Oral Answers to Questions

John Howell Excerpts

Tuesday 5th July 2016 Commons Chamber

[Mr Hunt]

First, I welcome the hon. Lady to her position. She is the third shadow Health Secretary I have faced in less than a year, and I am beginning to worry that it may be something personal. I wish her well; she knows the brief extremely well and has campaigned on it a great deal in her long parliamentary career. I will look into the case she brought up. I would not want anyone to be deprived of vital lifesaving drugs because of exchange rate fluctuations. The whole British economy, including the NHS, will have to deal with the economic shock that we may now face as a result of the Brexit vote. But now that the decision has been taken by the British people we must look for the opportunities for the UK and the NHS, and not simply worry about the uncertainties, although there will be lots of things we have to deal with.

[John Howell (Henley) (Con)]

4. What plans his Department has to increase capacity in general practice and primary care.

--- Later in debate ---

[The Secretary of State for Health (Mr Jeremy Hunt)]

We will be investing an extra £2.4 billion a year in general practice by 2020-21, a 14% increase in real terms. The General Practice Forward View, published earlier this year, sets out a package of support for general practice to boost the workforce, drive efficiencies in workload and modernise primary care infrastructure and technology.

[John Howell]

General practitioners in Henley have recently written a letter to all their patients pointing out the difficulties they face in fulfilling their workload. Will the Secretary of State explain what the Government are doing about that and how what they are doing will help?

[Mr Hunt]

I am happy to do so. I recognise the picture that my hon. Friend paints—not just in Henley but across the country—of a huge increase in GPs’ workload, which they are finding extremely challenging. What have we done? We have almost 1,300 more GPs working and training in the NHS compared with 2010. We have said that by the end of this Parliament we will seek to make available an additional 10,000 primary and community care staff, including 5,000 doctors working in general practice and 1,000 physician associates. We recognise the problem and are doing something about it.

Alcohol Consumption Guidelines

John Howell Excerpts

Tuesday 28th June 2016 Westminster Hall

[Byron Davies (Gower) (Con)]

I beg to move,

That this House has considered guidelines on alcohol consumption.

It is a pleasure to serve under your chairmanship, Sir Alan. I am delighted to have secured this topical and timely debate following the conclusion of the public consultation on the proposed new guidelines on alcohol consumption. Given the scale of public interest and levels of public and industry concern about this important issue, I am pleased to see so many colleagues here this afternoon from across the House to support the debate.

I want to be clear from the outset. I recognise the necessity for sensible and effective guidelines to help consumers—our constituents—to make better informed decisions about the amount of alcohol they consume. Ministers were right to ask the chief medical officer to carry out a review of the guidelines, and it is important that the guidance reflects the most up-to-date scientific evidence that is available across the world and that that is properly communicated to consumers.

I declare an interest as a member of the all-party beer group—unashamedly, given that 30 million adults across the UK drink beer each year and 15 million of us visit the pub each week. But I also know that this issue is a matter of concern for anyone who enjoys a drink and wants to drink responsibly.

We have made great strides in this country in promoting responsible enjoyment of alcohol through a partnership approach with industry. That achieves much more than a draconian approach to taxation or heavy-handed regulation. As a Conservative, I want to treat adults as adults and let them have the freedom to make informed choices about how they live, what they eat and drink and how they enjoy their lives. As a responsible Conservative, I also know that industry has a role to play in promoting responsibility through advertising campaigns, voluntary labelling initiatives and provision of consumer information. We have achieved a great deal, successfully reducing alcohol harm for more than 15 years.

The Office for National Statistics confirms that binge drinking has fallen by 25% since 2007. According to Public Health England, alcohol-related and alcohol-specific deaths have fallen since 2008 by 7% and 4% respectively. The Office for National Statistics confirms that alcohol-related violent crime has fallen by 40% since 2007. The number of children drinking alcohol has fallen by more than 50% since 2003 and is currently at the lowest rate on record. According to Public Health England, under-18 hospital admissions due to alcohol have fallen by 41% in the past six years.

[John Howell (Henley) (Con)]

The statistics that my hon. Friend has produced are absolutely fascinating. Of course, in the popular press, the one place that is singled out for its continuation of the old culture of drinking is the Palace of Westminster. Does he have a view on what role we should play in setting an example and does he agree that over the past few years the Houses of Parliament have been behaving absolutely immaculately?

[Byron Davies]

I thank my hon. Friend for that intervention. I can only quote my own example, which is one of extreme caution with alcohol, but it has been thoroughly enjoyable at times in the 12 months since I have been here. Of course, we should not be complacent.

Stillbirth

John Howell Excerpts

Thursday 9th June 2016 Westminster Hall

[John Howell (Henley) (Con)]

I congratulate the hon. Member for North Ayrshire and Arran (Patricia Gibson) on securing the debate. She has spoken with great passion from a personal perspective. We have all been moved by what she has said. It was very powerful.

I want to make a short contribution on behalf of a constituent and a member of my family. My constituent wrote to me to tell me about how she lost her first child to stillbirth:

“This life altering event has led to us being placed into a world we never knew existed. Sadly, the baby loss taboo leaves many unsupported and prevention affected.”

