Mental Health

John Pugh Excerpts

Thursday 16th May 2013 Commons Chamber

[John Pugh (Southport) (LD)]

I apologise to the House for not having been here at the start of the debate. I was in the Finance Bill Committee, and unfortunately I cannot be in two places at the same time. I also apologise for missing the introductory speech by my right hon. Friend the Member for Sutton and Cheam (Paul Burstow). I pay tribute to everything he has done to put mental health on Parliament’s agenda.

It is unquestionably the case that Parliament has got its act into gear on this. I refer to Parliament rather than the Government or the Opposition because this is genuinely an all-party matter. Last night I went to a very encouraging event, which other hon. Members attended, run by the Alzheimer’s Society. The Minister was there, as was the shadow Secretary of State, a Conservative Minister, and my right hon. Friend the Member for Sutton and Cheam, and they spoke with their customary eloquence. In fact, to be fair, there were not very many Members there. I think that other people were detained with matters that had something to do with Europe. However, all of us who were there would have to acknowledge that no matter how eloquently the Minister or the shadow Minister spoke, the most impressive speech was by a very feisty medical lady who had Alzheimer’s and discussed the importance of talking about her condition and people talking to her about it.

That emphasises the fact that there is a blurred division between people who have mental problems, allegedly, and those who appear not to have them. There genuinely is not a clear distinction, other than at the extremes. If we were asked who here has perfect mental health, we would not necessarily all volunteer with alacrity, any more than we would if someone asked who has perfect physical health. It is rather like the Bible saying that the person who is without sin has to step forward. We would not say that because we acknowledge that we all have our own peculiarities and weaknesses and are not as mentally robust as we would always wish to be.

I was made aware of that the other day when I went to an event organised by Liverpool Personal Service Society, which is a well-established charity. The event was a memory day for elderly people in which it invited me to participate. The old ladies and old men were passing round objects that came from their youth, and music was being played in the background that also came from their youth. The environment was made to look almost like a 1950s drawing room. I was very struck by what it did for them. It was like the events organised by football clubs such as Everton and my own local football club in Southport, which bring old men together to talk about teams long since vanished and the glories of the past.

I picked up on two important features of that occasion. First, it was undoubtedly beneficial to the people concerned, who have dementia. Secondly, it is not in any way onerous for anybody else to participate in it. It is incredible fun. It is really enjoyable to hear these people talking about things that are now obsolete, like cigarette cases, nylons of the kind that people had in the war, or EPs—things that we no longer have and that our children do not even understand. That brings it home to us that memory is very relative. There is no magic cut-off point between a memory lapse that may afflict us at any time—

[Mr Kevan Jones]

Nick Clegg knows all about that.

[John Pugh]

We are presumably talking about unintentional memory lapses—senior moments that may afflict any of us.

There is no absolute cut-off point between mildly obsessive behaviour and obsessive compulsive disorder, between mood swings and genuine bipolar conditions, or even between irrational fears of which everybody is sometimes a victim and some of the conditions we would call paranoia. There is a continuum; it is, to some extent, a matter of degree. It is even possible, apparently, to have hallucinations without having schizophrenia. Delusions are not unique to asylums; there are many victims in this place. There is nothing especially rational about clever, civilised people gathering here every Wednesday at 12 o’clock just to shout at one another.

There are two aspects to addressing the stigma of mental health. One of those is to persuade people that this can happen to anyone, including MPs. That is very important. The other job is to persuade the public that mental health is not an either/or, black/white distinction. I recognise that there are conditions such as serious neurological malfunctions, deterioration of the brain, and so on. Affective disorders can be evident in people classified as being well and also in people classified as being unwell with mental health issues. What determines the classification is not only the severity of the condition—the extent to which the person is down one continuum or another—but the capacity of society to deal with the condition and the ability of the person to cope within society with the condition. The cultural comparison made by the hon. Member for Bolton South East (Yasmin Qureshi) is useful in this context. The mental health of a society and the mental health of individuals are intertwined, and one is the index of the other. I wonder whether, when we talk in this place about producing a prosperous society or economic growth, or doing something about social mobility or social inequality, we ask ourselves sufficiently whether we are doing enough to make society a happy place for us all to live in.

Let me add one other point with which I think you, Madam Deputy Speaker, will be au fait. Community treatment orders were a bone of contention throughout the passage of the Mental Capacity Act 2005, when I served on the Bill Committee. We have to review that issue, and the Minister needs to make a response. I think that we made the right decision, but that depends on whether the Act is understood and implemented properly. There is a genuine case, particularly given some of the variations, for trying to see whether we have got it right.

