Acquired Brain Injury

John Hayes Excerpts

Thursday 9th May 2019 Commons Chamber

[Sir John Hayes (South Holland and The Deepings) (Con)]

It is a pleasure to follow the hon. Member for Rhondda (Chris Bryant) and to endorse and amplify his remarks about the Minister. Many people achieve office in this House, but few are more deserving of that opportunity than the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for South Ribble (Seema Kennedy). We are delighted to have her with us today. We will be even more delighted when she answers some of the questions posed by the hon. Member for Rhondda and gives us an assurance that the Government will continue—for they have begun well—to take this subject seriously and will act on the recommendations in this excellent report, which would not have happened without the initiative, enterprise and energy of the hon. Gentleman. His commitment has been exemplary.

The work of the all-party parliamentary group on acquired brain injury is illustrative of this House doing what it does best: coming together, highlighting a subject, and bringing it to the attention of the wider world and of those who exercise power. We have, I believe, done a good job, but it is only the beginning of a journey. The destination we seek is our recommendations being enacted in full. Perhaps I am being a little ambitious, but at the very least the Government have taken a renewed and reinvigorated interest—I would not for a moment suggest that they were not interested already—in this subject, which affects so many people.

Perhaps that is the place to start. The hon. Gentleman spoke about the definition of brain injury, but I want to speak about the scale of the problem. The number of families affected by acquired brain injury, which, as the hon. Gentleman described, includes anything from traumatic events through to brain tumours, is immense. Hospital admissions for head injuries number 162,544—one every three minutes. ABI admissions have increased by 10% since 2005-06. Although men are 1.6 times more likely than women to be admitted for head injury, the incidence of female head injury has increased by 24% since 2005-06. Families across our nation and in all our constituencies are affected. The challenges are profound, for the reasons that the hon. Gentleman described.

[Mr Steve Baker (Wycombe) (Con)]

I, too, welcome the report. May I add to my right hon. Friend’s list what I have discovered in my constituency? Even babies can acquire brain injuries from contracting meningitis, or during childbirth. I hope he will join me in encouraging the Government to consider that issue as well.

[Sir John Hayes]

I will—very much so. I have been terribly unlucky, by the way, having suffered a severe head injury as a result of a road traffic accident and, like the hon. Member for Rhondda, contracted bacterial meningitis. We both speak with some authority on this subject.

The patterns that those families endure are similar, one to another. Initially, of course, there is shock—a sense of disbelief—and the question that most people pose in these circumstances: “Why me?” Then there is a gradual realisation of the depth and scale of the effects of acquired brain injury, and an unhappy initial concentration on what the person can no longer do, followed eventually by a reconcentration on what they can do. Most families follow that pattern when they suffer this kind of event, and that is why all that is done beyond the treatment of the initial trauma is so critically important.

Neuro-rehabilitation is vital because of the dynamic character of these conditions. Most people who acquire a brain injury will change. Many will recover fully and some will recover partly, but all that takes place over a long period and is particular to each case. There is an unpredictability about the effects of acquired brain injury; it can affect physical capacity of course, psychology and cerebral function, as well as personality. Families dealing with that must cope with those kinds of changes, which can be terribly frightening for the individuals concerned and those who love them. The point is that a difference can be made by the quality of care that they receive during that rather difficult journey.

[Dr Julian Lewis (New Forest East) (Con)]

May I add one more category to those listed by my right hon. Friend and the hon. Member for Rhondda (Chris Bryant)? I am talking about service personnel who were blown up in Iraq and Afghanistan, some of whom, although apparently uninjured as a result of the great advances in vehicle technology that enabled them to survive improvised explosive devices, are believed to have been misdiagnosed with post-traumatic stress injury, when in reality they are suffering from mild traumatic brain injury. I believe that only two scanners in the whole country are capable of identifying mild TBI. There is not yet an adequate programme to make sure that the condition is discovered before irreparable damage is done.

[Sir John Hayes]

I am grateful to my right hon. Friend for making that point. The hon. Member for Rhondda talked about the understanding that we need in the welfare system and the expertise that we need to acquire in dealing with the repercussions of a traumatic event. Often, misdiagnosis is part of that problem. Because of the characteristics of acquired brain injury that I described earlier—the changes in personality and the effect on cerebral function—misdiagnosis is all too easy. Part of our mission in bringing the all-party group’s report to the House’s attention, and doing so again in today’s debate, is to get all of Government, including the Ministry of Defence, working together to understand the breadth and scale of the problem. That kind of intergovernmental approach is essential to the recommendations of our report, and I shall say more about it in my concluding remarks.

Before I do that, I wish to say a little about the difference between the initial responses to acquired brain injury, whether acquired through a traumatic event such as a road traffic accident—indeed, many are acquired that way, which is why so many young men are affected—or through the kind of illness that the hon. Member for Rhondda spoke about, such as a brain tumour, meningitis or some other disease. By and large, the initial response is, as is so often the case in the NHS, routinely excellent. People are treated quickly and highly effectively. It is what happens afterwards that is more variable in its effectiveness.

When people leave hospital, invariably having been treated extremely well by our superb NHS, whether their subsequent treatment is effective is a matter of some uncertainty. It can be, and often is; indeed I pay tribute to the good work of Headway—I am a patron of Headway Cambridgeshire and have been for many years—and the other organisations that play a part in supporting families, spreading understanding and sharing good practice, but it is to some degree a lottery. It is partly about where someone lives and how effective the local agencies are; it is partly about how well Government Departments and local government work together and how meaningfully they address some of the challenges that are the inevitable consequences of these kinds of injuries. The all-party group’s report deals with them and the hon. Member for Rhondda highlighted some of them. There are educational effects and effects in the workplace and in socialisation; perhaps there is even the risk of criminality as a result of the consequences of a brain injury. It is the business of neuro-rehabilitation, which we emphasise so strongly in the report, that lies at the heart of what we believe the Government need to do to improve the outcomes for the people and families concerned.

When I was a Minister, which I was for a long time but not for long enough, many people in the House tell me—it is not for me to say, of course—I found that perhaps the greatest challenge Ministers face is in dealing with matters that cut across Departments. It has become almost routine to talk about Departments working in silos, but it is certainly true that the character of the vertical structure of the way we run Government and organise ministerial responsibilities makes it quite difficult for Departments to interact, or sometimes even to interface. On this subject, perhaps as much as on any subject that I know of, it is critical that Departments do just that. We speak in our report of the Departments concerned, and my right hon. Friend the Member for New Forest East (Dr Lewis) mentioned another, the Ministry of Defence. I urge the Government to continue to explore how we can take a cross-departmental approach. We have had strong support from the Cabinet Office, but I hope that the Minister will take that further forward.

[Mr Sheerman]

The right hon. Gentleman is absolutely right about cross-departmental working. I am obsessively concerned with road deaths and road injuries; does he accept that getting the Department of Health and Social Care, the Department for Education and the Department for Transport together to push for proper head and brain protection for cyclists, motorcyclists and people who drive cars is very difficult?

[Sir John Hayes]

Not for the first time, the hon. Gentleman is absolutely right. The hon. Member for Rhondda spoke of, for example, sports injuries. The response we have had from Departments has been mixed. It is certainly true that they have all responded, but it is fair to say that some have done so with greater enthusiasm and clarity than others. The convivial and collaborative nature of this debate forbids me from being more critical than that, but the Minister will want to look at those responses, as we have, and at how those Departments that have been rather slower to take their responsibilities seriously can be brought up to speed.

The hon. Member for Huddersfield (Mr Sheerman) is right that cross-departmental working is vital. It is important that we also look at local government and other Government agencies and organisations. Given the breadth of local government responsibilities, of which housing is a good example as well as education, which the hon. Member for Rhondda spoke about and which is critical to our report, it is really important that local government is involved in this work, too. It is therefore not only a lateral challenge but about connecting the local approach to the national one.

Furthermore, it is important that we recognise the dynamic character of individual needs. Governments are quite good at disabilities that are fixed. People have dreadful things happen to them and either acquire disabilities or perhaps start life with disabilities, and the Government can be quite effective and the national health service is highly effective in dealing with those kinds of challenges, but dynamic disabilities are different again, because of course by its nature that dynamism means changing needs and that requires changing provision. It might be in respect of benefits—the hon. Member for Rhondda mentioned support for benefits—or simply a matter of providing additional resource to an individual to allow them to get back to work or to return to education. It might be a matter of ensuring that the teachers, employers and others associated with an individual are well equipped with an understanding of what that dynamic disability might mean and might lead to. It is vital that the Government appreciate that many people have changing circumstances that require a changed approach.

Others wish to contribute, so I shall end by highlighting some of the things we said in the report and to which we would like the Government to respond. First, simply raising awareness is vital, and I hope that the report and this debate have done that. Secondly, I have spoken about neuro-rehabilitation and the need for a joined-up approach across Government. Thirdly, I wish to amplify an excellent point made by the hon. Member for Rhondda about education: it is really important that acquired brain injury is included in the special educational needs and disability code of practice. Fourthly, in the justice system, it is vital that all agencies that work with young people—including schools, psychologists, psychiatrists, general practitioners and youth offending teams—should ensure that the needs of the brain injured are individually and carefully assessed.

