Autism

Baroness Gardner of Parkes Excerpts

Wednesday 4th February 2015 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness is right that timely diagnosis of autism is extremely important. I am glad she recognises that progress has been made. I believe that to be true but we know that there is more to be done. The update to the autism strategy, called Think Autism, draws specific attention to the needs of BME communities, and there is a specific action point within that document. I can tell the noble Baroness that we will include that specifically in the statutory guidance that follows on from the strategy. That guidance will be issued shortly.

[Baroness Gardner of Parkes (Con)]

My Lords, where I live, the daughter of a very nice man in the supermarket has just been diagnosed at the age of six. The problem is not the diagnosis—that has been made—but the fact that there seem to be no facilities of any sort to help him. He has been referred to the local borough by his Member of Parliament—an opposition Member, I might add, but a very nice man—and he has taken up the matter with the council, but nothing has happened. Is this, again, a problem of treatment as between care and health services, and what can be done to bridge the gap?

[Earl Howe]

My Lords, the answer to my noble friend’s question lies in more professionals being trained in autism and services supporting rather better the needs of children and adults with autism, and a lot of work is going on on those fronts. We are also asking local authorities to focus, in particular, on their own performance and to report back on the progress they are making on autism diagnosis, and indeed on other issues in Public Health England’s national autism self-assessment exercise. That process will draw out the shortcomings that exist in certain parts of the country.

Medical Innovation Bill [HL]

Baroness Gardner of Parkes Excerpts

Friday 23rd January 2015 Lords Chamber

[Lord Winston (Lab)]

My Lords, I shall not detain the House for great length. The amendment in my name and that of the noble Lord, Lord Saatchi, addresses patient safety, an issue which is dear to this Government. One of the concerns expressed again and again throughout the Second Reading and Committee stages of this Bill, and subsequently, has been that some patients might in desperation, for various reasons, seek treatment which is innovative but not properly regulated or properly justified. Particularly in the private sector, patients might be tempted to go into treatments which seem attractive but perhaps are overadvertised as sensible. In the end, they may be more futile than more recognised treatments that may carry known side-effects or perhaps be more frightening. I think that that is the case for cancer in particular.

This amendment is designed to make sure that any treatment given under this Bill would get broad support from responsible medical practitioners. There would be an onus, not only on the person doing the treatment, but on the person responsible for advising that the treatment was reasonable to the operator, the medical practitioner concerned. This would fall within that area. Essentially, there would be a legal onus, a responsibility, for that adviser to give advice which was regarded as serious and acceptable to a broad body of medical opinion in that field. That is the essence of this amendment, which we have discussed.

I am delighted that the noble Lord, Lord Saatchi, has agreed to put his name to this amendment. It is helpful. I hope that it will not prevent people participating in trials, particularly in cancer medicine. I also hope that it will make sure that private medicine is carried out responsibly. We all have reservations about this Bill but it covers most of the issues about which we have been concerned. I am concerned about reproductive medicine because I fear that that is now in a burgeoning private area. It worries me still that quite a lot of reproductive medicine done in the private sector is not properly validated and that patients are paying very heavily for it. Beyond that, broadly speaking, this is the amendment that I would like to see on the statute book. I therefore beg to move.

[Baroness Gardner of Parkes (Con)]

My Lords, I am slightly concerned about the wording of the amendment because I would not want it to become a way of dragging things on forever. How do you decide what is,

“a representative body of responsible medical opinion”?

To lay people such as myself, there seem to be heaps of medical bodies and I wonder how that would be determined. I would be interested to be satisfied on those points. The speech of the noble Lord, Lord Winston, was clear that he does not intend the amendment to represent any of those matters, but I would like someone who is more of an expert on the wording of these things to assure me that it would not be only a preventative technique.

[Baroness Masham of Ilton (CB)]

My Lords, having tabled an amendment to the Bill on patient safety, I am happy to support the amendment.