[Mr Charles Walker]

On that point, it is very important to ensure that advocacy requirements are being met.

[John Pugh]

Absolutely, and I hope the Minister will take that into account when he responds.

Childhood Obesity and Diabetes

John Pugh Excerpts

Wednesday 24th April 2013 Westminster Hall

[John Pugh (Southport) (LD)]

I pay tribute to the right hon. Member for Leicester East (Keith Vaz), who introduced the debate, for his characteristic generosity in congratulating all the other Members present; that is very much a feature of his style.

Let me start with the assumption that an obese child is an abnormality in some sense or other. It is not normal in nature for children to be obese; what is rather more normal is for people, as they get older, to find it difficult to stop being obese. If we think of portraits of obesity in literature, we think of Billy Bunter in the ’40s. Then, obesity was seen, in a very naive way, as a consequence of childhood greed, because it was a rare and not well-understood phenomenon. An earlier example is the plump lad in Dickens—I think he was called the fat boy—who was actually a thyroid victim. However, such children were unusual enough in those days to be pointed out; they were not at all a standard thing. Now, as all of us have recorded, the phenomenon of obese children is no longer a rarity in an advanced society.

Last week, the Minister and I attended an event organised by the all-party group on obesity, although I do not think she was aware I was there. A very earnest man told us we need to be careful about every extra Mars bar we eat every day; otherwise, we would increase our weight exponentially and eventually end up with serious problems. He was particularly horrid about egg custards and the like. Although what he said was probably broadly correct, I could not help thinking that it was not really sensible for any of us constantly to calculate exactly how much we had eaten, whether we had eaten too much or too little and by how much. I was slightly reassured by some research that came out after that event, which said, as the hon. Member for Inverclyde (Mr McKenzie) has just done, that there is more to this issue than meets the eye. If people become plump, it is not just a question of over-supply; it is sometimes to do with their glands and their endocrinology—whether they are burners or storers.

I recognise that this is a complex problem, but the fact of the matter is that the nations that have an obesity problem, as many advanced nations do, always have three principal characteristics: a relatively unlimited supply of food, easy access to that food—in other words, it does not have to be cooked or prepared in a long, elaborate way and can simply be grabbed—and a sedentary lifestyle. I do not see any of those changing any time soon. All three are probably necessary before nations have an obesity problem, and all three are, in many respects, here to stay.

I am therefore a little sceptical about claims that there is an easy solution to this problem. While other Members were speaking, I wrote down some of the solutions that were advocated, and every one can be faulted in some way. School dinners were mentioned. I used to be a teacher, and I used to see children walk past pictures of big, rosy apples, lettuces and things like that, before going straight for the pizza and chips. I was sometimes aware of how futile and ineffectual healthy eating programmes can be. The reality is that school dinners—many of us have experienced them—have never been notably healthy or low in calories, because it is assumed that children need lots of energy to get through the day. Working hard on school dinners and children’s choices is not, therefore, necessarily an easy solution.

A tax on fattening food was mentioned, and I am sure you would not warm to one at all, Mr Davies. The reality is that most food, if we eat enough of it, is fattening, with the possible exception of lettuce and something else, which requires more calories to eat it than we get from it—[Hon. Members: “Celery.”]

On education, the British public are not particularly lacking in knowledge about the things that make them fat and the things that are likely to have a less adverse effect. They are probably not quite as acutely aware as they should be about the calories in individual things. One of the easier ways of addressing some of the problems we have with alcohol is reminding people what the calorie intake from a glass of wine or a pint of beer actually is. However, that is not an automatic or a simple solution either.

Changes in family lifestyle were mentioned. Parental responsibility is important, but, at the same time, people’s lifestyles will be under increasing pressure in many ways—there is no evidence they will be under less pressure.

[Ms Abbott]

I am listening with interest to what the hon. Gentleman is saying, and I will respond to some of it in my remarks. He does not think the general public are ignorant of what food contains or the calorific value of food. However, people are often shocked to find that there is sugar in things such as baked beans and tomato ketchup; they often do not know how much sugar and fat there is in processed food. People who want to do right by their child will feed them these so-called breakfast cereal bars, but they do not understand how much sugar and fat there is in them.

