met by the NHS. The Commons Select Committee heard that this is a disincentive to local authorities to invest in community provision, as it would lead to more patients becoming their financial responsibility. This makes no sense. The Care Quality Commission estimates that hospitalisation costs roughly three times the price of community-based care.

The Government promised transformational change after the 2011 Winterbourne View scandal, but progress has been unacceptably slow, with the target of a 50% reduction in in-patient beds now pushed out a further five years to 2024. In the meantime, vulnerable and blameless individuals continue to suffer.

When will the Government produce a robust, detailed, costed, evidence-based, cross-departmental plan to deliver on this long-overdue commitment? What will they do to ensure that the right community support is in place, not just to enable successful discharges into the community but to prevent admission in the first place? What steps will the Government take to build the much-needed capacity and skills in the workforce about which the noble Lord, Lord Addington, just spoke? Will they act to remove the perverse financial incentives and redirect funding flows from poor care models to the development of robust community services? Will they stop commissioners buying places in services that are failing to meet appropriate models of care?

Also, will the Government deliver reform of the Mental Health Act, under which the vast majority of in-patients are held? Currently, people with a learning disability can be detained if they display challenging behaviour. However, all too often, this behaviour is not because of a complex mental health problem, but because one or more of someone’s social care, communication, environmental or sensory needs are not being met. Once admitted, their quickly get stuck in a system in which effective routes for challenge are hard to find. What will the Government do to ensure that care, education and treatment reviews take place and involve the right expertise, as well as families, and that recommendations are followed within specified timescales?

As we have heard, in the end, this is a question of human rights. The Joint Committee on Human Rights stated:

“The detention of individuals in the absence of individualised, therapeutic treatment risks violating an individual’s … right to liberty and security.”


It also found that

“their rights to private and family life … and their right to freedom from inhuman and degrading treatment”

are threatened. Sadly, in my limited experience, all of these ring horribly true. Those individuals who achieve their ambition to return to community living leave traumatised by the experience that they have undergone, with their families equally traumatised and, frankly, exhausted by their unrelenting fight to improve their loved ones’ situations.

It cannot be right that any one person should be failed so many times: failed by the absence of appropriate services, then failed again through the treatment they have received in a place where they ought not to have been. I think that 2,085 is too high a number, but it is also low enough that the development of individualised pathways to support community living should, in a civilised society, be an achievable goal. The costs might be high but the costs of the alternative are far, far higher.

Residential Social Care: Staff

Baroness Bull Excerpts

Monday 6th September 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, the average turnover rate in social care is high, as noted by many noble Lords, as it is in some other sectors, including retail and hospitality. However, turnover rates are 8.1% lower in the past year among social care workers, down from 37.2% to 29.1%, which reassures us that many have in fact found it a fulfilling career.

[Baroness Bull (CB)]

My Lords, can the Minister say what improvements have been made to staff training in light of the Out Of Sight—Who Cares? report from the Care Quality Commission, which highlighted the excessive use of restraint, seclusion and segregation in the care of people with learning disabilities and autism in residential settings?

[Lord Bethell (Con)]

We are enormously grateful for that report, which has made a huge impact. I am not sure of the specific impact of the measures the noble Baroness describes, but I would be glad to write to her.

Calorie Labelling (Out of Home Sector) (England) Regulations 2021

Baroness Bull Excerpts

Thursday 22nd July 2021 Lords Chamber

Moved by

[Baroness Bull]

At end insert “but that this House regrets that they may not have their intended effect of addressing concerning levels of obesity in the United Kingdom; further regrets that their introduction will have negative and damaging consequences to those living with, or at risk of developing, eating disorders; further regrets that they do not reflect the views of experts and those with lived experience of eating disorders and do not take an integrated public health approach to obesity and eating disorders; and calls on Her Majesty’s Government to commit to timely reviews of the impact of these regulations not only on obesity, but on eating disorders, as such disorders have the highest mortality rate of all mental health illnesses in the United Kingdom.”

[Baroness Bull (CB)]

My Lords, I share government’s commitment to addressing obesity. My concern with these regulations is not their underlying intent; it is that they will have limited impact on reducing obesity while causing real harm to people with eating disorders.

If body weight was entirely under volitional control, this measure might be the answer to the obesity challenge, but obesity is more complex than that. Metabolism, poverty, environment and psychology all play a part, while hundreds of different genes influence our propensity to gain weight. The assumption that voluntarily eating less and/or exercising more can entirely prevent or reverse obesity is at odds with a definitive body of evidence developed over decades. They are not my words, but those of 100 obesity experts in a statement co-ordinated by the World Obesity Federation. Yet government’s obesity strategy turns a blind eye to this evidence and to the complex interface between obesity and mental health. I am astonished that the Minister did not mention this.

