Psychological Therapies

Huw Irranca-Davies Excerpts

Wednesday 16th October 2013 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

It is a pleasure to serve under your chairmanship, Sir Edward. I pay tribute to my hon. Friend the Member for Halesowen and Rowley Regis (James Morris) for securing this debate, for his tremendous work on the all-party group in highlighting the importance of mental health and the need to continue to raise mental health issues, and for his supporting the Government in seeking parity between physical and mental health, to which we have been committed since the coalition came to power in 2010. I congratulate the hon. Member for Liverpool, Wavertree (Luciana Berger) on her promotion to her new role and commend her largely bipartisan approach to the debate and on recognising that some of these issues are bigger than party politics.

Before I deal with some important issues raised by my hon. Friend the Member for Halesowen and Rowley Regis, I want to touch on the contributions of other hon. Members and talk about the context in which we are operating. We recognise, as a Government—I think that all hon. Members in this debate have recognised—that for far too long we focused on crisis management in health care generally, particularly in mental health, rather than on upstream interventions, which is where IAPT plays such an important role to keep people well in their own homes and communities, instead of picking up the pieces when they become so unwell at the other end. There is a good economic argument for that, but it also provides much better care for the patients and the people we all care about as Members of Parliament, and whom I care about as a doctor.

The hon. Member for Strangford (Jim Shannon) raised some important issues about veterans’ health. He knows that I have personally committed to improving the provision of physical and mental health care for our armed forces veterans. There are now 10 dedicated teams in England, focusing on supporting our veterans who have post-traumatic stress disorder and other mental health problems, post-discharge. A lot of work is going on—much more collaborative work—between the NHS and the armed forces, to ensure that general practitioners and health care professionals in England are much more aware of armed forces personnel coming back into their care, after serving in the armed forces, that a more holistic approach is taken, that people do not present too late in crisis and that GPs can be much more proactive in offering reassurance and support to veterans who may be running into the early signs of difficulties. My counterpart in Northern Ireland has been working hard on that and he should be commended for it.

My hon. Friends the Members for South West Bedfordshire (Andrew Selous) and for Eastleigh (Mike Thornton) made important contributions about the holistic approach to health care in general, about how mental health needs to be considered holistically and about the benefits to wider society of upstream interventions. Getting health care right can also provide additional benefits for the economy; for example, by supporting families to stay together and bring up their children. All these things are beneficial and at the heart of my work on early interventions projects. My hon. Friend the Member for Hornchurch and Upminster (Dame Angela Watkinson), who is no longer in this Chamber, and I are working closely on that.

[Huw Irranca-Davies (Ogmore) (Lab)]

I apologise for being late. I was at another meeting. I, too, congratulate the hon. Member for Halesowen and Rowley Regis (James Morris) on securing the debate. Has the Minister already secured a meeting with Welsh Government Ministers, or will he do so in future, to discuss the approach towards veterans that he outlined? That issue is close to my heart, because I am aware of emergency rescue situations in which things have gone too far, when services, including mental health services, have been stretched way beyond their means in dealing with them. There would be benefits from sharing best practice across all the regions and nations.

[Dr Poulter]

The hon. Gentleman is right. We UK Health Ministers work collaboratively on many issues. However, on veterans, we have to recognise that, although we have UK-wide armed forces, health is a devolved responsibility. We need to share different initiatives better between the devolved Administrations. Some remote areas of Wales, in particular, could learn from best practice in the NHS about how we are using, to good effect, specialist mental health teams for veterans. I should be happy to share that and meet my counterpart in Wales to talk that through in greater detail.

I will focus in particular on the important contribution of my hon. Friend the Member for Halesowen and Rowley Regis. He addressed a number of issues that are central to the provision of good mental health care, and he threw down some challenges on how we could make things better. In particular, he praised the scale of the Government’s ambition to have genuine parity between physical and mental health, which has to be right; it is at the centre of everything that we are looking towards in the good commissioning of services locally.

I reassure the hon. Member for Liverpool, Wavertree that, with the addition of IAPT, there has been a substantial increase in the NHS’s total investment in psychological therapies. As she will be aware, however, it is down to local commissioners to prioritise their resources to meet local need, based on the local population that they serve. In the past, the challenge has been that good commissioning has too often been seen purely through the framework of physical health. Through the NHS Commissioning Board’s mandate, we are now ensuring that there is parity between mental and physical health. That journey is already well under way to ensure that good commissioning is no longer just about commissioning for acute services, such as stroke and heart attack, but about looking at the whole patient and considering the importance of upstream interventions, which are central to IAPT’s role in looking after patients.

My hon. Friend the Member for Halesowen and Rowley Regis also talked about the need to consider CBT and its evidence base. As he knows, it is not the role of Ministers to question the integrity of NICE, but NICE keeps its criteria under review, and there is a very strong evidence base to support CBT. The evidence base for IAPT is continually being developed and adapted, and a number of pilots are already in place to consider the potential to extend the scope of therapies, including to older people. I hope that that is reassuring. NICE will be listening to this debate, and it continues to evaluate the evidence. With mental health, there has always been controversy on how evidence is collated, because mental health is different from physical health, and NICE will keep that under review when it adapts and introduces future guidelines.

The debate has been called because all hon. Members in the room believe that, for too long, there has been too much focus on crisis management and acute response when patients with mental health conditions become very unwell. We would all like to see much more focus on upstream intervention, which is what IAPT is all about. We need to move the focus away from SSRIs—selective serotonin reuptake inhibitors—and drug-based therapy towards upstream, proactive intervention for what is sometimes a very vulnerable patient group.

The benefits of early intervention have been outlined by many hon. Members. There are clear health benefits, but there are also economic benefits, benefits to the family and benefits from getting people back to work, education and training, and from supporting people to have more productive and happier lives. That is why we will continue to ensure parity of esteem in commissioning for physical and mental health, and it is why we will continue to support upstream interventions in the early years—I will address early-years IAPT later. We will also ensure that we continually drive good commissioning to encompass mental health as well as physical health. That holistic approach to health care, by prioritising mental health, is good for people’s health care, good for families and good for the economy. That is why we will ensure that it remains a priority.

