Medical Technology Regulations and the NHS

Gary Streeter Excerpts

Tuesday 28th March 2023 Westminster Hall

[The Minister for Health and Secondary Care (Will Quince)]

It is a pleasure to serve under your chairmanship, Sir Gary. I congratulate my hon. Friend the Member for Gosport (Dame Caroline Dinenage) on securing this important debate. I am grateful for the opportunity to update her and the House on the subject, and I am proud to showcase the investments that the Government are putting into life sciences.

My hon. Friend showed eloquently and articulately that medical technology is of huge importance to the UK and its health and care system. As she rightly said, the regulations that govern medtech have to protect patients and ensure public safety. It is also important that they encourage investment and drive innovation in the sector. The NHS spends an estimated £10 billion a year on medical tech, and the sector is an essential provider of jobs and specialist skills across the UK. The hon. Member for Denton and Reddish (Andrew Gwynne) set out the value of medtech to UK plc; there are no fewer than 138,000 jobs in the sector in this country.

My hon. Friend the Member for Gosport rightly highlighted how the UK’s decision to leave the EU, coupled with huge advances in life sciences and diagnostics —many of which the hon. Member for Denton and Reddish set out—has presented a great opportunity for us to reform our medical devices regulatory regime. We are well placed to do that, and we have to seize the opportunity.

We have a dynamic and pioneering medtech sector and a world-renowned regulator in the Medicines and Healthcare products Regulatory Agency, which most people know as the MHRA. I know that there have been challenges with the MHRA, as my hon. Friend the Member for Gosport set out, and I will come to that in a moment. Before I do, I want to touch on the work that the MHRA is doing to update the medical devices regulatory regime.

The first set of changes will be delivered this year—in fact, by the summer. The updated regime will deliver improved patient safety, greater transparency and closer alignment with international best practice, as my hon. Friend rightly pointed out, and it will ensure that regulation is proportionate. I am still very much alive to the scale of change and the huge importance of giving the sector—as the hon. Member for Denton and Reddish set out, many of its businesses are small and medium-sized enterprises—the time that it needs to adapt. Certainty of supply and access to medical devices in the NHS is critical, so we will intentionally phase in the regulatory changes in stages to give industry certainty.

I want to touch on two other areas, both of which are really important to the industry: artificial intelligence and new routes to market. In both cases, the new regulations will support innovation in the UK’s life sciences sector and, importantly, accelerate access to innovative medical devices for UK patients.

We are improving the regulation of novel and growing areas such as AI to ensure that our systems are responsive to technological advances. We have to ensure that we continue to be best in class and world class in this space. I want us to be world leaders in the regulation of new technologies and new approaches, such as AI. At the heart of that ambition is our desire for patients here in our United Kingdom to have access to the very latest innovations in medical technology. I want them to have that as quickly as possible, and agility is key to ironing out the bureaucratic processes that historically have caused delay.

New routes to market are important because they will enhance the supply of devices, including the most cutting-edge products. The regulations will introduce a new pathway to support the use of real-world evidence in the conformity assessment process, with proportionate regulatory oversight for these devices. To be absolutely clear, though, because we cannot lose sight of this, the focus of the MHRA must be patient safety. That must remain paramount.

Importantly for UK plc—I turn directly to the point made by the hon. Member for Denton and Reddish—I believe that these improvements will help to create opportunities for small and medium-sized enterprises, including by ensuring that UK businesses have the ability to supply their UK-made and UK-developed products to the NHS and get them in use for patients more quickly.

I mentioned that my Department’s priority is to ensure that innovative, safe and effective devices reach patients as quickly as possible. That is an area of real focus and one where I want us to improve. Our inaugural medtech strategy, which was published last month, has been mentioned by everybody who has spoken. The strategy is key, because it recognises many of the systemic challenges to adopting innovative products that hon. Members across the Chamber have set out. It sets out a clear ambition to provide a streamlined pathway from pre-registration through to adoption in the NHS, which the hon. Member for Strangford (Jim Shannon) rightly pointed out. Importantly, it will ensure rapid progression for priority innovative products, including drugs, as my hon. Friend the Member for Gosport rightly said. The medtech strategy sets out our ambition and clear signals as to what we want to achieve.

Both my hon. Friend and the hon. Member for Denton and Reddish asked how we identify the products needed for the future, so that we can set innovators off to design products that tackle the challenges we face. We are working closely with senior clinicians across the NHS. It is our ambition to set out the big challenges in the health and care system, and then to give those challenges to innovators—ideally, but not exclusively, in this country—and set their minds, businesses, organisations and capital to work to design the products and devices that we need. That will allow us to introduce novel products to the NHS, and therefore our patients, faster.

I genuinely believe that medtech has the most enormous potential to improve patient outcomes, and I know that my hon. Friend the Member for Gosport does too, as a former Health Minister and a former Digital Minister—two areas that are very much combined in this debate. I see that potential already on my visits around the country —from a particular type of plaster that enables a wound to heal faster, to robotic surgery equipment that costs many millions of pounds. They have very different functions, but both fall under medtech regulations. It is therefore vital that we work more closely with industry to ensure that we have a robust pipeline of innovations that can be adopted at pace and scale, and can then support the delivery of our and the NHS’s key priorities.

The inaugural medtech strategy is an important milestone, but it is also important to back it with funding. As my hon. Friend rightly pointed out, the Government recognise the opportunities that we have before us and the importance of this topic. That is exactly why, in the Budget—the evidence is there—the Chancellor of the Exchequer announced £10 million of additional funding for the MHRA over the next two years. That will help us to bring innovative medicines and medtech to patients more quickly. It will support the development of a shortened but still thorough approval process for cutting-edge treatments such as cancer vaccines, which is an area that we are investing in considerably alongside industry. There is also AI-based technology. I know that I have mentioned AI a number of times, but it is the most exciting area of medtech. For example, the relatively new AI-based app Sleepio, which provides tailored therapy for insomnia at the touch of a button, is the kind of technology that will transform the lives of patients in our NHS.

My hon. Friend rightly mentioned international recognition, which I recognise is so important and is one of the Brexit opportunities that has come about. The funding will also be used to establish an international recognition framework, which will allow the MHRA to fast-track the approval of medicinal products that have been approved in other trusted countries. That will address the unnecessary duplication of regulatory processes from countries with the same standards as us and therefore reduce the time it takes for essential products to reach our market. It will make the most of the MHRA’s resources. Finally and critically, the additional funding put in by the Chancellor only a week or so ago will ensure that the MHRA has the resource and infrastructure more broadly to deliver on our ambitious vision for UK patients, by increasing the availability of life-saving medtech devices on the UK market while maintaining proportionate regulatory oversight to protect patients.

My hon. Friend asked three specific questions. The first was about the timescale and the fact that we need to act fast. She is absolutely right. We have published the medtech strategy, which has largely been welcomed by industry. The first set of changes will come in this summer. Then there will be a transition period for CE-marked devices into law. Later this year, we will introduce post-market surveillance requirements. Other updates will follow, but I am acutely aware that industry must have sufficient notice, and I will ensure that it has that throughout.

My hon. Friend’s second question was in relation to dementia and Alzheimer’s drugs. I will look very carefully at that. Understandably, the MHRA and NICE are independent, but of course I would be very happy to meet representatives of Alzheimer’s Research UK, because I understand the importance of potential new drugs. If a drug has received FDA approval, we would want to look very carefully at it and consider how it might benefit patients here.

The third question was about the global tech industry. I covered that off a little by saying how we plan to set out our big challenges and then say, “This is the innovation that we need you to come up with.” Of course we want to drive local innovation too, so if there are particular local challenges, we want to empower integrated care systems and integrated care boards to encourage local businesses and local innovators to come up with solutions to supply their local NHS.

My hon. Friend’s final question was about the ability of the MHRA to deliver. I referred to the £10 million. We have also recently increased the fees for the MHRA, which come directly from industry, because it is largely self-funding. I keep a real watchful eye on this. I regularly meet the chief executive officer and others from the MHRA. I have also visited the MHRA twice, which was fascinating. If anyone has not done so, I encourage them to arrange a visit with Dr June Raine; I know she would be very happy to set that up. It is an absolutely fascinating place, based in South Mimms.

In conclusion—I am conscious of time and I know that my hon. Friend would like some time to respond—I again thank my hon. Friend for securing this important debate. Dare I say that this is probably not an issue being discussed widely around dinner tables across the country? Nevertheless, it is of vital importance to UK plc, it is hugely important to our NHS, and of course it is really important to patients, too.

This afternoon, my hon. Friend has drawn on her personal experience as a former Health Minister and a former Digital Minister to highlight the importance of medtech, and in doing so she has done her constituents and patients across the UK a huge service. I very much look forward to working with her and others to seize the opportunities and break down the barriers, so that we can bring the very latest innovation to patients as quickly and as safely as possible.

[Sir Gary Streeter (in the Chair)]

Dame Caroline indeed has the final say.

Oral Answers to Questions

Gary Streeter Excerpts

Tuesday 24th January 2023 Commons Chamber

[Steve Barclay]

My hon. Friend raises an important point about the additional costs that the London Mayor is imposing not just on NHS staff but on all staff working in the capital, in contrast to the approach the Chancellor has taken to energy support to help staff across the workforce, including in the NHS, with the cost of living.

[Sir Gary Streeter (South West Devon) (Con)]

Most of the GP practices in South West Devon report to me that their biggest challenge is recruiting new doctors. Does my right hon. Friend have an estimate of the number of young doctors finishing their training this year who are likely to want to become GPs, and can he reassure us that that is a greater number than the number who are likely to retire in the next 12 months?