She has been trying to get information from her clinical commissioning group on what is happening to ensure that such things do not happen again and that more women can be protected. What she has got back from the CCG so far has been a general statement of Government policy, which includes the four principal activities that CCGs are asked to concentrate on: reducing smoking in pregnancy; monitoring foetal growth; raising awareness of foetal movements; and improving foetal monitoring.

That is all very well—I put great emphasis on the improvement of foetal monitoring, so that the information is provided and is fed back to the individual concerned—but my constituent also wants detailed information about what the CCG is doing to ensure that the issue is addressed. The CCG operates across two obstetric units and four midwife-led units and has a small number of babies delivered at home each year. She has not been able to get detail about what that CCG will do to address the situation for the future. I hope we can send a strong message to CCGs around the country that concentrating merely on the Government’s four key objectives is not good enough. What we need is the detailed information on how they are going to go about dealing with this issue through their sustainability and transformation plans to provide reassurance for women who are in this situation.

I appreciate the effect that stillbirth has on women, but it is not exclusively a woman’s problem. The fact that stillbirth occurs is a problem that affects the whole family, and it affects men as well. I know that, to my own cost, through a family incident. It is essential to bear in mind the impact on the mental health of men who are involved in cases of stillbirth and simply do not know where to turn in what is a completely traumatic experience. I urge the Minister to concentrate on providing information about what the Government are doing for the whole family and for the wider community.

My next point is that essentially we are talking about an artificial distinction here. We are talking about the distinction between miscarriage and stillbirth and about a particular period, which comes at around 24 weeks. That is totally unfair. Before the 24 weeks, parents are given no chance to grieve for the baby who has been lost, or to go through the process of putting their lives back together again. We ought to look at that to see whether that distinction is still relevant.

[Dr Lisa Cameron (East Kilbride, Strathaven and Lesmahagow) (SNP)]

Does the hon. Gentleman agree that counselling should be available for the whole family on request? We should be seeking to take that forward across the whole UK.

[John Howell]

The hon. Lady is absolutely right. Counselling needs to be provided for the whole family unit to see them through a very traumatic experience.

[Ms Tasmina Ahmed-Sheikh (Ochil and South Perthshire) (SNP)]

I pay tribute to my hon. Friend the Member for North Ayrshire and Arran (Patricia Gibson) for introducing the debate and to the hon. Gentleman for his point about the effect that stillbirth has on the family. To add to that—I know I am not alone; there are women with whom I am sitting here who have suffered miscarriages, too—after you have suffered a miscarriage or a stillbirth, it is extremely difficult to enjoy any subsequent pregnancy. Every minute of every day is spent wondering whether you are going to lose the next child too. It is worth while bringing that point to bear in this debate to ensure that support is available for women after their loss.

[John Howell]

The hon. Lady makes a valid point. It is not just about the individual stillbirth, traumatic though that is; it is about the future and ensuring that individuals can go through another pregnancy in the full knowledge that they are more likely to be safe than not. Anything that we can do to help that, we should. We should take any opportunity to take things forward. That is all I wanted to contribute to the debate, and I am grateful to have had the chance to speak.

Southern Health NHS Foundation Trust

John Howell Excerpts

Wednesday 8th June 2016 Westminster Hall

[Suella Fernandes]

I am grateful for my right hon. Friend’s point and I thank her for her work and for standing up for her constituents who have been affected by the issue. We have met with members of the CQC and with NHS Improvement, and we put those points to them directly. I share her concern, particularly on behalf of families and relatives, who would like swifter action in future. However, I am grateful to those organisations for keeping us informed and for taking the time to ensure that MPs are briefed of their actions and plans.

The facts of the issue are well known to many of those here today and to those watching beyond Westminster. However, in opening the debate, it is important for me to recount the broad sequence of events and key facts to help those who may not be familiar with them and because they deserve to be put on the record as the backdrop to the rest of the debate. Let us begin at the beginning.

The tragic starting point of the story was the death of Connor Sparrowhawk. Connor, who had autism, a learning disability and epilepsy, was 18 when he was admitted to Slade House in Oxford in March 2013. The facility was a learning disability short-term assessment and treatment unit run by Southern Health, which had taken it over from the previous provider, Ridgeway, in November the previous year.

On 4 July 2013, Connor was found submerged and unconscious in a bath at the centre. Staff tried to resuscitate him and an ambulance took him to John Radcliffe hospital but, sadly, he died the same day. The initial post mortem examination concluded that Connor drowned as the result of an epileptic seizure. Southern Health carried out a serious incident requiring investigation report and an initial management assessment, and commissioned an independent consultancy to undertake an internal investigation. That investigation concluded that Connor’s death was preventable and stated:

“The failure of staff at the unit to respond to and appropriately profile and risk assess CS’ epilepsy led to a series of poor decisions around his care…The level of observations in place at bath time was unsafe and failed to safeguard CS.”

Following the publication of that first investigation report in February 2014, Oxfordshire Safeguarding Adults Board and NHS England had ongoing concerns about the quality and safety of learning disability services provided by Southern Health in Oxfordshire, and the improvements that needed to be made. They therefore commissioned a further report in June 2014, which was charged with looking at whether the way in which learning disability services were commissioned or managed contributed to Connor’s preventable death.