[John Pugh]

There are benefits to the approach I outlined, although the people who are most acutely aware of the calorific content and the quality of their food are those who are already halfway to solving the problem. However, many people do not get even to that first base, and that is where public health messages have an impact.

[Mr Sanders]

Does my hon. Friend not think there would be an enormous benefit in having a simple traffic-light system so that parents buying children food understand that red means danger? Similarly, people queuing up at a fast-food restaurant will know which items on the menu contain the most sugar.

[John Pugh]

I hope hon. Members do not misunderstand me. I am not saying that the bits of the jigsaw cannot be put together and cannot ultimately constitute a perfectly satisfactory solution. I am saying that every one of the solutions so far advocated must come with a caveat, because it is not likely to be the magic bullet that will transform things. There is no magic bullet, and I will return to that theme when I conclude.

On sport, it is unquestionably the case that one reason why children acquire the extra pounds is that they move around far less than they ever did. When I was at school, the dinners were intensely fattening, but children moved far more, so the obesity problem was not that marked. One issue, however, is that if the problem starts early, as my hon. Friend the Member for Torbay (Mr Sanders) suggested, and the child is already overweight, he or she will be more reluctant to engage in sport and likely to look for excuses to avoid sport, so offering them a wider menu of sporting opportunities, by itself, will not help.

Pressure on producers and the responsibility deal were mentioned, and a lot can be achieved through such measures. The Minister will confirm that we have, almost without noticing, reduced the amount of salt in our food by agreement with the producers, and nobody has really minded. Clearly, similar results can be achieved by agreement with sugar producers, and there is no reason why that should not happen. Again, however, people tend to deceive themselves. We are all familiar with the phenomenon of people who sit there with a beefburger and chips, but who have a diet coke by their side. The assumption is that if they drink the diet coke, the effect of the chips and the beefburger will somehow be negligible.

The right hon. Member for Leicester East mentioned the issue of access. Access to fast food is one of the principal reasons why society has the difficulties it does. When we go to railway stations or other places where we are in a hurry to buy things to take on our journey, it is noticeable that we are presented with larger snacks than we would want, such as grab bags and extra-large chocolate bars. There is no explanation for that, other than that the producers are being blatantly irresponsible and trying to shift more of their product.

I must make a confession that may shock many Members present. As a student, I once worked as an ice cream salesman, driving an ice cream van. Our strategy was always to turn up at schools around lunch time, although my ice cream was of such low grade that the children would walk past my van. Instead, they would go to the Mr Whippy van, even if it got there later, so our strategy did not entirely work. However, Members can see that having food near lots of ravenous children is attractive to commercial interests, even if it is irresponsible of them to pursue such a strategy.

All those solutions have merit, but most of them have limitations. It is tempting simply to say there are a lot of issues—I have said as much myself—and that we have to press all the buttons to get the effect we want. I am quite happy to go along with that, I would like us to concentrate on what works and on what there is clear evidence to support; that is what I think needs to happen. One serious problem that concerns me, and which has been mentioned, is tokenism. I have seen tokenism in action; I have seen schools go through the motions of telling the children a bit about food and sticking up the appropriate pictures, but nothing really changes, so the phenomenon persists because it has not been properly addressed. There is irrevocably an element of personal and family responsibility. We cannot take that out of the equation. However, the most successful methods of making it easier for people to make the right choices must be evidenced, supported, endorsed and spread. We should not put into practice a mechanism that might or might not work.

A concern that results indirectly from concentration on the problem in question is the increasing incidence among children of not diabetes but eating disorders. However we pursue the agenda, we must do so in a way that makes it less likely that increasing numbers of children will, because of a legitimate concentration on their health and weight, become obsessed with their body shape and develop problems with eating behaviour that they would not have if they grew up naturally and in a satisfactory way.

--- Later in debate ---

[Ms Diane Abbott (Hackney North and Stoke Newington) (Lab)]

I congratulate my right hon. Friend the Member for Leicester East (Keith Vaz) on securing this important debate on childhood obesity and diabetes. We know the parameters of the problem: on current trends in childhood obesity, more than half of British children will be obese or overweight by 2020. A particular concern of mine, as the representative of an inner-city constituency, is that children in the poorest decile are more than twice as likely to be obese compared with those in a more affluent or middle-class decile. It is curious that, generations ago, obesity was a challenge faced by the well-off. We now live in a society, both here and in north America, where obesity is often a disease of poverty. I will return to that point.

