Public Health White Paper

John Pugh Excerpts

Tuesday 30th November 2010 Commons Chamber

[Mr Lansley]

No; the hon. Lady should not believe what she reads in newspapers. The Education Secretary is not scrapping the school sport partnerships; he is providing the resources directly to schools so that they can make the decisions on how they promote sport. From my point of view, I have always made it clear—this has been the burden of my conversation with my colleagues—that we are already supporting school sports clubs in secondary schools through Change4Life. We intend to maintain that and to expand the role of Change4Life, linking in to primary schools so that we stimulate activity and exercise for young people overall. That is entirely complementary to how schools, using their own resources, stimulate sport. With regard to competitive sport, they will be assisted additionally through infrastructure funding for the new school Olympics.

[Dr John Pugh (Southport) (LD)]

I congratulate the Secretary of State on his long-standing and personal commitment to public health as the best way of dealing with health inequalities. How do we stop GPs operating in silos and prescribing pills where they might prescribe exercise? How do we join up the pieces?

[Mr Lansley]

I am grateful for that question. The answer has two parts. First, the general practice-led commissioning consortiums will be members of the new health and well-being boards in local authorities to which I referred. They will participate in the joint strategic needs assessments and strategies through the commissioning framework, the outcomes framework and the quality and outcomes framework, which applies directly to general practice. The less we focus on processes, and the more we focus on outcomes for patients, the more general practice will be focused on preventive solutions, because they will deliver good outcomes at relatively low cost. To that extent, the preventive agenda in general practice and community health services will be incentivised through a focus on outcomes.

NHS Reorganisation

John Pugh Excerpts

Wednesday 17th November 2010 Commons Chamber

[John Healey]

I thought the hon. Gentleman was in his place at the start of the debate. In that case, he will have heard me say that one reason for having an Opposition day debate on both health and education is that we see many of the same ideological fingerprints over the plans for education and for health. These are Tory ideological fingerprints, and I hope that this will become clearer as the debate progresses.

Let us make no mistake: if these changes go ahead, patients will rightly question whether GPs’ decisions are about the best treatment for them or about the best interest of the GP budget and consortium business. The public will find “commercial in confidence” stamped over many of the most important decisions taken about our NHS services. Members of Parliament wanting to hold Ministers to account in future when hospitals go bust, there are no contracted services for constituents or there is a serious failure in the system will be told, “It’s nothing to do with me”.

[Dr John Pugh (Southport) (LD)]

Was the right hon. Gentleman perfectly happy about the situation under the last Government? When anyone complained in this Chamber about anything happening in their local health economy, they were told rather piously by a Minister that it was a matter for local decision making by a quango that was completely unelected and beyond their control. In what sense were the PCTs in any sense accountable?

--- Later in debate ---

[Mr Dorrell]

The hon. Gentleman is a fellow member of the Select Committee and I know from our discussions that the principle of clinical engagement in commissioning is broadly supported in the Committee. It is fair to say that none of us would support the view—I suspect the Secretary of State would not either—that clinical engagement means only GP engagement. We should see the GP as the catalyst for broader clinical engagement in the commissioning process if we are to deliver our objectives.

To deliver the Nicholson challenge, we must have strong commissioning, with clinical engagement, and we have to remove unnecessary processes that do not add value. We cannot afford to waste money on them. We must have greater local accountability for the commissioning process in order to embrace public support for change on this unprecedented scale.

[Dr Pugh]

rose—

[Mr Dorrell]

I have only 40 seconds left for my speech, so if my hon. Friend will forgive me I should like to conclude.

My key message is that as we look at the lifetime of this Parliament, I do not see the White Paper as the linchpin of reform, but as a key tool in the delivery of the reforms that are neatly encapsulated in what I have described as the Nicholson challenge.

Mental Health (Infants)

John Pugh Excerpts

Tuesday 26th October 2010 Westminster Hall

[Dr John Pugh (Southport) (LD)]

It is a privilege to talk in the debate under your chairmanship, Mr Bone. It is a tribute to your unswerving party loyalty over the years that you have got to your position.

I congratulate the hon. Member for South Northamptonshire (Andrea Leadsom) on starting an important and significant debate. I think we would all agree that the human infant, as she has analysed, has definite needs that go beyond the basic biological necessities of food, water and shelter. The human infant requires emotional support and, as the hon. Lady and my hon. Friend the Member for Mid Dorset and North Poole (Annette Brooke) have argued, an element of attachment—a mother or mother substitute—in the early stages to bond or imprint with. This is essential for wholesome psychological development.

The evidence for a child’s emotional needs is strong. I am aware of an experiment conducted with primates, in which a young rhesus monkey was separated from its mother but given two alternative “wire” mothers—wire constructions. One was surrounded with soft cloth and the other had milk attached to it. The monkey’s behaviour was interesting. It went to one mother for feeding, but after being fed it needed some comfort and went to the other mother and cuddled up close against it, requiring some tactile contact that was not strictly necessary in terms of its biological survival, but clearly deeply emotionally necessary. Some horrific but illuminating experiments have been done in this field. One recalls the behavioural psychologist, Watson, who endeavoured to bring up his child without any tactile direct contact but provided him with all the necessary immediate needs.

It is obvious that we have a raft of emotional needs over and above our ordinary biological needs. The lack of such contact—and the evidence about this lack—is always fairly apparent, showing itself in infants in rocking behaviour, attention-seeking, unresponsiveness and slow development. We also believe that we have discovered, in addition to these obvious symptoms of emotional deprivation and abuse, other effects that we would not have picked up without the benefit of modern science. For example, it has been argued that hormonal effects lead in turn to neurological effects, some of which are long term. Heightened aggression, for example, is suggested to be an outcome of poor attachment, and other social handicaps may ensue. The hon. Member for South Northamptonshire mentioned that psychopathy can be a consequence of severe lack of attachment.

The exact causal link between all these factors is not as clear as we would like to believe. In particular, ways of treating infants and neurological and behavioural outcomes are matters for debate. The evidence is complex and can be oversimplified; it has been contested in some areas and can be interpreted speculatively. We do not know enough about the effects of cortisol to be totally sure in this respect. We do not want to go down the Watson behavioural route to sort this matter out, conducting horrible, elaborate experiments on infants to find out what bottom-line evidence we ought to rely on.

We must recognise that the emotional deprivation and abuse endured by people in infancy is also overlaid in time by subsequent social and cultural differences. That slightly clouds the picture as well, and makes it rather more difficult to establish the clear causal links that the hon. Lady implied existed. If people believe in free will, there is an element of individual mediation at the end of the day. Despite all this, it is not difficult to spot when a child is turning out underdeveloped, unhappy and antisocial. Even if we disagree, according to our different values, about what constitutes a truly well-adjusted child, we certainly know when we have a severely maladjusted child on our hands. It is impossible to dismiss the role of first experiences in constructing those outcomes—that has been established for some time.

It is easier to identify failure than absolute success. After all, as my hon. Friend the Member for Mid Dorset and North Poole suggested, none of us does a perfect job of bringing up our children. All children—all of us—are brought up by amateurs. People do not get a set of children to practise on first until they get good at it. One recalls a quote from Philip Larkin, which I will not use here because it contains unparliamentary language, about the effects of parents on one’s general well-being. But it is still true that some people mismanage the process far more than others, even if none of us succeeds in getting it totally right. I recall Jack Dee’s remark, questioning the point of having children, because they only grow up to be teenagers and slag you off at parties. There is an element of truth in that.

There is a social policy issue concerning how we reduce incompetence, especially the worst sorts of incompetence that lead to the catastrophic effects that the hon. Member for South Northamptonshire mentioned. It is important that we find out what the state can do to encourage success, given that most parents appreciate some guidance, having never done the job before, and crucial that we find out what the state needs to do to avoid catastrophic failure—as in the case of baby P and other cases we could specify—or general failure, if that is what is happening.

The hon. Lady suggested that there is a general failure in society and quoted UNICEF statistics. She suggested that, collectively as a society—as a social group—we have something to learn. In a sense, that is what the debate on child care in the first two or three years in life has been about. There has been strenuous and long-standing debate about the conflict between the role of the mother as breadwinner and home-maker; about whether the social gains of early interaction in a nursery or child care environment are offset by emotional security; about whether encouragement to return to work is encouragement to short-change one’s child; and about whether the high percentage of nursery and child-minded children in our society correlate in an interesting way with levels of general child happiness. I will pass over that debate and leave it to hon. Members around me who are more expert than me, but I want to make two observations.

It is hard to generalise in this matter. I have two grandchildren. One took to everyone in the family very early and is very social, at home with other children, confident and assured, and I had a close relationship with the child from an early age. The other granddaughter has only just convinced herself that I am not an ogre. For the first few months of her life, she clung to her mother in a way that the first child did not. Not all children are the same, and not all homes are the same, so the consequences of keeping children at home with mum differ depending on whether the mother is middle-class and has lots of books and blocks and things, or is a heroin addict.

I do not want to embroil myself in a matter in which I have no expertise—whether the recommended techniques for dealing with babies in the early stages are correct. I do not want to get into the routine versus emotional spontaneity debate, about which there is plenty of literature that is scoured by many young mums as they take their first steps. However, the fame of experts in that field is usually in direct proportion to their tendency to challenge common sense. Books do not sell if they suggest something that is part of motherhood and apple pie, and has been well understood for years.

My fundamental point is that parenting is an art, albeit a rough art, that in some homes goes disastrously and persistently wrong. I had a chilling experience recently on a train. A young child of perhaps three or younger was being controlled by what seemed to be her grandmother. The child responded by producing expletives, which would have been a disgrace even in a football ground. The grandmother responded by saying things such as, “Please stop that because the man doesn’t like it.” The child showed the classic symptoms of one who has been brought up in the wrong environment with the wrong cues and has been given the wrong sort of discipline. It struck me as a disastrous way of carrying on.