The new report was published in October last year and contained a number of criticisms. It stated that there had been warnings about the standard of care in facilities including Slade House, and criticised the management processes following the transfer of services to Southern Health. It found that

“for Southern Health to only rely on its normal reporting mechanisms without addressing the…warning and ensuring that information from local managers was accurate was a serious failure.”

It also found that

“the trust did not evaluate or address the known concerns about the quality of local leadership”,

and that:

“An over reliance on a ‘business as usual’ approach to this acquisition was not appropriate.”

The report concluded:

“Southern Health should have ensured that any deterioration in the quality of services could be identified quickly and by processes that Southern Health had confidence in.”

That was the first serious criticism of the overall management of the services.

[John Howell (Henley) (Con)]

My hon. Friend described a catalogue of disasters. From the conversations she has had, what confidence does she have that the situation has been put right? I represent an Oxfordshire constituency. Can we have confidence in doing business with Southern Health?

[Suella Fernandes]

From speaking to families, relatives and patients, it is clear that they are struggling to have confidence in the services provided by Southern Health. The very reason that the debate it happening is so that we can air those concerns and, hopefully, find a pathway to restoring public trust. That is clearly the challenge facing the organisation.

Diabetes-related Complications

John Howell Excerpts

Tuesday 7th June 2016 Westminster Hall

[Paula Sherriff]

I thank the hon. Lady for her intervention, and I absolutely agree. As with so many other conditions, early intervention is crucial.

The total direct and indirect costs associated with diabetes in the UK are estimated at £23.7 billion. That is predicted to rise to £39.8 billion by 2035. Earlier this year, the Public Accounts Committee said that the cost of diabetes to the NHS would continue to rise.

[John Howell (Henley) (Con)]

I thank the hon. Lady very much for the speech she is making and for securing the debate. I want to take her up on the point she has just made. There is a belief that diabetes is not curable; actually, diabetes is curable. It is curable by the individual going through a process of losing fat around the liver, which takes away the—

[Liz McInnes (Heywood and Middleton) (Lab)]

indicated dissent.

[John Howell]

The hon. Lady is shaking her head. I am a living example of someone who has cured diabetes. I wonder whether more patient-centred education would be a big help to the NHS.

[Paula Sherriff]

I thank the hon. Gentleman for his contribution. While I acknowledge that some people may be cured of the condition, we must not be complacent about the causes of it or, indeed, the impact it can have on many people’s lives.

--- Later in debate ---

[Liz McInnes]

I wish to make the point that the hon. Member for Henley (John Howell) is talking about type 2 diabetes, which can be cured by weight loss. Type 1 diabetes, which is insulin-dependent, cannot.

[John Howell]

I did mean type 2 diabetes.

[Paula Sherriff]

I thank hon. Members for their contributions, and I will now try to make a little progress.

Earlier this year, the Public Accounts Committee said that

“the costs of diabetes to the NHS will continue to rise. In order to control these costs, the Department and NHS must take significant action to improve prevention and treatment for diabetes patients in the next couple of years.”

The wider impact on people’s health is significant. One in five hospital admissions for heart failure, heart attack and stroke are among people with diabetes. The condition is responsible for more than 135 amputations per week. It is the leading cause of preventable sight loss in people of working age and the single most common cause of kidney failure.

World Autism Awareness Week

John Howell Excerpts

Thursday 28th April 2016 Commons Chamber

[John Howell (Henley) (Con)]

It has become de rigueur in this debate to congratulate my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan), and I am absolutely delighted to congratulate her on initiating this debate and on her excellent work on the Autism Act 2009, which was also mentioned by my right hon. Friend the Member for Clwyd West (Mr Jones). I also congratulate her on all the work she has done with the all-party parliamentary group on autism.

I became aware of autism through a lot of activity in my constituency. Towards the north of the constituency, there is a big autism unit in the village of Chinnor. We also have facilities at Thomley Hall in the very north of the constituency, and it is a marvellous place to go to. The organised chaos there is wonderful to see, and it is a great privilege to be part of that and to see the enormous efforts being made by the staff to look after people with autism. In the south of my constituency, around Henley itself, we can see the work of Dame Stephanie Shirley and others.

I would like to pay tribute to a charity in my constituency called Music for Autism, which has spotted a link between music and autism. It is organised by the Orchestra of St John’s, many of whose members spend hours of their time, freely given, going into schools and other places and working with children with autism in order to show the calming effect of music on them and the enormous ability of music to take them forward to the next stage of their development. I pay tribute to them for doing that.

I want to make two points in the debate. They have already been made by other speakers, but I think it is worth reflecting on them and making them again. The first relates to diagnosis. The difficulty with late diagnosis is that people do not know what their situation is. The advantage of early diagnosis is that they are better able to understand the behaviour involved and how the role of partners can influence the way in which we look at people who have had the diagnosis. That is the view of people I have met in my constituency, including a couple I met in a café in Henley who told me about the difficulties they had had with a late diagnosis.

As we have heard, some people are able to lead pretty ordinary lives and manage their condition extremely well. I have met several such people over the years, including a young man I met at the last Conservative party conference who was able to demonstrate that. I agree with the hon. Member for Greenwich and Woolwich (Matthew Pennycook) that public recognition of the condition is not the be all and end all in relation to people’s needs, but it is certainly a good starting point. In order to help people to live a fulfilled life, we need public recognition of the illness. The need for early diagnosis is absolutely crucial, and I urge clinical commissioning groups and NHS England to bring down waiting times in line with the National Institute for Health and Care Excellence guidelines and to work with many different stakeholders to create a more responsive environment of diagnosis and support. Those words were used to describe the situation to me, and I think they do it extremely well.