[Steve Barclay]

My hon. Friend raises two important themes. The first relates to how many are in training, and I think it is around 4,000. We have boosted the number of GP training places and we have looked at medical schools as a specific issue. Also, he will have seen some of the changes being made around pensions in order to better retain staff, mindful of those clinicians who are leaving the profession, and further discussions are taking place with Treasury colleagues in that regard.

Oral Answers to Questions

Gary Streeter Excerpts

Tuesday 1st November 2022 Commons Chamber

[Maria Caulfield]

I agree and we are taking action now. Our aim is to expand the mental health workforce by an additional 27,000 healthcare professionals by 2023-24. We have already seen an increase—almost 6,900 more full-time equivalent staff. The workforce are the key to that, which is why are investing in them so heavily.

[Sir Gary Streeter (South West Devon) (Con)]

Waiting times to access mental health specialists in my area are unacceptably high, and I am constantly told there is simply an inability to recruit mental health specialists. I know the Minister works very hard on this subject and she just mentioned what we are doing over the next couple of years. What practical steps can the Government take to ensure that, this year, 2022, there are more mental health specialists available to serve my constituents in Plymouth and south-west Devon?

[Maria Caulfield]

My hon. Friend makes a good point. We have introduced standards to measure waiting times because the situation is very diverse across the country. NHS England is consulting on introducing five new standards so we can keep track of where the gaps are. Patients can also refer themselves to talking and psychological therapies: over 1 million people have self-referred through the NHS website without having to go and see their GP, so they can get direct access and support when they need it.

Procurement of Evusheld

Gary Streeter Excerpts

Wednesday 12th October 2022 Westminster Hall

[Sir Gary Streeter (in the Chair)]

There has been a lot of interest in this debate. I will call Daisy Cooper to move the motion and then call the Minister to respond. There will not be an opportunity for the Member in charge to have the final say, as is the convention for a 30-minute debate.

[Daisy Cooper (St Albans) (LD)]

I beg to move,

That this House has considered the procurement of Evusheld.

It is a pleasure to serve under your chairship, Sir Gary. I am pleased to have secured this important debate on behalf of the forgotten half a million immunocompromised and immunosuppressed patients in England, and the 18,617 people who have signed the parliamentary e-petition calling on the Government to fund the preventive covid-19 drug Evusheld. I pay tribute to the extraordinary campaigning work of Evusheld for the UK, Blood Cancer UK, Kidney Care UK and many other charities that have given their members a voice. There is clearly significant interest from colleagues across the House, and I will endeavour to take as many short interventions as possible.

Let me be blunt: the Government have got this badly wrong. Some of our most vulnerable people are now in an impossible position, or, as some of them have said, they have been left to rot. People with blood cancer, vasculitis, kidney transplants, multiple sclerosis, long- term conditions and rare diseases and those on immunosuppressant drugs are crying out for the preventive drug Evusheld. Why? For them, the covid infection is just as deadly—in fact, more so—than when we first went into lockdown two and a half years ago. They do not mount a response to covid through the vaccines like the rest of us. Covid is not just a bad cold or an inconvenience, but a killer disease. In a society where people are allowed to walk around with that killer disease without being required to wear a mask, test or isolate, nowhere is safe for the immunocompromised—not inside or out.

Community Pharmacies

Gary Streeter Excerpts

Tuesday 21st June 2022 Westminster Hall

[Several hon. Members rose—]

[Sir Gary Streeter (in the Chair)]

Order. The Front-Bench spokespersons are due to begin at 5.10 pm. There are four other Members who wish to speak, so you each have six minutes.

--- Later in debate ---

[Anna Firth (Southend West) (Con)]

It is a pleasure to serve under your chairmanship this afternoon, Sir Gary. Community pharmacists have long been one of the unsung heroes of our NHS. Indeed, I would go as far as to say that they are a keystone species of the NHS, serving as a minor injuries unit and providing a vital prescribing service and essential healthcare out of hours for so many people around the country. They are also our most accessible form of healthcare. Their contribution throughout covid-19 was perhaps the best example of their heroic and accessible work. Community pharmacies were the first to step forward during our world-beating vaccine roll-out programme. Millions of people, just like me, had both their first and second jab from their local community pharmacy. Many of us regularly visit our pharmacies for covid tests, travel jabs, flu vaccines and a plethora of other essential healthcare services.

One of the less well known but most inspirational initiatives that community pharmacies have been involved in during the covid pandemic is their support for women experiencing domestic abuse. The Government-backed, pharmacy-led Ask for ANI scheme was a lifeline for many abused women. They could go into a pharmacy and ask for “ANI”, which was the codeword for getting a safe space to raise this important and personal issue.

It is their community nature that makes those pharmacies so valuable. Being on every high street, and having a smaller number of patients than a GP or medical centre, means they can be truly local and embedded in the area. In my constituency of Southend West, we have 18 brilliant pharmacies, each serving an average of 5,162 people. They thus serve a whopping 93,000 people a year. I am delighted that the Government have already recognised the important role that pharmacies play. Earlier this month, the NHS chief executive announced that community pharmacies will be funded to spot early signs of cancer and trained to refer people directly for scans and checks without seeing their GP. That is so welcome and important. Every Member of Parliament will be receiving a welter of emails complaining about access to GP appointments. The Valkyrie surgery, in my constituency, is clearly struggling to cope with the demand for appointments, and it is certainly not the only one struggling in Southend West.

Enabling people to access specialist services without going through a GP will massively ease pressure on GP services. It will also ease the pressure on our beleaguered accident and emergency services, which are crumbling under the pressure. Southend Hospital is safe for around 50 people going through A&E every day, but it is, on occasion, having to cope with 150 people. The obvious solution to those twin problems is to upskill our community pharmacies and ensure they have the funding and training they need to take the burden off our GPs, ambulances and hospitals.

Pharmacies already save 619,000 GP appointments every week; that is 32 million every year. The services they provide also save around 3.5 million people every year from visiting A&E and walk-in centres. We must go further to transform our pharmacies into an even more vital community resource. In Southend West we have the brilliant Belfairs pharmacy, run by an inspirational pharmacist called Mr Mohamed Fayyaz Haji—known locally as Fizz. Fizz provides a great range of services, including cholesterol and blood pressure checks, health advice and prescribing. He has recently acquired further premises so that he can expand into even greater levels of primary and community care, from ear syringing through to community phlebotomy, and to earlier diagnosis measures such as measuring prostate-specific antigen levels for prostate cancer, as well as electrocardiograms and ultrasound screening for sports injuries and pregnant women. That is exactly the sort of care that we want to be championing and supporting to ease the pressure on our other services. I am sure that my hon. Friend the Minister would like to join me in applauding Fizz’s efforts in Belfairs. That is a model for community pharmacy care around the country.

That sort of expansion is obviously not free. I applaud the fact that the Government are already investing in this area. I welcome the community pharmacy contractual framework, which will provide £2.5 billion annually. It is providing clarity and certainty about funding for the first time. I also welcome the new commitment for an additional £15.9 million to support the expansion of frontline pharmacy staff, providing people like Fizz with the training that they need to develop the skills of their staff for the benefit of everybody in the local community. I want to see this continue and for our pharmacies to be able to offer routine medical check-ups and routine injections and to be able to spot the early signs of serious illnesses and refer patients straight on to specialist departments in our local hospital.

In conclusion, pharmacies already provide a huge range of local services and they deserve greater recognition for the essential work that they do. The Government are already doing great work. I would like to see the Government go further with upskilling pharmacists, easing the pressure on our NHS and creating a healthier society all round. Pharmacies, especially in Southend West, are keen to be part of this mission and offer more to their local communities. I welcome every step to empower them to do just that.

[Sir Gary Streeter (in the Chair)]

Last but never least—Jim Shannon.

[Jim Shannon (Strangford) (DUP)]

Thank you, Sir Gary. It is a pleasure to speak in this debate. First, I congratulate the hon. Member for Bootle (Peter Dowd) on setting the scene so very well. This subject is something that I am sold on. It is something that I fully endorse, as others have done. We all see the real benefits of it. I have a great interest in the topic. I believe that community pharmacies are an untapped resource that we need to unlock with clever funding and foresight. Over the years, I have worked closely with a number of pharmacies in my constituency of Strangford and have been impressed by the expertise and the potential that is ready to be unlocked.

Pharmacies were involved in covid-19 jabs. They do flu jabs, blood pressure tests and asthma checks, as the hon. Member for Bootle mentioned. Staff can look out for signs of illness and can, if necessary, refer people on—because they know the limitations of the service as well—and that is a good thing. I got the girl from the office to send through details of some of the things that they can do right there and then; people do not have to go to A&E to get these things done. Pharmacies can deal with athlete’s foot, diarrhoea, haemorrhoids, head lice, groin infections, threadworms, thrush, earwax, mouth ulcers, scabies and verrucas. Staff can deal with all those things, at the initial stage, in pharmacies. Although some of those things are probably fairly personal, pharmacies do have the ability to deal with them.

During my time in the Northern Ireland Assembly, I was a strong advocate for what was then called the minor ailment scheme. Although that may still be in operation to a small degree, the potential for more is at our fingertips. The enthusiasm and energy that local pharmacies have really excites me. I get extremely excited about the potential, about what could happen, when I speak to owners such as James McKay of McKay Pharmacy in Newtownards to hear of the schemes that he has ready to go—making space for community physio and nutritionist provision in tandem with the local GP surgery that has premises abutting the pharmacy. There is scope for a real community facility—with much more provision than perhaps pharmacies, with their space, can provide—and that needs to be progressed and replicated.