When one witnesses such incidents, which are repeated in many places, and recognises the terrible consequences for the individual and their emotional stability, and the huge collateral damage for society, one starts seriously to think about what society can do to support parenting in general and to support such parents who, for whatever reason—it may not be their fault—are not making a good fist of it. Should good parenting be taught in children’s centres? I certainly believe so. Do we need more health visitors? I certainly believe that we do. Do we need to build the skills of often damaged people? I certainly believe that we do.

One hugely overlooked dimension is that we simply do not do enough in schools to inculcate good parenting, or do what we can to get across to young people who are coming up to being parents how parenting sometimes works and sometimes does not.

[Annette Brooke]

My hon. Friend is making some important points. Does he share my vision that it should be considered normal to have parenting classes, and not a reflection on someone’s inability to do something? If someone has a perpetual headache, they go to their doctor, and if they have a perpetual difficulty with a baby or toddler, it should be the norm for them to seek assistance. My ideal is to reach the cultural perspective that seeking help is the thing to do. We would then be able to move forward.

--- Later in debate ---

[Dr Pugh]

Yes, that is an important and valuable suggestion. I am trying to say that we should take pre-emptive action to encourage people to think about parenting and what goes wrong at a time when parents are thinking about all the other important issues of life. There is a lot of good practice on such subjects in personal, social and health education in schools, but the people who are pointed in that direction and encouraged to treat that area of the curriculum seriously tend to be not the most academically high-flying, and tend to be female. There tends to be an exemption for people who have better things to do, but there can be few better things to do than to teach generations to come how better to bring up their children. That can only add value to society as a whole, and happiness to people’s life.

One may waffle on about academies and put money into the pupil premium, but the biggest indicator and determinant of success in the education system and therefore in life is a strong, supportive home in which good parenting is attempted. We are inclined to pay lip service to that and do not spend sufficient time on it. We tend to spend more time thinking about other things such the bias with which history is taught.

[Andrea Leadsom]

On the importance of a supportive family for education outcomes, does my hon. Friend agree that there is a lot of talk about intervening at all levels and all ages, but a supportive family either develops very early or not at all? That is why I focus on the under-twos. That is the point when lifelong good relationships can be set up between family and baby. It is much more difficult to put things right with later intervention.

[Dr Pugh]

I thoroughly agree, and that bears out the point made by my hon. Friend the Member for Mid Dorset and North Poole about the family approach. The arrival of children often puts a strain on relationships and finances, and creates a series of difficulties for couples, which may have severe ramifications. I have attended Home Start events in my constituency at which mothers testified to the initial difficulties and isolation when they became mothers, and the support that they needed. In the past, that might have been provided in the neighbourhood or by an extended family, but is no longer there for many people, who need to be able to plug into facilities and groups—charitable, voluntary, social enterprise and so on—for help with their difficult job. Society must ensure that that help exists because we all recognise the importance of parenting.

One reason for the restraint in our support for teaching parenting is the liberal angst about being too prescriptive in our society, but we must get over that. We must prioritise parenting and invest in it. We must insist on its being taught in schools, and we must assess secondary schools on how well they do that, not only with girls but with boys. Every child in every school is likely to become a parent at some time. Some will do that well and some will do it badly, but unfortunately some will begin without the faintest inkling of what to do and without the experience of a good example, or even the awareness that getting it right matters.

None of us can ultimately escape the inevitable guilt that parents feel about not having been a better parent, but we must not let people go out into the world without knowing what they should do or, worse, not caring whether they do it well or badly. The fundamental point made by the hon. Member for South Northamptonshire was that early years and early months are crucial determinants of someone’s fundamental personality. Freud also made that point, and even said that how someone is born matters. I must declare an interest. I was born easily and during a good summer, and I was a contented baby, which is probably why I became a Liberal Democrat.

Contaminated Blood and Blood Products

John Pugh Excerpts

Thursday 14th October 2010 Commons Chamber

[Rehman Chishti (Gillingham and Rainham) (Con)]

I thank the Backbench Business Committee for tabling this motion, because it is vital that such important, tragic and sensitive issues get debated on the Floor of the House. I welcome the statement by the Minister, because over a number of years those affected by this problem have gone on a rollercoaster journey. That is because in recent years the Archer report has been published, the Government have taken a position and a judicial review has been undertaken, and now we have reached a point where a Government are saying, “Within five months a review will take place and within three months we will come back with a position.” If that review can be carried out earlier than the end of the year, I ask the Minister to ensure that it is, because time is running out for some of the victims of this tragedy.

I wish to discuss the case of the father of one of my constituents, who suffered from a rare form of haemophilia. In 1984, he cut his finger while working, was given factor VIII to clot the blood and, as a result, has suffered from HIV and hepatitis C. It was not until four years later, when different blood samples were taken away and different analysis was done, that he was told that he had hepatitis and HIV. He then had to tell his wife, but at that point he was not given any specific counselling—not only between 1984 and 1989, but to this very day, no specific counselling has been given to him, and that must urgently be reviewed.

On the funding comparison with Ireland, from 1989 until today, this individual has received £78,000 in total compensation over a number of years, with £6,400 per rota. At one stage, after the Archer report, he was given £12,800. For the same period, someone in Ireland would have received a lump sum of £200,000. It is not the case that people simply want compensation; this is about the family. He feels that a lump sum gives security; if something happens he can leave some money for his family. He feels that if we cannot have comparability, he would very much appreciate having some measures that go towards it.

[Dr John Pugh (Southport) (LD)]

The hon. Gentleman mentions compensation and the difference between the situation in this country and that in Ireland—reference has been made to that several times. However, there is another huge difference: no UK Government have acknowledged negligence liability yet.

[Rehman Chishti]

The hon. Gentleman is absolutely right to say that there is the question of liability, and I understand that it was dealt with at the judicial review, when the High Court addressed it. In Ireland, the issue of fault was raised.

--- Later in debate ---

[Anne Milton]

The hon. Lady makes an important point that has crossed my mind already. I shall talk to colleagues and officials in the DWP to make sure that that issue is addressed.

It is important to put on record some relevant events. In the early 1960s, the life expectancy of someone with haemophilia was less than 40 years. In the early 1970s, the development of a revolutionary new treatment—clotting factor concentrates produced from large pools of human plasma—led to what was then considered an exciting new era of treatment. It offered the potential to extend significantly the length and quality of the lives of patients with haemophilia. The risk of viral transmission through blood and blood products was recognised at that time, particularly the risk of post-transfusion hepatitis. Generally though, the consensus within the scientific community was that the risk of using multiple donors was low and worth taking. Significantly, at that time, the Haemophilia Society said, in a bulletin published in September 1983, that

“the advantages of treatment far outweigh any possible risk”.

Sadly, we know how wrong that was. Tragically, the society was wrong and a devastating blow was dealt. The initial hope was ultimately replaced by the dreadful realisation that, although lives were extended, almost 5,000 patients with haemophilia in the UK and thousands more throughout the world had been infected with hepatitis C, HIV or indeed both.

Many of those people have since lost their lives to those conditions, and more continue to do so by the week, and we should pay tribute to the many campaigners who have died. I fully understand the sense of grievance and anger that people feel. I am not in that position, and it is impossible to know fully what it feels like, but I do understand some of it. I also know that for some time, whatever the Government do, sadly it will be far too little, far too late.

At the time, however, no other treatment was available. The UK blood supply and the only alternative, a product called cryoprecipitate, were both contaminated. The only real treatment, therefore, was no treatment at all, and that was the case not only in the UK, but in countries throughout the world. At the time, France, Germany, Japan and the United States all took a similar view, which was widely held by the scientific community throughout the world.

When those treatments were first introduced, we had a very different view also of the risks from hepatitis C. It was not until the mid-1980s that scientific and medical literature began to reflect increasing concern about the seriousness of disease associated with hepatitis C, and I, as somebody who was working as a nurse at the time, remember it well.

[Dr Pugh]

The Minister will be aware that in the Government’s response to the Archer report, certain documents are described as “misplaced”—they no longer exist or can be found. Do they have any bearing whatever on the analysis, and if they were discovered would they correct it in any way?

[Anne Milton]

I thank my hon. Friend for his question. We are talking about a long time ago; that is the trouble. I know that campaigners have been concerned about cover-ups, and that not all the documents have been released. I assure him that officials have told me that all documents have been released, but somewhere in the back of a cupboard, somebody at some point might discover more. It is a mistake to think that there is any conspiracy, however. I do believe, in all honesty, that previous Governments and the current Government have done, and continue to do, all that they can to ensure that all information is in the public domain.

As the consensus on the virus developed and technological advances occurred, the Government and the NHS moved quite quickly to address the risks. Heat treatment was introduced in 1985, and that effectively killed the hepatitis and HIV viruses. Validated tests for screening blood donations were also introduced. Since then, Governments have introduced a number of important safeguards to protect the blood supply, not least, as we heard today, from newer risks such as new variant CJD. We carefully assess, and shall continue to assess, all new evidence as it comes to light, and we now have EU directives that set standards of quality and safety.

I fully understand again the financial difficulties that many of those affected by contaminated blood products face. I have met some of them, and they have told me in some detail of their extraordinary experiences of living with the aftermath of infection. Not only were many of them infected, but they went on to infect their partners. They are, understandably, very concerned about their own and their family’s financial security, and they look to the Government to provide a degree of certainty in the years ahead.

Going—what may feel like—cap in hand to the state is demeaning, I know, but it is worth laying out the financial settlements that are currently available. Those infected with HIV receive a flat-rate payment of £12,800 per year, and they may also be eligible for additional discretionary payments. In the year ending April 2010, the average total payment to an individual infected with HIV was £17,400, although of course some received less and some received more. Those infected with hepatitis C are eligible to receive an initial one-off lump sum payment of £20,000 when they develop chronic infection. Despite contracting the virus, some people will make a full recovery, but many do not and go on to develop serious liver disease. For that group, there is a second one-off payment of £25,000. All those payments are tax-free and not used when calculating an individual’s eligibility for state benefits. Therefore, if they were unable to work for health reasons they would receive those benefits, but I take the point made by the hon. Member for Kingston upon Hull North (Diana R. Johnson).