A significant element is the involvement of health and social care in the care and management of adults with autism. I know that this is a broader point, but it provides a good example of an area in which we need the rapid integration of health and social care within the NHS. It will be much better when all these facilities are together under one roof.

[Tom Elliott (Fermanagh and South Tyrone) (UUP)]

Is the hon. Gentleman aware that, in Northern Ireland, health and social services form a single body, making it much easier to have an integrated approach? However, we still need integration and co-operation with other groups and organisations, and with statutory agencies such as the Department of Education.

[John Howell]

The hon. Gentleman makes a valid point. It is absolutely essential that we achieve that level of integration. We need to start by integrating the medical activities of the NHS with social care in the community, because until they are under one roof we will not have the ability to deal with these problems in the way that will be most effective for people who suffer from this condition.

My second point relates to education. I have a wife who, for many years, taught a young man with autism and struggled to provide him with the assistance he needed. She was remarkably successful in doing that. That was done on a private basis, but the vast majority of children with autism—over 70%—are in mainstream education, and it is there that we have to focus our attention. The teacher training programme needs to include enough information on autism to enable teachers to feel empowered to recognise it and deal with it effectively. If we can do that, we will have a much better chance of purposefully dealing with people with autism.

Ambulatory Care

John Howell Excerpts

Wednesday 27th April 2016 Westminster Hall

[John Howell (Henley) (Con)]

I beg to move,

That this House has considered the use of ambulatory care.

I will start by referring to the NHS England publication that prompted me to call for the debate. NHS England has recently published a multi-agency quick guide and supporting information to support local health and social care systems to reduce the time that people spend in hospital. It acknowledges that people’s physical and mental ability and independence can decline in a hospital bed. For people aged 80 and over, 10 days in hospital equates to 10 years of muscle wasting. The report therefore recommends that people should seek to make decisions about their long-term care outside hospital and preferably in their own home or in a bed where their true long-term needs are understood.

The report was prepared not by the Government, but by the emergency care improvement programme of NHS England. It adds to the overwhelming clinical evidence that this approach is by far the best way of proceeding. The report goes on to say that care at home enables people to live independently and well in their preferred environment for longer. It contains checklists of questions for patients and commissioners to achieve that situation.

I am immensely encouraged by that, as it is on that basis that the number of beds has been worked out at Townlands hospital in Henley and the answer of up to 14 initially has been reached. Those beds are to be associated with the hospital, but in the care home at the side of the hospital. It is reassuring to know that we are at the forefront of current thinking and action. This approach is supported by organisations such as the Alzheimer’s Society and clinicians throughout the NHS. It is the right way to proceed and in the best interests of the whole community.

Before I continue, I should probably say what ambulatory care is, besides what I have just described. Ambulatory care is medical care provided on an out-patient basis. It includes diagnosis, observation, consultation, treatment, intervention and rehabilitation services. This care can include advanced medical technology and procedures, the costs of which should not be underestimated. Under this new care model, outlined in the NHS five year forward view, GP group practices would expand and include nurses, community health services and, in particular, social workers. Those practices would shift the majority of out-patient consultations and ambulatory care to out-of-hospital settings.

Let us consider the effects of hospitalisation. For many older persons, hospitalisation results in functional decline despite cure or repair of the condition that took them into hospital in the first place. Hospitalisation can result in complications unrelated to the problem that caused admission or to its specific treatment, for reasons that are explainable and avoidable. Age is often associated with a number of functional changes—which I am sure you and I, Mr Owen, have no experience of at this stage in our lives—including reductions in muscle strength and aerobic capacity; diminished pulmonary ventilation; altered sensory confidence, appetite and thirst; and a tendency towards urinary incontinence, which I am not saying any of us suffer from.

Hospitalisation and bed rest superimpose factors such as enforced immobilisation, reduction of plasma volume, accelerated bone loss, increased closing volumes and sensory deprivation. Any of those factors may thrust vulnerable older persons into a state of irreversible functional decline, so hospitalisation is a major risk for them. I am talking particularly about the very old. For many, hospitalisation is followed by an often irreversible decline in functional status and a change in quality and style of life.

A recent US study showed that of 60 functionally independent individuals aged 75 or older who were admitted to hospital from their home for acute illness, 75% were no longer independent on discharge. That included 15% who were discharged to nursing homes.

[Victoria Prentis (Banbury) (Con)]

By intervening, I am not of course in any way suggesting that my hon. Friend needs to take the weight off his feet after that sad list of symptoms. He is rightly concentrating on the needs and degeneration of older people who go into hospital, but does he agree that ambulatory care is also important for younger people? In our local general hospital, the Horton, there is a marvellous new children’s out-patient service, which is used by both his constituents and mine. Does he agree that that is a centrally important part of the offer of that hospital, which provides acute in-patient care as well as the out-patient care on the side?