Eating disorders affect 1.25 million UK citizens and have the highest mortality rate of all mental illnesses. While some manifest in low body weight, others, such as binge-eating, lead to obesity. Obesity is not a mental illness, but the two often co-exist, with 30% of the extremely obese having a diagnosable eating disorder. Obesity measures will work only if they take these interactions into account. These regulations do not. While the impact assessment admits the poor quality of the studies supporting calorie labelling, the evidence for harm is strong. It drives people with anorexia or bulimia to eat less and those with binge-eating disorders to eat more. It leads to unhealthy weight control behaviours such as laxative use or vomiting, and it increases disorders in the wider population.

Calorie counting is an all-consuming obsession and a common trait in eating disorders. One person described her disorder as thriving off counting calories, while another said it ruined their life. Recovery is possible but fragile, with learning to eat in public a key part of the pathway. The affordable chains that these regulations affect are exactly the places where this happens. One sufferer described overcoming a terror of restaurants but said, “With calorie counts on the menu, I don’t think I’d have coped”. Given the complex and secretive nature of eating disorders, it is unduly cruel to insist that restaurants provide label-free menus only on request. Will the Government reconsider this, and can the Minister confirm that daily calorie requirements in the guidance now match what the NHS recommends?

Public health always involves trade-offs, with small harms to a few the price of gains for the many. The risk of my mammogram is worth it because I am screened for a disease to which I am vulnerable, but can it be justified for a public health measure to hurt people with no risk of the disease? If labelling was really going significantly to impact obesity, this prioritisation of physical over mental health might be justified, but evidence suggests it will not. We need instead an integrated approach to weight-related issues across the spectrum, recognising the co-occurrence and shared risk factors for obesity and eating disorders, and involving both fields from the outset. These regulations are not that. Given the high levels of concern, I ask government to commit to reviewing their impact not just on obesity but on any rise in the rate of eating disorders.

My regret today is genuine. I regret the limited effect that the regulations will have on obesity and the distress they will cause to those with eating disorders, and I deeply regret that we have failed in our efforts to protect them. I regret that, despite so many people bravely speaking out and despite the efforts of charities and clinicians, it has not been possible to work together on a public health approach to obesity, an approach that would more effectively support one part of the community without causing lasting collateral damage to another.

[The Deputy Speaker (Lord Brougham and Vaux) (Con)]

I remind noble Lords that the time limit for speeches is four minutes. I call the noble Lord, Lord Brooke of Alverthorpe.

--- Later in debate ---

[Baroness Bull (CB)]

My Lords, time is very tight, but I want to express my gratitude to everyone who supported my amendment, especially those who shared such moving and personal stories. I am grateful to the Minister for his invitation to engage with further suggestions and for his words on impact reviews—there is no time to explore them today, but I shall read them in Hansard and he can be sure that I will follow them up when the Recess is over.

I have no illusions about my ability to prevent the regulations passing. My intention today was to ensure that the unheard voices of those with lived experiences were on the record, and that we have achieved. I have learned the lesson of King Canute and I shall not divide the House. With regret, I beg leave to withdraw the amendment in my name.

Amendment to the Motion withdrawn.

Covid-19 Update

Baroness Bull Excerpts

Thursday 8th July 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, on the three specific locations the noble Baroness asked about, I understand that those practices will remain in place, but I am happy to check that and write to her. As for going back to where we were before, I think some things will change for ever.

[Baroness Bull (CB)]

My Lords, 120 scientists have written to the Lancet and today come together in an emergency summit to ask the Government to rethink their plans. The editor in chief warned against

“a plan driven more by libertarian ideology than prudent interpretation of the data”

and called for continued mask-wearing, distancing and increased vaccine coverage. A YouGov survey found that two-thirds of people want to continue with masks and an ALVA survey found that three-quarters of people did. So why have the Government decided to end this simple yet effective measure? It costs the economy nothing, but it would be life-changing for the clinically extremely vulnerable, who will be forced back into lockdown by this shift from a public health approach to so-called personal responsibility.