I was not surprised to read that, on average, pharmacies undertake more than 58 million informal consultations per year. I had to get malaria tablets for a trip to Nigeria just a few months ago. In the past that would have meant a trip to a Belfast private doctor to get a private script, at a large cost. But this was a matter of popping down to my local pharmacy, answering some questions and getting the malaria tablets. Last week, I had a bit of toothache. Again, I went down and spoke to the lady. She gave me the tablets; she gave me the gum rub, and there and then seemed to have solved the problem. Similarly, I believe that those informal consultations prevent an additional 70,000 people from needlessly attending A&E or an NHS walk-in centre every week. Yet community pharmacies receive no specific funding for holding such consultations. That needs to change. I look to the Minister, as I always do. She understands these issues extremely well and, more often than not, she has the answers to the questions we ask.

Delivering minor ailment care through community pharmacies rather than GPs could result in a 53% total cost reduction to the NHS. The cost of providing 40 million minor ailments GP appointments per year is £1.2 billion; it would cost just £560 million to transfer those appointments to pharmacies as a community pharmacy consultation service. Those significant savings cannot be ignored. In this day and age, when finances are important, it is important we look at these issues. It is not simple, straightforward maths and is more than just a number exercise.

We must understand that community pharmacies are ready and willing, and local GP practices are calling out for pressure on surgeries and treatment rooms to be relieved, as well as that on accident and emergency departments. This change makes sense. It has been shown to work in the past and will work again in the future. Let us make the most of the expertise we have and take the pressure off our GP practices where it is possible to do so. We need to get treatment and training in place and get the right people doing the right things.

The future of community pharmacies is intrinsically linked with that of the NHS. We need to work smart as well as expecting them to work hard, and get the minor ailments scheme in a funded and good position. This is a tremendous opportunity to do something good with our health service, in a way that we save money and also deliver better care across the whole community. Everyone of us here today is excited at the possibility of what could happen. I am sure when she responds the Minister will give us some encouragement. I know one thing: if this happens, we all gain.

[Sir Gary Streeter (in the Chair)]

We move to our Front-Bench speakers. I call Steven Bonnar.

--- Later in debate ---

[Andrew Gwynne (Denton and Reddish) (Lab)]

It is a pleasure to serve under your chairmanship, Sir Gary. I add my congratulations to my hon. Friend the Member for Bootle (Peter Dowd) on securing the debate, and I congratulate him and Members across the House on putting forward a compelling argument for supporting our community pharmacy sector and increasing its role in the provision of localised community healthcare.

We have heard from Members from across the House that community pharmacies are the cornerstone of our local areas. For many people, community pharmacists are the most accessible healthcare professionals in the NHS, and their work is invaluable. We have heard that more than 89% of the population is estimated to have access to a community pharmacy within a 20-minute walk, but, as my hon. Friend rightly pointed out, access is significantly higher, at 99%, in areas of the highest deprivation.

We have always known that community pharmacies are important, but it was felt acutely during the pandemic. Community pharmacies helped to administer 24 million covid vaccines and were at the forefront of our response to the virus. In 2020-21, they delivered more than 4 million flu vaccinations—an increase of 75% on the year before. Indeed, as the hon. Member for Southend West (Anna Firth) pointed, community pharmacies carried us through the pandemic and reacted with extraordinary speed to a virus that shut down the rest of the country. It is therefore essential that we not only protect this vital community resource but equip it for the future.

As has been noted throughout the debate, there are two broad areas of concern within the sector, and I would appreciate the Minister’s assessment of them. The first relates to resources. Despite the additional demand for services, there has been no increase in funding for the pharmacy network since 2014, and there have been cuts of around £200 million since 2016. The current framework, agreed in 2019, has not been adjusted, despite the covid-19 pandemic, and we have seen central Government’s failure to adapt. This has resulted in pharmacies being unable to meaningfully invest in staff and has been detrimental to infrastructure development as well as innovation.

What is perhaps most worrying, however, is that an EY study in 2020 found that 40% of the large pharmacy chains sampled were operating at a loss. That is not sustainable, and unless action is taken, we could see pharmacies shut and that vital point of access for people close. I think there is consensus across all parties, including from the Minister, that we want to avoid that, so I would be grateful if she could outline what steps the Government are taking to better support community pharmacies and what assessment her Department has made of the potential impact of fiscal pressures on the sector. Furthermore, has the Department of Health and Social Care made any assessment of the additional pressures that the pandemic has placed on pharmacies? Will that inform the next community pharmacy contractual framework?

The second issue I would like to focus on is strategy and workforce. That will not come as a surprise to the Minister, given the Opposition day debate in the main Chamber earlier. There has been a distinct lack of overarching Government strategy when it comes to workforce planning over the past decade, including in relation to community pharmacies. The community pharmacy model that the NHS needs has drastically changed, as have the needs of patients. As far as I am aware, there has not been any strategy outlining the Government’s ambitions for the sector. Instead, we have seen short-term thinking, a real-terms funding decline and radio silence on the future of this vital resource. That needs to change, and I impress on the Minister the urgency of working with her DHSC colleagues to develop a strategy for community pharmacies that is fit for the future. Crucially, it needs to address the workforce issues that have been reported by parts of the sector, particularly in rural areas, where the increase in patient demand is putting pharmacies under more pressure.

I understand that the Government will argue that extra resource is going into the NHS, but we must not get into the trap of taking community pharmacies for granted, and we need to build a resilient, innovative and adaptive service for the future. We must utilise community pharmacies to tackle the key issues of our time. For example, many pharmacies already offer a range of services geared towards tackling health inequalities, but the local commissioning structures mean that access is not equal throughout the country. There is a real opportunity for central Government to step in and to ensure that no matter where people live, they can access weight-management services, emergency contraception, smoking-cessation services and much more.

Community pharmacies are already embedded in communities. They are trusted by local people. We need, therefore, to ensure that the Government give full support to the sector. Every Member who has spoken would wholeheartedly support the Minister to make sure that happens.

[Sir Gary Streeter (in the Chair)]

I kindly ask the Minister to leave 30 seconds for Mr Dowd to speak at the end.

Antimicrobial Resistance

Gary Streeter Excerpts

Tuesday 7th December 2021 Westminster Hall

[Sir Gary Streeter (in the Chair)]

Before we begin our next debate, I remind Members that they are expected to wear face coverings when they are not speaking in the debate. That is in line with current Government guidance and that of the House of Commons Commission. I remind Members that they are asked by the House to have a covid lateral flow test twice a week if coming on to the parliamentary estate. That can be done either at the testing centre in the House or at home. Please also give each other and members of staff space when seated, and when entering and leaving the room.

[Kevin Hollinrake (Thirsk and Malton) (Con)]

I beg to move,

That this House has considered the health impacts of increasing levels of antimicrobial resistance.

It is a pleasure to serve under your chairmanship again, Sir Gary. Mark Twain once said:

“I am an old man and have known a great many troubles, but most of them never happened.”

This is not a trouble that will not happen. This trouble is happening now; this trouble will get much worse. The UK Health Security Agency chief medical adviser, Dr Susan Hopkins, said that antimicrobial resistance, or AMR, was “a hidden pandemic” and that it was important that

“we do not come out of COVID-19 and enter into another crisis.”

What I fear most is that, as Warren Buffet once said:

“What we learn from history is that people don’t learn from history.”

There can be no excuse this time if we do not prepare well for a future pandemic of AMR.

This is not the first time I have raised the issue in the House, and it will not be the last, because AMR is simply too important to ignore. Antibiotics are one of the most powerful tools in healthcare, underpinning every aspect of modern medicine. We need them not just when we are poorly at home with an infection but when we are going through significant life-changing procedures such as chemotherapy and hip replacements. Antibiotics work by killing bacteria but, in the same way that the covid-19 virus can mutate and evolve, so can bacteria, developing resistance to antibiotics.

Right now, this year, about 700,000 people will die from antibiotic resistance infections across the world. It is estimated that by 2050, AMR could claim as many as 10 million lives a year. It is not a hypothetical or vague threat that is happening elsewhere; it is happening in the UK, is getting worse and will get much more so. Professor Jennifer Rohn of University College London has said:

“AMR has very much not gone away, and in the long term the consequences of AMR will be far more destructive.”

The latest report from the English surveillance programme for antimicrobial utilisation and resistance found that antibiotic resistance increased by 4.9% between 2016 and 2020. That means that one in five people with a bloodstream infection in 2020 had one that was antibiotic resistant—a serious, potentially life-threatening situation.

I want to tell you about a mother named Helen. Helen experienced resistant infections in 2013 and 2018, which caused her a great deal of anxiety and pain. She was to experience a third resistant infection shortly after giving birth. When her baby was just six weeks old, Helen developed mastitis, an infection of the breast tissue. She soon developed flu-like symptoms, and a GP prescribed her an oral antibiotic. The infection was resistant and two days later it was getting worse, and she could barely hold her baby. She started vomiting and was sent to A&E, where she was kept on heavy-duty intravenous antibiotics for two nights. Luckily, the sepsis was caught early and she recovered, but it could have been a very different story. Sepsis causes 48,000 deaths in the UK every year, many of them due to resistant infections.