[John Howell]

I thank my hon. Friend for allowing me to have a rest and to make the most of that time—as I get older, I need that. I do agree with her; she makes a very valid point. I am concentrating on older people because traditionally that is where the population who have used the hospital in Henley have come from. I think that in the past year only one was under 55. But as I said, my hon. Friend makes a very valid point.

In many cases, the decline that people experience cannot be attributed to the progression of the acute problem for which they were hospitalised in the first place. An example is pneumonia. Even if the disease is cured in a few days or, indeed, if a hip fracture repair is technically perfect and uncomplicated, the patient may never return to the same functional status as they had before they went into hospital.

According to the US study, between 30% and 60% of patients with hip fractures are discharged from the hospital to nursing homes; 20% to 30% of those persons are still residing in nursing homes one year later. Only 20% of one large group of patients returned to their pre-operative functional level after a hip fracture repair.

Many hospitalised patients have difficulty implementing their habitual strategies to avoid incontinence. The environment is unfamiliar. The path to the toilet may not be clear. The high bed may be intimidating. The bed rail becomes an absolute barrier, and the various “tethers”, such as intravenous lines, nasal oxygen lines and catheters, become restraining harnesses. About 40% to 50% of hospitalised persons over the age of 65 are incontinent within a few days of hospitalisation. A high percentage of hospitalised older persons discharged to nursing homes never return to their homes or community. In one study, 55% of persons over the age of 65 who entered nursing homes remained for more than a year. Many of the others were discharged to other hospitals or long-term care facilities, or simply died. The outcome for many hospitalised elders is loss of home and, ultimately, loss of place.

It is most important that relationships among physicians, nurses and other health professionals reflect the interdisciplinary nature of the whole of this process. In particular, I am a great enthusiast for the integration of the NHS with social care. That needs to move ahead very quickly to give the clinicians the responsibility for commissioning the social care that is required. Maintaining wellness and independence in the community prevents conditions deteriorating and therefore results in better health outcomes. Emergency hospital admissions are distressing.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for bringing this very important issue to Westminster Hall for consideration. Over the past five years in Northern Ireland, category A ambulance call-outs have increased by 30.9%. It is a devolved matter, but it does indicate a greater dependence on and need for ambulance responses. Does the hon. Gentleman have any thoughts about the best way to ensure that the ambulance service and ambulance staff can do better for elderly people?

[John Howell]

The hon. Gentleman makes a valid point. The costs need to be offset. This is a balancing exercise within the NHS. Costs that are saved by stopping people going into hospital can be spent on the treatments and services they require to get them better. That is a far better way of working.

Emergency hospital admissions are distressing. Better management that keeps people well and out of hospital should lead to a better patient experience. The King’s Fund estimates that emergency admissions for ambulatory care-sensitive conditions could be reduced by between 8% and 18% simply by tackling variations in care and spreading existing good practice. That would result in savings of between £96 million and £238 million, which, as part of the overall management of the NHS budget, could be allocated against the provision of the often quite expensive services that provide the necessary medical investigations on the spot.

A doctor in my constituency, Dr Andrew Burnett of the Sonning Common practice, said:

“Very few of my patients want to be admitted to hospital.”

Most people, if they need to be treated or, indeed, if they are nearing the end of their life, would like that experience to be located at home. I think that probably applies to us all.

There is a particular problem in relation to dementia. I spoke to the Alzheimer’s Society, which said that people are often admitted with an acute physical illness on top of their dementia, and the combination of the two can cause their confusion to become worse. They are then taken out of familiar surroundings and placed on a hospital ward with lots of strange people, noises and smells. That can be terrifying for them and they rapidly deteriorate. The advice from the Alzheimer’s Society is to try to keep people out of hospital for as long as possible. That is why we, and the Oxfordshire medical facilities, are striving hard to develop systems to enable people with physical illnesses to be managed out of hospital.

That is one of the rationales for the new Townlands hospital in Henley, where the clinical commissioning group, along with Oxford University hospitals, Oxford Health and, indeed, the county council, are members of the ambulatory emergency care network, through which organisations can learn from one another to develop robust pathways. Some good case studies are involved in that, but time prevents me from going through them at the moment. I draw the Minister’s attention to those if he needs some examples of how ambulatory care actually works.

Another clinician, Pete McGrane of the CCG, has said:

“Patients who were recently hospitalized are not only recovering from their acute illness; they also experience a period of generalized risk for a range of adverse health events.”

There have been cases in my constituency where the health of elderly people has deteriorated following discharge, or even in hospital, due to other conditions. The relatives have sought to blame the health service for poor care. After following up on those cases, the complaints investigation has shown that it is not poor care that has exacerbated the patients’ distress and symptoms; it is a direct consequence of hospitalisation.

I went to see a hospital in Welwyn Garden City, which has no beds inside. Instead, it has beds in an adjoining care home at the side of the hospital. The place was absolutely heaving with people. I met a gentleman there called Dave. I do not have his surname, nor have I asked his permission to use his name, so we will just keep it as Dave. He could not speak highly enough of the treatment he got. He called in every day for treatment and then got on with his life at home. It revolutionised the treatment he received, which, doctors had confirmed, would otherwise have required a debilitating 56 days of medication, staying in hospital. His experience of hospital stays had shown up their disadvantages, and he pointed out that people were so much more likely to improve, as he had, and to feel better, as he did, if they could stay at home. He was clearly a great enthusiast for this type of service.