--- Later in debate ---

[Lord Giddens (Lab)]

My Lords, I strongly support this amendment and hope the Government will take it seriously because we are talking here about not innovation but scientific innovation. Science is a collective enterprise. It depends on the accumulation of evidence. It is crucial that that be recognised formally somewhere in the Bill, with this embodied as part of the advancement of scientific progress more generally.

[Baroness Gardner of Parkes]

My Lords, I support this amendment. I was surprised that the Government took a line similar to my own on the previous amendment because I was greatly reassured by what noble Lords said on that point. In this case, and right from the start of the passage of the Bill, we have all believed it essential to fully record what happens. The whole aim of this has been not only to give hope to people via an innovative treatment but also to have research that will benefit other people in future. No one has for a minute queried the need for recording the cases and results. I would be amazed and shocked if the Government denied that today.

[Lord Ribeiro (Con)]

My Lords, many noble Lords will remember the disasters that occasioned the introduction of laparoscopic cholecystectomy in the 1990s. Quite a few patients suffered as a result of the innovation of our surgeons playing with a new instrument, new tools and a new operation. At the time, I was secretary of the Association of Surgeons of Great Britain and Ireland. In recognising the problems, we introduced a voluntary register of all surgeons undertaking the procedure and got a very good response. Admittedly, it was not compulsory and not every surgeon introduced their data to it, but the net effect was that when we analysed our data we were able to identify where many of the problems lay. That led to further research and proper control trials in the procedure. We were able to turn to that from an innovation used by a succession of surgeons as and when they felt necessary, without any good evidence on how best to use it. On that basis, and mindful of the benefits that we saw in the 1990s, I would very much support some form of register to ensure that, if an innovation is introduced, we have the information, can go back and refer to it again, learn from the mistakes and improve the outcome.

--- Later in debate ---

[Earl Howe]

I would just say that the Bill is not to do with research but with innovative treatment, which is rather different. There is no question of the noble Lord, Lord Saatchi, promoting another form of clinical trial so while I accept the principle that the gathering of data is a very good idea, we must be clear that this is not for clinical research.

[Baroness Gardner of Parkes]

Before the noble Earl sits down, from the outset we have been very clear that this was to be recorded. Everyone has wanted someone reputable to come forward and say that they were going to record it. To see that this will possibly now not happen is just unbelievable because what is the benefit, unless people in the future can benefit from it and it is accurately recorded? I am sorry to say that I cannot accept the view that this amendment should not be accepted by the Government.

[Lord Woolf]

My Lords, before the noble Earl sits down for the last time, I am very conscious of the kind things said by the Minister about my interventions, and I can assure him that I hold his approach to all matters of this sort in equally high esteem, if not higher. He is a lesson to us all in the care with which he approaches these matters.

Just before we leave the subject, I want to draw attention to the words,

“comply with any professional requirements as to registration”.

That is a very important limitation in the amendment because—as I understand it; I did not have anything to do with the drafting—it presupposes that there should be professional requirements. Surely we can rely on the medical profession to put in sensible requirements.

Meals on Wheels

Baroness Gardner of Parkes Excerpts

Monday 19th January 2015 Lords Chamber

[Earl Howe]

My Lords, I do not recognise the figure of 40 million that the noble Baroness mentioned; perhaps she and I could confer after this Question. I think that what matters here is that those with eligible needs receive the service they require. It is up to local authorities to determine eligibility criteria, but the latest available data from ADASS show that all local authorities are setting their eligibility criteria to ensure that they meet at least critical and substantial levels of need.

[Baroness Gardner of Parkes (Con)]

My Lords, some years ago I was a chairman of social services, and many elderly people did not like the meals that came. I wonder whether that is still the position. I also wonder whether the position in hospitals is similar, as we have found that more people suffered from malnutrition after they had been in hospital than before. That happened because people could not feed themselves adequately and the maid or carer who delivered the food to them would come in and say, “Oh, you didn’t like your lunch, dear”, and take it away. Of course, they have found ways round that, but have they found ways to ensure that people are getting meals that they like, and is someone seeing that they actually eat them?