I could highlight many other things—our recommendations are broad, and I hope deep, too—but I shall end by quoting G. K. Chesterton, who said:

“How you think when you lose determines how long it will be until you win.”

When someone loses as a result of an acquired brain injury perhaps some cerebral function or the ability to mix and work with other people, or has some permanent disability, how long it is before they again see themselves as someone with a chance to win can be determined by what we here do, and on how the Government allocate their time, energy and resources to fight for, care for and campaign for people so affected.

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[Bill Grant (Ayr, Carrick and Cumnock) (Con)]

It is a pleasure to follow the hon. Member for Swansea East (Carolyn Harris).

I note and welcome the valuable work of the all-party parliamentary group on acquired brain injury, including its most recent report. I agree that Governments together need to lend their support and implement, where reasonably practicable and borne out by evidence, the measures that will bring about improved neuro-rehabilitation for those with acquired brain injury. About 1.4 million people in the UK are living with a brain injury. According to Headway Ayrshire and as has been mentioned, every 90 seconds someone in the UK is admitted to hospital with an acquired brain injury, and in 2016-17 some 1,816 people with a diagnosis related to acquired brain injury were admitted to hospital from the Ayrshire and Arran area within which my constituency lies. These are large figures and very worrying statistics.

It has been acknowledged that more persons are surviving trauma to the brain, which may occur after birth or because of disease, an accident, sport, military service or a criminal act. Let me stop for a moment on the question of accidents. Having spent 31 years in the fire service and attended numerous needless road accidents, I commend those who created, invented and install airbags—we have no measure of the number of brain injuries that they have prevented—and the Governments who introduced the compulsory wearing of seatbelts and of crash helmets. The number of people saved from accidents by that is wonderful. I will leave this hanging for a moment, but would it be possible and worth considering the compulsory wearing of safety helmets for cyclists? I am sure that that would reduce brain trauma injuries in the future.

Those people’s survival is to be welcomed, although regrettably some could have a degree of disability and might have a different persona, which can prove difficult for all to cope with. The individual and their families undoubtedly need an informed and readily available bespoke support package. The onus is on us to enable these individuals to regain their dignity, which they so richly deserve, and to have an active role in our society, which is their society as well.

To date, rehabilitation provision for in-patients and those returning to the community appears to have been sadly lacking, or, when it is provided, of varying standards and not always in line with those narrated by the National Institute for Health and Care Excellence, NHS England’s best practice tariff and the all-important person-centred rehabilitation prescriptions. Those prescriptions are so important to that individual, their family and their carers.

I support the desire for a specialist acquired brain injury rehabilitation consultant who would guide, oversee and co-ordinate matters. Oversight and co-ordination appear not to be as good as they could be. That is not to detract from the excellent work of charities mentioned in the Chamber this afternoon, such as Headway Ayrshire, which is part of Headway, the brain injury association, raising public awareness and working to improve life after brain injury by providing simple things like information on where people go for help. When someone puts their hand out for help, someone has to grasp it, and in many ways Headway does that, providing advice and support to the person, their family and their carers. Having previously sat on that charity’s local board, I have seen for myself how it is able to benefit my constituents and many throughout the UK in other branches of Headway. I thank Headway—its staff, volunteers and those who raise money for it—and welcome the contribution and support it gives individuals.

In 2017, the Scottish Government’s community justice funding enabled Supporting Offenders with Learning Difficulties, also known as SOLD. SOLD was able to assist those with alcohol-related and acquired brain injuries out of the dreadful cycle of reoffending. The prison community often does not understand these issues.

[Sir John Hayes]

The hon. Member for Swansea East (Carolyn Harris) made an incredibly important contribution—as my hon. Friend is doing—highlighting that many people become involved in alcohol, gambling or some other pursuit, which would never have happened had they not had their brain injury. The Government need to look at that aspect of the issue, because the consequences of brain injury can be as unpredictable as that.

[Bill Grant]

I thank my right hon. Friend for that welcome intervention. It is easy to identify someone with a physical injury—the leg in plaster or the arm in a sling—but an injury to the brain is not visible, and we need to be aware of that.

Scotland has seen the development of a brain injury e-learning resource, created under the umbrella of the Scottish Acquired Brain Injury Network, with funding and technical support provided by the national services division of the NHS. Glasgow University’s excellent Centre for Rehabilitation Engineering also undertakes work on the neuro-rehabilitation of hand and arm functions, neuropathic pain and the possibilities of retraining the central nervous system after spinal cord injury or a stroke. I should also mention a facility from which I benefited: the Douglas Grant rehabilitation centre, which is operated by NHS Ayrshire and Arran. The centre gives confidence back to people who have been subjected to brain injury or nervous system injury. It also gives them back their ability to find their own way in life, and great credit is due to the staff there.

As was mentioned earlier, the effect of sports injuries involving concussion is not quite fully understood, but it is better recognised, particularly in rugby, but such injuries can also happen in football. There has been great success in football of late. Dare I mention Tottenham Hotspur and Liverpool? Perhaps clubs should invest some of their money protecting their valuable players—not for today or tomorrow, but for later in their life—from the consequences they may suffer. Football still has some way to go on that front.

We may still need to educate the educators to understand the hidden disabilities and lifelong consequences for young people with acquired brain injury. Medical science is leading to a better understanding of ways to address rehabilitation, and organisations are seeking to communicate what is available. However, it is vital that this work is co-ordinated, and that a holistic treatment plan and the functioning needs of acquired brain injury patients are considered and acted on promptly. This should not be delayed, waited for or pushed down the line; we have to respond timeously.

Some patients may reach a plateau, but for others sadly the condition may be progressive, so there is no one-size-fits-all approach for victims of acquired brain injury. We need to continue to build on the Government’s good work in achieving and maintaining specialist centres of excellence and enhanced community support services for persons with acquired brain injury, their families, and—let us not forget—their carers.

I ask the Minister to look favourably on further measures to support those with acquired brain injury, their families and carers, and to ensure that the Departments of all Governments communicate with one another to make contact for these service users easier. Communication and form-filling may be extremely difficult for people with acquired brain injury, as their concentration levels are often depleted. Ease of application—a simple thing—would be a great step forward, with Departments sharing information, instead of individuals repeatedly filling in forms and going back to repeat the process several times. It is, indeed, time for change.

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[Sir John Hayes]

The hon. Lady is making powerful points. The key is that these plans have greater specificity and quantification so that the development of the response to someone’s needs could be as particular as it needs to be. That means quantifying exactly what happens once the needs and the response to them are drawn up.

[Liz Twist]

I thank the right hon. Gentleman for those comments. I most certainly agree that we need to have very specific proposals on how we can support people and to make sure that the support is actually put into place as well. As we know, there can sometimes be delays in achieving the ECHP, so I hope that more work can be put into that as well.

The Child Brain Injury Trust, which does excellent work in this area, has issued a call for action that includes some quite practical steps. It tells me that professionals across the field of acquired brain injury educational psychology are working hard to achieve the changes needed to support children in education following an acquired brain injury, but this requires all parties to listen and to implement the recommendations of the “Time for Change” report.

An acknowledgement of the support and interventions needed for paediatric acquired brain injury is required to limit the long-term societal costs and impact that this disability can have. Of course, it affects society as a whole, not just the individual. We want to give people the best chance in life, and that is why it is particularly appropriate to look at how we can support children who have an acquired brain injury. There needs to be improved training for newly qualified teachers—currently, acquired brain injury is not covered in that training—and a national campaign of recognition that acquired brain injury affects an additional 40,000 children and young people every year and has a significant impact on society.

The Child Brain Injury Trust says that acquired brain injury continues to be misdiagnosed and misunderstood, and our current system, and lack of knowledge and support, is letting down thousands of families. Funding is required for whole-family support. We need improved training for educators and youth justice teams, because over 60% of young people in custody report prior head injury. As other Members have mentioned, many young people affected by acquired brain injury are excluded from school due to their “inappropriate behaviour” and then go on to commit crime. Therefore, better knowledge of the condition and improved support has the potential to save society huge sums of money otherwise needed for youth justice.

The Child Brain Injury Trust calls for involvement and commitment from the Department for Education to support and fund some of these recommended initiatives. As I said, I hope that the Department for Education will take a more active part in looking after these young people and look again at its response to see how it can be improved.

The other area I want to touch on, which has already been mentioned by a number of Members, is acquired brain injury and carbon monoxide poisoning. This is not something that I had thought of myself. It shows, again, how many areas of our lives and our environment affect people and can cause acquired brain injury. I am a member not only of the APPG on acquired brain injury but the APPG on carbon monoxide, and earlier this year we had a special roundtable meeting chaired by my hon. Friend the Member for Rhondda. One of the difficulties is recognising when people are suffering from carbon monoxide poisoning, especially the impact that that can have on the brain. The shortage of support is particularly difficult for people with an acquired brain injury caused by carbon monoxide poisoning, as they are less likely to receive specialist treatment if they experience low-level carbon monoxide exposure that results in more subtle neurological effects. To address this, the APPG on carbon monoxide recommends that NHS England develop a specialist clinic for people with long-term neurological effects caused by carbon monoxide exposure. This will help to plug the gap in care provision and enable future studies that will innovate treatment methods.