As hon. Members will be aware, the mandate set by the Government for NHS England last year establishes a holistic approach as a priority for the whole NHS for the first time. Improving access to psychological therapies is fundamental to the success of improving mental health. The mandate makes it clear that everyone who needs them should have timely access to evidence-based services. That is particularly important for mental health. By the end of March 2015, IAPT services will be available to at least 15% of those who could benefit—an estimated 900,000 people a year. We are also increasing the availability of services to cover children and young people with long-term physical health problems and those with severe mental illness to ensure that everyone can access therapies. There is an emphasis on those who are out of work, the black and minority ethnic populations and older people and their carers.

IAPT is being made available throughout the country. The programme was started by the previous Government in 2008, and we now have an IAPT service in every clinical commissioning group. There are more than 4,000 trained practitioners, and more than 1 million people are entering and completing treatment. Recovery rates have consistently been in excess of 45%, and they are much greater in many areas. The programme already has a clear track record of evidence-based success, and it is helping to reach some of the most disadvantaged and marginalised people in our society, which we would all say is a good thing.

Hospital Mortality Rates

Huw Irranca-Davies Excerpts

Tuesday 16th July 2013 Commons Chamber

[Mr Hunt]

Of course I would be delighted to visit my hon. Friend’s local hospital. I am sure there will be a great deal that I can learn, and I hope I will be able to give encouragement to the staff there, who are working very hard in a very difficult situation. I hope today will give them encouragement that this is a Government who are determined to turn around their hospital.

[Huw Irranca-Davies (Ogmore) (Lab)]

On the basis of the very good and welcome Keogh report and also the Francis recommendations on safe staffing levels, does the Secretary of State feel that the reduction of 4,000 nurses over the past two or three years is in any way contributing to the very issues that he has described today?

[Mr Hunt]

We welcome and accept the Francis report’s recommendations on safe staffing and we recognise that that involves having doctors. We recognise and are pleased that our protection of the NHS budget means that there are 6,000 more doctors than when the hon. Gentleman’s Government were in power. If he looks at what is happening in his own Wales, he might find that there are a few lessons that the NHS in Wales could learn.

Health and Social Care

Huw Irranca-Davies Excerpts

Monday 13th May 2013 Commons Chamber

[Mr Hunt]

There is currently a difficult environment for public finance, for which the hon. Gentleman’s party bears considerable responsibility. The Labour party has given up on the budget; it says it wants to cut the NHS budget. We say that these changes are possible without cutting the NHS budget and in dealing with the inefficiencies caused when care is not joined up. Taken together, the measures represent more progress in three years than the Labour party made in 13 years. They represent our determination to prepare the country for the consequences of an ageing population.

[Huw Irranca-Davies (Ogmore) (Lab)]

The right hon. Gentleman knows that the cap on costs of care is a little way off the Dilnot proposals. How many weeks—surely his Department has made some calculations—would that involve for a typical older person before they reach the £72,000 cap?

[Mr Hunt]

The point of a cap is not that we expect everyone to have to pay £72,000 towards their care. First, through pension plans and insurance policies people can make provision so that they never have to pay that £72,000. Secondly, as part of the package, we are increasing the threshold, below which the Government help, to £118,000—much higher than it is currently—so that it will be available to help, I think, around 40,000 more people than are currently helped because of the level of the means-testing threshold.

Ankylosing Spondylitis

Huw Irranca-Davies Excerpts

Monday 25th February 2013 Commons Chamber

[Huw Irranca-Davies (Ogmore) (Lab)]

Let me begin this debate by posing what may seem a little like a pub quiz question. What do all the following people have in common: Mick Mars, the guitarist for rock band Mötley Crüe; Vladimir Kramnik, the Russian world chess champion; Mike Atherton, the English cricket player; Jens Stoltenberg, the Prime Minister of Norway—and, not forgetting, me? We all have a condition called ankylosing spondylitis—athletes, chess champions and rock gods and Members of Parliament: we can all get it, along with around 200,000 other people from all walks of life across the UK.

Ankylosing spondylitis is not a condition we hear a lot about, yet the 200,000 people with this condition are roughly twice the number who have Parkinson’s disease or multiple sclerosis. Perhaps it is the very name ankylosing spondylitis, which does not lend itself to easy headlines or easy campaigning, although it may also be due to the historical lack of awareness, including among GPs and clinicians, of the condition. AS is often overlooked and misdiagnosed, but it is a type of arthritis that can start when people are young—often between 15 and 35 years of age. It is a type of chronic, long-term arthritis that affects parts of the spine, including bones, muscles and ligaments. The condition can be severe, with around one in 10 people at risk of long-term disability. It is often misdiagnosed or diagnosed late—typically 10 years late—and that was certainly the case with me.

Let me begin by setting out drily and coldly the standard description, and I would like to thank the National Ankylosing Spondylitis Society for its help with that. It says:

“AS usually starts in the late teens and early twenties and can cause lifelong pain and stiffness. There is no cure for AS. It’s a form of inflammatory arthritis mainly affecting the spine and hips, which may fuse over time. Ankylosing means fusing together and spondylitis means inflammation. It can also cause inflammation in other areas of the body, including the heart, the bowel and the eyes. Unless treated and managed effectively, AS will lead to great pain and can render people immobile and unable to work”—

and so on. It is worth using the words NASS has collated to illustrate what this means practically. People with the condition have described the type of task that can cause difficulty. One person says, for example:

“Opening and closing the boot of my car is a nightmare for me and makes it so much harder for me to get out and about with my 2 year old and my 5 year old.”

Another draws attention to the problems of simply

“sitting on the grass having a picnic.”