AMR is the next pandemic. It is a hidden pandemic, but that does not mean that we can treat it any less seriously than covid-19. We must have the right plan in place. First, we need a strong system for monitoring the impact of rising AMR here in the UK. I welcome the fact that the Government have been looking into recording AMR or antibiotic resistance as a cause of death on death certificates and I had a welcome update from the Minister on where we are with those proposals. However, it is surprising that not many parliamentarians are focused on the problem, given its context and scale. It is good to see my fellow parliamentarians here today who are taking an interest, but until we have a proper register and until more parliamentarians are made aware of the issue through their constituents, I do not think the levels will be sufficiently high to raise awareness as often as we need in Parliament to make sure we take the matter forward and take action against it. Secondly, we need to support only the appropriate use and prescription of existing antibiotics. Thirdly, we need to ensure that we incentivise the development and research of new antimicrobials and antibiotics.

We need to take a one-health approach across all three issues that recognises the link between resistance and use in humans, animals, agriculture and the environment. The Government’s five-year national action plan on AMR set out the steps we need to take, but we are now just about halfway through and have yet to see any clear update on progress. The UK has been a trailblazer on AMR, but that lack of reporting is not where we need to be. We must be at the forefront of taking domestic action, not least because we are trying to maintain our leadership position as an example for other countries.

It was pleasing to see that the UK made AMR a centrepiece of our G7 presidency. We are long-standing global leaders in AMR and this is hugely important work, but we cannot afford to let our attention drop from what we can also do here and at home. The Minister and I shared many conversations on this matter as Back Benchers and I know she is very focused on and aware of the context, particularly in diagnostics, which I will talk about shortly. Will she consider introducing annual reports for all the partners on the actions in both this plan and in the next five-year action plan?

As has already been mentioned, one of the biggest issues facing us is the fact that there is not enough research and development of new antimicrobials. I would be interested to see what metrics of success we can use to judge the outcomes of the National Institute for Health and Care Excellence’s AMR project, formerly called the pilot, which is trialling a new model for valuing and paying for antibiotics. This is a world-leading, first-of-its-kind subscription-style payment model that will help incentivise companies to develop new drugs needed to tackle resistant infections and is supported by NICE.

The reasons we need a new model are complex. Bacteria naturally evolve to become resistant to certain drugs, but that evolution is happening faster than new medicines are reaching healthcare systems. That is partly because developing antibiotics is a long, complex and risky process, with many products failing along the way. At the end of that process, we do not have a viable commercial market for the new products. That is the key problem and that is because antibiotics are not like other medicines. Often, we want to reserve the new antibiotics for the patients who really need them, meaning the new products could just sit unused on the shelf. In that scenario, the cost of development could way exceed the return, undermining future research. The commercial model for developing antibiotics is broken.

I pay tribute to the UK’s leadership in introducing the AMR project in the first place. I know it is the result of many years of work by the Government, NHS, NICE and the industry sector, but we cannot afford that leadership and drive to slacken off now, because the price is simply too high if we do not succeed. As the Minister knows, the pilot looks at only two antibiotics and, as yet, there are no concrete plans to evolve into a new permanent model for all new antibiotics that come after them. Even though we are world leaders, we must urgently start thinking about the next steps and that must be built into the next action plan. The next steps must consider how we evolve the pilot and implement its learnings at scale and pace. Will the Minister comment on what conversations she has had with NHS England and NICE about how best to do this and what the timeframe might be?

We must also remember that the world is watching the world-leading AMR pilot. NICE has always been regarded as the gold standard and its actions have always carried weight, but now it is running one of only two pilots in the world considering this issue. It is therefore important not only that we get the project right, but that we also get right how we talk about what happened, the results and, indeed, what went wrong. Given that the goal is to incentivise private research and development, I urge the Minister to work with industry on that communication to ensure we are all aligned on the successes and learnings.

In 2019, in their five-year national action plan, the Government committed to reducing hospital-acquired infections by 2024 and halving gram-negative bloodstream infections in the NHS long-term plan. However, there is increasing concern that the covid-19 pandemic will have pushed those targets into the background. I would welcome the Minister’s comment on that issue, too.

As a final action point, in his landmark report, Lord O’Neill describes diagnostics as the most important of his 10 commandments to tackle AMR. The launch of the community diagnostic hubs represents an important opportunity to combat an increased incidence of AMR through accurate and targeted prescription. However, we need to tackle the false economy of simply prescribing antibiotics because they are cheaper than a diagnostic test.

I know other Members want to come in, so I will close by recognising those who do tireless work on this issue and with whom I work closely. First, Antibiotic Research UK or ANTRUK, which is in my constituency, is the world’s first charity specialising in antimicrobial research and education. It provides vital research and support services for patients impacted by resistant infection. Secondly, the British Society of Antimicrobial Chemotherapy provides the secretariat to the all-party parliamentary group on antibiotics, of which I am a member. Without its efforts, the efforts of the Minister and her team and the work of many others, we would not have achieved so much in our fight to stop the next pandemic, but that must be our challenge, to make sure that this time we prepare properly for a pandemic that absolutely will happen if we do not put the right steps in place.

[Sir Gary Streeter (in the Chair)]

Before I call Theresa Villiers, we are expecting three Divisions in the House in a moment. When we get to that point, Members should perhaps think about adjusting their diaries, because it will be 25 to 35 minutes before we come back.

[Theresa Villiers (Chipping Barnet) (Con)]

It is a pleasure to serve under your chairmanship, Sir Gary, and to follow my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake), whose track record on this important issue is second to none. I warmly congratulate him on securing more time in this Chamber on this important issue.

“Before Alexander Fleming discovered penicillin in 1928, an infection from a simple cut could mean the end of life. Nearly 100 years later, the antibiotic safety blanket we live our lives with is being pulled from us.”

That is a quote from the former chief medical officer, Dame Sally Davies, on the threat posed by antimicrobial resistance. She and many others have spoken out in apocalyptic terms about the catastrophe ahead of us if we do not stem the tide of infections resistant to treatment with antibiotics, as my hon. Friend has so articulately put it.

[Sir Gary Streeter (in the Chair)]

Order.

--- Later in debate ---

On resuming—

[Sir Gary Streeter (in the Chair)]

We will get under way. I know Karin Smyth is not here, but I am sure she will pick up the pace of the debate when she returns. The debate may now continue until 5.55 pm.

[Theresa Villiers]

I started my speech by referring to the remarks of the former chief medical officer, and I was about to say that she is entirely right to have spoken out on this issue. It is not just some millennium-bug anxiety about something that might or might not happen in the future, because people are already dying. Every year, an estimated 50,000 people die from drug-resistant infections, and that number will grow massively unless we deal with the problem.

During lockdown, many of us will have viewed the video of Bill Gates’s warning about a global virus pandemic, which was made years before it actually happened. If action is not taken now on a global scale to deal with AMR, people will look back on Dame Sally’s predictions in the same way. They will say that leading scientists highlighted the potential return to the days when routine surgery, childbirth, a cut in the arm or even an insect bite could give rise to a serious risk of death, and they will ask why we did not act. The good news is that a great deal of action is under way. The O’Neill report, commissioned by David Cameron, was groundbreaking. It was highly influential around the world, and 135 countries have finalised action plans on tackling AMR.

This year, it is very welcome that the UK Government have been using their G7 presidency to try to deliver more tangible progress, as they did last time they held the presidency, in 2013. However, the fact is that developing new antibiotics is massively expensive. The attempt to do so has already forced a number of smaller firms into insolvency and caused some bigger companies to exit their research and development programmes in this area. The fact is that many hundreds of millions of pounds can be pumped into R&D, with no return on that investment whatever if a project turns out to be unsuccessful.

The high failure rates of antibiotic development apparently leave just 40 antibiotics in clinical trials globally. The problem is compounded by the fact that if a new antibiotic is successfully discovered, we want to use it as sparingly as possible, keeping it for serious conditions and to head off potentially worsening AMR problems in the future. That creates even more problems with the risk-return ratio. There is therefore an urgent need for policy reforms to create market conditions that enable sustainable investment in antibiotic innovation, including properly valuing and paying for new antibiotics.

It is very encouraging that the industry has set up a £1 billion investment fund to try to bridge the funding gaps, particularly for smaller biotech companies, that will have a strong focus on drugs that could have the maximum impact in securing and safeguarding public health. Also welcome is the AMR project, which we have already heard about from my hon. Friend the Member for Thirsk and Malton. The project, launched by the UK Government, NICE and NHS, is trialling a new subscription-style model for antibiotics. Under the model, payment is based on the product’s overall value to the NHS, rather than on just counting the pills dished out to patients. Two medicines have been selected, and contracts are expected to commence in April 2022.

It is very welcome that the project has continued despite the pandemic, but we now need to press ahead with wider implementation in order to cover more research and bring in the devolved nations, so that we have a whole-country approach. We need the project to get beyond the pilot stage, and we need to learn from it to ensure that a sustainable solution is put in place for new antibiotics that reflects their long term value to society as a whole.

In conclusion, I very much welcome the leading role that the UK Government have taken on this issue on the world stage. However, if we are to succeed in addressing this great challenge of our time, there is still a lot of work to be done. For example, we need to increase public understanding of the dangers of over-prescribing or misusing antibiotics. We must also tackle the overuse of antibiotics in farming. I do not see that as a domestic problem with our sector—we have strict rules to prevent that from happening in UK farming—but we need to use our trade and foreign policy to raise standards on antibiotics use in agriculture all around the world.