In Henley, there is one issue, above all, which I have already touched on and want to emphasise. It was helped by some papers that were forwarded to me by the Health Foundation, which said that it is undertaking

“a joint research programme…monitoring how the quality of health and social care is changing over time.”

I have been very concerned by the way in which we move forward with the integration of social care and health in the county to ensure that it delivers the sort of services that are required in the full context of the patient.

I am pleased and proud that I have helped to deliver a 21st century medical facility for the people not just of Henley, but of the whole of southern Oxfordshire, and that that incorporates ambulatory care. It is clearly the way forward and it is a way forward that I am sure will work.

End of Life Care

John Howell Excerpts

Wednesday 2nd March 2016 Commons Chamber

[John Howell (Henley) (Con)]

It is a great pleasure to participate in this debate today. A number of common themes run through the debate, the first of which is the fact that most people want to die in their own beds. Before coming to this debate, I tried to find some statistics on the subject. I trawled through a whole lot of figures on the internet, and what I came up with was the fact that 70% of us want to die in our own beds, yet 60% of people die in hospital.

Why is there such a discrepancy in the figures? Is it a ridiculous aspiration for 70% of us to want to die in our beds, or do we need to be better at organising end-of-life care services? The evidence from the Netherlands suggests the latter In particular, there needs to be more emphasis on the social care aspect, the reorganisation of that and its delivery.

What does that come down to in practice? The issue came to the fore in my constituency with the re-provision of a hospital in Henley, the Townlands hospital. The hospital will be re-provided with a greater range of services for people to access and a limited number of beds at the side of the hospital in a care home. The gap is being taken up by a system that has come to be called ambulatory care, involving greater use of social care packages. This follows a change in practice, where the aim is to reduce the number of beds and keep people out of hospital for as long as possible.

[Andrea Jenkyns (Morley and Outwood) (Con)]

My own father died at home. The Government’s response to the report states that a priority is to ensure that families are kept in the loop in the final days, but in our case, we did not know it was my father’s final days. A nurse turned up on the last day with an end-of-life care kit. In front of my father she said, “Here’s the end-of-life care kit,” and he died a few hours later. Does my hon. Friend agree that better communication is needed with those who want to die at home?

[John Howell]

I thank my hon. Friend for making that point. As many hon. Members know, I recently lost my mother. Contrary to what I said earlier, she died in hospital, but I have to say that the services provided were exemplary. We were taken into the thinking of the clinicians as her illness progressed, we were told exactly what would happen, and this led to a greater feeling of comfort with the whole process when she eventually died. I am reconciled with the idea that it was what she wanted. That fits in with the idea of personal choice, where that is possible. In my mother’s case it was not possible because of the illness, but I do not know the circumstances of my hon. Friend’s case. It is something that needs to be borne in mind.

There are still those locally who cannot see that the best interests are served by reducing unnecessary admissions to hospital and moving people out of hospital as soon as possible. I have listened to the clinical advice and the clinical evidence that this is the best way to go. Hospitals, contrary to what they may seem, are not necessarily healthy institutions. Even a short stay reduces the ability of muscles to function and affects quality of life. I spoke to the Alzheimer’s Society about this. The evidence was clear: although admission to hospital or, better still, to care homes will inevitably be required, the best advice was to keep people out of hospital for as long as possible. That was true even in the case of people suffering from Alzheimer’s.

This approach is not just about providing services to those who need periodic treatment, especially end-of -life care. It demands a revolution in the way social care is provided. I am a great advocate of integrated social care and healthcare, and I have heard from doctors about the way in which they decide on the services to be provided. When somebody presents to them with an illness, whatever it might be, the choices are a medical solution—they can be shipped off to hospital or given a prescription—or a social care solution. The feedback I have received from doctors is that they do not have control over the social care aspect, they cannot provide the services and it is very difficult for individuals to access those services, particularly at weekends.

We need this revolution for better control of social care by clinical commissioning groups. We need this revolution for the better use of providing medicine in the home, for example by using internet services, as has been mentioned, which I think is a magnificent way to go. We need this revolution for the timeliness of the provision of services. I agree with my hon. Friend the Member for Poole (Mr Syms) that we need to work across organisations to get this right, including those in the charity sector. If we do that, we can get a really integrated approach.

IVF: Welfare of Women

John Howell Excerpts

Wednesday 20th January 2016 Westminster Hall

[Siobhain McDonagh]

I wholeheartedly agree with my right hon. Friend and hope to expand on that point in my speech.

[John Howell (Henley) (Con)]

I thought I would get an intervention in while the hon. Lady was in the mood for taking them. I appreciate that she is talking about women who are going through IVF, but has she considered the health effects on women who want IVF but are prevented from doing so due to their age?

[Siobhain McDonagh]

I have no comments in my speech that address the hon. Gentleman’s concerns about age and effectiveness. I mostly want to ask the Minister, and through her the Department of Health, to consider how figures are recorded, what the practice is and how we can improve on what is now a 26-year-old Act.