Another says that

“washing my hair and putting on tights”

is a problem. Others refer to

“pouring water out of the kettle”

or

“reaching high shelves or cupboards”,

and so on. NASS notes that

“people with AS deal with constant pain and stiffness, along with high levels of fatigue. In the early years it is an ‘invisible’ illness with bodies showing no outward signs of the pain and suffering, making it difficult for others to understand what they are experiencing.”

It is worth turning to some of the words that people with AS use to describe themselves. One person says that they feel

“isolated, lonely, fed up with pain, envious of”

what they say are “normal people”. Another says:

“I have low self esteem, feel isolated, depressed and in constant pain. I am fed up of swallowing all the tablets and sticking a needle in my leg…I hate the shape of my back and the position of my head. But people always say I have a smile on my face and look so well.”

Another says:

“I feel overly tired most days. Outside of work my participation in activities has been reducing. I don't spend as much time as I used to socialising with friends and family. I used to be very active and go out in the evenings but now I have early nights instead.”

Every single person with AS will have a different experience, but here is mine. I, like many others, was diagnosed very late in life. In my late teens, I played first division and county badminton, and competed in national competitions. My tennis was not too bad either, and I was a pretty keen leg-break bowler for my school, though my rugby had long gone. But during and after matches I would experience real stiffness and soreness in the neck and the spine. I found it increasingly hard to look up towards the shuttlecock as it descended. However, I thought that this was just routine, as I was extremely fit and active. As the years went by, the stiffness became more routine and more painful, and progressively the flexibility in my spine and my neck grew less and less. At the time, I was working in sports centres, I was coaching sport, and I was still actively playing many sports myself. I thought that it was just part of a sporting life: you end up creaking a little bit.

By my late twenties, the stiffness and the pain were periodically debilitating, and affecting my sport and my general health. I had been to see GPs over the years since my teens. I had been given strong painkillers, sometimes steroids. I had been to see masseurs and chiropractors who had stretched and crunched me, worked out the knots in my neck, and applied various odious potions to me. I had resorted to homeopathic medicines, including a vile concoction involving exotic mushrooms from Russia, complete with a handbook on how to use it, and various mail order medicines. Some of these were harmless but utterly useless. Others were probably directly detrimental to my health and even antagonised the condition.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for bringing this very important matter to the House. This debate will raise awareness, but does he agree that there is also a need for awareness in the benefits system, because I know people in my constituency who have difficulties in getting disability living allowance for this condition?

[Huw Irranca-Davies]

That is a very important point. People often refer to it as a bad back, growing pains, and as an assortment of other things, but that is a classic case of misdiagnosis. If somebody has AS, it does not go away. It is long term and debilitating and unless diagnosed, it will get worse and worse. The hon. Gentleman is absolutely correct.

At that stage of the development of the condition in me, no one had diagnosed it, so I was trying anything and everything. Then, as luck had it, in desperation I had an appointment with a different doctor because my usual one was away. He suggested that I visit a rheumatologist, and that is where I first heard of the condition called ankylosing spondylitis. There started the beginning of a more coherent diagnosis and a programme of treatment involving appropriate physio- therapy and, when needed, oral steroids or, when the problem was severe, steroid injections directly into joints. By this stage, in addition to the fluctuating but regular stiffness and pain, every few months I would have a major flare-up when my joints, especially ankles, knees and hips, would swell like billy-o and scream with pain. Yet—this is a common refrain from AS sufferers—I would just carry on. Sufferers get our heads down and carry on. We build a tolerance to pain and a dogged determination. It is far from heroic; it is just pragmatic. We have bills to pay, places to go and people to see. We just do not give up very easily.

My situation came to a head here in Parliament. The story I am about to tell will be disbelieved by many, because it reveals—wait for it—the compassion of the Whips Office. Back in 2003, I had been struggling along and getting by, but this was the mother of all flare-ups. I have the acute form of AS, which I sometimes feel makes me fortunate, although I guess that others who have it may disagree. Rather than enduring constant pain and discomfort, I could go for months without problems, then—bang!—when it hits, it hits big.

The early-warning aches, throbs and fatigue started about a month before the crunch. After hobbling slowly for a couple of weeks, I resorted to using a stick, then two sticks, and then switched to crutches a few days later. Progressively, I also looked like I felt—like I had been through 10 rounds with Mike Tyson after a week without sleep. Finally, for one particular vote it took me nearly 15 minutes to walk from one end of the voting Lobby to the other, which is the length of this Chamber. I was in so much pain. At that point, a friendly Government Whip whispered to me, “Huw, get yourself home.” Although that reveals the compassion of the Whips, the following sentence was telling: “Get yourself better, ’cos we need you back in two weeks for a crunch vote.” Still, I take compassion wherever it comes from and whatever the motive.

That episode finally got me on to the treatment that has transformed the quality of my life over the past decade and—touch wood—has meant that I have not had a major flare-up in all that time. I was fortunate to be referred, finally, to an AS specialist and was put on to an innovative and then experimental treatment called anti-TNF—anti-tumour necrosis factor—which is an immunosuppressant that has helped control the condition. It is not without the risk of side effects and I would prefer not to be on medication for the rest of my life, but my quality of life has been transformed. Anti-TNFs, which are now moving on to new generations that can target specific types of AS, will not be right for everyone, but I say to the Minister that, where appropriate, they really must be made available, and investment in research must also be maintained.

People such as me have much to thank Arthritis Research UK for its research in London in the 1990s, which led to successful trials of anti-TNF therapy.

[Andrew George (St Ives) (LD)]

As the hon. Gentleman knows—we have discussed this on a number of occasions—I also suffer from AS and many of my experiences mirror his, although I have never experienced the compassion of those in the Whips Office. Although the condition affects many esteemed people, it also affects many humble people such as me. I was also involved in the campaign for anti-TNFs. Does he agree not only that proper and effective diagnosis is critical, but that it is vital that medicines are properly prescribed and made freely available to those who are suffering very badly from the condition?

[Huw Irranca-Davies]

That is absolutely right. The hon. Gentleman makes a very important point and I will touch on it when I describe my mini manifesto for how we should move forward on AS. Different sorts of treatment will be appropriate for different people with AS.