[Earl Howe]

My noble friend makes a series of important points. I do not have information on how many people dislike their meals on wheels, but the fact that many purchase them must indicate that the quality of those meals in many areas is of a high standard. There is also charitable provision, which I should have mentioned as well. The context here is surely the new regime that will be ushered in by the advent of the Care Act, which builds support around the individual and their needs and preferences.

HIV

Baroness Gardner of Parkes Excerpts

Thursday 15th January 2015 Lords Chamber

[Earl Howe]

The noble Baroness is absolutely right. If we were to single out three things that are important in this context, they would be prevention, testing and tackling stigma and discrimination. The NHS, local authorities, government, community and faith groups, the media and individuals themselves all have a part to play in eliminating HIV-related stigma. Our framework for sexual health improvement is clear that action needs to continue to eradicate prejudice based on sexual orientation. That depends on building an open and honest culture where everyone can make informed decisions and responsible choices about relationships.

[Baroness Gardner of Parkes (Con)]

My Lords, is it not a fact that there has been a great change in attitudes about HIV, and not only because of the treatments that are now available? I recall the days when people went into a hospice because it was a terminal condition. I have sat on various inquiries and know that people used to hide—in the fridge, for example —any evidence that they had HIV because they were frightened of other people knowing. Because that no longer applies, there is a great opportunity for people to have testing without any embarrassment at all.

[Earl Howe]

My noble friend is right. I think that we have come a long way since my noble friend Lord Fowler was Secretary of State, when stigma and discrimination were very apparent in virtually all sections of society. We do not see that so much now, I am glad to say, as evidenced by the fact that we are reporting a continuing reduction in late diagnosis. It was down to 42% last year from 47% in 2012, and that is a key indicator in this context.

NHS: Dermatology Services

Baroness Gardner of Parkes Excerpts

Wednesday 17th December 2014 Lords Chamber

[Earl Howe]

My Lords, the Government have mandated Health Education England to provide national leadership on education, training and workforce development. Dermatology is currently a key part of the generalist undergraduate medical curriculum and a component of GP training. The General Medical Council requires that the undergraduate medical curriculum should provide enough structured clinical placements to enable students to demonstrate the outcomes for graduates across a range of clinical specialties, including dermatology.

[Baroness Gardner of Parkes (Con)]

My Lords, with my typical Australian fair skin and the strong sunlight there, I had a skin cancer some years ago. I have to go back and be checked and I consider that I am being looked after very well. However, the one thing that the consultant always says when he sees me on this annual basis is that there is a lot of unhappiness about the research money. When people apply for research funding, it tends not to go to those who are actually doing the work, but to someone who carries the name of being the research officer in the department. The money is spent on administration rather than on actual research. Can my noble friend tell me whether that has improved since I last raised this point, which must be about two years ago?

[Earl Howe]

My Lords, the National Institute for Health Research’s clinical research network is currently recruiting patients to more than 60 studies in dermatology. Specifically, it funds a wide range of research on skin cancer. It has awarded £1 million for research on GP and patient interventions to improve early diagnosis of malignant melanoma in primary care. Another NIHR award is on understanding the experiences and support needs of patients with melanoma and their carers, and patients are being recruited to 18 melanoma studies. I will take away my noble friend’s point about administrative costs but clearly any research project carries such costs, which must be covered somehow. Unless the balance is wholly wrong, I do not think we should be worried that some funding goes towards administration.

Learning Disabilities: Health and Care Services

Baroness Gardner of Parkes Excerpts

Wednesday 3rd December 2014 Lords Chamber

[Earl Howe]

My Lords, that is a very interesting idea; the noble Baroness is right to draw attention to the Dementia Challenge programme, which has been hugely successful. At this point, once we and the system have delivered on our Transforming Care and concordat commitments we will consider how the lessons learnt from the Dementia Challenge programme might be applied in the next programme delivery phase, and indeed in other policy areas as well.