We also know that diabetes is the No. 1 health threat in the UK, where 3.7 million people live with the disease, and as the Royal College of Paediatrics and Child Health has told us, care processes and outcomes for children with diabetes in England and Wales remain significantly worse than those for adults, which is what makes this debate so important. Thinking on the issue has changed. When I was a child, people said of a child who was a bit chubby, “Oh, they’ll grow out of it.” It was not seen as anything to worry about. We now know that overweight children become overweight adults, with all the associated health problems.

As always, the hon. Member for Southport (John Pugh) made an interesting speech, but he said a few things that perhaps need amplification. He seemed to say that it was inevitable that there would be a problem of obesity in advanced societies. I was in Finland last week, and Scandinavian countries—Finland, Sweden, Denmark—do not have our problems with obesity. That is for all sorts of reasons, one of which is that Governments have taken the issue seriously and made what were sometimes hard decisions to try to change public health outcomes.

The hon. Gentleman seemed to imply that school dinners are not necessarily part of the solution. I believe that, certainly for primary school age children, being exposed to a range of healthy foods and having healthy school dinners makes a difference to outcomes for diet. I also believe that it is worth educating school children about diet. There has been a complete turnaround of public attitudes to smoking over the past 30 years. Many things contributed to that, including Government action, but it was also due to the role of education and public heath campaigns. I believe that, in the medium term, we can do that for healthy eating and diet issues.

We therefore know the parameters of the problem and that, as has been said, it cannot be fully accounted for by genetics; it is due to a mix of a more sedentary lifestyle and the consumption of far too many calories through the eating of more fatty, salty and sugary products. We should note, however, that one reason why people eat more fatty, salty, sugary and processed foods than they did when we were children is that they are marketed aggressively at families and children. I want to talk about pester power. If a child sees endless advertisements for Ronald McDonald, the parents, even if they know better, find themselves under great pressure when they are out to purchase foods that they know in their hearts are probably not the best for their children. An occasional treat is one thing, but the problem relates to when such foods are not just an occasional treat, but have become the mainstay of a child’s diet.

Government Members have talked about parental responsibility. I believe in that, but we must bear it in mind that childhood obesity and related conditions, such as diabetes, are issues not just for the child and their family, but for us as a wider society that is concerned about the health and well-being of all our people. To be blunt, there is also the cost of childhood obesity and of diabetes, hypertension and all the related conditions. I think that fully 20% of the NHS drugs budget currently goes on drugs for diabetes. It is all very well to talk about parental responsibility, and about the nanny state as opposed to the Pontius Pilate state, but I think that the state owes its people a philosophical responsibility, and we certainly owe the taxpayer a practical responsibility to do something about the financial consequences of the growing wave of childhood obesity and diabetes.

[John Pugh]

I want to take the shadow Minister back to her remarks about marketing. I genuinely accept much of what she said, but there is this phenomenon: firms such as Waitrose tell us that it spends a lot of time promoting healthy options, presumably to customers who can afford to shop there, but nevertheless records that people buy more convenience food from it. The fact that we go for convenience food is not just a direct result of marketing.

[Ms Abbott]

The hon. Gentleman has to understand that the problem is multifaceted and needs multifaceted solutions, one of which is more parental responsibility. The role of supermarkets, and what and how they market, is part of the problem. I live in east London, which is very varied demographically, and I can go half a mile to one supermarket that largely serves working class people—at the front and centre it has unhealthy foods—and half a mile in the other direction to Waitrose, which has fruit and wine. Supermarkets are part of the issue.

Hon. Members may remember the case last year of what The Sun newspaper described as the fattest girl in the UK. She became so obese that the back wall of her house had to be knocked down, and she had to be taken out of the house with a crane and taken to hospital. The point about her is that she had been obese all along, but had been sent to a health farm in America and had lost a considerable amount of weight. She and her mother were reported as saying that the day she came back after several months in the US on a healthy diet, her mother somehow did not have any healthy food in and sent out for fish and chips. With some obese children, it is almost an issue of co-dependency. If we are to work effectively with childhood obesity, we have to work with the family—whatever that family unit constitutes. Will the Minister tell us what action her Department is taking on marketing and promotions, and how it intends to encourage the reformulation of food products, because we need to reduce the high salt and sugar content of breakfast cereals and other items that are marketed at children online?