The independent public inquiry on NHS-supplied contaminated blood and blood products, chaired by Lord Archer of Sandwell, investigated the circumstances surrounding the supply of blood products. It made several recommendations, the majority of which are in place in one way or another. However, a small number of recommendations have not been implemented. These primarily relate to aspects of the ex gratia payments, free prescriptions in England, and access to insurance.

I have instigated a review of those recommendations to see what more can be done. I know that hon. Members would love me to finish that review before Christmas. I will do what I can in the time available; I know that time is of the essence. The review will be conducted by Department of Health officials, but with the support of relevant clinical experts and external groups. The terms of reference should be in the Library. At this stage, let me put on record that I will place in the Library how the costs of implementing the Irish scheme in the UK were arrived at. I know that that has caused some concern, but I will come back to it, because time is very short.

I do not have time to go into detail on what happened in Ireland, but it is important to place on the record that in an article in The Irish Times—I will ensure that this is also in the Library—Brian Cowen, then Minister for Health and Children in the Republic of Ireland, and currently Taoiseach, confirmed that the Irish Government knew in 1995 that the Blood Transfusion Service Board had been negligent and had attempted to conceal that fact.

Epilepsy Services

John Pugh Excerpts

Tuesday 12th October 2010 Westminster Hall

[Dr John Pugh (Southport) (LD)]

I congratulate the hon. Member for Blackpool North and Cleveleys (Paul Maynard) on speaking in such a personal and informed way. With your indulgence, Mr Streeter, I welcome the new shadow Health Secretary, the right hon. Member for Wentworth and Dearne (John Healey), to our midst. I congratulate him on his party’s endorsement of him. Achieving such a position in the rankings can only be a reward for the competence and ability shown over a sustained period.

Flattery aside, epilepsy is one of the oldest diseases known to man. It has affected many celebrated and distinguished people—not only the hon. Member for Blackpool North and Cleveleys but Julius Caesar and Dostoevsky, whose book “The Idiot” contains the best literary encapsulation of what it is like subjectively to experience the condition. However, for many people, it is a profoundly socially debilitating experience. My first encounter with it as a fact of life was when I was a child in primary school in Maghull. On my way to school, I walked past what was in those days called an epileptic home, where it was not uncommon to see the rather distressing sight of a man—he seemed quite elderly, but was presumably younger than I am now—lying on the floor while his workmates gathered around him, spoon in hand to stop him swallowing his tongue.

The presumption in those days was that epilepsy debarred people from a range of activities. Those men were obviously considered suitable only for farm labour and lived, as I said, in what was then called an epileptic home. It is now a nice flat development; care has moved on. Things have improved enormously, largely due to the intervention of drugs, better neurological understanding and the involvement of patients and patients’ groups—I think the hon. Member for Blackpool North and Cleveleys alluded to the expert patient programme. People have become better at controlling the condition and, indeed, at preventing seizures within the condition. These days, many people who have epilepsy do not actually have seizures.

However, when we consider the provision available for the condition, it is manifest that we need centres of special excellence, such as the Chalfont Centre and the Walton Centre for Neurology and Neurosurgery NHS. There is a high rate of misdiagnosis and epilepsy is not a subject on which even an acute hospital always has the relevant or best expertise. It is also clear that the prevalence of the condition means that specialist support has to be available locally in the acute environment and in the community. Nurses need to be able to give the patient the support that they need. That is particularly the case for children who, of course, are not expert in their condition. Such general provision is needed to improve diagnosis and treatment, to control symptoms and to provide advice. As well as doctors and specialists, nurses are clearly crucial, and that was, in fact, the theme of the hon. Gentleman’s comments.

My research on the subject so far has clearly shown that treatment is a lottery for patients across the country and that access to centres of excellence varies. Appointment times, local commissioning and support differ from primary care trust to primary care trust. Such is the variation that the Minister of Health in the previous Government suggested that strategic health authorities should be asked to review their provision because the statistics were showing that 64% of PCTs had no specialist nurses, and there was a 20% to 30% misdiagnosis element in treatment. It was also said that there were 400 avoidable deaths. I am not sure how that figure was established, but appreciable costs are obviously involved in suing—I have seen £138 million and £183 million mentioned. There are different figures given on that, but clearly the amount concerned is substantial and we need to take the issue seriously, particularly in a time of austerity when resources are perforce stretched.

I hope—the hon. Gentleman certainly shares this hope—that, as we gravitate towards GP-led commissioning, some of those ills will abate and the situation will improve. Presumably, specialist neurological services will be a matter not for local PCT commissioning, but the national commissioning body. However, it is not entirely clear how good or able such a body will be—whether it will be in a strong or weak position—to deal with the matter.

In terms of tracking parliamentary answers, many of which have been provided by the Minister or his officers, no information is collected centrally on specialist appointments or on readmission rates. There is also no information available on the destiny of specialist nurses—how much time they spend performing their specialist function and to what extent they get drafted into other work. There may be enough evidence for a national commissioning body to do a good job and produce the right kind of service across the country to the satisfaction of the hon. Gentleman and all other epilepsy sufferers, but it is not currently apparent that the data are there to allow that to be done.

In addition, it cannot be assumed that all GP commissioners would be able and willing to commission well. I was interested in what the hon. Gentleman said about his journey of moving from one doctor to another, and the expertise being available in one practice as opposed to another. There are quite good reasons why GP commissioners and GPs themselves might not be able to field every episode of epilepsy to everybody’s satisfaction—for example, they might have limited clinical experience or be new to the profession. On the basis of the statistics I have seen—I have put them to some use and come up with a figure—I calculate that most GPs probably have on average around 10 patients who suffer from an epileptic-like condition. GPs might not see many people with such a condition very often at all.

So how do we ensure that GP commissioning is, as we all hope, better and not worse than PCT commissioning? I think we all recognise—indeed, the previous Government recognised—that PCT commissioning was by no means perfect. Monitoring GP performance is particularly difficult because epilepsy sufferers are very much a minority. It is not clear who will monitor how well GPs are dealing with the matter. After all, GP performance monitoring is currently done by PCTs and, clearly, GP monitoring that is done by GPs might not be as good as GP monitoring done by others. The legislation does not make it entirely clear how big GP commissioning bodies will be, but presumably they will be on a smaller scale and have fewer resources than the PCTs that they will replace. That is an issue.

When the new regime appears, how will we get improved commissioning, so that there is not a repetition of the problem of a minority condition not being treated particularly well? The Department of Health has a mantra that goes something like this: commissioning is a matter for local decision making and the Department will not tell local commissioners how to do it. However, it will judge them against a quality framework and assess how well they are doing it. I think that the expression is that GP commissioners will be “held to account” on how well they deal with epilepsy as a condition.

That is fine by me. I am very comfortable with that being done—it certainly should be done and I think that the hon. Gentleman will be very comfortable if that is done—but what does the expression “holding to account” mean? The phrase is relatively undefined and I can think of about three different meanings I could give it. The Minister can perhaps tell me which definition is right. If a GP commissioning body fails to perform well in dealing with this chronic complaint, does “holding to account” mean that they will simply be named and shamed? Does such an expression mean GP commissioning bodies will be financially penalised, which is another way of being held to account—if someone does not do the job they are supposed to, they will lose resources as a result; or does the phrase mean—this is the third definition—that GP commissioning bodies will be overruled? The actual task of holding to account is important and it is vital we are precise about what we mean by that. Unless we get the right profile locally, talking a good game here will not make much difference.

In holding GP commissioning bodies to account, we must ask ourselves not only how the issue is examined, who examines it and what they then do, but from where the information comes for such an examination. In other words, five, six or seven years down the line, if we have to examine how one local commissioning body performs compared with another, will the only way to do that be by asking that commissioning body to mark its own papers and provide data of its own choosing? Clearly, that would not be adequate or satisfactory. Those are fair questions.

I think that the Minister and all hon. Members here want progress in dealing with this chronic condition. We do not simply want frameworks, guidance and detail here and there of what should be in place—the hon. Member for Blackpool North and Cleveleys used the phrase “decorative features”—without there being a hard-edged attempt to ensure that what we believe should be in place actually is in place. I conclude by simply pressing the Minister to say what will happen when a GP commissioning body performs less than adequately. Who will do what, when and with which data? That is not a trivial question; it is important to all epilepsy sufferers.

--- Later in debate ---

[Owen Smith (Pontypridd) (Lab)]

I thank the hon. Member for Blackpool North and Cleveleys (Paul Maynard) for securing this debate, and for speaking so eloquently and passionately. I do not hope to speak with his expertise, but I do have some expertise, inasmuch as I have a close family member—a brother—who has suffered with epilepsy over the past 15 years. I have some insight into the nature of the difficulties that he has encountered, the problems in the current NHS system, and the issues that emerge in dealing with this chronic but particular condition in that system.

My brother is one of the 500,000 people in this country who have epilepsy. They are a minority, but a significant one—that is a lot of people. He is also one of the 50% of the 500,000 who are not seizure free: he has had a seizure every month, if not every week, for all of the past 15 years. That has had a dramatic impact on his life in terms of what work he is able to do, the energy he has, and the fear that he lives with, which the hon. Gentleman described so eloquently and which all people who have epilepsy have to contend with on a daily basis, of sudden unexplained death as a result of the condition.

That is my interest. It has given me an insight into issues that have already been raised today about the postcode provision, to use the vernacular, that exists across the NHS. We have a fragmented NHS, particularly in respect of epilepsy. That is the case for many other conditions, but it is particularly true for epilepsy. The phrase “Cinderella condition” is rather overused in the press these days, but epilepsy is one of those conditions. We can genuinely say that it does not have the high profile that it ought to have and therefore does not receive the concentration that it should.

There is clearly fragmented, unequal distribution of expertise in the NHS in terms of general practitioners, who, as the first point of call for anyone suffering with epilepsy, are critical, and nurse specialists. I believe that that is widely recognised. Like the previous Government, the current Government recognise that specialist nursing for epilepsy is under-resourced in this country and, equally, that it is an extremely important means of redressing the problem of insufficient provision of expert GPs.