Women’s Health Outcomes

Baroness Bull Excerpts

Thursday 8th July 2021 Lords Chamber

[Baroness Bull (CB)]

My Lords, I congratulate the noble Baroness, Lady Jenkin of Kennington, on securing this debate, which feels particularly timely as we mark the 73rd birthday of the NHS this week. Women were undoubtedly among its most immediate beneficiaries, as the expansion of maternity care put an end to many of the horror stories of obstetric disasters, post-delivery haemorrhage and infections needlessly killing mothers after childbirth, for want of sterile surroundings. We have come a long way since then, but there is still some way to go.

The Library’s helpful briefing makes clear a range of healthcare areas in which women experience worse outcomes than men, including mental health. The Mental Health Foundation reports a strong relationship between women’s physical and mental health, with 85% of its surveyed members reporting that menstruation, menopause, pregnancy, fertility pressures and contraception impacted negatively on their mental health.

I will focus on eating disorders—serious mental health disorders that can affect anyone, but which are much more prevalent in women than men. A recent Finnish study found that one in six female adolescents and young adults met the criteria for an eating disorder, compared with one in 40 males. The pandemic has seen eating disorders spike, with demand for services up 200% in some areas and waiting lists at record highs. Those with high-BMI eating disorders cannot access treatment, since clinical pathways for binge eating are currently closed, as the NHS struggles to cope with the increase in low-weight disorders.

This is nothing short of a public health crisis, yet it receives neither the attention nor the funding it warrants. The best-known eating disorder, anorexia nervosa, has the highest mortality rate of any psychiatric disorder in the UK, yet the last available dataset comparing all mental health related research grants from major UK funders revealed that eating disorders received just 1% of the near £500 million available over the four-year period surveyed.

It is hard not to conclude that eating disorders suffer a triple whammy of perception and misperception: first, they are seen as a niche problem largely affecting a middle-class elite, which is not true; secondly, they are mental health conditions and, despite claims to the contrary, we have yet to live up to our promise to give mental and physical health parity of esteem; and finally, above all, they are seen as women’s issues.

Earlier this year, in the other place, the Minister Nadine Dorries said,

“for generations women have lived with a healthcare system that is designed by men, for men.”—[Official Report, Commons, 8/3/21; col. 535.]

Women continue to suffer as a result. I look forward to the forthcoming women’s health strategy and hope that it has some effect in redressing this age-old imbalance.

Covid-19 Update

Baroness Bull Excerpts

Tuesday 18th May 2021 Lords Chamber

[Baroness Bull (CB)]

My Lords, I declare my interests as set out in the register. With the move to stage 3 of the road map, university students can now return to campus. Most of them are too young to have received vaccines so students around the country will form a significant cohort of young people undertaking regular and frequent testing as a matter of course. What consideration has been given to the benefits of sustaining PCR testing and sequencing at scale in universities as a way of rapidly identifying and understanding new variants? Will the Government consider providing funding to support that in future?

[Lord Bethell (Con)]

My Lords, I pay tribute to the vice-chancellors and to the universities and colleges of Britain for the way in which they have embraced campus testing. It has been a salutary lesson in what can be done, and it has helped to keep infection rates down on campuses where there has been a small number of returning students to date. That is done mainly through LFD testing. Positive tests then have a complementary PCR test, and the PCR test is automatically sequenced if it is positive. The combination of LFD, PCR and sequencing is the right one for keeping infection rates down, but we tweak the formula as and when best advice comes in.

Eating Disorder Services: Referrals

Baroness Bull Excerpts

Monday 17th May 2021 Lords Chamber

Asked by

[Baroness Bull]

To ask Her Majesty’s Government what assessment they have made of the change in referrals to eating disorder services since April 2020.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)]

My Lords, eating disorders are serious, life-threatening conditions. We recognise eating disorder services are facing increased demand from children and young people, with 719 urgent cases starting treatment in the fourth quarter of 2020-21. That is why we made £10.2 million of additional funding available to mental health charities, including those that address anorexia, at the beginning of the pandemic, we convened a cross-government ministerial group to publish a mental health recovery plan and we are holding a ministerial round table on eating disorders.

[Baroness Bull (CB)]

My Lords, Q4 data on waiting times released last week showed, as the Minister said, 719 patients starting treatment for urgent cases of eating disorders, but this compares to 353 at this time last year. At this point in 2020, 18 people awaited urgent treatment, and 543 awaited routine treatment; those numbers are now 130 and 1,404. While much has been said about the pandemic’s role in driving this spike, most studies into young people’s mental health over the last year were not designed to detect eating disorders so, beyond anecdote, the reason for this increase, and therefore the best way to address it, is not clear. What will Government do to better understand this sharp increase? Does it represent broader and lasting behavioural changes among young people? Will the Government closely monitor the impact of their obesity strategy on referral rates, given that some of the planned measures—calorie labelling on menus, for instance—are shown to exacerbate existing eating disorders and increase the risk of their development in the general public?