We must also remember that, as the Government said in their November 2018 health and social care policy paper, prevention is better than cure, and preventing carbon monoxide poisoning will also prevent some of these acquired brain injuries. The APPG recommends that the Government introduce preventive measures, including mandating carbon monoxide alarms in all tenures. I know that the Government are already looking at this in certain tenures, but it should be across all tenures. Carbon monoxide monitors should be provided for those in first-time pregnancy. We must tackle substandard housing that increases the risk of carbon monoxide exposure. We also recommend that Public Health England and the Foreign and Commonwealth Office do more to raise public awareness of carbon monoxide, to encourage risk-lowering behaviours at home and abroad. The special roundtable meeting that we had was very productive. We had a high number of medical people there who were recognising this problem that perhaps the rest of us had not recognised until now. We need some practical steps to improve that.

I have mentioned the Child Brain Injury Trust’s recommended actions, particularly on education. There is so much more that I could say, but much of it has already been said, so I will only mention a few things. We are seeing more people survive severe trauma, and we must give more effective support after they recover from their immediate injury, to help them develop their life.

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[The Parliamentary Under-Secretary of State for Health and Social Care (Seema Kennedy)]

It is a real pleasure to respond to this excellent debate on behalf of the Government. I would like to begin by thanking the hon. Member for Rhondda (Chris Bryant) for securing the debate. I commend him for the all the work he has undertaken as chair of the all-party group on acquired brain injury. He began by giving us a very vivid description of the physical impact of brain injuries, and went on to describe a whole gamut of mental health and emotional effects they have on people—and, of course, their families. He set me a challenge and I shall endeavour to meet it.

My right hon. Friend the Member for South Holland and The Deepings (Sir John Hayes) spoke with his usual eloquence. He reminded us about the scale of ABI, and emphasised the complexity of the issue and how it touches on many areas. The hon. Member for Swansea East (Carolyn Harris) told us all about George, reminding us that ABI can have extremely unexpected and devastating effects on the people who live with it and their families.

My hon. Friend the Member for Ayr, Carrick and Cumnock (Bill Grant), with his long career in the fire service, saw many people who had an ABI. He set us a very interesting challenge about having compulsory helmets for cyclists. I will take that point away and speak to my colleagues in the Department for Transport about it. The hon. Member for Blaydon (Liz Twist) outlined how people “just don’t get it”. That is a very important point, and it shows how important it is that we are debating ABI here today. She made a point about carbon monoxide poisoning, and I am due to have a meeting with the hon. Member for Rhondda on that very issue.

The hon. Member for Mitcham and Morden (Siobhain McDonagh) told us that the excellent charity Headway, which was mentioned very many times during the debate, is based in her constituency. She reminded us that a brain injury can strike any of us at any time. We also heard from the hon. Member for Caithness, Sutherland and Easter Ross (Jamie Stone). He spoke very movingly, as he did in the debate last year, about his wife’s experience and his. All I can say is keep going on the crossword.

Brain Injury Awareness Week is from 20 to 26 May. I welcome the time Parliament that has set aside to discuss this issue. Prevalence estimates for ABI are problematic to make, but it is likely that the number living with ABI is definitely over half a million and could be as high as 1 million. The total cost of brain injury in the UK is estimated to be at least £1 billion per year. Charitable organisations such as Headway and the UK Brain Injury Forum, as well as other local and national groups that hon. Members have referred to, are highly valued by those affected. They raise awareness and provide help to those with the condition, as well as to their families and carers, and I want to put on the record our appreciation for everything they do.

As we have heard, in 2018 the APPG held a wide-ranging inquiry into the causes, impact and treatment of ABI. My predecessor, my hon. Friend the Member for Winchester (Steve Brine), to whom I pay tribute for the energy he brought to this matter, agreed to respond to that report, and my Department co-ordinated with officials across Whitehall to deliver that response on 19 February. In responding today, I will draw on key areas of the response to set out the relevant activity that is under way.

[Sir John Hayes]

I thank my hon. Friend for giving way, and I know she will address these matters with her usual acumen and assiduity. I spoke about dynamic disability and the pace of recovery, but will she take into account the fact that aligned with that is the subtlety of the effects of brain injury? Sometimes a person may be deemed to have recovered completely and to have returned to normal—whatever normal is—but their manner, meter and mood might have changed and their sense of appropriateness might have altered, and that has effects in education and employment, in particular, as well as in personal relationships.

[Seema Kennedy]

My right hon. Friend makes an extremely important point, showing that this is an issue not only for the health system and my Department but for others across Government.

While the majority of rehabilitation care is locally provided, NHS England commissions specialised services for patients with the most complex levels of need. For people who have ABI, neuro-rehabilitation that is timely and appropriate is an important part of their care. Access to high-quality rehabilitation improves outcomes for patients and can save money. The shadow Minister mentioned rehabilitation prescriptions. RPs reflect the assessment of the physical, functional, vocational, educational, cognitive, psychological and social rehabilitation needs of a patient and are an important element of rehabilitation care. The APPG report was clear that all patients with ABI should benefit from an RP.

NHS England’s major trauma service, where acute phase rehabilitation begins, sets out that patients should be reviewed by a rehabilitation consultant. The shadow Minister asked about this. The development of major trauma centres, which the hon. Member for Rhondda supported, has improved recruitment to this specialty, while the national clinical audit of specialist rehabilitation recommended that all trauma networks review access to rehabilitation consultants and make improvements. Patients should have either a rehabilitation consultant or an alternative clinician with skills and competencies in rehabilitation to provide an initial formulation and plan to complete and perform the initial RP. At discharge, all patients should have a patient-held record of their clinical information and treatment plan from admission as they move to specialised or local rehab.

The “National Clinical Audit of Specialist Rehabilitation for Adults Patients with Complex Needs Following Major Injury”, published in 2016, found that on average 81% of patients had a record of a rehabilitation prescription. The audit recommended that MTCs take action to improve compliance. The audit report appears to have had a significant impact. The latest data, from the last quarter of 2018, from the trauma and audit research network shows that the national average rose to a 95% completion rate for RPs. This is good news. NHS England has worked with patients, clinicians and charities to improve the RP design and set new standards for communication and involvement of patients, families and carers. It is hoped that the new RP will support the development of a rehabilitation dashboard to monitor the performance of the system. Audits play an important role in helping services to improve. The report also recommended that all organisations within a trauma network work together to review capacity.

The majority of rehabilitation care is commissioned and managed locally. To support commissioners to plan services for local populations, NHS England has produced a document, “Principles and Expectations for Good Adult Rehabilitation”, that describes what good rehabilitation looks like. Additional guidance covering adults and children sets out a commissioning model and the evidence base for delivering high-quality rehabilitation services.

The hon. Member for Rhondda mentioned that ABI spans many Departments, and I shall take away all the comments that concern my ministerial colleagues and will ask them to respond. On support for children with ABI in school, the special educational needs and disabilities system is designed to support all children and young people with additional needs. The arrangements for SEND are intended to support joint working between health, social care and education; multi-professional assessment of a child or young person’s needs involving relevant experts; and the development of an individual education, health and care plan to meet those needs. This should provide a basis for the sharing of information and expertise to ensure the needs of children and young people with ABI are supported in school.

The hon. Member for Blaydon mentioned the ABI card. The Department for Education has said that promotion of the card is a matter for individual schools, but as far as my Department is concerned, Professor Chris Moran, a national trauma director, said that he would be happy to promote the card in trauma networks, working with the Brain Injury Trust. The statutory guidance on supporting children with medical conditions at school covers a range of areas, including the preparation and implementation of school policies for supporting pupils, the use of individual healthcare plans, consulting with parents, collaborative working with healthcare professionals and staff training. The Department for Education continues to work with organisations such as the Health Conditions in Schools Alliance to help to raise further awareness of the duty on schools.

On prisons, there is an increasing body of evidence linking ABI to offending behaviour. NHS England’s liaison and diversion service has collaborated with Headway to develop workshops to improve awareness and identification of ABI in vulnerable offenders and the support available. The “train the trainer” workshops were designed so that attendees could return to their services and cascade workshop learning to their colleagues. Representatives of all NHS England-commissioned liaison and diversion services attended. Over the past two years, the Ministry of Justice has also piloted approaches to improve screening and support for prisoners through new link worker roles at six sites on the male secure estate. I take the point about female offenders and will speak to the relevant Minister. There was a pilot at a female prison between 2016 and 2018, but I will take away the point about the female estate.

I want briefly to touch on the point raised by my right hon. Friend the Member for New Forest East (Dr Lewis), the Chair of the Defence Select Committee. The veterans trauma network delivers comprehensive medical care to veterans, including those suffering from brain tumours, and, as he knows, the Prime Minister opened the successor Defence centre to Headley Court last year. We do not recognise his statistic that there are only two machines, but I will take that away and report back to him.

Diabetes

John Hayes Excerpts

Wednesday 9th January 2019 Westminster Hall

[Sir John Hayes (South Holland and The Deepings) (Con)]

I beg to move,

That this House has considered diabetes.