[Baroness Gardner of Parkes (Con)]

My Lords, I declare an interest as I have a grandson in this position. Is the Minister aware of just how extremely difficult it is to get any action at all in these cases? When someone in their early 20s who is no longer a child has to give up whatever educational establishment they have been at, parents find themselves confronted by a situation where everyone is saying, “Yes, you need mental health services”, but none are available. Do I understand correctly that the suggestion made by the noble Baroness might help that situation? If so, I strongly support it.

[Earl Howe]

My Lords, the report contains a number of important recommendations which we will consider. This report was commissioned by NHS England for NHS England, to make recommendations for a national commissioning framework under which local commissioners would secure community-based support for people with learning disabilities and/or autism. It is an important report, it is right that we take a bit of time to digest it, and, together with NHS England, we are looking carefully to do just that.

Care Sector

Baroness Gardner of Parkes Excerpts

Tuesday 25th November 2014 Lords Chamber

[Baroness Gardner of Parkes (Con)]

My Lords, I am very grateful to the noble Baroness, Lady Kingsmill, for bringing up this subject. It is something in which I have taken an interest for some time.

I am not a qualified solicitor, but I sat for many years as a lay member on industrial tribunals, which are now of course called employment tribunals. I was therefore fascinated when it was mentioned how badly paid these people were, with no pay for their travel time between jobs. A noble Lord who spoke earlier said that they should take their case to an employment tribunal, and that without doubt the employment tribunal would give them the right to be paid. That is all very well, except that all these people are working as individuals, usually for an agency, and the agency determines everything.

I have been trying to help a particular woman who has worked for many years caring for elderly people, usually for five, six, seven years. She has just finished seven years with someone who died in their 90s. When they died, the son came over from America and said, “We will not need you any more now she is dead”. He never offered to pay a penny of notice or said anything to her whatsoever. He just vanished, and she was left with nothing. I have spoken about this to various people in this House, such as the noble Lord, Lord Whitty. He said, “She must have had a contract of employment”. There was no contract of employment, as she was considered self-employed. The elderly lady had someone else to care for her five days a week and this carer’s responsibility was to go in on Friday night and stay through till Monday morning. I worked out that that was 48 hours or more. She was paid £100. It turned out that was around only £2 an hour—I had to use my calculator—for two full days in which she had to get up many times during the night to look after that woman. One talks about people being vulnerable, but a lot of old people also get very difficult. This was such a case. But this carer is such a caring person that she would say, “She does not mean to be difficult”. The carer really did her best for this woman.

Having lost that last person, the carer decided she would join a system that the councils use, whereby they are associated with a particular employment agency. I did a lot of phoning to various employment agencies to see which would be a good one to go to. The differences that came up were quite interesting. The important thing was that the workers had to have had training. The noble Baroness mentioned that there is no such thing as a national standard of training. There is none. When you ask the agencies, “What do you mean by training?”, they tell you, “You have got to pay for it,” and the carers pay from £25 to £40 for this. When the workers get the training, it is simply a bit of paper that applies to that particular agency. They cannot use it to go to any other agency. If they want to go to another agency, they have got to do that agency’s training. Someone here who does a lot to help people into employment said to me, “That is the way they lock them into that agency. If they have got to pay for new training, they are not going to leave their place of work, because that is the one that approves them”.

When I asked the agencies what things they trained their workers in, I was told they wanted to be sure a carer knows how to get a patient in and out of the bath, or how to cook a little meal—all the things that are practical. They only ask you in a written question what you would do in an emergency if, say, a person is unconscious on the floor. It seemed very unsatisfactory to me, to say the least.