Arthritis Research UK is currently funding research into other aspects of AS, including the award of more than £1.3 million to seven experimental arthritis treatment centres that aim to fast-track the most promising treatments to market, research into the genetic factors of AS, and even education resources to help families affected by AS. It is tremendously commendable work.

The Minister is not here just to listen to my or anybody else’s sob story, or to help me regain my prowess on the badminton court or at the cricket crease. I want the Government to help other people with AS, now and in the future, to get the best care, so here is my wish list.

First, we should increase the awareness and recognition of AS. AS has always had a low profile among both the medical profession and the public. Because back pain can have a number of causes, it is easy for AS to be misdiagnosed or to go undiagnosed.

Secondly, we should improve the way in which people with AS are referred. GPs may focus on trying to manage people with lower back pain and not consider referring them on to appropriate specialists such as rheumatologists.

Thirdly, please can we use MRI, not X-rays, for early diagnosis? Clinicians now agree that MRI scanning is a far better option because it can pick up the early joint damage due to AS before it is evident on an X-ray. X-ray changes because of AS may take years to show up.

Fourthly, we should improve access to the right specialists. Experts in other forms of spinal pain are not necessarily skilled in treating inflammatory back pain and associated conditions. For the best outcomes, it is vital that people with AS are managed by the right specialists as part of a multidisciplinary team.

Fifthly, we should improve access to the best medical and surgical treatments. The last decade has seen much improvement in imaging, which is vital to improving the safety and effectiveness of surgery, and treatments that offer better symptom control and quality of life. Early access to those is critical.

Sixthly, we should implement long-term follow-up and management. For the right decisions to be made at the right time, people with AS need long-term monitoring by appropriate experts and ready access to advice or treatment when necessary.

Seventhly, we should develop quality standards and clinical guidelines for AS. In the absence of those, perhaps the Minister will say what can be done now to focus local clinical decision making on AS.

We also have a range of things that we want from GPs. We want them to consider AS as a possible diagnosis if patients have symptoms of back pain and stiffness that are not improving. GPs should refer patients to a rheumatologist as soon they suspect AS. MRI scans should be part of that process. There should be access through GPs to specialists, including rheumatologists, physiotherapists and specialist nurses. There should be access to physiotherapy sessions, either as part of a group or individually. Information should be provided in GP surgeries. There should be access to expert surgical assessment and treatment for people with severe spinal deformity who may wish to have surgery to correct it. There should be regular follow-up appointments and ready access to expert reassessment, including monitoring for bone health, osteoporosis and cardiovascular risk. Finally and critically, there should be information on, and access to, sources of support including physiotherapy, financial advice and psychosocial services.

I say to the Minister, on behalf of 200,000 people who have AS, that that is our manifesto for improved diagnosis, improved treatment and improved quality of life. Despite my late diagnosis and early mistreatment, I am pleased to say that thanks to great, if late, support from tremendous NHS clinicians and staff, I am currently active, sporting and able to be a thorn-in-the-side— or should I say constructive critic—of the Government whenever the need arises.

I am part of a team alongside great friends and campaigners such as Gillian Eames who are taking part in the worldwide “Walk Your AS Off” event for the next month promoting exercise as part of the self-management of the condition. On 1 and 2 April, I will be walking 50 miles at the age of 50 to raise awareness of AS and funds for the National Ankylosing Spondylitis Society. I invite the Minister to join us. Take a walk in our shoes, as people say, and we will show how a little support goes a long way, reduces health and social care costs, helps people to stay active and in work for longer, and gives people a far better quality of life. If he cannot make the walk, perhaps he will agree to meet me and a delegation from NASS and Arthritis Research UK to discuss further our ideas. I thank the Minister for listening and hope for a positive response.

Dementia

Huw Irranca-Davies Excerpts

Thursday 10th January 2013 Commons Chamber

[Paul Burstow]

My hon. Friend makes an important point. Yes, there is scope for that; indeed, many research organisations in this field are already collaborating internationally. However, as a country with a very reputable research tradition, it is important that we should be in the vanguard of that research and put in place the necessary infrastructure to drive it forward.

[Huw Irranca-Davies (Ogmore) (Lab)]

I thank the right hon. Gentleman for giving way and welcome his very good introduction to this debate. I would make the same point about research within the UK. Post devolution, we often tend to look at it in terms of the different nations and regions in the UK. We should be sharing the best expertise and best practice right across the nations, because 800 of my constituents have been diagnosed—I suspect that there are many more who have not and they, too, need the very best assistance and support.

[Paul Burstow]

One of the great things about devolution is that we can try out different things in different jurisdictions, but it is great only if we learn from that by taking the best and using it elsewhere. I therefore agree entirely with the hon. Gentleman that that is an important part of this debate. The ability to exchange and learn—and, yes, sometimes reject things that others are doing—is important.

My final point is about reform. I hope this year might be a tipping point for dementia. Reform of our broken care and support system has never felt closer. For people with dementia and the families who care for them, it cannot come soon enough. When the Prime Minister launched the dementia challenge back in March last year, he acknowledged the catastrophic costs that some people incur as a result of drawing the card in the lottery of life that says “Dementia”. He said:

“We are determined to do the right thing by these people”.

A dementia diagnosis is traumatic enough, without the knowledge that care costs can often spiral out of control as the disease progresses. While care financing is left unreformed, people with dementia face the prospect of losing both who they are and everything they have ever worked for.

I therefore very much welcome the news in Monday’s mid-term progress report that the Government are to press ahead with a cap and increased means test, and the confirmation that the House received on Tuesday from my right hon. Friend the Deputy Prime Minister that the necessary legislation will be enacted in the lifetime of this Parliament. In my capacity as Chair of the parliamentary inquiry into the draft Care and Support Bill, let me tell the Minister that the Committee has made it clear to me—and I absolutely agree—that we expect as much detail as possible on any new clauses or other changes that will flow from the introduction of a capped cost system into the legislation, so that we can do the House the service that we have been asked to perform, which is to report on and scrutinise the provisions and help the Government to introduce the best possible legislation to Parliament.