What a delight it is to serve under your chairmanship, Mr Robertson. C. S. Lewis, the great Christian writer, said:

“Courage is not simply one of the virtues, but the form of every virtue at the testing point.”

Every day, our constituents—people across Britain—are tested by the challenges that are the effects of diabetes, which is the fastest growing health crisis of our time. There is barely a family in Britain that has not been touched by it. As so many elderly ladies do, my late mother contracted type 2 diabetes when she reached her 70s. I spoke to colleagues from across the House in preparation for this debate, and many of them, including one this morning, said that they had a family member who had been affected by the disease.

In the last 20 years, the number of people in the UK living with diabetes has doubled, reaching 4.6 million. Every day, 700,000 people are dealing with the worst effects, and 700 people are newly diagnosed as suffering from some kind of diabetes. Amazingly, that is one person every two minutes, so this debate is not only necessary and apposite; rather, I would go one further and say that it is essential.

[Nick Thomas-Symonds (Torfaen) (Lab)]

Will the right hon. Gentleman give way?

[Sir John Hayes]

I shall just finish the next exciting sentence and then I will happily give way. By 2025, there could be as many as 5 million people living with diabetes in the UK.

[Nick Thomas-Symonds]

I thank the right hon. Gentleman for giving way and congratulate him on securing this debate. The statistic for Wales is that one person in 14 is affected. Does he agree that, going forward, we must look at prevention—seeing the warning signs and looking at lifestyle changes—as well as having excellent treatment for those who are formally diagnosed?

[Sir John Hayes]

Absolutely. I will deal with that during my speech. Information that leads to a better understanding of risk, which in turn leads to prevention, is critical, particularly with respect to type 2 diabetes, which is the type that I mentioned earlier when I referred to my late mother.

I spoke of hundreds of thousands of people who suffer from type 1 diabetes—about 500,000 at the moment, but that could easily rise to 700,000—but of course 90% of sufferers are type 2 diabetics, and prevention is particularly critical in their case.

[John Howell (Henley) (Con)]

My right hon. Friend is making a very strong case. Is he aware of the new research into the treatment of type 2 diabetes, which suggests that a change of diet can eradicate it, giving the person a clean bill of health?

[Sir John Hayes]

I was going to refer to the achievements of the deputy leader of the Labour party, the hon. Member for West Bromwich East (Tom Watson), later in my speech, but my hon. Friend obliges me to highlight them earlier than I had planned. He is a model example of someone who, having contracted type 2 diabetes, adjusted their lifestyle and diet, lost large amounts of weight, and fought back against—indeed, fought off—type 2 diabetes, exactly as my hon. Friend suggests. Many other hon. Members, including some in the Chamber today, are living with diabetes. Remarkably, our Prime Minister not only manages to hold down her job with immense dedication and determination, but manages type 1 diabetes simultaneously. I spoke about every family and every constituency, but many Members of this House have personal experience of dealing with both type 1 and type 2 diabetes.

During the debate, I will focus on three areas in which we can make real progress: the human and financial cost of diabetes; how education and technology can enable self-management and improve outcomes for both type 1 and type 2; and how, in the case of type 2 diabetes, intervention on societal and individual levels can prevent the onset and mitigate the effects of such a serious problem.

To prevent just a fraction of the complications arising from diabetes would have a big impact on the national health service, generating significant savings as well as fundamentally reducing pain and distress for individuals. Every week in England, over 160 lower-limb amputations result directly from the effects of diabetes, so the ability to provide high-quality diabetic foot care is of particular concern. The recently published NHS long-term plan makes a renewed commitment to the diabetes transformation fund, and I know that that will be welcomed by the whole diabetes community.

I hope that the Minister will set out what steps the Government are taking to encourage the use of education and technology to better support people in self-managing their diabetes, as that will reduce the burden of diabetes both on the individual and on the NHS. A few years ago, a family came to my constituency surgery, with a tiny, wonderful little girl. She was just about to start school. She had already been diagnosed as a type 1 diabetic. That little girl, Faith Robinson, was wearing technology that allowed her glucose to be monitored and insulin to be administered to her—that was absolutely necessary because she was so young. The family came to me with a request, which I will pass on to the Minister so that he can work with colleagues across Government to ensure that this happens routinely for all constituents who need it. They asked that Faith receive one-to-one support at school to manage that technology. The little girl was under five, and needed people at the school she was about to attend to understand the condition and how to deal with the challenges that she faced.

I estimate that there are constituents across the country in similar circumstances, with very young sufferers who need that kind of care and support. I invite the Minister not necessarily to comment today—I do not want to catch him out; that is not my intention—but to reflect on that and to say more about what can be done for that little girl, who I was able to help in that circumstance, and for many others like her.

[Mr Philip Dunne (Ludlow) (Con)]

I not only congratulate my right hon. Friend on securing the debate but thank him for allowing me to intervene on that point. My second daughter was two and a half when she was diagnosed as an insulin-dependent type 1 diabetic. I very much empathise with the story that he has just told us about his constituent. My daughter was barely able to describe her feelings because she was only just talking at the time, which was really quite challenging for the clinicians treating her, as she was unable to describe the impact of treatment and how she felt.

I agree with my right hon. Friend that the introduction of technology—both a result and part of the significant research efforts in this country by charities and the Medical Research Council—is leading to opportunities in treatment provision, in particular the flash glucose monitoring device, which I know the Government will introduce across the country in a more even way than in the past. That is very welcome, but it remains subject to clinical guidance. I urge the Minister to look at that guidance and the attributes required for people to have access to those devices, because they remain quite restricted.

[Sir John Hayes]

With the insight and acumen that characterised my right hon. Friend’s ministerial career, he has identified a point that I was going to make later. With his permission, I will amplify that in my speech. I was aware of his personal circumstances and of his expertise as a result of having a daughter with diabetes. He will recognise that the average sufferer spends about three hours a year with a healthcare professional. Self-management is therefore critical and, in turn, technology is essential to such self-management. We cannot expect a healthcare professional to be on call every time someone needs support or the kind of treatment that is routine for someone such as my right hon. Friend’s young daughter. I entirely endorse his remarks. The Minister will have heard them and will respond accordingly.

In essence, I want a world in which all people with diabetes have access to the right information, advice and training, not just at the point of diagnosis but throughout their lives. People will say, “Well, of course, we all want the very best, and we all want the ideal,” but if we do not aim for the very best, we will get something very much less than that, so I make no apologies for being definitive in my determination to aim for that ideal. It is critical that we as parliamentarians should look to more distant horizons than sometimes the prevailing powers in Government—as I know from my long experience of that—would encourage us to do. Such debates as this allow us to do that in a cross-party way, for this is not about party political knockabout but about something much more fundamental.

Only if we can achieve the ideal will people be well placed to gain confidence and to cope as the Prime Minister does—as I have described—and as the deputy leader of the Labour party does. They can manage their condition and do not have their lives inhibited by it, and so believe that their opportunities are unaffected by the condition.

To ensure the early uptake of education, it must be provided in a useful format: digitally and through every kind of agency, whether that is schools working with health professionals, or local authorities, which have a responsibility for public health following the Health and Social Care Act 2012, stepping up to the mark too. I shall say a little more about the co-ordination of that, although the Minister is already aware of my concerns. It is about ensuring that our public health effort on diabetes is co-ordinated, consistent and collaborative. That is vital, for reasons already mentioned by colleagues in interventions.

I welcome the commitment in the NHS long-term plan, as I said, to expand the support on offer for people with type 1 and type 2 diabetes, including through the provision of structured education.

[Sue Hayman (Workington) (Lab)]

The right hon. Gentleman is making incredibly important points. He mentioned the deputy leader of the Labour party, who turned his life around through diet and exercise—nutrition. That is an incredibly important issue in my constituency. Throughout west Cumbria, we have serious levels of diabetes, health deprivation and obesity. I thank the right hon. Gentleman for making what is an incredibly important point about bringing together health education at a very young age, and I encourage the Government to invest in that.

[Sir John Hayes]

I hope that the Minister, in respect of that excellent intervention and my earlier remarks, will say how he will ensure that that kind of vital education is provided in a format and at a point that works for everyone. This is about getting to people by a means and at a place that will penetrate, have effect and be comprehensible. The objectives in the long-term plan are right, but how we deliver those objectives has become the vital next step.

We have already spoken in this debate about technology. A flexible approach to the provision of technology, as well as education and support, is critical. Once equipped with information and skills, people must have access to, and the choice from, a range of technologies to help them to manage their condition in everyday life, as my right hon. Friend the Member for Ludlow (Mr Dunne) mentioned a few minutes ago. For people with type 2 diabetes, that is about ensuring access to the required number of glucose test strips. In the rapidly developing world of type 1 technology, insulin pumps and continuous glucose monitors can radically transform lives.

Decisions on which technologies are available should be made with reference to advice from clinicians, patients and, perhaps most importantly, health economists, who will help to determine value to the NHS.

[Mr Edward Vaizey (Wantage) (Con)]

Will my right hon. Friend give way?

[Sir John Hayes]

I will give way, but I want to make my point before I do so, and it might well inform and inspire my right hon. Friend’s intervention: it concerns me that, in contrast to medicines, medical devices and now digital solutions do not have clear processes for appraisal and subsequent funding once approved.