They asked her to sign on with the company and I asked her to show me a copy of the paper. “They do not give you a copy”, was her reply. I told her to ask for a copy. How would she know what the conditions of work are otherwise? I then asked about travelling between jobs. The answer was that you are sent to client A for an hour and then you are sent to client B, but they might be an hour apart in travel terms. There is no pay at all for the travelling time. I have spoken to local authorities about this in a meeting in one of the Committee Rooms. They said that they should not really be using these agencies unless they know that they are paying proper wages.

Time is running out because I have only six minutes in which to speak, unlike the wonderful speech we have just heard. I come to the most important thing, and it is worth spending the last minute on it. We need a nationally recognised standard of training. The training should not be too complicated or difficult for people to achieve, but it should cover the essentials. Someone with the qualification should be able to go anywhere in the country, and it should be accepted. That would be a great help.

There is a great deal to this subject. I am a retired dentist. No one can just help out in a dentist’s surgery any more. The staff all have to be fully and extensively trained. Every field in care or health requires training that is recognised nationally, and that is what we need in this sector. When we have that, it will mean that we would be able to help the very large number of people who are going to need care in the future.

Medical Innovation Bill [HL]

Baroness Gardner of Parkes Excerpts

Friday 24th October 2014 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I declare an interest as Professor of Surgery at University College in London and as a member of the General Medical Council. I welcome the interventions of my senior clinical colleagues, the noble Lords, Lord Turnberg and Lord Winston. They have helped us to understand that, although it is hard, this is a vitally important Bill to drive forward the practicalities of innovation in clinical practice. I hope that it will also drive forward a positive culture of putting innovation at the heart of all clinical thinking. However, there must be safeguards to ensure the protection of vulnerable patients. A number of amendments in this grouping try to address that issue. When this Bill was first made available for public comment some years ago, I was initially anxious about the fact that there were insufficient safeguards. The approach that I wished to adopt was one that I know has been considered but has been also dismissed. I have, however, become reassured by the process under the supervision of the Medical Director of the NHS, Sir Bruce Keogh. He has consulted widely among the profession and I believe that the amendments in the name of the noble Lord, Lord Saatchi, particularly Amendments 12 and 16, bring us to a place where appropriate safeguards have now been introduced. I hope that they will be judged sufficient to provide the protection that all responsible and reasonable clinical practitioners would want in a Bill of this nature.

There are two other amendments being considered in this group that I believe to be vital, Amendments 15 and 19, dealing with the registration and reporting of the results of innovation. There is no doubt that if this Bill is to achieve what it hopes to, the innovations that are provided as a result of having this provision available to us in clinical practice must be reported widely and be available for other clinical practitioners to consider. I know that, at this stage, the view is that other mechanisms are available that provide the opportunity for that reporting to be made, but I wonder whether the Minister might consider during the further passage of the Bill how very powerful a provision of the kind suggested in the two amendments would be in securing the greatest benefit for the largest number of patients.

Another question to have been raised on this group of amendments is that of being certain that the Bill does not apply to situations of emergency care and does not in any way interfere with the mechanisms available for ethical and appropriate clinical research. A strong research governance structure supported by strong legislation is available in our country, and this Bill should not be seen to impinge on that in any way. I am reassured by the noble Lord, Lord Saatchi, saying that the Bill does not relate to the conduct of research and should not be confused as doing so, nor does it in any way interfere with what are, as the noble Lord, Lord Winston, said, acute and deeply stressful decisions that have to be taken in the situation of providing emergency care. I hope that the Minister will be able to reassure us that other legislation, guidance and mechanisms exist to ensure that the Bill does not impinge on those two areas.

[Baroness Gardner of Parkes (Con)]

My Lords, I strongly support the Bill and hope that we will be able to reach agreement on important points today. It is essential that patients should feel safe, so all the safeguards being put forward are welcome, but patients also want to feel hope. When I think of Les Halpin, referred to by the noble Baroness, Lady Masham, I recall his rapid deterioration with motor neurone disease. When he first launched the idea of doing something, it was hard to detect that there was anything wrong with him. Within no time at all, it seemed—but probably it was about a year—he could not stand; he was in a wheelchair; and he had to have his head supported. It was unbelievable. What he wanted, not only for himself but for others, was hope.