It goes without saying that OHSS has a huge emotional cost to women and a huge financial cost to the NHS, but it is preventable. It is widely known that there are modern OHSS-free protocols that can entirely prevent the syndrome from manifesting, but they are underused. In a 2011 article in The BMJ, authors Bewley and Braude reported on women’s deaths as a result of the complications around IVF treatment. The article states:

“The last Confidential Enquiry into Maternal Death recorded four deaths directly related to IVF via ovarian hyperstimulation syndrome and three deaths related to multiple pregnancy after IVF. Thus, more deaths were related to ovarian hyperstimulation syndrome than to abortion…despite many fewer procedures (for example, 48,829 IVF cycles v 198,500 abortions were performed in the UK in 2007). IVF associated maternal deaths may be underestimates, because record linkage is not allowed by the Human Fertilisation and Embryology Act”.

The article worryingly concludes that:

“infertility treatment now poses a higher risk for maternal death.”

Despite the potentially fatal risks to the health of women going through IVF, there is little accurate or complete information regarding the incidence of OHSS. Instead, the HFEA records it only via a flawed self-reporting system. In practice, that means that clinics must indicate when a patient has been admitted to hospital with severe OHSS when it is entirely induced by their IVF treatment, but that system of self-reporting is inadequate, for obvious reasons. The HFEA’s own data suggest that there is gross under-reporting of the condition.

We know that the number of eggs collected is a predictor of OHSS. The collection of more than fifteen eggs significantly increases the risk of OHSS, without improving the live birth rate. Bearing that in mind, over the first half of 2013, there were over 1,700 IVF cycles in which more than 20 eggs were collected—cycles that therefore posed an increased risk of OHSS. Yet, that same year, only 46 cases of severe OHSS were reported. Between 2010 and 2012, only 60 cases of severe OHSS and 150 cases of moderate OHSS were reported. During the same period, however, there were more than 3,000 IVF cycles in which more than 20 eggs were collected per cycle. Those examples demonstrate the worrying, and dangerous, trend of under-reporting. We also know that the stimulation dose given in IVF is negatively correlated to live birth. In other words, the higher the stimulation, the lower the rate of live births. Research has also shown that a high number of eggs collected increases rates of prematurity and low birth weight in babies. The risks are clear when considering how many cycles feature high stimulation and high numbers of eggs collected.

The HFEA database demonstrates that, between 2008 and 2013, more than 20 eggs were collected per egg collection procedure in more than 18,000 IVF cycles, more than 30 eggs were collected in 2,285 IVF cycles, and more than 40 eggs were collected in 313 IVF cycles. It cannot be stressed enough that those figures show a very worrying trend in IVF treatment in the UK, potentially placing women in real, and avoidable, danger. The evidence also demonstrates the pressing need for a change in legislation and for reliable data to be collected by an empowered regulator.

Furthermore, research from last year has observed an increased risk of ovarian cancer among women undergoing IVF in the UK compared with national averages. That was based on the HFEA database of more than a quarter of a million women who have received IVF treatment between 1991 and 2010. Similarly, a large Dutch study from 2011 of 20,000 women who had received IVF treatment concluded that ovarian stimulation for IVF may increase the risk of ovarian malignancies, especially borderline tumours. The link between ovarian cancer and IVF treatment, as well as the many health risks I have outlined, so obviously justifies the collection of reliable data by the HFEA.

As if the risks were not enough, several clinics are using a cocktail of drugs off-label in a manner for which they were not intended. It is most common in the use of drugs and intravenous infusions during IVF treatment and pregnancy that affect a woman’s immune system. However, they are often used without any supporting scientific evidence, posing significant risks to women. Both the Royal College of Obstetricians and Gynaecologists and the US Food and Drug Administration have issued warnings about the use of drugs off-label. The HFEA, while stating on its website that there is no evidence to support such practice, has admitted that it has no powers to stop it from happening despite being aware of the considerable potential harm posed to women. That clearly needs to change.

Despite the potential threat to women’s safety, the HFEA states that it does not have the statutory authority to take action in the so-called areas of clinical judgment and drug administration. Indeed, in relation to the HFEA’s limited response on the incidence of OHSS, the Minister stated the following:

“They have no express powers concerning the administration of drugs, which is a matter of clinical judgment. Although the HFEA does not collect data about the overall incidence of OHSS, clinics are asked to report when a cycle has been abandoned because of risk of OHSS. Severe OHSS is treated as an incident and depending on the nature of incident and the patient outcome, the HFEA will either expect an incident report or conduct an incident review itself”.

Given the severity of the risk to women that I have outlined, however, that response is clearly inadequate.

Considering the evidence, the absence of comprehensive data collection seems to be the result of a bizarre regulatory remit. That limited remit seems to see the safety of women as secondary. The McCracken review into the HFEA, the recommendations of which were entirely accepted by the Government, argued that the balance of HFEA activities was unacceptable. Recommendation 10 stated:

“The HFEA should conduct a review of the balance of its regulatory focus to ensure that it reflects the relative risks of the different activities that it oversees. Its approach should reflect the relative maturity of the sector it regulates…the need to ensure appropriate oversight of technical developments in the field of ART”—

assisted reproductive technology—

“the need to ensure that appropriate standards of practice are implemented consistently throughout the sector, and the continuing need for a high degree of public assurance regarding the sensitive activities that it oversees. This should not lead to any overall increase in regulatory activity or cost, but a rebalancing of activity.”