It is clear that there are few centres of excellence for epilepsy in this country, and, therefore, that people such as my brother, who lives in Wales, have to travel long distances to hospitals or other centres of excellence for prolonged examinations to monitor brain patterns. He, too, suffers from nocturnal epilepsy, and therefore needs to be studied in clinical conditions in hospital to try to determine the nature of his condition and what resources might be brought to bear to alleviate it.

I, too, have some fears about the extent to which the creation of the new GP consortiums will exacerbate the problem of fragmentation and inequality of provision across the country. I can accept that, in areas where there are GPs with a special interest or particularly strong centres of excellence, there may be a beneficial effect in massing GPs together and spreading their expertise through a wider network. Equally, I can see significant potential for unintended dangers if we do not have GPs in those consortiums and we have a diminution of control over, and certainly insight into, their activities. It is unclear what the sources of commissioning will be, and who exactly will be commissioning specialist services. That has yet to be clarified, and I look forward to the Minister’s giving us some greater insight into that.

Another thing that I worry about in respect of consortiums is data. We have poor data on epilepsy: how many people suffer, the nature of their condition, how often they attend hospital, how often they are treated for acute episodes. Perhaps if their condition had been managed more effectively, it would not have reached that point. I have tabled numerous parliamentary questions about that recently, and all the answers confirm that we do not gather enough data.

There will be a further danger that we will not gather data if we fragment the NHS to the extent that is proposed with the creation of the consortiums. I hope that the Minister will give us some reassurance that information gathering will be a priority, whatever the structural make-up of the NHS, and that we will continue to see that critical piece of the jigsaw applied in respect of epilepsy care. In recent years, we have seen data gathering become an important tool for tackling other chronic conditions, notably cancer.

I worked in bioscience before coming to this House, and therefore have some insight into the science around epilepsy and the economics around the production of medicines. Prescribing of epilepsy medicines seems to involve a form of Russian roulette because our understanding of this neurological condition is deeply imperfect. For example, my brother has been through 11 or 12 medicines and combinations of medicines. Doctors still employ what is pretty much a hit and hope strategy. Perhaps I am being slightly unfair, but I believe that many epilepsy experts recognise that they do not really know which medicine will work, and therefore they try various drugs until they find the one that works for their patient. In my brother’s case, and in the case of 50% of sufferers, they often do not find the one that works, and we get into the more complicated issues around whether surgery is required.

Generic substitution is clearly an issue. We all understand that we need to make savings, and the importance of substituting generic medicines for the original brands when they are available.

[Dr Pugh]

The hon. Gentleman made a good point about data, which is worth repeating. However, there must be data on every episode dealt with through acute hospital care. His Government introduced the tariff system. Therefore, in some shape or form, the data are there—they just do not appear to be available for clinical purposes.

[Owen Smith]

The hon. Gentleman is absolutely right, and I have recently had answers from the Government about that. It is not simply a question of gathering the data. The NHS is a wonderful sponge, soaking up data. The critical thing is wringing it out and employing data to improve services. Epilepsy is a condition that has not been concentrated on, and therefore there is no emphasis on garnering data.

We must be careful about generic substitution of epilepsy drugs. I know that many sufferers agree with that. Another point is that genericisation of a market in medicines leads to changes in the economic incentives for research and development companies to produce them. There clearly are not incentives for companies to produce new epilepsy drugs. That is inevitable because of the large number of epilepsy medicines, many of which are effective, and many of which have been genericised.

Part of the answer in fixing markets that are not working has to be Government intervention to try to improve incentives. The previous Government were making effective inroads through the innovation fund and the innovation pass that they were negotiating with the pharmaceutical and biotechnology industries, which would have encouraged and incentivised further R and D into more recondite diseases and the production of medicines where there is not an immediate economic incentive.

I was therefore discouraged to hear that the innovation pass is being abandoned by the Government—it will not be taken forward. I would like to hear some reassurance from the Minister that he is aware of the issue and interested in looking at how he can work with the pharmaceutical industry to incentivise further R and D into those areas where this country does not perform well. Epilepsy is one of them. We have a higher incidence of unnecessary death from epilepsy, and, bluntly, we do not prescribe terribly well for it. It is an area where we could produce more and take advantage of the great skills in the pharmaceutical industry, and where the Government could have a positive impact.

--- Later in debate ---

[Paul Burstow]

The hon. Lady makes a very important point. I was talking about using the data to improve standards, but we also need to ensure that, through NHS information prescriptions, we provide better and more timely information to people. Further work is also necessary in that area.

A message that comes through strongly is that commissioning is key to better epilepsy care. We believe that placing decision making much closer to the patient through general practice consortiums will unlock new opportunities and lead to more sensitive and responsive decision making about care and treatment pathways. Some patient groups and some hon. Members in this debate have expressed concern about the experience and knowledge of GP commissioners in designing epilepsy services. Let me say a little more about that.

The NHS commissioning board will have a vital role to play in supporting consortiums. It will set commissioning guidelines based on clinically approved standards developed by the National Institute for Health and Clinical Excellence. In addition, the long-term conditions delivery support team will work closely with new directors of commissioning, their commissioning boards and GP consortiums to build skills and awareness. For example, the team has already developed a new commissioning pack, bringing together information that commissioners will need to design good epilepsy services.

My hon. Friend the Member for Southport has asked me, within about four days of the close of consultation on the White Paper, to describe in full and complete detail every aspect of the new accountability regime for the new system. I will not do that in the debate today, because that would not do justice to the 5,000 respondents to the consultation. The Department is in the process of properly considering the responses to the consultation and we shall give a considered and proper response. What we have done so far is set out clearly the direction of travel and reform. I think that my hon. Friend has conflated two or three things in his test of accountability: professional accountability, accountability to the public and accountability to other organisations. We will make clear, when we set out the next steps to the reforms that we have proposed in the White Paper, precisely how each part of the accountability conundrum that he posed is properly addressed.

[Dr Pugh]

I thank the Minister for that response. He has spoken about frameworks and about commissioning standards. I hope that he will go on to speak about what happens when the frameworks are not in application and when the commissioning standards are not observed, for whatever reason. The only thing that I have heard him say so far is, “We’re going to have a competitive local environment. People can vote with their feet.” That is an awfully London-centric view, because in many areas of the country, that is not a realistic option.

[Paul Burstow]

I think that my hon. Friend perhaps needs to reflect a little further on the White Paper proposals and what I have said in the debate, because what we are actually talking about is not competition in terms of people always choosing to go somewhere else, but in terms of the ability to see what somewhere else looks like and make a comparison and to ask commissioners locally why they are not commissioning to the same standard. It is as much about that as about being able to move around the country, and certainly that is what we are determined to deliver.

Accident and Emergency Services

John Pugh Excerpts

Tuesday 14th September 2010 Westminster Hall

[Dr John Pugh (Southport) (LD)]

It is a pleasure to serve under your chairmanship, Ms Clark. I understand that this is your first time in the Chair, and you are to be congratulated. Obviously, years of fierce political independence have finally paid off.

The subject today is accident and emergency provision. We have to accept that most TV hospital dramas are set in casualty departments, in the same way that most soap action seems to take place in pubs. That is not simply because they are eventful places, but because they are actually very varied places. Traditionally, every hospital has a casualty—an A and E—and it traditionally confronts a whole range of varied cases, from major trauma to self-referred cases of all kinds. Some people are anxious and simply need assurance, and some are anxious and genuinely need treatment. A and E departments also deal with the self-inflicted consequences of over-indulgence in legal or illegal drugs. Alcohol is, of course, regrettably an enormous source of business to A and E departments. Too often, the people who come there repeatedly do not get precisely the kind of treatment that they require and need. A and E departments also deal with simple things such as sprains, breaks and simple mishaps. They deal with mental health cases of all kinds—cases showing a greater or lesser degree of urgency.

What all those cases have in common is the factor of urgency. A patient either needs treatment urgently or urgently feels—which is not quite the same thing—that they need treatment. In some cases, regrettably, people are simply too impatient to seek treatment that they could get in good time elsewhere.

I have made three visits to casualty departments over the past three or four years. All of them have been different in kind. In one case, I had pins and needles in my left arm, which my wife persuaded me was an incipient heart attack. I went to casualty, was given a good grilling, and was gently diagnosed as having pins and needles in my arm. As for the second time, for reasons we will not go into, I had hit myself on the head with an iron bar. Again, I was simply checked out for a large bump and a haematoma, which had no lasting consequences—or none as far as I can tell. More critically, having had an accident in a car on the M1—I was not driving—I accompanied my daughter to an A and E department in Northamptonshire. In none of those cases did I receive any treatment, but each case was, in a sense, different. Treatment in an A and E department can be very different. It can vary from massive defibrillation to a gentle word of advice; from simply a conversation to a major life-saving intervention.

The bottom line is that A and E departments are everybody’s community back-stop. It is their security; knowing that there is one in their town is crucial to a lot of citizens. As what is in an A and E department varies, they are very hard to assess by any normal yardstick or benchmark. They require a whole formidable range of skills. The skills to deal with someone who has had a cardiac arrest differ markedly from those that might be required if someone wanders in in a confused or deranged state. A and E departments have tried to deal with this informally and internally by, to some extent, organising their work streams in different ways. My local A and E department in Southport used to have a colour-coding system. One would be told what colour one was, and attached to that colour was an expected waiting time. One knew where one was, in priority terms. There was—and there still may be—the expectation, and maybe the hope, that the patients, the users of the service, would appreciate that kind of prioritisation and understand what it is about. After all, nobody wants to wait for a long time for something they themselves have defined as urgent care. Unhappily, in many hospitals some of the customers—if I can use that inappropriate term—do not always feel that they ought to wait as long as they should, even when there are higher priority cases being dealt with.