Above all, the Government need to be bold and ambitious in putting in place a long-term market solution that changes how we pay for antibiotics, so that we can reward and incentivise the scientific research that can save us from the nightmare we face: a return to Victorian medical outcomes, where 40% of our population have their lives cruelly cut short by infections we cannot treat. I look forward to hearing from the Minister what action the Government are going to take to drive this crucial issue forward.

[Julian Sturdy (York Outer) (Con)]

It is a pleasure not only to serve under your chairmanship, Sir Gary, but to speak in this important debate. I warmly thank my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) for having secured it. I share his view on the priority of keeping the Government’s focus on this very important subject: as a co-chair with my hon. Friend of the all-party parliamentary group on antibiotics, I urge the Minister to reflect very carefully on the suggestions my hon. Friend has made and that continue to be made in this debate. I also want to highlight a few other important points that we need to consider.

First, the Government need to carefully assess how covid has impacted on the global and national antibiotic resistance challenge. Unsurprisingly, the once-in-a-century scale of the pandemic has generated concerns that the increased prescribing of antibiotics worldwide on the back of covid will amplify the problems of growing resistance. The scale of the virus disaster and the variety of global health systems has led to a huge, unco-ordinated and large-scale use of different antibiotics, and we need to know how the nature of the AMR threat has evolved as a result.

The covid experience and the size of the Government’s response also offer lessons for the AMR debate by indicating that, when necessary, we can rise to the challenge and assign huge resources to protect the public. The costs involved in developing the new drugs needed to beat the resistance are enormous, as has already been touched on in this debate, but arguably our perspective on that has shifted somewhat when we consider the scale of the fiscal firepower deployed against the covid virus—some £378 billion in this country alone, as of October’s Budget.

Given the potential of AMR to equal or surpass what covid has done, as my hon. Friend the Member for Thirsk and Malton mentioned, with the very plausible prediction of 10 million dead annually across the world by 2050, it seems reasonable to increase our national financial commitment now. With a much more significant—but still relatively small—investment, we can really make a difference. As has already been mentioned during this debate, and as the Association of the British Pharmaceutical Industry has called for, raising the £10 million cap for the Government’s AMR project subscription trial could be one such investment.

The Government should also explore whether they can build more laboratory capacity in middle income countries and the developing world, as part of our public health and wider aid strategies. The lack of significant medical microbiological facilities in such nations is a significant factor in the mistaken prescribing of antibiotics that fuels the growth of AMR around the world. These labs are necessary to generate the guidance on which antibiotics best fit which disease.

The source of the deficiency is an absence of quality, accredited training and the lack of medical microbiological biomedical scientists, producing a situation in which under-informed prescribing practices simply spread resistance. Building that capacity would be a helpful addition to the UK public health and aid policy, because, as the pandemic has shown, disease mutations that develop abroad do not stay there for long.

Growing antibiotic resistance in lower income countries is both a disaster for them and a serious threat to lives in this country. I urge the Department of Health and Social Care to engage closely on this aspect of the problem and listen to calls, such as those from the British Society for Antimicrobial Chemotherapy, for the creation of a global antimicrobial stewardship accreditation scheme to ensure co-operation across health and research systems and to generalise global good practice. Ministers should constantly remember the need to address the challenge of resistance across Government—I mean making sure that other Government Departments know the impact that AMR has.

I want to touch on one example of that. At the APPG on antibiotics, we recently connected scientific researchers at the University of Exeter with Ministers at the Department for Environment, Food and Rural Affairs, so they could share the case for amending the Environment Bill so that it took account of the issue of antimicrobial residues in water and sewage. I understand DEFRA’s decision that although it should not adopt the specific University of Exeter recommendations, it will continue to listen to this research work, including through the new shared outcomes fund pilot project on AMR surveillance, which is in the Environment Act 2021, but we need to see a level of engagement across the board, from all Departments. A Government assessment of whether a further statutory basis is needed to step up action on AMR should be welcomed.

I finish on this brief point, Sir Gary. Many of us in the Chamber now have sat here before, talking about AMR. We are constantly raising the same arguments and the same points, but we really need to spread that message wider. The biggest disappointment is that it is the same few Members raising the same points: the subject does not seem to be getting the political traction it needs. Given where we have been with covid, that might be slightly understandable, but we have to remember, as my hon. Friend the Member for Thirsk and Malton said: if we take our eye off the ball, AMR has the potential to be a much larger pandemic than we have ever seen before.

[Sir Gary Streeter (in the Chair)]

The winding-up speeches will begin at 5.32 pm. We are now going to have seven and half minutes of pure gold from Jim Shannon.

--- Later in debate ---

[Karin Smyth (Bristol South) (Lab)]

It is a pleasure to serve under your chairmanship, Sir Gary. I congratulate the hon. Member for Thirsk and Malton (Kevin Hollinrake) on bringing this very timely debate to Westminster Hall. It is timely because if we do not learn from the situation that we are in, we will end up in a very bad place; it is with that in mind that I give my remarks.

This is a really unusual subject; I have not been involved in a debate on it before, but it is one on which there is so much agreement. We have a problem, we have evidence of a problem, we agree that we have a problem, we have solutions that we generally agree on and we are genuinely world leaders. I think the Government sometimes bandy around the fact that we are world leaders when we are not; but we are genuinely world leaders in this area, and that is something to be proud of. We have some fantastic people in this country. However, why is the situation not improving? What more needs to be done, and, crucially, has enough been done in recent years? How do we know what has been done? As the hon. Member for York Outer (Julian Sturdy) said, why is there not greater interest and political pressure on this subject?

It was 2013 when Professor Dame Sally Davies described this as a

“catastrophic threat”.

She said:

“If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection.”

It was in 2014 that the estimated figure of 10 million people dying as a result of AMR by 2050 was mooted. I was working in the health service when that discussion was being had, back in 2013-14. I vividly remember the concern of specialists, particularly colleagues in pharmaceuticals, about that, and the actions that were being taken to support clinical practice to make sure that did not happen. However, I do not think that most people walking the streets are aware of the catastrophic prediction made then.

We have a problem—we agree on the problem—and we know the causes of the problem: inappropriate use of antimicrobial drugs in healthcare; poor infection prevention and control practices; use of antimicrobial drugs in agriculture, and accelerated spreads of AMR infections through global trade and travel. Additionally, as the right hon. Member for Chipping Barnet (Theresa Villiers) and other hon. Members have said, there are limited numbers of new drugs available to replace those that become ineffective. The former Prime Minister, David Cameron, launched a review in 2014, and the list of 10 recommendations was published in 2016. In 2017, the cost of global action was estimated at $40 billion. That is an eyewatering sum, but when compared with what is being described as the incalculable cost of covid, which reaches trillions of dollars, that $40 billion estimate starts to look quite small. Others have indicated that in reality the cost of this could be unimaginable to most of us.

There was an excellent debate in Westminster Hall on 26 April 2016, in which my hon. Friend the Member for Ellesmere Port and Neston (Justin Madders) addressed the hon. Member for Mid Norfolk (George Freeman), who is also an expert in this area. My hon. Friend said:

“Although I welcome the renewed focus that today’s debate brings, I fear we are no closer to a solution than we were two and a half years ago.”—[Official Report, 26 April 2016; Vol. 608, c. 540WH.]

I think there is concern in the Chamber that that remains the case today.

The Government have targets, although they are not terribly specific. Many are for the period 2021 to 2025—for example, being able to

“report on the percentage of prescriptions supported by a diagnostic test…by 2024.”

On the eve of 2022, I expect the Minister to be able to outline how meeting those commitments is going. The hon. Member for Thirsk and Malton made some helpful suggestions for what we should be measuring, how we should be measuring it and how that should be reported, which I am sure the Minister will address.

On animal use, which the hon. Member for Strangford (Jim Shannon) highlighted, the investment required by farmers was yet to be formally evaluated in 2019, so it would be useful to know whether the Minister has evaluated that cost. It would also be helpful to have an understanding of how we are collaborating with our European neighbours, now that we have left the European Union, because we know that collaboration is really important, particularly in the agricultural industry.

We should be prepared, and we should certainly be on track, but I fear we are not, so the crucial issue is: what do we need to do? I pay tribute to Dame Sally Davies, our special envoy on AMR, and her work to highlight this issue, which, as she has said in the last year, is a silent pandemic. As she has told us, covid needs to be a wake-up call to the warnings that she has issued over the years. I have listened to her speak on this issue, as has another all-party group, and she has recently used quite a vivid image to describe the situation: covid is like putting a lobster into boiling water, but AMR is like a lobster in cold water. It is a silent pandemic.

One of the issues is that fewer adults know about this. I absolutely agree, and I think that is also true of Members of Parliament. We need to learn from covid, including about things such as altering behaviour, washing our hands and access to water. We also need to support those on the frontline much better, including through clinical direction, to help them in the way that they need in order to treat patients.

[Sir Gary Streeter (in the Chair)]

I call the Minister. Please remember to leave two or three minutes for Kevin Hollinrake to respond.

NHS Efficiency

Gary Streeter Excerpts

Tuesday 2nd November 2021 Westminster Hall

[Sir Gary Streeter (in the Chair)]

Before we begin, I encourage Members to wear masks when they are not speaking, in line with current Government and House of Commons Commission guidance.

[Paul Bristow (Peterborough) (Con)]

I beg to move,

That this House has considered NHS efficiency.

It is a pleasure to serve under your chairmanship, Sir Gary. I draw Members’ attention to my entry in the Register of Members’ Financial Interests.