On the role of local authorities, we should—and I have said this more than once—move public health to local authorities. There are challenges to such a move, but also great opportunities. Potentially, it could mean an end to silo working, because in an ideal world, the education, environmental and leisure services departments work alongside public health professionals to achieve better public health outcomes. We must not forget that for every pound that is spent on things that affect our health, only 10%, I think, is spent by the NHS. The rest is spent by housing and leisure departments. Moving public health to local authorities represents a tremendous opportunity to deal with diabetes and obesity-related issues.

This has been a friendly debate, and people have fallen over themselves to be nice to each other, but let me perhaps insert a slightly cautious note. The great Professor Terence Stephenson, chair of the Academy of Medical Royal Colleges and of the Royal College of Paediatrics and Child Health, said this in relation to responsibility deals:

“The food industry cannot be relied upon to help lead the policy response to obesity. This is not a criticism of the food industry. It would be extraordinary if an industry with a duty to make profits for shareholders should act against its mission to push products and sell as much of them as possible. Asking the food industry to solve the problem is counter-intuitive; you would not put Dracula in charge of a blood bank.”

Of course it is fine to co-operate with industry, but industry must know that the Government are serious and that, in end they will legislate if it does not co-operate. Responsibility deals are fine in principle, but if industry thinks that it is all carrot and no stick, we will not get the results that we all want.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 16th April 2013 Commons Chamber

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

That is an absolutely extraordinary question given that it was the previous Labour Government’s decision to contract out out-of-hours services in the first place, which has led to the massive pressure on so many A and Es. The regulations in place for many of these arrangements were laid by the previous Labour Government.

[John Pugh (Southport) (LD)]

T9. What is the Department doing to deal with the difficulties presented by poor data sharing between health and social care agencies and the threat to integration that that presents?

[Mr Jeremy Hunt]

My hon. Friend makes a very good point, and I pay tribute to him for raising this issue frequently. We will not have properly integrated, joined-up health and care services unless we crack the issue of data sharing. There need to be protections for people so that they can prevent their data from being shared if they do not want that, but by the same merit we have to make sure that there is better availability. For example, delayed discharges from hospitals, which are causing pressure on A and Es, would be directly helped if we cracked this. That is why we have called for a paperless NHS by 2018.

Mid Staffordshire NHS Foundation Trust

John Pugh Excerpts

Tuesday 26th March 2013 Commons Chamber

[Mr Hunt]

The hon. Lady will know that, when it comes to individuals—appalled as I am, and as appalled as all hon. Members are, by what happened at Mid Staffs—I must try not to prejudge due process. If we are to bar people from employment, we must have a fair process and system and a right of appeal, which is required under our law anyway. However, I would not expect any manager responsible for the kind of things that happened at Mid Staffs to be able to get a job in the health service ever again.

[John Pugh (Southport) (LD)]

Peter Walsh from Action against Medical Accidents has described the legally enforceable duty of candour as the

“the biggest advance in patient safety and patients rights in the history of the NHS.”

Does the Secretary of State agree?

Sudden Adult Death Syndrome

John Pugh Excerpts

Monday 25th March 2013 Westminster Hall

[Steve Rotheram]

My hon. Friend and city of Liverpool colleague will know that where Liverpool leads, others often follow. The hope is that other people will recognise that what Liverpool has done is progressive. It has been done with the help of the mayor of Liverpool, the city council and, of course, the OK Foundation and it will demonstrably save lives. We do not know when that will happen, of course, because we do not know when someone will have an attack, but at some stage, that provision will save someone’s life. That will be a tremendous legacy of all the work and campaigning that the OK Foundation has done.

What is perhaps even more heartbreaking than the sudden loss of life, if such a thing is possible, is the sudden loss of life when it is avoidable. There is a quick, simple and extremely effective device that can save lives. The treatment will not cost millions of pounds in research or development, nor is it a procedure that people require a medical degree to administer. Instead, it is as simple as first aid training in schools and defibrillators in public buildings.

At this point, I declare an interest: I unashamedly want there to be a defibrillator in every public building, in much the same way as there are fire extinguishers and fire alarms in every building. As the London Ambulance Service pointed out in its briefing for today’s debate,

“56 people died in London from a fire in 2011 compared with 10,000 Londoners who suffered an out of hospital cardiac arrest—yet fire extinguishers are statutory in every building—and defibrillators are not”.

We have them here in Parliament. If they are good enough for us in Parliament, they are good enough for every other public building.