Recently—this is where the trouble starts—within the NHS there has been an attempt to disaggregate work streams. There are two reasons for that. One is that it is thought that A and E departments are dealing expensively and inappropriately with all sorts of cases that could be dealt with better in other settings; or that doctors are referring cases to A and E departments in circumstances where references should be made to other facilities or alternatively dealt with by the doctors themselves. Secondly, there is a raft of very good research that shows that in the case of the most severe traumas, the most critically injured and sickest patients are better dealt with at a major trauma centre that is kitted out and has all the facilities and expertise necessary to deal with the problem. We all have to recognise that there is quite a lot of empirical research about survival rates that points in that direction.

The net effect of both those thrusts is that across the country there has been a downgrading of many A and E departments at many district general hospitals. Given that they are the community back-stop for many people, there is significant alarm attached to that. One notes, in Health questions and so on, that that is a common refrain. The situation is aggravated in many cases by the fact that the NHS, by and large, disowns any interest in transport arrangement. Having reconfigured services, it does not think too hard or too long about how people will get to those services. Superimposed on that is a degree of political manipulation of the proposed changes, because they are politically very sensitive. We have had an independent MP elected to this place purely on the back of the reconfiguration of such services.

In many cases, there is an attempt to think the matter through, and to soften the change and manage whatever changes are deemed necessary by means of the introduction of community facilities—walk-in centres, minor injuries centres and urgent care centres. That is a fine expression: urgent care centres. I think people respond positively to that. How and whether those changes happen in individual places seems to be a matter of chance, or certainly not a matter of clear planning. Across the country, we get a haphazard, patchwork system of urgent referral, if I can call it that. That is localism, if we can call it that. The Government have a responsibility here to set a standard. The public may accept that major trauma services sometimes require, even in these days of telemedicine, to be concentrated to be most effective. What they will not accept, and should not, is a longer journey for basic urgent care. That, sadly, can be what they get.

I want to emphasise that point by giving an extreme example in my constituency. In my town, as a result of a report that divided the spoils between two sites in a single hospital trust, children’s A and E facilities were taken 9 or 10 miles down the road to a smaller country town, Ormskirk. Adult A and E remained in the town and is still there. We have an odd configuration, with adult A and E and children’s A and E in two different places. The net effect of taking children’s A and E out of a town as large, and with as many children, as Southport was one of mass outrage. There were major demonstrations, huge petitions that were handed in at Downing street, and the kind of documents that eventually wash up on a Minister’s desk. People recognised that a genuine problem had been precipitated by ill-advised reconfiguration. Successive primary care trusts acknowledged the problem and endeavoured to deal with it. Southport and Formby PCT, when it still existed, endeavoured for some time to progress what it called a health village, which would have had a minor injuries unit. The PCT got £500,000 for it and was going to proceed with it, but, unfortunately, it was abolished, and the hopes of the people of Southport were, pro tem, crushed.

The new, successor PCT discovered exactly the same thing as the previous PCT—that there was a huge, yawning gap in service provision, which nobody could quite explain rationally and which needed to be addressed in some way. The new PCT made progress towards establishing a minor injuries, or walk-in, centre in Southport. The PCT involved stakeholders, as the previous PCT had done, as well as parents and various groups and political representatives in the town. We should bear it in mind that that was done to address only some of the issues precipitated by the reconfiguration.

It was absolutely unthinkable to people that a large seaside town would have to tell children who had had any kind of accident, such as falling over on the rugby field, hurting themselves in the street or whatever, to leave town in a taxi or in their mother’s car, supposing that she had one. People thought that that was wholly irrational, given the talk these days of bringing services closer to the community.

For two years, we spoke to the PCT. For two years, we had meetings. For two years, we planned the new centre. Then, a few weeks ago—to some extent, this is what precipitated my calling the debate—we suddenly found that the PCT had commissioned a report saying that the centre could not go ahead. It argued that the viability of the out-of-town, Ormskirk-based paediatric A and E required there not to be a walk-in centre in Southport. It argued that the costs were prohibitive and that what is done in many other places—such as Solihull, where two hospitals have exactly the same arrangement as Southport, but deal with the matter very differently and more sensitively—cannot be done in Southport.

As is often the case when someone needs a report to make their case, the PCT amassed a set of statistics, which have been questioned. It spoke to witnesses, all of whom were hand-picked to take a relatively adverse tone and not to be enthusiastic about the project. It presented shaky arguments, and as is often the case on such issues, it confused financial viability, which is a completely distinct, although important issue, with clinical safety, which is a different and separate issue. It did not bother to consult the local council’s overview and scrutiny committee. It spoke to GPs, but it did not consult the GP body. The result is that the public are absolutely baffled as to why we cannot have a sensitive and sensible set of clinical networks for children, based partly in Southport.

It is not just the public, but schools that are baffled. What do they do in the middle of the day if a child falls over in the school yard and someone has to take them not to a local facility, but to a facility outside town? In the past day, I have had constructive and helpful discussions with the Secretary of State for Health, and my views, far from being outrageous, strange and madly populist, are actually quite sane and rational, and it is legitimate that the PCT should take them into account.

The PCT’s report set out to answer a fundamental question, although, significantly, it failed to answer it: if a mum or grandmum finds that a child whom they are caring for on that day has fallen over and hurt themselves, and they think that an urgent attempt should be made to get the medical advice that is probably required, why the heck should they have to think through getting an expensive taxi, finding a neighbour to ask for a lift or doing something else that most people in less deprived areas do not have to do? I use the word “deprived” quite deliberately because although Southport might not be defined as generally deprived, we are deprived of a resource that is widely available elsewhere.

I hesitate to argue with clinicians, and I do not know a great deal about clinical matters, but I do know something about logic, and I am fairly confident about what I know. I am confronted here with the perverse argument that if we are to have a state-of-the-art clinical facility outside town—it is suggested that it must be there because it needs to be a specialised, full paediatric facility—that can dedicate itself to playing an important role in dealing with certain things, we cannot have run-of-the-mill care in another place to deal with the ordinary hazards of childhood life. We are told that if services are to be centralised in Ormskirk, it is necessary to have no services anywhere else. That does not follow at all, because it contradicts one of the basic premises of moving A and E services in the first place—that they should not be bogged down by, or confused with, minor injuries services and that they should be fielded closer to home.

It has been suggested that if what I am saying is the case, people should have nothing in Southport and should simply go to their local GP, but that presupposes some important things. It presupposes that every GP offers the kind of service that I have outlined, which is not the case. It also presupposes that everybody has a GP. People might or might not know this, but Southport is a seaside town, and a number of children arrive every week and every weekend simply to enjoy themselves. They do not have a GP in town. If they hurt themselves on the beach, they do not expect to be told, “I’m sorry, there’s nothing in this town for you. You have to go somewhere else.” That is an absolutely absurd scenario. Southport should provide assurance, triage and a diagnostic base for the worried mum, grandma or teacher who does not necessarily need a blue-light service, but who, in most other parts of the country, would be the sort of person to turn up in A and E.

The people of Southport are no longer uninformed about the issue; they have an intelligent grasp of what is required, but they have difficulty getting their point across to the NHS quango that disposes of the resources and commissions the facilities. The general direction in the country should not be that clinical networks are designed on the assumption that children, patients and parents will travel indefinitely—at any time, to any place—but that clinicians should not.

I do not need it spelled out to me that there are constraints on finance in this age of austerity; finance is always an issue. Equally, it is perfectly valid, particularly in paediatrics, to say that there are chronic staff shortages in various parts of the country. The lady who did the report that was so useful and helpful to my local PCT told me that the situation is so critical in paediatrics that any new facility is almost a threat to any existing facility. However, that presupposes that the provision and availability of staff, as well as demands for them, are the same right across the country. I would take some convincing that we cannot staff a modest facility in Southport and that we must sacrifice any basic care just to keep a unit down the road going.

There is a genuine need for local commissioners to think further about this issue, and, encouraged by my discussions with the Secretary of State yesterday, I am convinced that they will. I am convinced that some of the points that I have tried to get across today have got across—albeit the hard way—to local commissioners. There are, however, two important general issues, on which other Members might wish to comment, that arise from that case and from others with which I am familiar.

First, there is the general issue of standards. Where, amid all the reconfiguration that is going on across the country—we think that we understand some of the rationale behind it—is the baseline standard for urgent care that we can expect and accept in the UK? Clearly, it will vary between urban and rural populations, and with the age of populations; demographic factors will kick in. We set standards for waiting, and most of us believe that such a standard should be set, although as hon. Members will appreciate, there have been all sorts of problems with the gaming that sometimes results from that, and with the difficulties generated. We should also set a standard for access; I am afraid that we are forgetting that in all the reconfigurations across the country that have been carried out on the basis of clinical advice. Someone cannot wait for a service that is simply not there. That is one issue raised by the Southport situation, and others.

The second issue, which is also absolutely pivotal, is democratic accountability. What levers does a community, which ultimately pays for the local NHS in one form or another, have when its requests and demands persistently, and in some cases unreasonably, go unheeded? I am not calling for some type of naked populism; I can understand the concern of anyone in the NHS. We all tend to do things on the basis of what the crowd may or may not call for in all circumstances, but the NHS trusts are often confronted with a tension between how they want to deliver a service and how the population wants to receive it. That is certainly the case with paediatrics in the Southport and Formby area.

The Minister might advise me to the contrary, but I do not think that that tension will necessarily go away if GPs hold the purse strings; it may just appear in another form. All clinicians, I think, have a predilection, for a combination of personal, genuinely clinical and philanthropic reasons, for delivering any care in an optimal clinical environment, and we cannot afford that everywhere. To some extent, that will always conflict with access issues. I sometimes think that doctors’ heaven would be a massive all-capacity ward in the middle of Birmingham, with expressways joining the city to all parts of the UK in under 20 minutes. That is the implicit model behind some of the thinking that I have heard. In the real world, however, we cannot get that, but there is another way of doing things: having well-understood clinical networks with appropriate protocols. Designed in the right way, such networks can be just as safe. In their absence, we will get continual tension between communities and the local NHS on such issues.