Our NHS is in my DNA. Both of my parents were nurses and worked in the NHS for most of their working lives. It was the NHS that brought my family to Peterborough when I was just five years old, and I have worked in NHS policy for 20 years. My commitment to our NHS and its principles is clear. Few things inspire as much national pride as our national health service, and I want to keep it that way.

The NHS has lost its ranking as the best healthcare system in a study of 11 rich countries by an influential US think tank. Most worryingly of all, it fell to ninth when it came to healthcare outcomes. We must do something about this. We must ensure that the record investment that we are putting into our NHS is spent well. I suggest that that money should come with some very specific key performance indicators that would ensure that it is not wasted.

I feel strongly that the money should be in the gift of Ministers in the Department of Health and Social Care, who are accountable to Parliament, rather than NHS England or NHS Improvement. Like the Department for Levelling Up, Housing and Communities would do with a local authority that does not run a balanced budget or provide statutory services, the Department of Health and Social Care should be able to intervene directly, or at least provide incentives. Recipients would not get their share of the extra cash unless they addressed the challenge of access to care and improved outcomes.

I am keen to help Ministers. I almost feel thwarted, because progress on many of the things that I spoke about at the party conference last month have started to be reflected in Government announcements. That is obviously a good thing, but extra money must come with strengthened incentives to do the right thing and, quite honestly, consequences for not doing the right thing.

The first area in which we need to make progress is local NHS management. Local government has had to make a series of savings in recent years. Armies of local government managers all doing the same jobs in neighbouring local authorities have been an easy target for those defending the interests of taxpayers. However, local authorities have done rather a good job of sharing senior officers. For instance, the chief executive of Peterborough City Council is also the chief executive of Cambridgeshire County Council. As a former Hammersmith and Fulham councillor, I also remember the 2011 tri-borough shared services agreement in west London, between Westminster, Kensington and Chelsea, and Hammersmith and Fulham, which saved over £33 million in just four years. Labour-controlled Hammersmith and Fulham petulantly took their toys home a couple of years later, but the bi-borough arrangement is still saving the taxpayer millions, and this practice is replicated across the country.

That practice is unheard of in our NHS, but why is that? There are no reasons why NHS trusts and new integrated care systems cannot share officers and back-office functions. Let us do away with every NHS trust having its own specific CEO, finance director, human resources director, estates director or diversity director. It is not controversial to ask our NHS to learn from local government. If certain localities cannot make those management savings, are unwilling to share back-office functions, cannot look to make savings, why would we give them the extra cash? I suggest a KPI on a reduction in management costs and back-office costs. I think it would be warmly welcomed by the taxpayer and those in our NHS who know that money is wasted.

Children and Young People’s Mental Health

Gary Streeter Excerpts

Wednesday 16th June 2021 Westminster Hall

[Sir Gary Streeter (in the Chair)]

I remind hon. Members that there have been some changes to normal practice in order to support the new hybrid arrangements. The timing of debates has been amended to allow technical arrangements to be made for the next debate. There will also be suspensions between each debate.

I remind Members participating physically and virtually that they must arrive for the start of debates in Westminster Hall, and they are expected to remain for the entire debate. I also remind Members participating virtually that they must leave their camera on for the duration of the debate, and that they will be visible at all times, both to one another and to us in the Boothroyd Room. We would have it no other way.

If Members attending virtually have any technical problems, they should email the Westminster Hall Clerks’ email address, which is westminsterhallclerks@ parliament.uk. Members attending physically should clean their spaces before they use them and before they leave the room.

I also remind Members that Mr Speaker has stated that masks should be worn in Westminster Hall. Members attending physically who are in the latter stages of the call list should use the seats in the Public Gallery— I think we have one or two there already—and move to the horseshoe when seats become available. Members may speak only from the horseshoe where there are microphones.

[Munira Wilson (Twickenham) (LD)]

I beg to move,

That this House has considered children and young people’s mental health.

It is a pleasure to serve under your chairmanship, Sir Gary. I am very grateful to be given the opportunity to lead a debate on this critical issue. Eighteen months ago in my maiden speech, I pledged that children and young people’s mental health would be an issue that I champion in this place. It is a cause for which I will fight relentlessly, because children and young people are our future. Their hopes and dreams depend upon us doing the right thing by them.

Those who are struggling with their mental health and wellbeing, whether those suffering mild anxiety to those young people attempting to take their own life, deserve the very best care and support. Yet children and young people do not have a voice in the political system and are too often overlooked. In fact, the former Children’s Commissioner, Anne Longfield, said in her final speech earlier this year that in Government there was an “institutional bias against children”—never more so than during the pandemic when, frankly, they have been an afterthought at every turn. From new born babies to schoolchildren to university students, the Government have let them down in planning and providing for their social and educational needs, and again in their announcements about children’s recovery.

Teenagers and young people in my constituency who are ambassadors for the fantastic local charity Off The Record tell me that uncertainty over exams, combined with the social isolation of being stuck at home away from their peers, worries about loved ones and now concerns about their future job prospects have all taken their toll. But this crisis in children and young people’s mental health started long before the pandemic. One reason why I made it my priority at the start of last year was because following my election, I was astounded week in, week out by the emails from parents or conversations at my surgeries, of stories of battles with child and adolescent mental health services to access treatment for children who are considering suicide, self-harming or withdrawing themselves from school. Yet they were having to wait six months or sometimes a year for treatment.

At a lower level, support in schools is patchy, with only some having access to a counsellor or mental health support team. Community-based support to intervene early can be dependent on voluntary sector provision in any given area. The pandemic has only served to highlight and exacerbate the existing lack of access and inequalities within children and young people’s mental health. In 2017, one in nine children had a diagnosable mental health condition. That rose to one in six at the height of the pandemic. The Government need to use this moment to renew their focus on mental health and overhaul the support available.

I want to focus on three elements within the system and what needs to be done: CAMHS, schools and community services. Turning first to CAMHS, referrals are at their highest ever level, with over 65,500 referrals for 0 to 18-year-olds received in March 2021. That is more than double the number in March 2020 and almost 70% higher than in March 2019. Behind the staggering numbers is a child or a younger person in turmoil, often left in limbo waiting for treatment, and a carer beside themselves with worry. From talking to NHS leaders in my area, I know that unplanned admissions for children suffering a mental health crisis are at extremely high levels with services struggling to cope.

While it must be acknowledged that the Government have increased spending in this area, resulting in the NHS slightly exceeding its 2019-20 target of community mental health support for 34% of children needing support, there is still a long way to go. Last week, a local GP said she is increasingly finding that children she refers to CAMHS are being knocked back, and she is routinely requesting schools make a supporting referral to secure therapy. When referrals succeed, the wait can seem interminable. I heard from the adoptive father of a seven-year-old who suffered significant trauma and abuse within her birth family. She was referred to treatment, the initial assessment took several months to secure, and then the family were told that there would be a year’s wait—yes, a year’s wait for a seven-year-old for an eight-session course of treatment, only if deemed necessary.

There is a postcode lottery of spending across the country. Eight local areas spend less than £40 per child on mental health services, while 21 areas spend more than £100 per child. That brings me to an important point about data and reporting, which is so important for accountability. Inconsistencies in financial reporting across clinical commission groups makes it difficult to interrogate the data to check they are meeting NHS England guidance to increase year-on-year the proportion of spending on children and young people’s mental health. This measure should be included in the mental health investment standard.

The other issue with data collection and publication is that it is impossible to judge whether different areas are meeting access targets, as the percentage of young people with a diagnosable mental health condition is only available nationally, not on a local basis. The Children’s Commissioner should not have to request this comprehensive data on waiting times and referrals every year. The Minister will know that I tabled an amendment during the passage of the NHS Funding Act 2020 to improve transparency in operational expenditure and performance at a local level. I discussed this with her ministerial colleague, the hon. Member for Charnwood (Edward Argar), a few months ago. He assured me that the Minister is taking this forward, and I hope she can update us on when this local data might be routinely available.

However much money is pumped into CAMHS, improving access to it is contingent on plugging big holes in the workforce. The Royal College of Psychiatrists’ 2019 workforce census found that the rate of unfilled NHS consultant psychiatrist posts in England has doubled in the last six years, with one in eight CAMHS psychiatrist posts vacant. We urgently need a proper long-term work- force strategy, adequately resourced and with an annual report to Parliament. The forthcoming heath and care Bill is the ideal opportunity to hardwire this provision.

Turning to the role of schools in tackling mental health concerns, they are key to early intervention, and step in where children do not meet the CAMHS threshold. Provision of counselling and other mental health support services in schools can be variable and dependent on already massively overstretched school budgets. Mental health support teams can fill the gap. However, the current roll-out rate is very slow. The Government are aiming to reach a fifth to a quarter of the country by 2022-23, and have recently provided more funding to accelerate the roll-out, but I urge the Minster to be more ambitious.

On children’s recovery from the pandemic, most of the education catch-up funding announced by the Government has been largely focused on academic catch-up, with little focus on emotional wellbeing and mental health support. All the research shows that it is difficult for children to learn if they are struggling with their mental wellbeing. Liberal Democrats supported YoungMinds’ call for a £178 million ring-fenced resilience fund to allow schools to provide bespoke mental health and wellbeing support packages, as appropriate to their pupils and context. So far the Government have committed just £17 million of dedicated mental health support for schools as part of the recovery. A recent Ipsos MORI poll showed that parents put increased wellbeing support at the top of their priority list as part of any education recovery plan.