I will shortly come on to the main argument with regard to my desire for defibrillators in public buildings, but before I do that, I am keen to touch on another element of tackling SADS: screening. Three young people die each week from SADS, and in more than half of the cases the cause is a genetic problem affecting the heart. I believe that targeted expert assessment of families in which there is a high risk of inherited cardiac disease or in which there has been a sudden unexplained death will lead to a considerable decrease in the number of SADS victims annually. No one is claiming that that is a panacea; it is simply a vital step in the diagnosis of those most at risk.

I praise organisations such as Cardiac Risk in the Young, which is subsidising screening for young people, ensuring that those who believe that they need an ECG—electrocardiogram—can afford one. The OK Foundation and others are also doing that, but screening should be more widely available.

[John Pugh (Southport) (LD)]

The hon. Gentleman said earlier that Liverpool leads the way. He will be aware, as the right hon. Member for Leigh (Andy Burnham) will be aware, because we were both at the same event, that Liverpool John Moores university does an enormous amount of work on the screening of young sportsmen. A huge amount of work is being done and it is being done, again, in Liverpool.

[Steve Rotheram]

Again, I could not agree more. John Moores and other universities have done fantastic work. I looked at some of the material from the Football Association. It runs the association football medical screening programme for youth trainees, which involves the screening of 750 youth players. The International Olympic Committee has recommended that all countries screen their athletes to minimise the risk of SADS. That indicates the benefits of screening, so let us look at an early intervention strategy for at-risk groups as an initial step.

Even in the past week, it has been pleasing to see the Football Association and the British Heart Foundation form a £1.2 million fund to ensure that 900 defibrillators are made available to clubs in non-league football and the women’s super league. That is real action that will make a real difference, but although it is encouraging that sport has woken up to this condition and recognised what I would term its social and moral responsibility, there is more work for the medical profession to do and more support for the Government of this country and our partners across the developed world to give.

A simple ECG can expose whether a patient has irregular electrical or structural problems with their heart that can lead to SADS. Currently, however, standard cardiovascular risk assessment screening is not as precise as it needs to be in identifying symptoms relating to sudden cardiac arrest, which is why the British Heart Foundation is undertaking vital research into the genetics around SADS, on which it hopes to publish a report shortly. In the meantime, the Government can play a leading role in encouraging pathologists and coroners who determine that a person has died of SADS to inform immediate family members to ensure that they receive an ECG at the earliest possible opportunity. The Government should also support the medical industry’s work to improve the scientific precision of screening. Such Government measures should form part of the proposed new national strategy to improve heart safety and reduce preventable deaths from sudden cardiac arrest, as set out in the motion.

I hope that today’s debate and any subsequent debates will achieve a number of things, but it is pivotal that the imperative relationship between CPR and defibrillators is exposed: a defibrillator on its own cannot save a life; CPR on its own has an outside chance of saving a life, but the two together have a more than 50% chance of saving a life. How do we know? Ask people such as Fabrice Muamba. His collapse on a football pitch, in front of thousands of spectators at White Hart Lane and millions watching on television, was perhaps the most graphic illustration of SADS, and his recovery is the best example of what can be achieved with swift and targeted intervention.

Bystanders witness more than half the cardiac arrests that occur in public, but not enough people have the life-saving skills to help those heart attack victims. CPR is the first action in the chain of survival and is crucial in the first minutes after a cardiac arrest, because it helps keep oxygen moving around the body, including the brain, which is why the British Heart Foundation campaign tells us to phone 999 and press hard and fast to the beat of “Staying Alive”. It is a simple message, which works, and we have all seen it on television. CPR essentially buys a patient time. A defibrillator starts the heart, but cannot be used on a still heart, so unless CPR is administered, a defibrillator is effectively useless.

That point is crucial, and is at the heart of—forgive the pun—why colleagues and I, in consultation with my right hon. Friend the Member for Leigh, chose to include first aid in today’s motion. Medical experts believe that CPR combined with a defibrillator shock can triple the survival chances of somebody who has suffered a cardiac arrest outside hospital. I shall repeat that: it can triple survival chances. That is extraordinary. CPR and a defibrillator shock can buy paramedics time to arrive, prevent serious brain damage and ultimately increase the chance of a full recovery. I am not sure that there is any need for further debate. If someone’s child or loved one had a cardiac arrest, would they not want to triple their chance of survival?

Immigrants (NHS Treatment)

John Pugh Excerpts

Monday 25th March 2013 Commons Chamber

[Mr Hunt]

The rules existed for 13 years under the Labour Government, who did absolutely nothing to change them. We are tackling the problem. If Labour Members had any grace, they would thank us for doing so.