[Lord Bethell (Con)]

My Lords, undoubtedly, the increase in referrals is something of concern. It is something we are monitoring closely, with the round table and the ministerial group dedicated to looking at this. That shows the seriousness with which we regard it. The reduction in the impact of community services, which is the best way of addressing these kinds of issues, has undoubtedly had an effect on urgent needs. During this period, there has also been a large increase in the number of young people who have started treatment, which is encouraging. If the noble Baroness has evidence that measures such as nutrition information on packaging has an effect on anorexia, I would welcome correspondence from her.

Office for Health Promotion

Baroness Bull Excerpts

Thursday 29th April 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, consultations are there to have an honest conversation. It would be wrong for me to try to pre-empt the outcome of that consultation from the Dispatch Box.

[Baroness Bull (CB)]

My Lords, the Government have pointed to Singapore’s health promotion board as a model, citing its digital public health schemes such as the national steps challenge or the “Eat, Drink, Shop Healthy” challenge. Is the Minister aware of the risks that gamification and incentivisation of what for many of us are healthy behaviours present to people living with eating disorders? With its responsibility for both obesity and mental health, will the office ensure that eating disorder experts are always involved in planning obesity interventions so that the complex relationship between the two is taken into account?

[Lord Bethell (Con)]

I completely take the point of the noble Baroness. We are extremely conscious of the challenge presented by social media in particular to identity and sense of body image. I know that there is much liaison between Public Health England and obesity and anorexia charities about its marketing to ensure that it hits the right note. We are investing in digital technology to try to get people moving and change their lifestyles; I pay tribute to the team behind Couch to 5K, who have used apps and digital engagement to encourage millions of people to take important steps towards a more active lifestyle.

Botulinum Toxin and Cosmetic Fillers (Children) Bill

Baroness Bull Excerpts

2nd reading
Friday 16th April 2021 Lords Chamber

[Baroness Bull (CB)]

My Lords, I too congratulate the noble Baroness, Lady Wyld, on bringing the Bill to the House and on her excellent introduction.

Restricting the use of Botox and cosmetic fillers in young people seems to me such an unarguable proposition that I could resume my seat at this point. However, I would like to take a moment to set this legislation in the wider context of body image and, in particular, the causes and impact of body image negativity in children.

The term “body image” describes our relationship with our body—how we think and feel about it and how much other people’s opinions affect that view. The recent report from the Women and Equalities Committee in the other place reveals that 66% of children feel negative about their body image, with body dissatisfaction identified in children as young as five.

Poor body image matters because of where it leads: low self-esteem, depression, anxiety, body dysmorphic disorder and eating disorders. Poor body image prevents young people from taking exercise, joining clubs, visiting their GP or even speaking up in the classroom. It increases risky behaviours, reduces quality of life and, at the extreme, can lead to self-harm and suicide ideation. It does not go away: poor body image lasts a lifetime. It is not surprising that Professor Chambers of the Nuffield Council on Bioethics describes body image as nothing short of a public health issue.

The factors acting on our sense of our bodies are manifold and unrelenting. From early childhood, we are bombarded with images of unrealistic bodies on screen, in print and online—ideals that young people internalise and then pursue, with social media the perfect platform to idealise and compare. The Commons inquiry highlights the damaging impact of digitally altered or filtered images in advertising across social media, with image editing apps readily available to change our shape or our appearance—apps regularly used by 45% of 11 to 16 year-olds.

I stress all this today because body image dissatisfaction is understood to be a motivator for the pursuit of cosmetic medical interventions. Preventing these procedures for young people who do not have the maturity to give informed consent at least addresses the supply side of the equation, but can the Minister say what we can do to address the demand side? What steps will government take to reduce the image editing, ban altered images and encourage use of a greater diversity of body types in advertising? Will the Government ensure that the forthcoming online harms Bill covers harms related to body image, and will they reconsider the potential harms inherent in the obesity strategy, particularly those relating to calorie labelling, which the Minister has been good enough to discuss with me?

The Bill is important, I support it and its provisions are welcome, but it addresses only part of the problem. Unless we create an environment in which children are supported to accept and enjoy their bodies as they are, they are likely to carry on chasing the fairy tale dream of a skin-deep perfection that does not in reality exist.