Finally, I will touch on the importance of community support services. We know that half of all mental health conditions present themselves by the age of 14 and three quarters by the age of 24. That is why prevention and early intervention are so critical. We know that some children and young people do not want, or are unable, to access mental health support in schools, but community-based services can be a lifeline.

Waiting until children reach crisis point is far too late. For younger children, family-based interventions, such as those offered by Kids Matter, are an effective approach. The Purple Elephant Project in Twickenham, founded by the inspirational Jenny Haylock, who has built a team of art and play therapists, works with children and their families from a very young age. Coram is also doing some incredibly important work on boosting children’s self-esteem and resilience.

For teenagers and young adults, I warmly welcome the campaign launched by a range of children’s and young people’s mental health charities, called “Fund the Hubs”. It calls for early-support hubs, offering easy-access, drop-in support on a self-referral basis for young people up to the age of 25, who do not meet the threshold of CAMHS.

The hubs would offer a mix of clinical staff, counsellors, young workers and volunteers, providing a range of support services. Additional services could be co-located under one roof, such as sexual health services or employment advice. The hubs could be delivered in partnership with the NHS, through local authorities or working with the voluntary sector, depending on the local area. Such an approach has already been tried in Manchester, Ireland and Australia, and has been shown to relieve pressure on and deliver cost savings to the health service. I hope the Minister will look at that innovative model.

In conclusion, we owe it to our children and young people to offer them the very best start in life. As a Liberal, I am passionate that every child gets the maximum opportunity to reach their full potential. With spiralling figures of children suffering anxiety, who are self-harming or struggling with eating disorders, as well as many more who are grappling with low confidence and self-esteem, we need to use this moment as we emerge from the pandemic to hit the reset button.

I urge the Minister, who I know shares my passion on this issue, to develop a proper cross-departmental strategy to tackle this growing crisis. Let us re-envision what support looks like for children and young people. Let us break down the silos between schools, local authorities and the NHS. Let us make sure that we prevent and intervene early to stem the tide, while also investing in training the mental health workforce.

I have heard too many times, from too many parents sick with worry, that CAMHS is simply not fit for purpose. I have yet to see much evidence to disagree with them. I hope the Minister will make it her mission to fix it, and work cross-party, if she is willing. I stand ready to do so for the sake of our children and their future, and I hope my Labour counterpart will, too. Not only is it morally the right thing to do, but our country’s recovery depends on their success.

[Sir Gary Streeter (in the Chair)]

Colleagues, we have 45 minutes and nine Back-Bench speeches to fit in, so that is exactly five minutes each. Please try to keep to time, so that I will not need to impose any restrictions.

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[John McDonnell (Hayes and Harlington) (Lab) [V]]

I thank the hon. Member for Twickenham (Munira Wilson) for not just securing the debate but superbly setting the scene.

I want to reinforce the message that has just come so eloquently from the hon. Member for Bath (Wera Hobhouse) with regard to eating disorders. I saw the recent paper by Dame Til Wykes and other scientists and campaigners, supported by the Government’s national adviser, Chris Whitty. They discussed the end goals for mental health research. The first end goal was halving the number of children and young people experiencing persistent mental health problems.

Eating disorders are just one of the serious persistent problems that start early and often persist into adulthood. As the paper sets out, they are associated with extremely poor outcomes, so it is appropriate to try and stop these disorders persisting from an early age. It makes sense for the individuals and their families, but also for the NHS, in terms of reducing costs, and for the economy overall, because people can contribute so much more fully to society.

What came out of that paper is the decision that we need to implement what we know already, but also support more research to improve recovery. As the hon. Member for Bath said, we already know that eating disorders are a growing problem. Some of the statistics are startling. The NHS 2019 health survey for England found that 16% of adults aged 16 and over screened positive for a possible eating disorder. In recent years, we have seen a fourfold increase in eating disorder hospital admissions, and waiting lists are at an all-time high. Hon. Member after hon. Member is finding this in their constituency, particularly when they are approached by distressed parents.

It is estimated that one in three young people experiences an eating disorder. Because these disorders occur among so many young people, they are still sometimes viewed as almost a teenage girls’ illness—a diet, a lifestyle choice or something a person grows out of. Yet, the statistics on their severity are shocking. It is reported that eating disorders have the highest death rates among all mental health disorders, and the rate of suicide is 23 times higher in people with eating disorders, compared with the general population—one in five deaths in eating disorder patients is reported to take place because of suicide, and I pay tribute to the work my hon. Friend the Member for Blaydon (Liz Twist) and her all-party parliamentary group on suicide and self-harm prevention are doing. According to the reports that we receive as constituency MPs, these serious consequences result from eating disorders partly because of the lack of access to psychiatrists who are fully trained in eating disorders and who specialise in eating disorder treatments.

As the hon. Member for Bath said, evidence is emerging that there has been a significant rise in people with eating disorders during the covid pandemic. Those in recovery have been set back, and new eating disorders have developed among a wider range of the population. From what I hear from my constituents, there is a vicious cycle of a lack of awareness, a lack of training and a lack of research funding at the scale needed. Let me just quote the parents from one family, who said: “Tell them right now the support, the treatment and the understanding is just not out there for us.”

Concerns have also been expressed about what some people consider unhealthy messages being pushed by the Government’s obesity strategy, which is being developed at the moment. I hope that more consideration will be given to consulting organisations that represent people with eating disorders in the development of that strategy.

I want to pay tribute to Hope Virgo. Many will have heard of her campaign “Dump the Scales”, which has been calling so effectively through the media for proper investment in eating disorder treatments. Just this week, Hope told me she has received numerous letters from parents whose children have been naso-gastric-fed on general wards, with no psychological support in some health settings.

F.E.A.S.T., a global website campaign, is reporting thousands of people contacting it through Eating Disorders Support UK, and 5,000 have signed up for its 30-day support scheme. Hope Virgo is the founder of the Hearts, Minds and Genes eating disorder coalition, which is the first coalition to declare a state of emergency around eating disorder treatment, and I am pleased that it is now meeting the Department of Health and Social Care. This serious issue needs ministerial support to drive through the new programme, and I hope that pathways and support will be developed within a timescale that recognises its urgency and seriousness.

[Sir Gary Streeter (in the Chair)]

The winding-up speeches will begin at 3.28 pm. Jim Shannon has five minutes.

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[Sir Gary Streeter (in the Chair)]

May I remind the Minister to leave one minute at least for the hon. Member for Twickenham (Munira Wilson)?

[Ms Dorries]

I am going to sit down.

[Ms Dorries]

I do not think there is time.

[Sir Gary Streeter (in the Chair)]

You have one minute of your time left.

[Ms Dorries]

I have not got time, I am so sorry. There is only one minute left.

The hon. Member for Twickenham asked about data. That data is produced on the mental health dashboard every quarter. There is work ongoing, but I will come back to her on the details of it. I do not know whether she has access to the dashboard and the data, but I will make sure she does. If the hon. Member for Blaydon (Liz Twist) would like to speak to me when the debate is over, I will come back to her on the points she raised. I will sit down now to give her a chance to respond.

Black Maternal Healthcare and Mortality

Gary Streeter Excerpts

Monday 19th April 2021 Westminster Hall

[Sir Gary Streeter (in the Chair)]

Welcome, everyone, to this important debate. I remind hon. Members that some changes have been made to normal practice, to support the new hybrid arrangements. Timings of debates have been amended to allow technical arrangements to be made for the next debate. There will be a suspension between each debate. I remind Members participating physically and virtually that they must arrive for the start of debates. Members are expected to remain for the entire debate.

I remind Members participating virtually that they are visible at all times, both to one other and to us in the Boothroyd Room. If Members attending virtually have any technical problems, they should email the Westminster Hall Clerks’ email address. Members attending physically should clean their spaces before they use them and before they leave. I would also like to remind Members that Mr Speaker has stated that masks should be worn in Westminster Hall.

Before I call Catherine McKinnell to move the motion, I must say that we have 12 Back-Bench speakers. We normally allow 10 minutes for each Front-Bench speaker. If Catherine speaks for about 10 minutes, that should allow for in the region of four minutes for each Back-Bench speaker. I will not impose a formal time limit, but I ask everyone to try to deliver your speech within four minutes. That would be most helpful.

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[Marsha De Cordova (Battersea) (Lab)]

It is a pleasure to serve with you in the Chair, Sir Gary. I am grateful to my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) for leading the debate on behalf of the Petitions Committee. I also congratulate the formidable campaigners Tinuke and Clo, the founders of the Five X More campaign, who got the petition debate in Parliament today. The petition received more than 180,000 signatures. It is not before time that such a huge injustice is finally receiving the attention it deserves.

We have heard some powerful contributions from right hon. and hon. Members this evening, including my right hon. and learned Friend the Member for Camberwell and Peckham (Ms Harman), the Chair of the Joint Committee on Human Rights. Just last year, the Committee published its report “Black People, Racism and Human Rights”, which contains shocking findings, particularly that the care that many black people receive is unequal to what is given to white people. I urge the Minister to accept all the recommendations of that report.

My hon. Friend the Member for Edmonton (Kate Osamor) highlighted, as others have done, the choice made in the report of the Commission on Race and Ethnic Disparities to sideline the institutional and structural racism that exists across society, but more so in the health service. My hon. Friend the Member for Streatham (Bell Ribeiro-Addy) made a powerful contribution sharing her lived experience. I thank her for doing so, but also for her tireless campaigning on the issue. She has been brave, and I thank her for that.