[Mr Vaizey]

My right hon. Friend has indeed inspired me. I do not have diabetes, but I tried a FreeStyle Libre sensor because a constituent of mine is involved in the company. Given my right hon. Friend’s remarks, he seems to agree with me that a robust process of cost-benefit analysis would show that the more people who were issued with that device, the more the health service would save in the long term from people being able to avoid catastrophic incidents because they could monitor their glucose levels much more effectively.

[Sir John Hayes]

I agree entirely with my right hon. Friend. In the modern idiom, we need to be technology-neutral about that, because the field is changing rapidly. As new technology comes on stream and improves, we need to be sufficiently responsive to and flexible about those changes to ensure that people get the very best, latest technology available to them, for the reasons he gave.

The limits on self-management by the restrictions on technology inhibit people’s wellbeing, confidence and, thereby, opportunities. I want to ensure that the provision of technology is consistent throughout the country. There are suggestions that such provision is patchy, that some places are better than others and that some of our constituencies are not getting all that they deserve. The Minister will not want that, because he is an extremely diligent and resourceful Minister—I know that from previous experience—and I want him to tell us how he will ensure that the technology is appraised properly, is delivered consistently and, accordingly, will change lives beneficially.

[Mr Dunne]

My right hon. Friend is being generous with his time. May I elaborate a little more on that specific point to give an indication to the Minister of the specifics that might cause difficulty between different clinical commissioning group areas? In my experience, those who are allowed to have clinical access to a glucose monitoring device already need to have their blood sugar levels under control—in single digits, below nine. For many people, however, the monitoring device is the one thing that gives them the ability to get better control of their blood sugar glucose levels. Therefore, if they do not get access to it until they are under control, it does not have the immediate benefit to their lifestyles that it would if the regime were slightly more permissive in the allocation of the devices.

[Sir John Hayes]

My right hon. Friend makes a very shrewd point about cause and effect. In Scotland, for example, both the processes leading to allocation and the actual allocation of technology are much more routine, as he suggests should be the case. I hope the Minister will tell us today or subsequently how he will ensure that that becomes true for the whole of our kingdom—that the very principles set out by my right hon. Friend become embedded in the way in which we approach technology, ensuring that it is allocated according to need.

We all agree that the resources should be targeted to secure optimal outcomes for the 4.6 million people who have been diagnosed with the condition. In addition to those diagnosed, however, one in three adults in the UK has pre-diabetes and might be at risk of developing type 2 diabetes if they do not change their lifestyle—a point made by a number of Members in interventions. About three in five cases of type 2 diabetes can be prevented or delayed. A focus on preventing the onset of diabetes should be of paramount importance. G. K. Chesterton said:

“It isn’t that they can’t see the solution. It is that they can’t see the problem.”

By seeing the problem, the solution will be implicit, because many more people will never develop type 2 diabetes if they make those adjustments to their lifestyle.

There is a dilemma, though: is it better that 50,000 people get a perfect solution and are prevented from having diabetes, or that 5 million people reduce their risk marginally? Let me set that out more clearly. Is it better that a small number of people achieve what the deputy leader of the Labour party, the hon. Member for West Bromwich East, has done—losing immense amounts of weight, changing their lifestyle and completely revising their diet? Or is it better that a very much larger number of people make a smaller change, lose less weight and change their lifestyle more marginally, but by so doing significantly reduce their risk of developing type 2 diabetes?

That is a challenge in health education; it affects many aspects of the health service’s work. It probably means that, rather than seeing this issue purely from a clinical perspective, we have to democratise the diabetes debate, spread the word much more widely and get many more people to lose a couple of inches off their waist, to lose a stone or half a stone. That effect would be immense in reducing the risk of diabetes, not for tens of thousands but for millions of people.

If the figures I have brought forward are so—I have cited them only because I have learnt them from Diabetes UK and others who have helped me to prepare for this debate—we would change the lives of very large numbers of constituents in a way they would be able to manage, understand, comprehend and act upon reasonably quickly. I want the Minister to reflect on the dilemma I have described; it may not be quite so much of an either/or as I have painted it, but we need a democratic debate about that, which is part of the reason I have brought this debate to the House. Certainly we need an open and grown-up conversation about some of those measures and how we go about tackling what I have described as a crisis.

I do not want to speak forever, Mr Robertson—I know you and others in the Chamber will be disappointed to hear me say that. That will cause disappointment and even alarm among some, but I want others to contribute the debate. However, I have a couple of other points to make so I will move on—having taken a number of interventions already, I hope colleagues will bear with me.

I have been fascinated to read about research funded by Diabetes UK that proves that remission is possible. I would like to take the time to congratulate the hon. Member for West Bromwich East once again and to say that I hope many more people will recognise that remission is a real possibility for them by making changes in what they do.

Part of the issue is how lives more generally have changed. My father cycled five miles to work and five miles home every day, but now most people do not do that. Once many more people worked in manual jobs—my father had a physique like Charles Atlas, but the nearest I have come to Charles Atlas is reading an atlas. Part of the problem is the way we live now; far fewer people exercise implicitly in the way he did, and it seems that junk food is more appealing to many people than eating fresh, healthy produce—indeed, that has been recognised by successive Governments as significant for health outcomes.

Evidence shows the best way to reduce the risk of diabetes is through a healthy diet, being physically active and reducing weight. That can be facilitated through societal approaches and targeted individual interventions. Technology, including digital services to support lifestyle changes, is increasingly critical in diabetes prevention. To be sustainable, methods to prevent type 2 diabetes should focus on individual behaviour change, not just short-term activity levels.

We recently learned that, by their 10th birthday, the average child in the UK has consumed 18 years’ worth of sugar. That means they consume 2,800 more sugar cubes per year than recommended levels. The current food chain has become badly distorted. Basic knowledge that my parents’ generation took for granted about how to buy, cook, prepare and store food has steadily but alarming declined.

We have allowed soulless supermarkets to drive needless overconsumption of packaged, processed, passive, perturbing products, and it is time that the greed and carelessness of corporate multinational food retailers gave way to a better model. It is not a coincidence, it is something considerably more than that; as local food retailers have declined—people knew from whom they were buying, understood what they were buying and where it came from—the consumption of processed, packaged ready meals has grown. We need to rebalance the food chain in favour of locally produced, healthy produce and to re-educate people about how to buy, cook, eat and enjoy it.

[Luke Graham (Ochil and South Perthshire) (Con)]

I will certainly give no lectures on buying and cooking food, but will my right hon. Friend join me in supporting Diabetes UK’s Food Upfront campaign, which calls for a front-of-pack traffic light system to ensure that the content and nutritional value of processed foods are much clearer for people who are suffering from diabetes, and for a whole other range of dietary and nutritional needs?

[Sir John Hayes]

Entirely; in fact, I call on the Minister to do just that: will he introduce a mandatory front-of-pack traffic light labelling system, which is supported not only by my hon. Friend but by 83% of the population when asked whether that should happen? The Minister will be in tune with popular opinion; he will become something of a popular hero by responding to my hon. Friend’s request, which I amplify.

[Mr Vaizey]

We have Belisha beacons—could this not be the moment for Brine indicators?

[Sir John Hayes]

It could indeed. Not only that—I wonder whether we might consider a watershed on the advertising of junk food. Wherever children go, they face adverts suggesting that they eat all kinds of foods. As children, we never ate those things, did we? We were not exposed to the same kind of seductive, alluring advertising suggesting that children should consume that kind of food. There is an argument for cracking down, and Government have a role to play. Again, that kind of watershed on junk food advertising is supported by 76% of the population. The Minister would be a double hero if he did that.

Fitness matters, too. There must be a focus on exercise, given that studies illustrate that regular exercise pays dividends in respect of health and wellbeing, including diabetes. That is why we should not build on playing fields, close down sports halls and concrete over green spaces where people walk, play, run and enjoy all the opportunities to get healthy.

There is a link between poverty and ill health, as Members in the Chamber know very well. Although 6.6% of Britons have diabetes, that percentage falls markedly in wealthy areas. In Richmond upon Thames, 3.6% of residents have diabetes; in Bradford, the number rises to 10.4%. In south Lincolnshire, where my constituency is located, 7.3% of people have been diagnosed as diabetic. Such health inequalities must be addressed. It is with that in mind that I have campaigned so hard for the protection and maintenance of our parks and green spaces, which are often the only places that communities in less advantaged areas have to exercise, play sport and get healthy. In the case of diabetes prevention, do we perhaps take too puritanical an approach by rigidly pursuing individual outcomes? As I said, contrast that with what I described as the democratisation of the debate and the wider view that I have begun to outline today.

I commend, finally, the work of Government and the NHS on moving towards a fresh approach to diabetes in the NHS long-term plan, with a commitment to double the number of diabetes prevention programmes to 200,000 places. None the less, hon. Members will agree that that is a fraction of the 12.9 million people who are at high risk. Will my hon. Friend the Minister say how he plans to take a measured approach and appraise the evidence for all available solutions that might reach the wider population, beyond those targeted special programmes for that relatively small number—well, 200,000 is not a tiny number, but it is a relatively small proportion of the total number of people at risk of contracting diabetes?