[John Pugh (Southport) (LD)]

When I tabled questions last year, I was told that we collect £51 million a year for treatment from EU countries, but that they collect £451 million—nine times more—back from us. Is this an issue not of immigration, but of coding, charging and collecting?

[Mr Hunt]

My hon. Friend might be right—we need to look at that—but as I have told my hon. Friend the Member for Dover (Charlie Elphicke), one factor is that a number of our pensioners retire to sunnier climates, which leads to that imbalance.

Accountability and Transparency in the NHS

John Pugh Excerpts

Thursday 14th March 2013 Commons Chamber

[Mr Dorrell]

I have a lot of sympathy with what my hon. Friend says. The successful delivery of a culture change that supports real transparency would build on the fact that it is not only a right but an obligation for a registered doctor or nurse who sees care being provided that falls below proper standards to raise their concerns and, if no action is taken, for those concerns to be raised with the regulator. Change will be required right through the health service if that professional obligation is to be made real.

[John Pugh (Southport) (LD)]

My right hon. Friend has mentioned the instinct to protect and to circle the wagons. Would he accept, however, that that is not exclusive to the NHS, and that it also exists in the police service, for example? It also existed in Parliament during the expenses scandal. It is an institutional feature of many kinds of organisation.

--- Later in debate ---

[John Pugh (Southport) (LD)]

I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on calling for this debate, which I want to widen and, I hope, put on a more consensual footing.

I have a constituent whose grown-up son tragically died of leukaemia some time ago. He went to the doctor many times and was diagnosed as a young, healthy man with glandular fever. A blood test was made far too late, and he died. After the funeral, the mortified doctor wrote to the parents and apologised frankly for her failure and her error. There was no litigation or talk of system failure; there was simply a frank admission of individual human error and a sincere apology, which was accepted.

In many cases of NHS failure, there is no one individual to blame, so people talk of systems and cultures, which we have talked about constantly today. No one individual can be held entirely to blame for the system, so it always seems that no one person is to blame or is prepared to take the blame—even those who manage and design the system, such as Sir David Nicholson.

When a hospital performs badly, and the one in Mid Staffs is simply the most telling example, some of the reasons lie in external factors: in the targets imposed on it, in the requirements made of it—becoming a foundation trust is one it could have done without—and in directions that impaired it. The NHS reorganisation certainly got in the way, according to Francis. When outcomes are poor, it can be hard to determine exactly how to apportion blame and responsibility. Do we blame those who witnessed what went on and did nothing; those who failed to notice worrying trends; those who did notice them but covered them up; or those who could have intervened from on high but did nothing? In one sense, they are all responsible—and some are more responsible than others. But we live in a very harsh and judgmental climate, as was said earlier, and we forget that people at every stage have mixed motives—good and bad—for not kicking up a fuss, for covering up, for not intervening. Some are good—usually, they are bad—but in most cases institutional or personal reasons outweigh the concern for patients. There are quite legitimate fears that the hospital or branch will be criticised or seen as underperforming, which will be bad for morale in hospital, or that one’s career will be in jeopardy—a legitimate concern—or that one is getting a colleague into trouble. Institutional or personal goals get separated from the avowed patient-centred mission of the NHS. Frankly, that is all too human an outcome, and it has always happened to some extent. The NHS is full of very good people, but it is not yet staffed by saints. All of us at some time cover up for colleagues.

However, we always try to find in an institution a way of correcting for this, which is why we have professional standards in the medical profession and an NHS constitution. It is why we need true accountability, good complaint-handling, protection for whistleblowers, duty of candour, the learning of lessons and, of course, proper redress. That is why we have had legislation on the NHS constitution and increased democratic scrutiny, introduced by both Governments, which I applaud. I am not entirely certain what has happened to the NHS redress Bill, but I applaud that too.

However, we build other sorts of incentives into the system, and it is as well to record them. They appeal to a different aspect of human nature, a more selfish side, perhaps out of realism, perhaps because of an ideological conviction that that is how people work. We model hospitals on profit-making institutions. We make survival dependent on competition with other profit-making institutions, which have gagging clauses in their contracts for good reasons—their competitors. We try to modify clinician behaviour not always by appealing to clinical judgment, but by appealing to the pocket. Therefore, we should not be surprised if the moral atmosphere, at times, becomes a little cloudy. We, as legislators, are partly responsible for that.