More importantly, my hon. Friend the Member for Vauxhall (Florence Eshalomi) highlighted some of the issues related to underlying health conditions in her own experience of being diagnosed with fibroids and also of being a sickle cell carrier. I also urge the Minister to listen to my hon. Friend the Member for Luton North (Sarah Owen), to give 20 minutes of her time to her and her constituent and to hear their experiences.

I also want to mention the contribution of my hon. Friend the Member for Dulwich and West Norwood (Helen Hayes), who highlighted the fact that we need to focus more on issues relating to research. Unless we do the work, we will not move forward and bring an end to this crisis.

As we have heard, it is absolutely shameful that black women continue to be four times more likely to die in childbirth and pregnancy than white women. That inequality has existed for decades, with little action being taken to address it. [Interruption.]

[Sir Gary Streeter (in the Chair)]

Order. Does any Member present have to go to vote physically, or is everyone on a proxy vote? If everyone is happy, let us continue.

[Marsha De Cordova]

Last week I met campaigners, obstetricians, midwives and black, Asian and ethnic minority women with lived experience of maternal health complications. They were very clear that socioeconomic determinants such as income, housing and occupation and comorbidities only partially explain the inequalities affecting black maternal health. It is absolutely clear that structural racism is a driver of disparities in treatment, and it is a missed opportunity that the Commission on Race and Ethnic Disparities chose to sideline that important issue. I hope the Minister will choose to ignore and reject that view.

Black and Asian women, and their partners, regardless of their socioeconomic status, are not being listened to, not being respected and not being cared for. When they voice pain or concern during pregnancy or childbirth, they are branded as “aggressive” or “angry”, while dangerous stereotypes about “strong black women” mean that black women are often not offered the same treatment as white women.

It is outrageous that racist myths about black women having higher pain thresholds than other women continue to affect their treatment. Meanwhile, the lack of cultural competency in medical training means that complications experienced by black women are not spotted early enough. For example, black women have shared accounts of how their anaemia was not picked up soon enough because of the colour of their skin.

So I ask the Minister what action she is taking to tackle structural racism and to build trust in maternity services for black, Asian and ethnic minority mothers and their partners and for healthcare professionals, including midwives, as many have shared their experiences of occupational discrimination, as was highlighted in the Public Health England report last year. I would really like the Minister to address this issue. Additionally, cultural competency and unconscious bias training is an essential part of ending these inequalities, so will she commit to improving training in the health service and in medical schools?

We are all aware of the importance of data, which as we have heard is central to closing the maternal mortality gap. Many mothers and medical professionals have shared accounts of how pregnant women are recorded as being white if they do not disclose their ethnicity, meaning that it is difficult to track complications. Therefore, the recording of data is essential, so will the Minister commit to ensuring that all maternity services record the specific ethnicity of all mothers?

It is clear that fatalities are just the tip of the iceberg, with many women speaking of the near-misses and poor treatment they have experienced. I have heard from many medical professionals that data on near-misses could easily be made available, but it is not being. Will the Minister therefore commit to collecting and publishing data on maternal near-misses by ethnicity, and, if so, can she set a timeline for that commitment, with some clear milestones?

Midwives consider the continuity-of-care model as a way to help bridge some of these inequalities. A 2016 study found that women who see the same midwife throughout their pregnancy are 16% less likely to lose their baby. The NHS standard contract for 2019-20 stipulated that 35% of women will be booked on to a continuity-of-care pathway by March 2020. Can the Minister confirm whether that target was met? Can she also say what is being done to meet that target in the NHS long-term plan, which aims to provide continuity of care for 75% of black, Asian and ethnic minority women by 2024?

Before I close, I want to mention how the hostile environment is exacerbating this problem, as mentioned by my hon. Friends the Members for Erith and Thamesmead (Abena Oppong-Asare) and for Dulwich and West Norwood. Charging for maternity services and no recourse to public funds conditionality mean that many women are either becoming indebted as a result of their pregnancy or are turning away from health services all together for fear of being reported to the Home Office. Many women subject to charging are destitute and unable to pay, and three of the 209 women whose deaths were investigated in the 2019 MBRRACE-UK report were affected by charging for NHS maternity care. Does the Minister agree that charging women for maternity care is cruel and dangerous during this pandemic?

I want to make it clear that black maternal health and mortality is an avoidable inequality, and it is scandalous that the Government have not yet set a target to end this injustice in the NHS long-term plan, so will the Minister commit to doing so today? The NHS long-term plan sets many targets for other issues, so why not for black maternal health?

Let me be absolutely clear that a Labour Government would be committed to ending the crisis in black maternal health and mortality, and that the Government must take urgent action now. We need a national strategy to tackle health inequalities as a matter of urgency, which must include a target and a commitment to end the mortality gap between black, Asian and ethnic minority women and white women and to tackle structural racism once and for all, not deny its existence. We cannot afford for this not to be a priority.

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[Ms Dorries]

That is certainly one of the many issues highlighted in the report, but it is not the only one. We have commissioned the policy research unit in maternal and neonatal health and care at the University of Oxford to undertake research into the disparities in the near misses, and to develop an English maternal morbidity outcome indicator. The research will explore whether the indicator is sufficiently sensitive to detect whether the changes made to clinical care are resulting in better health outcomes. Five X More called for that in its list of 10 requests.

We are putting the research in. We have found a way to look at the research in order to make the differences that need to be made. We can do that by examining the near misses. What happened in those cases and in those women’s experiences? What went wrong? Do the women feel that they were not listened to? Was it a matter of treatment? Was it a lack of understanding? We need to understand that by looking at the near misses. The research is being undertaken, but it will take some time. Hopefully, when that is reported, we will be able to make progress on the issue of setting targets.

This Government are no strangers to setting targets. On the very sad issue of baby loss, we set a target to reduce neonatal stillbirth and neonatal mortality rates by 20% by 2020. We have reached almost 25%. We have smashed that target and are still pushing forward to improve that situation even more. We are not afraid of setting targets, but when we are setting them we have to know how to achieve better outcomes. The hon. Member for Battersea (Marsha De Cordova) mentioned continuity of carer. She is absolutely right about those figures. We know that continuity of carer works incredibly well, particularly for black women and women from ethnic minorities. Having the same midwife throughout the process of pregnancy makes a huge difference. That is being rolled out across the country. I am sure that the hon. Lady has spoken to the chief midwifery officer, who is a huge supporter of the policy. We are continuing to roll it out and make progress with it. It has been slightly more difficult during the 12 months of the covid pandemic, particularly because many trusts did not continue with home births.

We are not afraid of setting targets, however. Setting targets in maternity units is what we are about, to make them safer places in which to give birth and in order to reduce both neonatal and maternal mortality rates, but we need to do the research on the near misses, to understand what the problems are. We cannot set targets until we know what we are trying to achieve through those targets and what we need to address. Five X More has asked for that research to be done. It needs to be done, and it will be done.

We are committed to reducing inequalities and to improving outcomes for black women—we work at that daily. I established the maternity inequalities oversight forum to focus on inequalities so that we in Government understand what the problems are. The forum also brings together experts from across the UK—we have met MBRRACE-UK and Maternity Voices—who have done their own research and studied this problem, to hear their findings and recommendations. Professor Jacqueline Dunkley-Bent, the chief midwifery officer for England, is leading the work to understand why mortality rates are higher, to consider the evidence on reducing mortality rates, and to take action to improve the outcomes for mothers and their babies.

NHS England is working with a range of national partners, led by Jacqueline Dunkley-Bent and the national speciality adviser for obstetrics, to develop an equity strategy that will focus on black, Asian and mixed-race women and their babies, and on those living in the most deprived areas. The Cabinet Office Race Disparity Unit has also supported the Department of Health and Social Care in driving positive actions through a number of interventions on maternity mortality from an equalities perspective. The Royal College of Obstetricians and Gynaecologists has established—

[Sir Gary Streeter (in the Chair)]

Order. Will the Minister kindly leave two minutes for Catherine McKinnell at the very end?

[Ms Dorries]

I will end there, but if any hon. Members wish to speak with me about the work we are doing and the research we have undertaken with Oxford University, we are happy to share more. I say in response to the hon. Member for Luton North (Sarah Owen) that very few personal meetings have taken place, but I would be happy to meet her and her constituent.

[Sir Gary Streeter (in the Chair)]

Thank you very much, Minister. It is very important that Catherine McKinnell has the final word.

Covid-19 Response

Gary Streeter Excerpts

Wednesday 22nd April 2020 Commons Chamber

[Sir Gary Streeter (South West Devon) (Con) [V]]

May I put on record my personal thanks to the Secretary of State for his remarkable personal efforts over the past few weeks? He is doing a terrific job in unprecedented circumstances. I welcome what he said earlier about non-covid-19 treatment. Will he set out, as soon as possible, a clear plan to enable elective surgery to take place again in hospitals that have capacity, so that we do not build up a nasty backlog of unmet health need?

[Matt Hancock]

Yes; that is an incredibly important issue. We want to get non-covid-19 treatment back up and running as quickly as is safely possible. We are of course putting in place the arrangements to make sure that when people do go into hospital without covid-19, they are not infected by people who are in hospital with covid-19—that segregation is a very important part of our considerations. The answer to my hon. Friend’s question is that yes, within very short order we will start to restart the NHS. He asked about elective operations, which are an important part of the matter, but so too is people presenting themselves. It is important to give people the confidence to call their GP if they have a problem or, if it is urgent, call 111, because with cancer, for instance, we know that early diagnosis is critical, and I want people who think they have a risk to come forward for treatment.