Much commendable progress has been made, but it is now time for the Government to do several things. First, they must intensify their public information campaign and encourage everyone to speak about their own type 2 diabetes with their healthcare professional. Secondly, they should ensure that healthcare professionals offer a range of proven solutions, be that education or technology to enable self-management, or the resource to facilitate prevention at scale. Thirdly, they should continually review a rapidly changing environment and update the House on the tough political decisions being made to tackle this crisis of immense proportions. Politicians can no longer afford to abnegate their responsibility to a so-called expert class driven by bureaucracy. Too much is at stake. I know that the Minister will not be able to respond now to all my points, but I invite him to meet me and other concerned colleagues once he has had a chance to reflect on some of the issues, so that we can take the debate forward.

I began with C. S. Lewis, and I will end with him as well:

“We all want progress…If you are on the wrong road progress means doing an about-turn and walking back to the right road and in that case the man who turns back soonest is the most progressive man.”

I do not think we are entirely on the wrong road, but we must be honest about what more we can do. That is not for our own interests or sake, and it is not even for the Minister’s heroic reputation, which I championed earlier. It is for all those who are suffering, or who might suffer, from the crippling illness that is diabetes.

--- Later in debate ---

[Steve Brine]

Not only do I agree with my hon. Friend, but the company would agree with him. It is very aware of how much pressure that I and the Government are putting on it to change its products. I would say that it is top of my Christmas card list. Many other manufacturers have not yet made it on to my list, and I ask them to step up and raise their game to the level of the best. I am sure that they can.

In 2018-19, the diabetes prevention programme achieved full national roll-out, making England the first country in the world to achieve full geographical coverage. That is a great achievement, and the figures are good. As set out in the long-term plan, NHS England intends to double the capacity of the programme up to 200,000 people per annum by 2023-24. As my right hon. Friend the Member for South Holland and The Deepings said, it is a modest number in context, but it is also a big number. This is still the largest diabetes prevention programme of its kind. He asked whether we keep these things under constant review and whether we have the ambition to go further. You bet we do, and I think we need to.

There has been much talk this morning about technology. We are also developing an online, self-management support tool called HeLP, comprising a structured education course that has content focused on maintaining a healthy lifestyle for people with type 2 diabetes. That includes content on weight management and alcohol reduction—that can of course help with many health challenges—and cognitive behavioural therapy related to diabetes-related distress. NHSE hopes, once the tool has been developed, to roll it out in the summer of this year.

[Sir John Hayes]

In my opening remarks, I called for a new system for appraising technology and ensuring that it is allocated according to need and consistently across the country. On education, it does seem to me that there is a littered landscape. We have Public Health England, the NHS and local authorities. That littered landscape could easily lead to complication, confusion and even, possibly, contradiction, so will the Minister look at that, too?

[Steve Brine]

Of course I will look at it. I talk to Public Health England regularly about all these matters, and I take my right hon. Friend’s challenge on board. In the time that we have, I cannot respond in any more detail, but I totally take his challenge on board.

There are public health campaigns such as One You, the behavioural change campaign aimed at people in the 40-to-60 age bracket—sadly, that now includes me—and designed to motivate people to take steps to improve their health through action on the main risk factors, such as smoking, inactivity, obesity and alcohol, which will help to reduce the risk of developing type 2 diabetes.

I would like to say so much more, but as ever in the House of Commons there is no time to do so. What I will say is this. We have great ambition in the long-term plan. The long-term plan is a living document, a document that we will build on—we have ambitions to go even further—but I hope that the Government and I, as the Public Health Minister, have shown our commitment to improving outcomes for people with diabetes and living with it through treatment, but also to helping to prevent people from developing it in the first place. Our constituents demand that from us, and our health service, if we believe in it as a publicly funded, free at the point of use health service, which we do, needs us to deliver on that, and we will.

[Sir John Hayes]

I think that this has been, as the Minister generously said, a useful debate, but I hope that it is also the start of a process, rather than the end of a story. That process should involve, exactly as the right hon. Member for Knowsley (Mr Howarth) recommended, a continuing dialogue with Government. I hope that the Minister will agree to the meeting that I suggested with a small delegation of colleagues, so that we can explore further the matters raised briefly today. There are real issues in relation to prevention and education, as I hinted a moment ago, but also with regard to treatment, as the Minister has acknowledged. The long-term plan puts the strategy in place. We now need to ensure that that strategy is delivered in a way that brings relief from need for constituents across this country. That need is illustrated by the commitment of all those who have contributed to this debate. I am immensely grateful for your stewardship of it, Mr Robertson, for all the contributions and for the Minister’s typically robust but sensitive response to the remarks made this morning.

Question put and agreed to.

Resolved,

That this House has considered diabetes.

Acquired Brain Injury

John Hayes Excerpts

Monday 18th June 2018 Commons Chamber

[Mr John Hayes (South Holland and The Deepings) (Con)]

I do not make a habit of exorcising personal demons in this Chamber and I am not going to start now, but we are all shaped, and are certainly affected, when we are shocked by what we see, perhaps in our constituents or other people, and so it was almost 40 years ago when I was in hospital and in the bed next to me was a young man, I suppose in his 20s or 30s, surrounded by a family—young children, his wife—being taught to feed himself and speak again following a traumatic event which had led to a severe head injury. He was a postman; he had slipped on the ice and hit his head on the pavement. As simple an event as that had changed that man’s and that family’s life for all of time.

From then on I became interested in ABI, and when I was elected to this place began my relationship with Headway, which has continued ever since. I am proud to be associated with the work it does and am delighted to endorse all that has been said by both Front Benchers about that work.

That postman all those years ago has, sadly, been followed by many others. Not always such a simple event has led to their injury; it is often a car or motorbike accident or something of that kind, which is why it is disproportionately young men who are affected by traumatic injuries of this type. But the results are common; they are complex and varied, but common themes emerge.

The first theme is of course the immediate, traumatic effect—invariably dealt with efficiently and effectively by the national health service. Those who have that kind of dramatic injury get pretty good treatment from our NHS, and it deserves credit, as do all those associated with it, for providing that treatment. But the ongoing issues associated with ABI are met with various kinds of responses. Sometimes the follow-up care is good, strong and effective, but that is not always the case because of the need to continue to respond to what are often rapidly changing circumstances. People’s speed of recovery can vary, as can the effect of their injury on their life, their competence and their skills.

In this very welcome debate—for which I was pleased to call, alongside the hon. Member for Rhondda (Chris Bryant); we have worked as a team; I am delighted that the Government have offered us this time—I want to argue for a number of simple things, which I will summarise. Co-ordination: we need to ensure that all the agencies—charitable, Government and local government— work together. Perpetuation: we need to understand that the condition might require care and treatment over a very long time. It is a dynamic condition and it needs that kind of perpetuation. Accentuation: we need to drive this issue up in the consideration of all public policy makers and those who make policy in the health service in particular. Having this debate is all about that. Concentration: we need to pool resources and target them where they can have the greatest effect. Accumulation: we need to build on the experience of the Headway groups and others that do this best. The NHS looked at this issue in 2004, and its international studies—particularly relating to the United States of America—need to be revisited.

The hon. Member for Washington and Sunderland West (Mrs Hodgson) was right to say that knowledge is vital. To get people back into work, which is often their aim, we need to work on educators and employers to enable them to understand that the pathways that people follow need to be attuned to their complex and changing needs. If we can achieve all that, we will be sending a signal to all those people affected, as that postman was all that time ago that, in the words of C. S. Lewis:

“You are never too old to set another goal or to dream a new dream”,

regardless of the misfortunes you might suffer.

--- Later in debate ---

[Dr Cameron]

Yes, that is a fair point. Mobility is about not just how far someone can walk, but being able to plan a journey and many other aspects of day-to-day living skills that people can find so difficult. People may require support for such things, but that may not currently be picked up properly by an assessment.

Psychology is important in the assessment of such cases, because access to neuropsychology means that individuals can have memory and cognitive assessments at the time of injury and six and 12 months later to examine which functions have been recovered. That is important because different parts of the brain can take on functions that have been lost and because the individual’s pattern of recovery can be mapped, meaning that a rehabilitation plan can be specifically adapted to their needs. Access to neuropsychology is a key part of rehabilitation, so I will be interested to hear the comments of the Under-Secretary of State for Health and Social Care on neuropsychology services, particularly for those with an acquired brain injury.

Prisoners have been mentioned. Yes, there is a high level of acquired brain injury within that population and that has an impact in three ways: acquired brain injuries can increase impulsivity, they can lead to people making the wrong decisions and not thinking through the consequences, and they can lead to difficulty in undertaking the normal treatments available in prisons, such as cognitive behavioural therapy, meaning that such treatments may have to be adapted for prisoners to benefit from them. I am unsure whether that is occurring in our prison system, but it should happen right across the United Kingdom if cognisance is taken of such difficulties.

[Mr John Hayes]

This will be my last contribution because I know that others want to get in. The change in a person’s cognitive function, which is often perceived as a change in their ability to do things, is often also about them knowing how to do things, what to do, when to do it and why. That is different from losing a skill. It is about losing the ability to order things and to prioritise them, and that has a dramatic effect both on education and on their subsequent ability to work.