National Health Service

Huw Irranca-Davies Excerpts

Monday 16th July 2012 Commons Chamber

[Andy Burnham]

This is really important; it is where all of what the Government are doing comes together. They have put in place restrictions in treatments— 125 separate treatments, as I have just mentioned— and at the same time they have given a 49% cap to NHS hospitals to do more private work. So as the NHS decommissions services, hospitals are then free to start offering those services. That is why my hon. Friend is beginning to see the changes that she is noticing, and this is the clear agenda of the Conservative party.

[Huw Irranca-Davies (Ogmore) (Lab)]

Does not the fragmentation that my right hon. Friend is describing raise the crucial question about when the national health service ceases being a national health service under this Government?

[Andy Burnham]

The Bill that the Government brought through is an attack on the N in the NHS; that is what it was designed to do. It was designed to break national standards; to break national pay; to break waiting time standards; and to allow primary care trusts to introduce random rationing across the system. That was the intention of the Bill that they brought through; they wanted an unfettered market in the health service, and my hon. Friend is absolutely right. That is why we are saying that we will repeal this Act and restore the N in NHS at the earliest opportunity.

Local Pharmacies

Huw Irranca-Davies Excerpts

Thursday 24th November 2011 Commons Chamber

[Huw Irranca-Davies (Ogmore) (Lab)]

May I thank you, Madam Deputy Speaker, and your good offices for granting this Adjournment debate on a subject that affects hundreds if not thousands of people right across the country in England, Wales, Scotland and Northern Ireland? I hope to encourage, support, prompt, cajole and beat the Minister—in a very nice way—to put some urgency into this matter, which I know he is aware of and is working on. I think that we need to do more. I can understand why this issue has not grabbed the headlines that other health-related issues have.

A very wise MP once said to me, “Don’t go looking for issues. They will walk though your door.” That is exactly what happened. A female constituent came through my door about a year ago and said, unbelievably—it was unbelievable and I had some scepticism about it—that she could not get Femara, a cancer treatment drug. I said that that simply could not be the case because it is a readily available drug. It is not a drug that is not prescribed or that there is any shortage of. She left feeling a little disgruntled, but I agreed to take up the issue.

I contacted the chemist, who said that my constituent was absolutely right. They said, “I cannot get hold of it in my own stocks, I cannot get hold of it locally by ringing other chemists and I cannot get hold of it from my regular distributors. I actually have to ring the manufacturer.” Even having done that, there was a delay before it was delivered, leaving somebody without their cancer treatment drugs. The implications of that are not only physical and medical, but emotional.

Having looked into the matter further, it appears that this is a widespread concern. Like most people, I assumed that if a drug was a prescribed medication, it would be widely and freely available. I did not know about the systemic problem that we face in the UK in ensuring the supply of life-saving medicines. If one looks behind the façade of normality, one can see clearly the pressure on the pharmaceutical drug supply chain from manufacturers, through wholesalers and distributors, to pharmacists and right down to individual patients.

The Minister will be aware that today there are problems with about 50 products. Those medicines treat a wide range of conditions including cancer, Parkinson’s disease, schizophrenia, depression, asthma, diabetes and high blood pressure. All of those products seem to be in short supply due to the problem in the supply chain. In the midst of coming to terms with a serious medical condition, the last thing that I, the Minister, you, Madam Deputy Speaker, or anybody would want to face is the fear of not being able to receive their treatment or of having it interrupted because of a problem in obtaining the medicine. Yet that is the precise situation for too many people on a daily basis.

It is our community pharmacists on the front line who see the overwhelming reality of this problem. I know that the Minister will recognise that when pharmacists cannot get hold of a drug for their patients, they work hard behind the scenes, under the calm waters, often in a Herculean effort, to ensure that nobody is left without their vital medicine. I have seen in my constituency the hoops that pharmacists are obliged to jump through to obtain medicines on such occasions. All too often, they have to ring round other pharmacists in the hope that they have the medicines available, spend time on the phone to the wholesaler or the manufacturer, or send faxes with copies of prescriptions to manufacturers in the desperate effort to find supplies on the day for their patients. On too many occasions, they are told that there is no stock available from the wholesaler or the manufacturer. Despite the time spent on that wild goose chase, pharmacists still try to provide the multitude of other services that the NHS and we ask of them.

[Margot James (Stourbridge) (Con)]

I congratulate the hon. Gentleman on securing this debate on such an important topic. Is he aware of the survey conducted as recently as this month by Lloyds Pharmacy of its pharmacists, which confirmed the point that he is making? It found that 50% of the pharmacists surveyed were spending between one and three hours a week trying to source medicines, and that 16% were spending between four and six hours a week doing so—almost a day of their working time.

[Huw Irranca-Davies]

Absolutely. The hon. Lady makes a very good point. I am aware of that survey, and I will touch on it. This is not a party political issue at all, it is very much cross-party, and I know she has a real interest in and specialist knowledge of the matter. We can help the Minister by suggesting to him some ways forward.

The Lloyds survey to which the hon. Lady refers was of 400 pharmacists, and it showed that 80% of pharmacists were unable to dispense items, or had had to call their local GP surgery, for four or more prescriptions a week. For 26%, that number rose to more than 10 prescriptions a week. On average, half of pharmacists surveyed were spending at least one to three hours a week trying to resolve stock availability problems for patients. That includes ringing around other stores, contacting suppliers and liaising with prescribers. Critically, as she said, 16% spend at least four to six hours a week doing so, and 8% spend more than six hours a week chasing down stock.