I genuinely think that there is a democratic deficit of sorts here. If I may hark back to the subject without it being too tedious for hon. Members, who may have lost interest in the topic—I hope that they have not—a genuine tension can be almost felt in my constituency. Over the past few years, what we have had is not no expenditure but too-large Darzi clinics, which we struggle to fill; people wonder how they came about. Equally, there is something that we dearly want, and the PCT has twice let us down over it. One can stop any individual in the street in my town and hear their anger about the facilities that they would like. They are not asking for utopia; they are just asking for obvious deficiencies—in children’s services, in this case—to be corrected. I simply ask: why does this have to go on?

--- Later in debate ---

[Anne Marie Morris (Newton Abbot) (Con)]

This has been an interesting debate and I commend hon. Members on their contributions. It is clear that accident and emergency is close to all our hearts. I am particularly blessed with two very good district general hospitals—one is at Torbay and the other is the Royal Devon and Exeter hospital. I am extremely fortunate. However, there are three minor injury units in the smaller towns of Newton Abbot, Teignmouth and Dawlish. The challenge for me is in many ways an echo of the points raised by my hon. Friend the Member for Southport (Dr Pugh). Clearly, the issue is access. I am concerned to ensure that we use the minor injury units to their fullest extent. For my constituents the journey to Torbay or the Royal Devon and Exeter is quite a long one. My concerns, on which I hope the Minister will look favourably, are that we should think about making better use of the minor injury units. If we do so, we shall help the overall NHS budget very much.

I do not know how many people realise that the number of people who attend A and E is growing faster and faster. In just the past three months of this financial year, 5.49 million people have been seen at A and E. Mathematically, extending that over the year gives a figure of 22 million people visiting A and E throughout the country. That breaks last year’s record of 20.5 million. Such a figure would mean 40% of the population visiting A and E at least once, assuming that each individual who visited was responsible for only one attendance. That is a huge figure. The challenge for the Government and the country, given the current economic climate, is how we afford that. One of the issues is the number of people who inappropriately attend A and E—not through any fault of their own.

Just going through the door at an average hospital costs the NHS £100. By comparison, the average cost to go through the doors of a minor injury unit is £50. Those figures are averages, but the cost differential is significant.

[Dr Pugh]

The hon. Lady has mentioned the statistics and the increased number of inappropriate self-referrals. She is probably also aware, because she is extraordinarily well informed on the issue, that GPs are referring more people than hitherto to A and E. Therefore primary care—the GP setting—is not the answer. The answer is probably the minor injuries unit.

[Anne Marie Morris]

I thank the hon. Gentleman for that valuable contribution; I agree with the earlier comments that the answer is probably an appropriate network of different provision. However, we need that to be clearly signposted. That is the way forward.

The challenge for the Government and the Minister is to quantify the percentage of people who present at A and E who would be better dealt with in, for example, an MIU. People have tried to quantify that, but the figures vary wildly, from 60% to a more modest 10% to 30%, which is the latest finding of the Primary Care Foundation. Further work on that would be very worth while. However, the Minister could sensibly consider several steps now, even before that investigative work, to examine how we can manage A and E attendance more effectively. The figures show that 20% of presentations at A and E are alcohol-related. We all know that is a huge burden on the NHS and the country as a whole, because of crime and other issues. Minimum alcohol pricing and improving education in schools might make a significant difference to the Minister’s problem.

Secondly, I suggest that the Minister and his colleagues consider the availability of other services, such as dental care, in communities. Often, it is because there is not adequate NHS dental care that patients present themselves at A and E units. A and E services are cheap, they are there, and they are now. If we could fix that situation it would make a big difference. Such problems cannot be the right reason to attend A and E. Although the PCTs have tried to assist the public’s understanding of where to go for which service, it is abundantly clear that they have failed. People know about 999 and A and E, and that is where they go. We need to find a much more effective way of educating them. I commend the Minister on the commencement of the 111 service, which is excellent, if we can educate people to use it appropriately.

The Minister might also like to take into account how we give prominence to and promote MIU services. However, to do it effectively we need to ensure that across the country everyone knows what the service is and that it is consistent—for example, that opening hours are consistent. In my constituency, it depends on which MIU someone attends; if they turn up at Dawlish after 6 o’clock, the door will be closed, but that would not be the case if they turned up at Newton Abbot. It is equally bizarre that for someone who needs an X-ray, the X-ray unit is not coterminous with the MIU opening hours. Those are exactly the sort of things that put people off going to an MIU. In that regard, some steps forward would be extremely helpful.

If I may, I shall take the opportunity to refer to a couple of helpful things that my local health community is doing in my constituency. First, in Torbay hospital, local GPs attend A and E at the point of entry, so, rather than going through standard A and E routes, some patients see GPs, which reduces costs. The second good initiative in my constituency comes from our mental health practitioners recognising that, often, a stay in hospital is extended because someone has the symptoms of depression. Devon Partnership NHS Trust, which is responsible for mental health care in my constituency, has placed mental health care practitioners in hospitals to assess individuals, and, as a result, is beginning to reduce the time that individuals stay.

I am grateful to hon. Members for their contributions and to the Minister for his attention. I commend to him the idea of looking further at consistency in MIUs, how to reduce alcohol-related admissions, using mental health care practitioners to reduce the length of stay in A and E, and making other services, such as dentistry, available, as they should be, to avoid people unnecessarily going to A and E.

[Dr Pugh]

On alcohol-related admissions, which the hon. Lady mentioned twice, one problem that besets many A and Es is repeat customers—chronic alcoholics who appear again and again. Clearly, alcohol pricing would make little difference to them, so a linkage between A and E and other services in the community is normally required in those contexts. In many parts of the country, that linkage simply does not exist, which creates repeat custom for A and E.

[Anne Marie Morris]

I have finished my speech.

--- Later in debate ---

[Gordon Birtwistle (Burnley) (LD)]

Thank you, Ms Clark. This is my first time in this Chamber, and I hope I succeed as well as you will no doubt succeed in the Chair. I congratulate my hon. Friend the Member for Southport (Dr Pugh) on securing the debate.

In Burnley, we have been fighting for over three years to resolve a major problem with our A and E. I shall give a brief history of the area, which is Pennine Lancashire and includes Burnley, Pendle and Rossendale. Not many years ago, we had five hospitals. That was reduced to one, which was a very successful, well-loved and well- thought-of hospital—Burnley general. Over the past three years, it has been decimated, and the A and E has disappeared. The hospital covers an area—Burnley, Pendle and Rossendale—with a population of more than 250,000, and the A and E services have been moved to the Royal Blackburn hospital, which is brand new, built in Blackburn, and, I believe, built for the area that Blackburn covers. It is attempting in some way, shape or form to cope with the extra influx of people travelling over from Burnley.

Our A and E was changed to an urgent care centre. What an “urgent care centre” is, nobody seems to know. I certainly do not know, and when people ask me what “urgent care” means, I say, “Well, if you need it urgently and you need some care, that’s where you must turn up.” They say, “Well, what’s the difference between that and an A and E?” That debate is still going on in Burnley, and it is a question that I have asked the chief executive of the trust to answer, without much success.

This started three years ago with the “Meeting Patients’ Needs” study by Sir George Alberti, who decided that the 250,000 people in Pennine Lancashire did not need an A and E and it could be transferred comfortably to Blackburn. The vast majority of the 250,000 do not feel that they have had their needs met in one way, shape or form or even at all. Royal Blackburn hospital is constantly overwhelmed and permanently on red alert. On one occasion, it had to close the A and E due to being swamped with what I would class as patients or, as my hon. Friend the Member for Southport said, customers—

[Dr Pugh]

A horrible word.

[Gordon Birtwistle]

Indeed. People turning up at A and E were being either stored in ambulances or transferred to Lancaster, and, in one case, a gentleman came to me who had been transferred to Bury. On arrival in Bury, in his carpet slippers and cardigan, after taking his wife initially to the A and E unit in Burnley, he was told that she was being kept overnight and he could go home. When he questioned where he was, they said, “You’re in Bury.” He said, “I only went to Burnley, how the hell have I finished up in Bury? How do I get home? I’ve got my carpet slippers on, I’m in my cardigan and I’m 76 years old.” He was pointed to a taxi, which took him home at great expense. That is an example of what is happening with an A and E unit that was built some 35 miles away from the outskirts of Pendle and some 15 miles away from Burnley—the area that it is supposed to support. How on earth can it cope with the extra work? It cannot. If it could, it would not be on red alert permanently.

The misunderstanding over what A and E and urgent care are is a big concern, and I understand that the Government are looking into renaming urgent care in future, which may make it easier for people to understand. I accept that we do not need to go to a major A and E unit for a cut finger, a stitch or something like that, but major traumas happen. In fact, a major trauma happened in Burnley when an old lady parking her car in a car park that was less than 100 yards from the entrance to the hospital got her foot jammed in the car pedals and crashed into another car. Burnley hospital refused to treat her. The hospital entrance was less than 100 yards away; they brought out a blanket and covered her up, and sent 15 miles for an ambulance to take her to the A and E in Blackburn. That old lady said to me, “I wasn’t badly injured. All right, I was shook up, I’d got my foot jammed in the pedals and I’d banged my head. I’m sure a hospital this size—a hospital I’ve been proud of all my life in Burnley—could have treated me for something like that.” But, they sent an ambulance 15 miles to pick her up, took her to Blackburn to give her a check over and sent her home under her own steam. In this day and age, 2010, when not many years ago men were walking around on the moon, that is outrageous. It is totally unacceptable. Either the urgent care unit should advise people what it does at the hospital and if it is prepared to do it, or the whole A and E facility should be transferred back to Burnley.

Following on from that point, I have stood behind a campaign table outside Marks and Spencer every Saturday morning for more than 107 weeks. A petition of 25,000 names has called for our A and E unit to be brought back. We have the support of almost all our GPs, the people of Burnley and the borough council. When Sir George Alberti conducted a study, he was supposed to consult all the relevant people in the area. He consulted the borough council, and I sat in on the meeting as leader of that council. However, there was no consultation; we were presented with a fait accompli. It was almost as if he was saying, “We are moving the A and E to Blackburn and that is that.” When we asked him why, he said that in his view people in Burnley would be better served in Blackburn. I have to say that the hospital in Blackburn is fantastic. It is brand sparkling new, except for the A and E unit, which is an oversized portakabin that is stuck outside and not yet incorporated into the hospital. Therefore, the people of Burnley, Pendle and Rossendale have an appalling service. My hon. Friend the Member for Pendle (Andrew Stephenson) is also supporting our campaign to get the unit back to Burnley.