The noble Baroness, Lady Masham, referred to Ebola, where they are trying things, irrespective of whether they know they are right, and in many cases they are probably working. It is hard to know. When I was chair of the hospital that has the Ebola clinic here in the UK, we had a case and the man recovered. In those days, there was no treatment other than just isolation and patients relying on their own strength to pull through. The noble Lord, Lord Winston, related a story about an ectopic pregnancy. It was interesting to see there how there was a conflict between two highly qualified medical practitioners. If he had not bravely taken that action, irrespective of any action that might be taken against him, that woman would not have survived. We do not want to make the procedure so enormously complicated that, by the time you have the result, it is too late for the person that you are aiming to help. On the other hand, I think that everyone agrees that the recording of the information, referred to by the noble Lord, Lord Turnberg, in speaking to his amendments, is essential. Unless it is recorded and open for use by everyone, it might help one individual, but no one will know what happens and how to help any others afterwards on a wide scale.

I think that everything that can be said on this Bill today will be said. I remember at Second Reading that the noble Lord, Lord Winston, was worried about people being sued for failure to innovate. I feel that that is only a remote prospect and should not be worried about too much. If all the safeguards are put in place, I believe that that will not happen. I strongly support the Bill and hope that the Minister will assure us that we will be able to proceed with it.

--- Later in debate ---

[Lord Saatchi]

I hope that this may help my noble friend Lord Kirkwood. What we have just heard from the former Lord Chief Justice and the Minister is completely clear to me. I will try to explain it in this way: if the doctor feels completely confident that the innovation he is about to attempt will be approved when the Bolam test is applied in a subsequent trial, he will go forward with his innovation. If a trial then takes place, he either will or will not be proved right when the test is applied—that is, if he departed from standard procedure and decided to do it on the basis of his confidence that the Bolam test would make him innocent of negligence.

However, as we all know—this is fundamental to the Bill—if the doctor is obliged to speculate in advance about what might or might not happen in a trial, that raises a very high degree of uncertainty. If it is possible for a doctor to move the Bolam test forward and comply with it in advance, which is what would happen as a result of the Bill becoming an Act of Parliament, that would enable the doctor to move forward with an innovation without the fear that a subsequent trial will find him guilty. I therefore say to my noble friend Lord Kirkwood that what we have here in simple, plain language, is that the Bill is giving the doctor an option if he wants to be certain before he goes ahead with an innovation. It is not a requirement that he does that. If he is confident of the result of a subsequent application of the Bolam test, he does not need the Bill at all. It is a fundamental benefit of the Bill that it gives that option, which I think is a very simple one.

[Baroness Gardner of Parkes]

Can I seek some clarification? I wonder whether anyone could make clear for the Committee whether, if the doctor says that he does not want to do the innovative treatment, there is a defence in court on the grounds that he thought that it would be unwise or unsatisfactory. I say this because everyone seems concerned about the effect of not doing something innovatory.

[Earl Howe]

I can reassure my noble friend on that score that a doctor’s clinical judgment not to go ahead with something innovative would be something that the doctor would be able to cite in court, if necessary, as being the most reasonable course to take in the circumstances.

Health: Dental Implants

Baroness Gardner of Parkes Excerpts

Wednesday 23rd July 2014 Grand Committee

Asked by

[Baroness Gardner of Parkes]

To ask Her Majesty’s Government what action they are taking to make the public aware of the medical need for periodontal checks following the fitting of dental implants.

[Baroness Gardner of Parkes (Con)]

My Lords, peri-implantitis may seem to be a somewhat obscure matter to debate today, but that is the very reason why I am raising the subject. As a long-retired dentist, I was quite unaware of the condition. I found it most interesting when I heard Professor Nick Donos, head and chair of periodontology and director of research at the UCL Eastman Dental Institute, address an international dental conference on this subject in London last month. I thank him and others who have provided me with valuable material for the discussion tonight.