[Dr Cameron]

Individuals with a frontal lobe injury find planning extremely difficult and, in fact, may never again be able to plan in the way they once could. These are some of the issues that treatment would have to take on board, and perhaps further support will be required. The types of cognitive behavioural treatment that rely on people thinking things through in a sequence, which is particularly difficult for those with a brain injury, will not always be appropriate and may need to be adapted.

So many Members want to speak on this important issue, so I will finish by mentioning the funding for a new Scottish trauma network. Since January 2017, four major trauma centres, in Glasgow, Edinburgh, Aberdeen and Dundee, have been working extremely hard to try to ensure a good care pathway for those in Scotland who suffer brain injury. It is incumbent on us all to communicate and to find evidence-based practice right across the United Kingdom.

--- Later in debate ---

[Chris Bryant (Rhondda) (Lab)]

The truth is that acquired brain injury is an invisible epidemic in this country. It is invisible because all too often we do not even know the numbers. I know the Minister means well, but I suspect his numbers were a hideous underrepresentation of the truth, because the figures I have seen suggest that there are more like 1.3 million people in this country living with a disability brought on by an acquired brain injury, with nearly half a million presenting to hospital last year. As my hon. Friend the Member for Washington and Sunderland West (Mrs Hodgson) said, that is one a minute—1,500 a day. That is a very significant number of people. All too often, it feels like an invisible epidemic to the individual concerned, because they might not ever have known they had a brain injury in the first place.

Some of the most distressing work that I have seen has been done by people working in prisons. I was in Cardiff prison a couple of weeks ago—some would say not a moment too soon—to see the work being done there with prisoners, because the work Huw Williams has done at HMP Leeds showed that when we screened every prisoner arriving in through the door we found that 47% of prisoners had an acquired brain injury, that 76% of those had several and that 30% of those had more than five brain injuries. This is often invisible in the case of children, too. The latest figures I have seen show that five children in every primary school class in this country will have an acquired brain injury. If we think that figure is bad enough, the figure for poorer constituencies, and for poorer families and areas, will be considerably higher. The research is a bit difficult to be precise about, but a study in Exeter showed that it was 4.3 times higher in poorer areas, and another survey elsewhere found it was three times higher in poorer families. So, for me, as a socialist—I still like to use the word—this is still a matter of social justice as much as anything else.

[Mr John Hayes]

As a non-socialist and member of the party of Wilberforce, Shaftesbury and Disraeli, I believe in social justice, too. The key thing that the hon. Gentleman has said, as did the hon. Member for Washington and Sunderland West (Mrs Hodgson), is that we have to get teachers to be more aware of this. If one thing comes out of this debate, it should be exactly that. We need to co-ordinate across Departments to get teachers to recognise and know this.

[Chris Bryant]

I completely agree with the right hon. Gentleman on that, not least because of one thing that sometimes happens to teenagers. Part of their brains will be quite well developed—the reward bit, the one that knows how to seek out pleasure—but the area of the brain most likely to be hit if they have a brain injury is the bit that is not yet well developed, which is the executive function. It is the bit that gives that youngster the ability to say no to things or to control their emotions and their functions. All too often, if that bit goes wrong, they can start to present in school as somebody who is a problem. They may then get excluded from the school, because it is not understood that this is actually about a brain injury—perhaps the student themselves does not understand that. They may then start offending and we may find several years later that they have a whole career of offending and that if we had managed to do the rehab properly right at the beginning, when the first brain injury happened, we might have been able to save that individual their self-respect and self-esteem, and we might have been able to save society the costs of all the criminality. We might, thus, be able to strengthen the whole of the way we do our business.

One memory that really strikes me is the story of Ben Robinson, the 14-year-old who was playing rugby for Carrickfergus Grammar School in Northern Ireland. He was sent back on to the field three times after brain injuries on the field and then died of double impact syndrome. He was pronounced dead when he arrived at the hospital. I am so proud of Ben’s family, who have campaigned on this issue. His mother, Karen, has always referred to these injuries as rugby’s dirty secret.

Rugby has tried to clean up its act in recent years, but in so many sports, even all these years after footballer Jeff Astle’s brain injury, which was determined to have been an industrial injury brought on by heading the ball, we still see in matches people being sent back on by the club medic. Only an independent medic should make the decision about whether somebody should go back on. If there is any doubt, sit them out. It should be simple and that should apply across all sports.

The Government have had a great success thanks to the major trauma centres which, as somebody said earlier, now manage to save an extra 600 lives every year. That is brilliant, but let us save the quality of their life as well. The miracles that can be achieved in saving lives can be matched by the miracles that can be achieved through really good, long-term, sustained rehabilitation. If we can take an 18-year-old who has had a big brain injury from needing six carers to wash, dress and feed them and get them up and so on, to a place where they no longer depend on those people, are mostly independent and need only one carer, think how many millions of pounds we can save the taxpayer across their lifetime. That must of course be the most effective way to change things.

I repeat the points made about PIP and ESA. One woman said to me, “The doctors say to me that I should spend all my emotional energy on getting my brain to work again, but I am spending all my emotional energy on trying to understand the forms and going through the process so that I can put food on the table for the rest of my family.”

I have a great deal of time for the Minister for Disabled People, Health and Work; she has had meetings with me and I know that she will want to make changes. This is about the whole of Government. I very much hope that we will be able to have another debate soon, because there are so many issues that we have barely managed to touch on in this one.

East Midlands Ambulance Service

John Hayes Excerpts

Wednesday 21st February 2018 Westminster Hall

[Ruth George]

That illustrates the point completely. We have seen a lack of primary care services, and doctors’ appointments are far harder to get than the 48 hours it took under a Labour Government. In consequence, we have a hugely overburdened ambulance service.

Now we come to funding. East Midlands ambulance service is already one of the most efficient in all the regions. In spite of the relatively sparse population and demanding geography, EMAS’s costs per face-to-face response are the third-lowest of all the regions—9% lower than the average across England. The costs per call are, again, the third lowest and more than 10% below the average.

By any measure, East Midlands ambulance service is very efficient, with 99% of its staff working on the frontline. Almost all managers take shifts so that they know exactly what is going on. It has cut all that it can, and it has had to make cuts, because EMAS has the second-lowest funding of all the regions—8% lower than the average across England. Only the North East ambulance service, which serves a more densely populated area, has lower funding than the East Midlands ambulance service.

The funding has not kept pace either with inflation or with the increased demand—in fact, it has barely increased at all in the last six years. In 2010-11, EMAS received £160 million for patient care activities. By 2016-17, we had seen over 16% inflation and a 50% increase in activity. Funding should be at least two thirds higher—£105 million extra would be the proportionate cost. Instead, East Midlands ambulance service received less than £5 million extra compared with 2011. That is less than 3% extra funding when it needed 66%.

East Midlands ambulance service has never been well funded—our region has always been the poor relation, as colleagues on both sides of the House often concur—but the cuts over the last seven years have made it impossible for it to meet its targets, and to deliver the right standard of service and care to some of the most sick and injured people, and the most at risk. That is what the Nottinghamshire coroner concluded in May 2016. In an urgent case review, she said:

“Demand is clearly greater than the resources they have most of the time”.

That is not the fault of any of the staff at EMAS. Last summer, the Care Quality Commission found that although the service was in need of improvement, it was caring and responsive—but it could not be safe or effective. The report states that there were

“caring, professional staff delivering compassionate, patient focussed care in circumstances that were challenging due to the continued demand placed on the service.”

The increased demand for primary care, emergency care and ambulance services is not being resourced. Our ambulance service is on the frontline. Our crews do their very best, but it is tough. Yes, staff sickness is slightly higher than average at EMAS, but I am not surprised. It is not just what the crews deal with; it is the constant stress and pressure, and the distress and anger that they sometimes face when they can finally arrive.

[Mr John Hayes (South Holland and The Deepings) (Con)]

The hon. Lady is making a very articulate and compelling case, but I think she would be the first to acknowledge that, while there may well be a resource challenge of the kind she described—she has already made that clear—there are issues around administration, management, process and protocols. She has already mentioned ambulances waiting outside hospitals for a very long time because they cannot or will not admit patients. Those are systemic problems, not just resource problems.

[Ruth George]

It might not be a resource problem at EMAS, although EMAS has been trying to fix that with staff put on especially to try to reduce the handover times at hospitals. A&E departments are struggling at absolute capacity. My local hospital had 97 A&E patients in need of a bed last weekend, and they had seven beds. The fact that the number of beds in the NHS has been reduced by 14,000 since 2010 is a resource issue. It might not be an EMAS issue, but it is very much a resource issue, and I put that to the Minister along with the issue of EMAS.

The situation is not fair on our ambulance crews. It is not fair on our patients. Our ambulance service is holding emergency care together. East Midlands is doing it with more pressure and less resources than almost anywhere else in the country. It needs support from us and it needs the resources to meet its targets. I call on the Minister to commit to that today.