I am delighted to say that Burnley has a brand spanking new £30 million extension to the maternity unit, which has a birthing suite and all the related facilities, and we welcome it with open arms. Adjacent to that is a children’s ward, but that is now being closed down and moved to Blackburn, so we have all the facilities in Burnley for newborn babies but none for children. A child is classed as such from three months upwards, so if they are unwell when they are born they will only be treated in Burnley for three months. Thereafter, the parents will have to trail them to Blackburn, which is 15 miles away, and many of them, as the hon. Member for Hartlepool (Mr Wright) says, do not have cars. What happens to a young mother who has two children? Her husband or partner may be working or she may be on her own. How does she manage to take one of her children to Blackburn when she does not have transport? The hospital says that there is a minibus that runs from one hospital to the other. It is a joke.

[Dr Pugh]

My hon. Friend is clearly aware of the irrationality of the problem. However, he might not know that in Southport and Ormskirk, the paediatric department and the children’s A and E was moved to Ormskirk because that was where the maternity suite was based and it was felt that it was essential for the paediatric and maternity suites to go together. That is completely the opposite argument, and we are only about 40 miles away from one over in Lancashire.

[Gordon Birtwistle]

My hon. Friend makes a good point. The children’s ward is moved from one town to another because that is where the maternity suite is based. In Burnley, the children’s ward is being moved to make way for a maternity suite. It is hard to make any sort of sense of how all this is configured, who has dreamed it up and what they are going to do about it. To say the least, I am confused, and I have been involved in such matters for a long time. How on earth are the people of Burnley, Pendle and Rossendale supposed to know what is going on?

The movement of the children’s ward might not be totally linked to the A and E unit, but, none the less, it is being done against the wishes of the people and the new guidelines that have been laid down by the Secretary of State. The Secretary of State makes it quite clear that the borough council, the GPs and the people of the town have to agree to such a move. Of the 66 GPs whom I wrote to, more than three quarters have replied. One is totally in favour of the proposal, but that is because he sits on the health board, three are neutral about it and the rest are vehemently against moving not only the A and E unit but the children’s ward as well. The borough council has moved a motion opposing the proposal and the people of Burnley have signed many petitions against it.

We in Burnley demand that the children’s ward not be moved. I urge the Secretary of State to put a stop to such a proposal. Having said that, the trust is totally oblivious to such objections. I have challenged the trust to stop the move, and it is almost as if it says, “We are moving it and we don’t care what anybody says.” The trust seems to think that it is more powerful than anyone, and it takes no interest in what the people, the patients and the politicians say.

The situation is a mess. I am sure that Burnley, Pendle and Rossendale are not on their own. We have already heard that Hartlepool and Southport have the same problem. I am sure that it is the same all over the country. Torbay obviously has one hospital too many. The hon. Member for Newton Abbot (Anne Marie Morris) should keep her eye on it because it may well be closed. It is critical that we solve this problem because millions of people depend on their A and E unit and children’s ward. They need the confidence to turn up to such facilities if something happens. Deciding what urgent care does is important, but we should also be more linked to the idea of smaller, proper A and E units if we do not want full-blown A and E units across the country.

--- Later in debate ---

[Mr Burns]

As the hon. Lady will be aware, this is a coalition Government. That means merging the best practice that each party to the coalition has to offer. That is why we have adopted from the Liberal Democrat manifesto the policy of abolishing SHAs. When we unveiled our proposed reforms, which concentrate commissioning with GP commissioners and GP consortiums, because GPs are at the forefront and are closest to patients, it became clear that if we were to have proper democratic accountability with local authority involvement, the role of PCTs would be diminished to the point where it would have been a waste of resources to keep them, as their functions would be performed by other groups, such as GP consortiums and local authorities. It is a question of merging best practice to get the best solutions and provide the best health care for all our constituents.

[Dr Pugh]

Will the Minister give way?

[Mr Burns]

I will, but I am relatively short of time if I am to deal with all hon. Members’ questions.

[Dr Pugh]

It should be said that the previous Government shied away from every chance to give a decisive voice on the construction of health services to anybody who held elected office. I promoted a private Member’s Bill that endeavoured to introduce a different form of democratic accountability, but the test of the White Paper will be whether people with a democratic mandate have a voice in deciding health services.

[Mr Burns]

I am grateful for that intervention. The hon. Gentleman makes a valid point.

As we do away with politically motivated, top-down-process targets, we will focus all the NHS’s resources on what doctors and patients most want: improving health outcomes. Accident and emergency and urgent care services will be reshaped to reflect those changes in the coming years. I will outline some of our plans.

For many years, accident and emergency services have been operating under the rigid law of the four-hour wait target. How long someone waits in A and E before receiving treatment is important, of course. Not only does it affect the patient’s overall experience of care, but timely treatment generally means better and more effective treatment. However, the problem with the four-hour wait target, an incredibly blunt instrument by itself, was that it became the be-all and end-all of performance management. Such a narrow focus led to the distortion of clinical priorities. I am sure that we are all familiar with tales of hospitals admitting patients unnecessarily, solely in order to meet the target. There have even been persistent allegations that some hospitals have failed to record figures properly, undermining confidence in the whole system. I am sure that hon. Members will agree that that will not do.

From next April, we will introduce a range of more meaningful performance indicators balancing timeliness of treatment with other measures of quality, including clinical outcomes and patient experience. I trust that the shadow Minister will reflect on that. She is looking a little puzzled, because that is at variance with the shock-horror statement about targets and A and E that she made in her contribution.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 7th September 2010 Commons Chamber

[Mr Burstow]

It is perhaps worth noting that the Select Committee on Health, when there was a Labour majority on it before the election, back in March, identified significant weaknesses in PCT commissioning. In particular, it identified the lack of clinical input. Our White Paper puts that clinical input back into commissioning. When one considers that one in four of all consultations involve mental health problems and that 90% of all mental health care is delivered in primary care settings, one sees that putting the GP right at the centre is critical to better outcomes.

[Dr John Pugh (Southport) (LD)]

On the subject of consultation, what consultations have taken place with the mental health charities, either prior or subsequent to the proposals?

[Mr Burstow]

In July, I and the Secretary of State had a successful and long engagement with all the mental health charities, and we are continuing to have a dialogue with them.

NHS White Paper

John Pugh Excerpts

Monday 12th July 2010 Commons Chamber

[Mr Lansley]

Because patients will have increased choice—[Hon. Members: “How?”] Because patients will make their choices on the quality of service they receive, because the service will be free to them.

[Dr John Pugh (Southport) (LD)]

The coalition agreement pledges to introduce true local democratic accountability through citizens actually being elected on to a health board. What can the Secretary of State do to persuade me—because he has not so far—that we will have local citizens, not doctors, making any decisions about the shape and configuration of local NHS services other than in public health, and will any of them be consulted about his structural changes or allowed to do things differently locally?

[Mr Lansley]

Yes. I feel very strongly that we have deliberately set out to improve local democratic accountability and we have found an effective mechanism for doing so. Local authorities will themselves have statutory powers to agree local strategies that encompass not only local health improvement, but the commissioning plans and the social care commissioning strategies locally. If a major service change is contemplated as a consequence, the commissioning consortiums will not be able to proceed without the agreement of the local authority through its joint strategic assessment. The White Paper makes it clear that if they do not agree, the local authority will continue to have the capacity to send the proposals to the independent reconfiguration panel and, if necessary, to the Secretary of State.

Child and Adolescent Mental Health Services

John Pugh Excerpts

Wednesday 7th July 2010 Westminster Hall

[Jonathan Reynolds]

I am grateful to the hon. Lady for her intervention, and I acknowledge her work and expertise in this field. I approach this subject primarily as a parent, so I am happy to say that more needs to be done. I am not making this a party political issue between this Government and the previous one. I am trying to highlight the issue and, I hope, move forward together, across the House.

I wish to identify some good practice relating to the hon. Lady’s question. Dudley primary care trust operates an autism clinic that focuses on diagnosis and assessment, and has the specialist expertise to assess complex autism cases. The clinic takes a “broad apprenticeship” approach to training new staff, which gives them the opportunity to observe specialists and more experienced clinicians assessing children from behind a one-way mirror.

After new staff have watched several assessments, they progress to shadowing colleagues and then to taking the lead with children with autism, with support from a specialist. Finally, they are able to work alone and train new starters themselves. They learn through practical experience, rather than theory. The clinic also shares its expertise more widely and trains external agencies. For instance, it trained a group of specialist autism teachers and key workers to provide social skills training to children, meaning that social skills training could continue once a child had left CAMHS, making it far more effective than if it had been delivered once and then discontinued.

There is clear evidence that a good understanding of autism is vital to delivering an effective service to the high number of children with autism in the CAMHS system. All professionals working in CAMHS must have their training needs relating to autism recognised and addressed. In “Fulfilling and rewarding lives”, the Government’s recently published strategy for adults with autism, there is a commitment for

“all NHS practitioners”

to

“be able to identify potential signs of autism, so they can refer for clinical diagnosis if necessary… but more importantly so they can understand how to adapt their behaviour, and particularly their communication, when a patient either has been diagnosed with autism or displays these signs.”

The same strategy commits the Government to working with the General Medical Council and various professional bodies

“to improve the quality of autism awareness training in their curricula.”

What action do the Government intend to take to ensure that the NHS training objectives made in the autism strategy, “Fulfilling and rewarding lives”, are met, so that all CAMHS practitioners receive some basic training in autism?

[Dr John Pugh (Southport) (LD)]

The hon. Gentleman has made two distinct points so far: that mental health problems can be masked by autism so that a person who really has mental health problems may be seen only as having autism, and that autistic behaviour can be misdiagnosed as a mental health issue. Surely that is a very tricky situation for any diagnostician to be in.