This is an important and growing health problem and there needs to be an awareness and a degree of understanding of the present position and the growing risks associated with this increasingly popular form of dental treatment. The condition is peri-implantitis. When I attended my first international dental conference in 1955 in Copenhagen, dental implants were a new idea and early cases reported by those dentists present had often failed spectacularly. In some cases, large portions of a jaw were lost in the process, mainly due to the rejection of the foreign body—the dental implant —by the patient’s immune system.

Time moved on and it was found that the metal titanium was accepted by the body. Since then, titanium-rooted dental implants have become widely used in the replacement of missing teeth. Half a million adults have at least one dental implant, according to the latest Adult Dental Health Survey. Studies suggest that one third of these patients will have a milder disease—peri-implant mucositis—which is common and treatable. If undetected or untreated, these red swollen gums can develop into peri-implantitis, which is associated with both inflamed gums and jawbone loss around the implants. As with so many health conditions, smokers have a significantly higher risk of peri-implantitis.

The European Association for Osseointegration emphasises the importance of appropriate patient selection. Most of us would accept that view and, as patients, we would expect to receive sound advice from the appropriately trained dentists performing implant procedures. It is important to indicate for the patient, particularly in complex cases, that implant dentistry should be seen as a multidisciplinary treatment. Within the objectives of the General Dental Council curriculae for dental specialists, it is indicated that periodontology, the treatment of gum conditions, is the specialty in charge for the planning and execution of the surgical component, and prosthodontics is the branch of dentistry that deals with replacement of missing parts with artificial structures and executes the relevant implant superstructures.

Complications of implant therapy, particularly peri-implantitis, are within the objectives of periodontology. Some experts studying the condition of peri-implantitis, a growing problem, believe that there should be formal national registration of implants, national health and private, in the UK. This would probably be the first in Europe, and would enable regulation of the type and quality of the implant-related procedures.

An implant is a titanium screw that is inserted into the jaw under a controlled protocol and, when fused with the bone, forms an artificial tooth root. Their use is growing rapidly in the UK, and although they are costly they are often considered the treatment of choice for replacing missing teeth. They can also be used as a support for a more extensive prosthesis.

When I googled “dental implant”, as a patient often would if they had heard about this treatment, I was disturbed to read the advertisement:

“Get smiling again with our same-day dental implants”.

That is surely what can cause adverse conditions post-treatment and is contrary to all the recommendations from the official dental bodies, which believe the patient must be fully assessed prior to treatment and informed and treated if there is an existing periodontal condition before the implant procedure. It must also be made clear to them that an implant is not a treatment you just have and forget. Regular follow-up visits are required to ensure that a periodontal condition does not develop, first into mucositis, and then progress on to the more serious disease, peri-implantitis, which causes loss of bone supporting the implant and often loss of the implant itself.

Remembering the time when so many women were at serious risk from cheap silicone breast implants and the heavy cost of dealing with unsatisfactory, even dangerous, treatments, including removal or replacement of these, it is particularly important that we are aware that many people seeking dental implants are tempted by cheap offers from abroad. These usually have the great disadvantage that the patient does not have continuing care and may be totally unaware that periodontal follow-up is essential to ensure continuing oral health. These patients certainly need to be clear that care and control of the gums before and following implants are most important.

My noble friend Lord Colwyn sends his regrets that he is unable to be here tonight. He also sends the message, as someone who has done implants himself, that implants should be put only into healthy mouths.

When I tabled this Question for Short Debate, I had seen nothing in the press on the subject. I was pleasantly surprised to see that on 14 July the Daily Telegraph had a very informative article on peri-implantitis titled “The ‘Time Bomb’ in Dental Implants” about a patient, age 52, who had four teeth implanted at a cost of £13,000 in 2002. Three months ago this patient felt a lump on her lower jaw, near one implant. She went to have this checked, and it responded to antibiotics, but the X-ray showed that the bone supporting the implant was receding, and the diagnosis was peri-implantitis.