Further, as part of the preface to the recommendation, McCracken stated:

“Similarly where there are well known side effects of ART techniques, such as…OHSS…the HFEA should make sure that appropriate standards in managing them are being adopted across the sector...It is worth noting here that the work that the HFEA led in reducing multiple births, the ‘One at a Time’ project, is universally praised and may provide a model for addressing some of these other topics.”

To reiterate, the report states that reviewing the HFEA remit should not lead to an increase in regulatory activity or cost, but simply a rebalancing of its activity. However, the HFEA has not taken any specific action on OHSS or on the other interventions so desperately needed. That is why we need Parliament to act.

What can be done? I have a number of recommendations that I hope the Minister will be able to implement to address the risk to women’s health. First, an explicit commitment to the protection of the welfare of women urgently needs to be added to the Human Fertilisation and Embryology Act 1990 in order to give powers to the HFEA to regulate and monitor drug administration to safeguard the short and long-term health and welfare of women undergoing IVF.

Secondly, the HFEA must immediately start collecting information about all drugs, dosages—whether daily or cumulative—and off-label drugs administered to women during IVF treatment and pregnancy. The HFEA already collects extensive data about embryos, including the use of consumables or culture medium. In other words, what is administered to eggs, sperm and embryos is regarded as of primary importance, but what is administered to women is deemed to be of limited importance. We urgently need to redress that imbalance. Adequate information is desperately needed to gauge the adverse effects of the drugs on gametes and embryos, and to assess their threat to women’s health. Those data are already collected in the USA, Australia and across Europe. It is about time the UK followed suit.

Thirdly, the HFEA should introduce a campaign and licence condition expressly focused on reducing the incidence of OHSS, which can be fatal. That could be modelled on the HFEA’s successful multiple births minimisation strategy.

Finally, the HFE Act should be amended to link the HFEA registry with the hospital, cancer and death registries. That would allow accurate recording and publication of the links between IVF treatment and incidence of severe OHSS, cancer and mortality among women. The HFE Act has typically used patient confidentiality as a reason to have a hands-off approach to collecting important information. Links between IVF treatment and such incidences, however, have already been established in other developed nations by using such data. I am sure the Minister will agree that the more we understand such links, the more we can do to prevent unnecessary harm to women.

We urgently need a regulatory body that has the powers to monitor drug administration during IVF treatment, and to take action where needed to protect the welfare of women. We need to have adequate information to assess the safety of fertility treatments. Indeed, it seems absurd to have a regulator that is dedicated to licensing and monitoring clinics that carry out IVF, but that is unable to take action because it lacks statutory authority.

According to the McCracken report, such changes can be cost-neutral, and the HFEA has already achieved success in other areas. By including the welfare-of-women protection in the HFE Act, alongside the “welfare of any child”, we can finally act on the issue. By doing so, Government can oversee the collection of information about drugs administered to women during IVF treatment and pregnancy. What I am calling for is not unusual elsewhere in the world, and such systems of data collection are prevalent in so many developed countries. Changing the Act will also enable the HFEA to implement fully the recommendations of the McCracken report, in particular that

“appropriate standards in managing…are…adopted across the sector.”

That should include the use of modern OHSS-free protocols that prevent the incidence of potentially fatal OHSS.

Patients undergoing IVF treatment are often vulnerable, forced into paying for treatment themselves, and they desperately need someone to protect them. As more and more people use IVF treatment, the issue is no longer one for only a minority. It is time to give the safety of women the recognition that it desperately deserves in the Act. Let us not sit back and allow another woman to suffer or die unnecessarily during IVF treatment.

In the HFEA, we have a body dedicated to regulating IVF. Let us give it the tools to fulfil its duty. Twenty-six years since its creation, it is time to maintain what is good about the HFE Act and to reform what is inadequate. I hope the Minister will recognise the opportunity for the Government to pioneer a new chapter in the young history of IVF treatment.

Oral Answers to Questions

John Howell Excerpts

Tuesday 5th January 2016 Commons Chamber

The Secretary of State was asked—

[John Howell (Henley) (Con)]

1. What progress his Department has made on integrating and improving care provided outside hospitals.

[The Minister for Community and Social Care (Alistair Burt)]

Happy new year, Mr Speaker—and happy new year to the familiar faces opposite in the shadow Cabinet.

The Government are committed to transforming out-of-hospital care for everyone, in every community, by 2020. We have seen excellent progress in areas led by the integration pioneers such as Torbay and Greenwich. The Government remain fully committed to delivering integration through programmes such as the better care fund and the vanguards.

[John Howell]

Seventy per cent. of people would prefer to die in their own homes, yet we still allow 60% of people to die in hospital. This has to change, as it has in the Netherlands owing to the better social care provided outside hospitals. What message would the Minister give to clinical commissioning groups, such as mine, which are trying hard to bring this about and to integrate services?

[Alistair Burt]

I am grateful to my hon. Friend for raising this issue. We share his view: we want to see greater choice in end-of-life care so that people are able to be cared for and die in the place they choose and which is appropriate to their needs, whether that is a hospice, a hospital or their own home. The recent Choice review set out a vision of enabling greater choice at the end of life. I am working with NHS England to see how this can be best achieved and the Government expect to comment on that soon.