Another survey that has been undertaken, of which the House may not be aware, is a 2011 preliminary survey on medicine supply shortages by Chemist and Druggist online. It found, echoing those earlier findings, that 93% of respondents were spending more than one hour a week sourcing key medicines. It found that 54% were spending more than two hours a week doing so, and that 10% were spending five hours or more. If they are doing that, they are not providing the front-of-counter services that we want them to, such as helping people with minor ailments and providing other assistance. That survey also found that 90% had had to ask GPs to change a prescription in the face of shortages, and that 70% had found getting hold of branded medicines even harder in the past year than in previous years. Those figures mirror those in the previous survey the year before. The problem is at least as bad as it was a year ago, and possibly getting worse.

Let me personalise the matter. I spoke to a community pharmacist from Rasharkin in Northern Ireland this week, who told me:

“Supply chain issues are becoming an increasing problem as I continually have to telephone the manufacturer directly for stock. For example today”—

Monday 21 November—

“we had four prescriptions outstanding for a drug for depression; we had ordered these electronically through the manufacturer’s chosen supplier five days ago but the stock has still not arrived. We had to telephone the manufacturer for stock today and they insisted we supply copies of the prescriptions. I refused as I believe there are issues here with patient confidentiality. They agreed to send only a partial order. Two of the above patients will be without their medication until the supply arrives, the other two have enough to keep them going for a few days.”

Patients in that situation are all too often left with only a small supply, and sometimes with none of the medicines that they need. Research by the Patients Association found that half of those surveyed had had to wait two or more days to get their medication when there were stock availability problems, and that two thirds felt from their personal experiences that medicine shortages were definitely having an impact on people’s health. That situation will see real harm caused.

The Chemist and Druggist 2011 survey has already found tangible incidents of harm caused to patients by a lack of available medicines. To cite some examples, it found incidents of a pharmacist having to refer a patient back to hospital because of a shortage of drug supply; patients describing themselves as “stressed and upset”, and suffering severe emotional trauma; a patient experiencing difficulties with anxiety that had previously been controlled by their medication; and a diabetic patient suffering a hyperglycaemic episode while waiting for their medication.

The evidence showing the problems in the supply of medicines to local pharmacists is clearly overwhelming. The reality for patients, including the one who came through my door a year ago, is frightening. Despite the hard work of pharmacists everywhere, the results could be fatal. We must avoid that. The situation was noted by the all-party group on pharmacy this week when it announced that it will hold a full-scale inquiry into the continuing problem of shortages in NHS medicines.

The reasons for the shortage in the supply of such crucial medicines, as in any situation, are varied. First, as the Minister will know, European competition policy promotes a free market in medicines. The trade is legal and encouraged by the EU. With the weak pound, there is money to be made—by pharmacists, wholesalers and others—by selling drugs to those in Europe.

The Association of the British Pharmaceutical Industry states that the recent Medicines and Healthcare products Regulatory Agency announcement that it will repeal section (10)(7) of the Medicines Act 1968 to prevent pharmacists from trading without a wholesale licence is an important step in the right direction, but it will not solve the problem. Experience has shown that supply in the market well beyond what is needed for UK patients does not solve the problem of shortages at pharmacy level —it simply results in more stock being diverted overseas.

The second reason is the number of wholesalers. There are now 1,800 wholesale dealer licences in the UK. Additionally, according to the British Association of Pharmaceutical Wholesalers, six years ago, a pharmacist could order from their chosen wholesaler almost any medicine manufactured, but nowadays, they need to order from at least two or three wholesalers, which means two or three deliveries at different times of the day, with two or three times the paperwork.

Thirdly, quotas put in place by manufacturers to control demand are crude and lack the flexibility to meet ordinary fluctuations in demand. In one case, a pharmacy was restricted by a quota to 28 days of supply for a medicine, meaning that it was unable to fulfil 56-day prescriptions. To overcome such situations, pharmacists must place so-called emergency orders directly with the manufacturers for stock to be delivered individually in unscheduled deliveries, which often arrive via courier companies one or two days after the identified patient need.

Increasingly, patients are forced to wait while the pharmacists make daily emergency orders with various manufacturers. They often have to go through quite intrusive audit questions to prove they have a genuine patient need. On top of that, the patient has to await delivery. Another pharmacist—from Gwynedd—said of this unacceptable situation:

“In many instances after phoning our wholesalers and the manufacturers and even…specialist wholesalers, we are eventually able to source the drug, but it doesn’t arrive for 2 to 3 days.”

In March 2010, the then Secretary of State, my right hon. Friend the Member for Leigh (Andy Burnham), held a summit meeting of all industry stakeholders and formulated an action plan. In February 2011, the Department of Health published guidance, but as we approach 2012, a solution is still not in sight, unless the Minister brings some clarity today. The guidance is a step in the right direction, as recognised by Pharmacy Voice, but it is not the silver bullet—there is no silver bullet. Problems remain and it is time for further affective action to be taken.

What should that action be? We should update the regulations on patient access to medicines to make them fit for purpose. Currently, there is a duty to supply, but no time scale in which to do so within the UK. Other EU nations, including Belgium, France, Finland, Germany, Greece, Hungary, Italy, Norway, Portugal and Spain, have implemented a patient or public service obligation—I prefer the phrase “patient service obligation—on the manufacturers and wholesalers to ensure that community pharmacists can get medicines to their patients when and where they are needed. It is time for the UK to implement its own, albeit adapted, version of a patient service obligation. The Minister might be hesitant to do that, but we place obligations on distribution network operators to connect people to the national grid to ensure that they receive an uninterrupted supply of electricity, and yet we have no obligations on an uninterrupted supply of medicines.

There are different ideas on what would constitute a patient service obligation, but let me suggest some principles that might underpin one. First, all those who supply medicines, whether manufacturers, distributors or dispensers, should have a duty to ensure that the medicine supply chain is economically efficient in line with the clinical needs of patients, so it delivers to them on time. Secondly, all those who supply medicines should have a duty to ensure that patients can easily and quickly obtain the medicines they need and to prioritise the supply of medicines to UK patients. Thirdly, medicine supply arrangements must be sufficiently robust and stable to guarantee a continuous supply to patients, including the rigour needed to absorb any short-term disruption—for example, through extreme weather conditions, as we saw last year.