Ten years ago this disease was almost unknown, but it is now a serious possible consequence of implantation, particularly when the implant patient has not continued to have regular periodontal checks, with treatment if necessary, following an implant. Some studies suggest that one-third of implant patients will be infected, and because jawbone loss is silent and invisible, people do not realise that they are at risk. Early warning signs are red, swollen gums and bleeding, which is often apparent when tooth-brushing; smoking seems to aggravate the situation, and significantly more smokers develop peri-implantitis.

The Faculty of Dental Surgery at the Royal College of Surgeons points out that long-term assessment and maintenance need to be assured if this threat to stability of the implant is to be prevented. It believes that the General Dental Council should introduce minimum standards of education and training for complex dental treatment, such as implants, to ensure patients are treated by a qualified professional. It supports the view that the General Dental Council should include peri-implant assessment and maintenance in the undergraduate curriculum. Too often the practitioner who inserts the implant does not provide long-term support for the patient, discharging them back to their general dental practitioner.

Periodontal disease has been associated with diabetes, cardiovascular disease and pneumonia. Some people speculate that an increase of bacteria in the body may aggravate these conditions but it is not considered to cause them. Professor Donos says:

“The main challenge is for the patients suffering from periodontal disease who represent a significant proportion of the population. As you know, due to the silent nature of the disease, it does not always provide ‘pain’ as a symptom for the patient”.

He continues:

“I think it is important for the public to be informed that even though implants are successful and offer great functional and aesthetic solutions in terms of replacing missing teeth, appropriate patient selection is required”—

as my noble friend Lord Colwyn said—

“control of periodontal disease before and after implant placement is essential and all risk factors need to be controlled through regular follow up according to the susceptibility profile of the patient”.

In my experience, pain is the thing that brings many patients into the dental surgery. I cannot end this dental discussion without mentioning the report this week that 26,000 children in England aged between five and nine have been hospitalised to have multiple tooth extractions in 2013-14, which is nearly 500 children a week, at a huge cost to the NHS and a great disturbance and upset for the children and their families. However, that is a debate for another time: I flag it up here for the Minister.

Tonight, I hope that patients who want and should have dental implants will benefit from understanding the importance of dealing with periodontal conditions before and after treatment. I look forward to a positive response from the Minister and to his assurance that his department will create public awareness of this condition.

NHS: Ambulance Response Times

Baroness Gardner of Parkes Excerpts

Monday 21st July 2014 Lords Chamber

[Earl Howe]

My Lords, patients have the right to a high-quality urgent and emergency care service whenever they call upon it, and we expect ambulance trusts to provide that. We are aware that independent or voluntary ambulance services may be used to support NHS ambulance services because they can help manage peaks in demand. Individual NHS ambulance services have got to ensure that 999 calls are attended by staff who are properly trained and adequately equipped. Indeed, since 2011 the providers of independent ambulance services have had to register with the Care Quality Commission, which monitors, inspects and regulates all services.

[Baroness Gardner of Parkes (Con)]

My Lords, is it not a shame that London has only one air ambulance, which is run by a charity, when Sydney and Paris have six and four respectively? Does the Minister not think that it would be to the advantage of patients to have more air ambulances operating in London, because at least they can deal with any major traffic problems?

[Earl Howe]

My Lords, we owe a great deal to the air ambulance services across the country, all of which, I think I am right in saying, are organised as charities. However, it is the case that in every instance the NHS pays for the clinical staff on those ambulances while the charity pays for the helicopter and the pilot. That is the balance we have struck and successive Governments have taken the view that it is the most cost-effective model for the NHS. However, that is not to downplay the very important role that ambulances perform in our society.