[Jonathan Reynolds]

Yes, it is difficult. To be clear, my point is that the prevalence and frequency of co-occurring mental health problems with autism require CAMHS professionals to have specialist training. Without that support, there can be misdiagnosis, which can lead to the situation that the hon. Gentleman referred to.

Does the Minister agree that, given the high proportion of children with autism who access CAMHS, all CAMHS professionals should receive some autism training?

I have explained how a basic knowledge of autism among all CAMHS staff is essential to ensuring that appropriate interventions are delivered to children with autism, but that alone is not enough. Providing mental health support to a child with autism is a specialist skill. Research has found that when an autism specialist has been involved in the support of a child, the outcomes and service satisfaction both improve dramatically.

The NAS found that parents who reported that their child had received support from a professional specialising in autism were twice as likely as those whose children had not to agree that CAMHS had improved their child’s mental health. They were also four times as likely to say that a good understanding of autism by mental health professionals had positively influenced their child’s mental health. However, only two in five parents say that their child has had such support.

--- Later in debate ---

[Dr John Pugh (Southport) (LD)]

I want to add a few footnotes to the excellent introduction to the debate by the hon. Member for Stalybridge and Hyde (Jonathan Reynolds), who set out the major issues carefully and meticulously. Mental health and autism cropped up emphatically in debates on the Mental Health Act 2007. We were then largely concerned with the treatment of young people, including making treatment specific to them, rather than putting young people into adult accommodation or the like, or giving them adult services when juvenile services would be appropriate. While recognising that that was not always possible, I pay tribute to the campaign by YoungMinds for adolescents to receive adequate, full treatment no matter what their condition or mental health.

I pay tribute to the work done on the 2007 Act by the hon. Member for East Worthing and Shoreham (Tim Loughton), who has gone on to greater things, and to Baroness Browning, the former Member for Tiverton and Honiton, who was a champion of autistic people in this place and who pioneered the work that was taken on by other hands as the basis for the private Member’s Bill that subsequently became the Autism Act 2009. Off the back of the 2007 Act, I carried out my own research on provision for children and adolescents and wrote to every PCT for which I could obtain a name. I wanted to focus particularly on adolescent mental health provision, rather than childhood provision, and on waiting times. I accept the point that all the hon. Members who have spoken have made about the critical nature for families and, obviously, patients, of waiting times—the time between a suspicion that something is wrong and getting a diagnosis and treatment. Those are of course different things—one can get an early diagnosis but be slow in getting treatment.

It is not surprising that that issue is crucial during adolescence, when huge hormonal, physiological, social and personality changes are happening. That is a stage in life when, often, psychotic and other disturbances first become evident. One of the more depressing passages included in the Library debate pack deals with that fact. It states:

“Mental illnesses are the chronic diseases of young people.”

It continues:

“It is a curious paradox that better physical health in young people has been accompanied by steadily worsening mental health.”

That is indeed what the national statistics show, and it is why early intervention matters, because if it is successful and efficacious it means someone does not have a life of ongoing suffering and disturbances.

My inquiries of the various PCTs unsurprisingly produced patchy results, in accordance with the well-documented contributions made by other hon. Members. There was a general variation in standards, which I think people might expect, and which has been vouched for today, but what disturbed me more was the lack of clarity about who was responsible for the standards. My inquiries were passed from PCT to CAMHS and back. People did not seem clear about who would carry the can if provision were less than adequate. The implication is that for people using the services no one is ultimately responsible; that is the nagging feeling.

Another feature that cropped up in my research was an apparent lack of dedicated facilities and expertise in many places, and a recognition that although in some places there were adequate facilities for children, facilities for adolescents were wholly inadequate. There is no excuse for that state of affairs in relation to Asperger’s syndrome and the autistic spectrum, because what is required for progress is very clear. Certainly, early diagnosis is required, but the National Audit Office report that I have seen—which I think Baroness Browning did something to trigger—clearly stated that specialist autism teams were the way forward, coupled with good integration, and so on. That is all known, but hon. Members have reported that across the country none of it has been perfectly accomplished.

May I make a personal constituency point? I increasingly receive complaints from parents of children who are mildly autistic but are now being excluded from services because needs must—there are pressures on local authority resources, as the right hon. Member for Oxford East (Mr Smith) illustrated. That is profoundly depressing, because the result is that people who could progress to independence and, in later life, manage far better for themselves and not become problems as adults are not making progress at the key point at which they could be making the progress necessary to become independent of parents and institutions.

My conclusion and, I think, the conclusion of the whole debate is that we are confronted with a situation in which there is a known complaint, a known solution, enormous support from the voluntary sector and clarity about what is required, but on the statutory side there is a somewhat ham-fisted response. Getting that ham-fisted response removed and replaced with something better is the thrust of the debate.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I congratulate the hon. Member for Stalybridge and Hyde (Jonathan Reynolds) on securing both this debate and his seat. The subject is of huge importance to him, and he brought with him his invaluable personal experience, as indeed did the hon. Member for Manchester, Withington (Mr Leech) and my hon. Friend the Member for South Swindon (Mr Buckland). Those personal experiences are crucial to the debate, as are the contributions from those who are experienced in the provision of services. This debate is vital, and I will ensure that all the representations that have been made today are fed back into the policy process. Time is short, but I will just say to the hon. Member for Worsley and Eccles South (Barbara Keeley), who speaks for the Opposition, that some of us were fortunate enough to have listened to and participated in debates on the Autism Act 2009, promoted by my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan), as it made its passage through the previous Parliament. At the time, there was an increasing dislike of and disillusionment with politicians, so I mention that measure because it showed this place in its very best light. It was about cross-party working and building a consensus. It was a genuine attempt by Members from all parts of the House to work together to improve the lives of others—in this instance it was the lives of those with autism. I pay tribute to Angela Browning, the former Member for Tiverton and Honiton, who was sometimes a lone voice calling for services for people with autism. She, too, brought her own personal experiences to the debate thereby helping to raise us to the next level.

I echo the comments made by the Minister of State, Department of Health, my hon. Friend the. Member for Sutton and Cheam (Mr Burstow), at the recent National Autistic Society reception. He said that the standards of care highlighted by the society in its “You Need to Know” report are unacceptable. He was grateful to the society—as indeed we all are—for its tireless campaigning, and was struck by the particular contribution of the young campaigners group. I am sure that he would pay tribute to them were he able to be here today.

The coalition’s programme for government makes it clear that we are committed to supporting the most vulnerable and to tackling health inequalities. There is strong consensus on what needs to be done to improve the emotional well-being and mental health of children and young people. More work is needed on prevention, early diagnosis and early intervention. Those are the key things that are needed by people with autism and mental health problems. We need better integrated working and more evidence-based approaches. The work force must be developed, and, crucially, we must do more to tackle stigma for people not only with autism but with mental ill health.

The National Advisory Council for Children’s Mental Health and Emotional Wellbeing report earlier this year reinforced the scale of that challenge. It called for action to strengthen leadership, build a confident and skilled work force, improve commissioning and ensure real participation by children and young people in service development. For me, commissioning is a vital part of that. It has never been done that well, but there is a general acceptance of the fact that if we improve commissioning, the services will then follow. As has been mentioned during this debate, there are examples of best practice, which we need to be able to transport to other areas. We need to consider all those issues to get the services that we want.

The Government have also promised to deliver measures in “Fulfilling and rewarding lives: the strategy for adults with autism in England”. There are many areas in which improvement in adult autism services will yield benefits for children’s services, such as developing local autism teams, improving access to diagnosis, better planning and better commissioning of services. As several hon. Members have said, raising awareness of the issue and improving skills in the work force should go much wider than just those working in the autism field, and should include teachers and sports clubs and all those who are involved with young people.

Our focus must be on improving the quality of services that we provide to all children. We must ensure that no one suffers the indignities and difficulties that are sadly all too common. I am referring to the frightened young person who is restrained by police because crisis services were not available; the child who feels isolated and frustrated, only to find that health care staff are not trained to help or able to understand them; the parents who desperately want to see an improvement but feel let down by services that do not treat their children as people with individual needs; and parents who are desperate, isolated and at the end of their tether. That is why it is so important to improve the standard of care across the board.

We must plan and build on the work that has been done on integrating services so that local partnerships can work together to deliver what we want. It will require incredible commitment from local NHS providers to engage with the work force to resolve difficult issues such as training and service design. Improving the reach and quality of child and adolescent mental health care means looking carefully at the different services that make up the whole picture. I am referring to universal services that play a pivotal role in promotion for all children and young people; targeted services that provide early interventions for vulnerable children and young people; and specialist services, which the hon. Member for Stalybridge and Hyde mentioned, for young people with complex, severe or persistent needs.

[Dr Pugh]

rose—

[Anne Milton]

I am sorry, there is no time. I already have far too many questions to answer. If hon. Members feel that their questions have not be answered or addressed, I urge them to write to me and I will make sure that we respond.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 29th June 2010 Commons Chamber

[Mr Lansley]

I agree with the hon. Gentleman—it is just that that did not happen under a Labour Government in the way that it should have done. For example, the national quality registers in Sweden have 69 areas of clinical practice for which such comparative data are published. I have made it clear that one of our priorities is that we focus on outcomes and on giving patients real empowerment. To do that, information for patients on outcomes will be absolutely critical.

[Dr John Pugh (Southport) (LD)]

T10. I have here a letter from my local PCT indicating that the clinical review of the safety of a proposed children’s walk-in centre in Southport is to be conducted by Dr Sheila Shribman and the Minister’s Department. Will the Minister arrange to meet me and relevant officials to ensure that the Department is properly aware of the background to this vital access issue and that we have a clinical network suitable for patients, as well as for practitioners?

[Anne Milton]

I thank the hon. Gentleman for that question, of which he gave our office prior warning. It is important that decisions made locally focus on outcomes for people, that they are about choice, that they have support from local clinicians and commissioners, and that they are based on sound clinical evidence. I would be happy to meet him to discuss this further.