Such a patient service obligation would receive support across the supply chain from manufacturers, wholesalers, pharmacists and patients. The National Pharmacy Association and the British Association of Pharmaceutical Wholesalers are already on board, and the Association of the British Pharmaceutical Industry is keen to learn more. Indeed, the Government have not ruled out a patient service obligation. I see no reason why active discussions between all interested parties—the manufacturers, wholesalers, pharmacies and patients associations —cannot begin immediately, brokered by the Minister and the Department of Health. Perhaps the Minister would like to know that a recent Pharmacy Voice survey has shown that such a move would find considerable favour with the public.

It is time for the Department of Health to lead on this vital issue. The evidence is overwhelming and the urgency palpable. Everyone is ready to find a solution and ensure that the aims of a patient service obligation—ensuring that no one goes without their vital medicines—are more than just an ambition, and become a reality. I hope the Minister in his response—I know that he is aware of the critical nature of this issue—can assure the House of his intention to act on this issue with real urgency.

[The Minister of State, Department of Health (Mr Simon Burns)]

May I begin by congratulating the hon. Member for Ogmore (Huw Irranca-Davies) on securing this debate? I know that he has been assiduous in highlighting this important issue in his constituency and beyond, and anyone who doubts that need only have listened to his speech—or read it in Hansard tomorrow—to know about his commitment to, knowledge of and passion for this issue of genuine concern in many areas. It is also a pleasure to see my hon. Friend the Member for Stourbridge (Margot James) in her place, as I know that she has a long-standing interest in the subject, having secured a debate on the pharmaceutical situation earlier in this Session.

I assure all hon. Members that I am sadly all too aware of the difficulties that pharmacists and members of the public have had in obtaining some prescription medicines. It was particularly moving when the hon. Gentleman spoke of the experience of someone he knows who regrettably had trouble getting hold of one of her medicines, Femara, which is used to treat breast cancer. We freely discuss policy at meetings and in the Chamber, but those discussions suddenly seem very distant when we are confronted with the reality of what it means to be unable to access a drug. I am aware that some pharmacists have had difficulties getting Femara, but those difficulties have recently been greatly reduced following the expiry of the patent earlier this year. The generic version of Femara is now widely available under the name letrozole. I know that it is of little consolation to the hon. Gentleman’s friend, but what it does mean is that other people will not have to go through the same heartache as that lady.

I am also aware of how frustrating it is when such problems occur with other drugs—not simply cancer drugs—because for people who need them at the time, they are equally important. The coalition Government have already taken action and we will take further action if necessary.

Supplying medicines to patients requires a complex, international infrastructure. There are around 16,000 licensed medicines covering tablets, capsules and injections, and different dosages, and nearly 900 million NHS prescription items are dispensed every single year. As hon. Members will appreciate, it is a vast undertaking. Given that complexity and scale, there are difficulties from time to time, and not only the UK is affected: recently the US has had problems of its own. There are many different reasons why patients might have problems getting hold of their medicines, and they range from difficulties in obtaining raw materials to manufacturing problems and the overseas sale of medicines intended for this country. I would like to speak about all of these.

Supply issues can arise as a result of parallel trade, as the hon. Gentleman mentioned. That is when medicines are bought at low prices in one European country and then resold at higher prices in another. When the euro got stronger relative to the pound, exporting UK medicines to other European countries become more profitable. At the moment, parallel trade exports are therefore reducing the supply of medicine available to UK patients. I stress that this parallel exporting is legal and can be carried out by anyone who holds the necessary licences under the medicines legislation. Indeed, in the past, UK patients have benefited from medicines being imported to this country by the same process.

I cannot stress firmly enough that there are existing legal duties on manufacturers and distributors, within the limits of their responsibilities, to maintain a suitable supply of medicines to pharmacies so that the needs of patients are met, but regrettably a minority of operators in the supply chain are thought to be putting profit before patients. I know that this is not condoned by the majority of those in the supply chain. Indeed, manufacturers and pharmacies have to fill the gap that these practices create.

Manufacturers have introduced quotas to try to target supply but this reduces pharmacies’ flexibility to meet unexpected patient need. Pharmacies use contingency arrangements to get medicines directly from the manufacturer rather than from their usual wholesaler. We have recognised this in NHS funding for community pharmacies but it still annoys the majority that are putting patients first. I understand that that is frustrating for many parts of the supply chain and can lead to delays in some patients getting their medicines. However, the Department of Health, the Medicines and Healthcare products Regulatory Agency and the supply chain stakeholders—manufacturers, wholesalers and pharmacies —are working together to reduce the impact on patients.

In order to address the issues with supply, the previous Government set up a ministerial summit in March 2010. A wide range of organisations and individuals participated, including those representing pharmacists, wholesalers and doctors. The summit agreed a package of tough actions to be taken forward in collaboration with the industry and other partners. This Government have taken forward many of the actions proposed by the previous Government. We continue to work with all parts of the supply chain to make sure it functions as well as possible through collaboration and collective agreement rather than by increasing the regulatory burden.

Actions taken forward following the summit include: publishing updated guidance on the legal and ethical obligations placed on manufacturers, wholesalers, registered pharmacies and others involved in the supply and trading of medicines in December 2010; publishing best practice guidance agreed by stakeholders of the supply chain clearly stating that under normal circumstances pharmacies should receive requested medicines within 24 hours—if all members of the supply chain followed this, patients might get medicines more quickly—and developing and maintaining a list of products in short supply published on the Pharmaceutical Services Negotiating Committee’s website so that no one trading in these products can say that they are not aware of supply difficulties.

On top of that, MHRA site inspections and follow-up inspections have been conducted and progress has been made, including through written undertakings to comply with the agency’s recommendations. To date, no breaches of the regulation have been established.