--- Later in debate ---

[John Mann (Bassetlaw) (Lab)]

I have three points to put to the Minister. No. 1—will the Minister commission a report into the locations that have disproportionate numbers of ambulance call-outs by East Midlands ambulance service? I have highlighted one previously—Sports Direct in Shirebrook, which was getting more than a hundred a year. What was going on there was that the workforce was not allowed to make GP or other appointments in work time and therefore were continuing at work, fearful of taking any time off when sick, until they required an ambulance to be called. That could have been solved in very simple ways, but EMAS did not investigate the fact that there was an extraordinary level of call-out there.

A more common example is a care home that does not have properly qualified nursing staff, and therefore over-uses ambulances. I suggest to the Minister that if there are more than, say, 20 call-outs to one location, EMAS ought to be required to go in to see exactly what the solution is. The solution is not to send ambulances there expensively if they ought to be elsewhere saving lives. It is a simple process. It is amazing that that was allowed to happen at Sports Direct. The stats were there, but there was no intervention.

No. 2 is privatisation. One of the problems with EMAS—

[Mr Hayes]

Will the hon. Gentleman give way before he rushes from No. 1 to No. 2?

[John Mann]

I will.

[Mr Hayes]

The hon. Gentleman is again making a compelling case. He is actually arguing that demand varies, and that we need to look at the character of demand, at how we respond to it, and at the drivers of demand. It is of course always about resources, but it is not just about resources. The hon. Gentleman is making that case in his typically sophisticated way.

[John Mann]

A very wily intervention by an experienced Member. I look forward to such a commission, which I think would be very helpful to the Government and residents of the east midlands.

The absurd privatisation of the non-emergency ambulance service in the east midlands—Arriva is responsible for it in Nottinghamshire—was cross-subsidised. The £5 million that it really cost EMAS came from, in essence, ambulances that were diverted. Put simply, if there was an emergency call, an ambulance ferrying somebody routinely to hospital would be diverted, and the patient waiting would wait an hour longer. That was a rational cross-subsidisation. The moment it was privatised —sadly in 2009 by a Mr Burnham, under EU procurement rules—there was a serious deterioration. It is obvious in an area that is rural, but not just, that an ambulance going from point A to point B that could be immediately diverted into being an emergency ambulance would increase the capacity significantly. Reversing that privatisation with the freedoms we are about to have once we have left the European Union would be a significant improvement for the NHS.

No. 3, most controversially, is geography. Why is the ambulance service based on the east midlands? I am not exactly sure where the east midlands is. The South Yorkshire ambulance service operational base is actually in the east midlands—it is across the border in Chesterfield. Senior managers were clear to me in private that for certain areas, including mine, given that ambulances go to hospitals in Bassetlaw, Chesterfield, South Yorkshire, Doncaster and Sheffield, which they do—all heart attack patients in my area go directly to Sheffield and all stroke patients go directly to Doncaster—rationally we should be part of the South Yorkshire ambulance service. It makes no sense to have this historical, arbitrary divide, given that in the practical, real NHS world any business would have reorganised it in that way. The fact that the major response centre for South Yorkshire is actually in the east midlands demonstrates that point vividly. We need a bit of common sense here.

We need a reversal of privatisation. As it was an absurd Labour-inspired proposal initially, it will be easier for the Minister to agree to that and to whack Mike Ashley and other misusers of the service. Rather than simply respond to the people who are wrongly using the service, they could be, if necessary, publicly embarrassed so they change their systems. I offer those three easy options to the Minister.

--- Later in debate ---

[Stephen Barclay]

I will be happy to, Mr Davies. As I was setting out before the votes, a number of key measures have been announced. I will elaborate on those further, but, before I do, I will address some of the points raised by colleagues across the House in this constructive and well-supported debate.

The hon. Member for High Peak very reasonably opened her remarks by putting some of the challenges in the context of the good work being done. She cited in particular the case of her constituents, Vinnie and Jo, which illustrates the fantastic work done alongside some of the challenges that we will come on to. She also mentioned specific issues faced in terms of geography and low population density.

The hon. Lady mentioned empowerment of 999 call staff as a specific issue. My understanding is that revalidation can be done by call handlers where they are clinically trained, but not where they are not. Even where they are clinically trained, it cannot be done if the initial 111 call is either a life-and-death call—a category 1 or category 2 call—or where the initial assessment has been done by someone from 111 who is clinically trained. There is a framework there, but I am happy to have a further conversation with the hon. Lady if she has areas of specific concern about how that guidance is operated. She will be aware that, in any event, only 12% of NHS 111 calls are referred to ambulance trusts, so the 12% is a subset initially; within that, there is a subset of those who are clinically assessed and what power there is. I am, however, very happy to have a further conversation.

The hon. Lady also mentioned funding, which I will come on to specifically. The trust has had additional funding, but on the challenges set out by colleagues from across the House, the trust is undertaking a demand and capacity review that will determine the level of additional resourcing required. That will inform the commissioning for 2018-19. Of course, it will have taken note of the concerns raised.

The hon. Member for Great Grimsby (Melanie Onn), who is no longer in her place, raised a point about whether there are peaks of demand linked to drug and alcohol-related calls. I am happy to pick that up as a specific action and investigate that further.

As so often when we debate matters of health, my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson) brought a much-valued practical experience to the debate. I was particularly struck with her comparison between the one-to-one staffing rate in intensive care and her concern about the number of crews, and how that interplays with the handover at hospital. As she will be aware, a lot of work is happening on hospital ambulance liaison officers and how hospitals deal with ambulances. NHS Improvement and NHS England are looking at that issue specifically in relation to this trust, but again she made a helpful contribution. I know she mentioned that she had spoken to the Secretary of State about the issue.

[Mr Hayes]

I, my wife and our 17 and 13-year-olds have all been at A&E at Pilgrim Hospital, on two occasions by ambulance in an emergency, so I speak with that knowledge. The Minister will appreciate the problems in rural Lincolnshire; he knows it very well, as he represents a seat just on the border of my own. Will he apply the work he has just described specifically to Lincolnshire and ask for his officials to look at the circumstances in Lincolnshire? It might well apply to other rural places, by the way. We feel particular pressure, as he has acknowledged, and that kind of reappraisal would be welcome in the county.

[Stephen Barclay]

My right hon. Friend makes a pertinent point. As he mentioned, he is my constituency neighbour and I am very aware of the specific challenges posed by the geography and the road network in Lincolnshire. I am happy to take that specific point forward. It will not surprise him that I have already zeroed in on some of the challenges in Lincolnshire, particularly around United Lincolnshire and Northern Lincolnshire and Goole, how that interplays across the spectrum of primary care, how the patient pathway goes through, the various blockages in the system and how we look at that in a more systemic way.

That issue interplays with a much wider debate, outside the scope of this one, but to give my right hon. Friend one statistic, 43% of beds are occupied by 5% of patients. If we take the average length of stay from 40 to 35, that is the equivalent of 5,000 hospital beds, each at £100,000 per year. We can see how there is an interplay between what we are debating with the ambulance services and the wider Lincolnshire health economy, which is a specific point. I am happy to have further discussions with him on that.

The hon. Member for Bassetlaw (John Mann) raised three points about the report on the disproportionate calls, which were pertinent to a conversation I had just this morning about spikes in care homes and what action might be taken. For example, to what extent can we improve GP access into specific care homes in Lincolnshire through Skype, as one of the mitigations of ambulance demand? We are looking at how we assess the return on investment between the cost of ambulances and emergency admissions and what that investment might do if it were put into a more preventative role—care homes, for example.

On the specific matter of Sports Direct, which I was not aware of, the hon. Gentleman makes a valid point, which I will be keen to look at with officials—where there are peaks of demand, what is driving those peaks and how to mitigate them. He also mentioned the issue of privatisation from 2009. We are looking at how we take a more holistic view across a landscape and how mutual support from different parts of the system can provide assistance to that. It will not surprise the hon. Gentleman, knowing my views on Brexit, that for all the talk of some of the challenges of Brexit, the opportunities of Brexit should not be missed. I share his desire on that.

There is also the geography point—whether it is the way services elsewhere have been reconfigured or the extent to which there are, for example, centres of excellence to which his constituents are being taken. Is the issue the formal geography or how the operating protocols within that geography have evolved? That, again, is a perfectly valid point and one we can look at on a case-by-case basis.

I know my hon. Friend the Member for Boston and Skegness has championed a number of these issues over a period of time. He raised how we can get the ambulance service working together with the other emergency services. I know that is an issue that many police and crime commissioners have also identified, and many within the fire service are keen to ensure that we have a better join-up between the blue-light services.

The hon. Member for Lincoln (Karen Lee) raised the issue of hospital handovers. I assure her that daily reviews are currently being undertaken by NHS England and NHS Improvement. Greater transparency and targeted assistance are being provided, and there are also specific initiatives linked to individual hospitals, particularly including the hospital-ambulance liaison officers.

The hon. Lady also mentioned pay. It is worth reminding the House that the pay band that applies to paramedic staff has been increased from band 5 to band 6, so there has been a recognition in the system of the importance of paramedics, alongside an increase—around 30% since 2010—in the number of paramedics. However, we recognise that there is also an increasing demand, and that this service has been under considerable pressure.