[Huw Irranca-Davies]

This is not a new phenomenon. As the Minister said, the previous Government recognised it, set up the taskforce and introduced proposals on which this Government are acting. The difficulty is that the system is not working properly, despite the best will in the world. I understand the one-in, one-out rule and the necessity to avoid an undue regulatory burden, but a light-touch approach would be welcomed by most of the industry. A manufacturer told me the other day that he was producing 140% of the needs of the UK but there was still a shortage of the drug that he was supplying. Surely a patient service obligation would fit the bill by ensuring that certain things have to happen. It has been done in most other European countries.

[Mr Burns]

I am grateful to the hon. Gentleman, and I will come to that point a little later in my remarks.

As I was saying, exporting medicines is only one source of supply difficulties. Problems such as obtaining raw materials or problems with manufacturing processes can also cause supply problems. The increasing concentration of pharmaceutical manufacturing has made the situation worse. A medicine may be made only in one or two sites globally, which means that there is not much flexibility if problems are experienced at a particular factory or manufacturing site. Production schedules have to be planned months in advance and if one company has a shortfall, suppliers of alternatives may be unable to make up the shortfall at short notice.

The current trend in the supply chain of pharmaceuticals over the past few years is to move towards a “just in time” set-up, which results in lower stocks of medicines throughout all parts of the supply chain. This trend has resulted in significant savings, but requires more active and reactive stock management. Again, the Government work closely with pharmaceutical companies, wholesalers, pharmacists and the NHS and have well-established procedures to manage these risks.

The Department of Health published joint best practice guidelines with the Association of the British Pharmaceutical Industry and the British Generic Manufacturers Association in January 2007. The guidance gives companies advice on what to do in the event of a shortage and recommends early communication with the Department about possible shortages that might affect patient care. This allows us to work together to explore whether any action can be taken to reduce the impact on patients.

The Department has also created a small buffer stock of some medicines to help manage shortages during pandemics and other emergencies. We are also taking action through the European Commission’s falsified medicines directive to strengthen the supply chain against the risk of counterfeit medicines. This aims to improve the reliability of the medicines supply chain and to respond to the increasing threat of falsified medicines entering it.

As a direct result of the arrangements I have described, combined with the diligence and professionalism of most of the supply chain, patients overwhelmingly have access to the right medicines in a timely and efficient manner. We are continuing to monitor the situation very closely. Of course, we are not prepared to be complacent. That is why we are working so closely and collaboratively with the supply chain, monitoring and intervening as appropriate.

The hon. Gentleman’s intervention was about the public service obligation. I am aware that some—like him, and quite honourably—would prefer to see a public service obligation placed on the medicines supply chain to maintain supplies of medicines. As I have said, it is already the case that manufacturers and distributors must ensure continuous supplies of medicines to meet patients’ needs. Failure to do so could put them at risk of regulatory action or criminal prosecution.

Some other EU member states have a very precise definition of how soon medicines should be received, but we are cautious about going down that road. It would vastly increase regulation on the industry and drive up costs across the board. This is why, as I have said, we have chosen to go down the route of best practice guidance instead. Best practice arrangements exist; they have been agreed with all parts of the supply chain and they have been very successful in minimising the impact of shortages. It is a much more flexible approach than statutory regulation.

In conclusion, I am grateful to the hon. Gentleman for raising this issue—one that will be relevant to all Members across all party divides, as well as to every single community and individual person. It is an issue of true universal interest and concern. I assure the hon. Gentleman that the coalition Government are absolutely committed to patients getting their medicines as quickly as possible. We are also certain that in the supply of medicines, everyone in the supply chain has their part to play, including manufacturers, wholesalers, pharmacists, prescribers and patients. The Government will continue to work closely with all those involved in the supply chain, making sure patients receive their medicines in a timely manner and without any unnecessary complications. This is not an issue that will be discussed just once and then forgotten. We are determined to keep a watchful eye on the situation to see if there are ways to improve it and minimise disruptions or problems for patients, ensuring that they get the best service, to which they are entitled.

Question put and agreed to.

Oral Answers to Questions

Huw Irranca-Davies Excerpts

Tuesday 22nd November 2011 Commons Chamber

[Mr Lansley]

I am grateful to my hon. Friend for that question. I do not think I am in a position to say what figure is appropriate, but the national clinical director for cancer has already indicated to the NHS that he wishes us to develop a national tariff for stereotactic radiotherapy. A quarter of centres across the country already provide it, and our intention is to ensure that that is supported by a national tariff as soon as possible.

[Huw Irranca-Davies (Ogmore) (Lab)]

Regrettably, there are still many thousands of attacks by dangerous dogs every year that end up with people in A and E, and occasional fatalities. Has the Secretary of State carried out any assessment of the cost to the NHS of treatment for attacks by dangerous dogs? If not, may I ask him to instruct his officials to do so?

[Mr Lansley]

I do not have those figures to hand, but I will gladly see whether we have them available, and I will write to the hon. Gentleman.

Oral Answers to Questions

Huw Irranca-Davies Excerpts

Tuesday 18th October 2011 Commons Chamber

[Mr Lansley]

This is an area in which the medical director of the NHS, the General Medical Council and others issue guidance to the NHS. I will gladly write to my hon. Friend setting out the details.

[Huw Irranca-Davies (Ogmore) (Lab)]

T3. I know that I am not alone in being an MP who represents pharmacists who are struggling on a daily basis to access life-saving drugs to treat asthma, diabetes and cancer, even to the point at which some of them are running out of those products. What more can the Secretary of State do to ensure that manufacturers and wholesalers have those life-saving drugs that people’s lives depend on? This is not good enough. What more can the Government do?

[Mr Lansley]

The hon. Gentleman will know that we inherited significant supply problems to pharmacies from the previous Government, not least because of the exchange rate and the possibility of countertrade. We have worked with the industry to resolve those issues. The hon. Gentleman would be well advised to talk to the Welsh Assembly Government about the fact that patients in Wales cannot access the latest cancer medicines, as patients in England can do under the cancer drugs fund.