If we turn the NHS into a set of businesses united by a corporate brand, should we be surprised if occasionally, individual branches put their interests ahead of those of their patients, choosing to satisfy those who pay—the Government—rather than the patients they serve?

There are many good things that we can do and would wish to do. We can make the complaints process easier. We can assign accountability better, so that an individual’s job and survival in an organisation depends on serving the patient, not on always doing what the institution necessarily requires. We can ban gagging orders, and I applaud the Secretary of State’s move in that direction. We can improve inspection, not by making it more ferocious—we do not need to do that—but by linking it better to improvement. Above all, we need to start thinking about what we want the NHS to be. If we are unhappy with the culture, exactly what sort do we want to have? Do we want the moral enterprise that Bevan envisaged—a contract on behalf of the hale and hearty, to protect the sick and vulnerable—or a set of businesses that sink or swim depending on how good they are at getting state funding? We can either rediscover the moral purpose of the NHS, or regard it as an organisation that brings to book from time to time the businesses that work within it, independently of the Secretary of State.

Frankly, I know which I prefer, but I have to record that currently we exist in a strange kind of moral limbo. We are judging an institution that looks very different from the original NHS, according to the high standards and moral mission Bevan set. I have a lot of sympathy with the remarks of Harry Cayton of the Professional Standards Authority, who said in The Times only this week that the NHS must rediscover its “moral purpose”. We exist in a kind of moral fog, a state of limbo, and if we want to know who is accountable for that, it is us.

--- Later in debate ---

[Valerie Vaz]

Let us look at what is going to happen in 18 days’ time when the Health And Social Care Act 2012 comes into force. I do not want to rerun the arguments about the Act, but let us look at what is to come. Let us look at the accountability of the structures under the Act. The NHS Commissioning Board becomes the conduit for everything, including the flow of money, and all the strategic decisions filter down. If anyone cares to look at the Department of Health website and the new structure, they will see a series of concentric circles. Parliament, the Department and the Secretary of State all appear to be in the outer circle, running round in circles. Where is the accountability in that?

I have to tell the Secretary of State—although I am pleased to see him here, this is a Back-Bench business debate—that section 75 regulations were signed off, under a negative resolution, by a Minister who is not accountable to the House. Section 75 says that everything has to be tendered except for technical reasons, or reasons of extreme urgency. That had to be changed to state that contracts can be tendered if the relevant body is satisfied that the services to which the contract related are capable of being provided only by that provider.

Regulation 10 previously said that commissioners may not engage in anti-competitive behaviour; otherwise, Monitor will be after them. Sorry, those are my words. That was changed to say that commissioners must not be anti-competitive unless it is in the interests of patients.

What of the future? I pay tribute to the right hon. Member for Charnwood (Mr Dorrell), who made an excellent speech. I want to draw attention to a report that our Select Committee produced on complaints and litigation in June 2011. I urge the Secretary of State, if he cares to listen, to read that report and consider all the recommendations. Even then, we called for all providers to have a duty of candour to patients. We also said that we found it striking that the Government did not mention complaints in the information revolution consultation and were surprised that they did not see how complaints information could help people see what is going on. My hon. Friend the Member for West Lancashire (Rosie Cooper), who is no longer in her place, was right to say that complaints can provide information about what needs to be put right.

Mr Deputy Speaker, I am not sure whether you are aware that the NHS litigation bill has now reached £1.3 billion. I urge the Secretary of State to look into the reasons why that is happening. We have to redress negligence, but there are other reasons why that bill is rising. There are remedies that do not involve money or changes in structures or reorganisations.

[John Pugh]

Does the hon. Lady acknowledge that that is what the NHS Redress Act 2006 was supposed to do? I am genuinely puzzled, and I hope that the Minister will resolve this puzzle for me, about how much of that Act has been formally enacted.

[Valerie Vaz]

I cannot answer that; I am not on the Front Bench.

We all agree that there is no place for gagging clauses if lessons are to be learned about patient care. I agree that the Government have made an important announcement today, but let me remind the Secretary of State that the NHS issued management directions in 1999 and 2004. I am concerned that the NHS still needs reminding about these gagging clauses. We must get away from a system in which whistleblowers are driven out of their jobs on spurious disciplinary issues. At Mid Staffs, doctors and nurses are under disciplinary reviews, but as yet I have not heard anything about whether managers will also be held to account.

Action plans that arise from complaints are a vital part of organisational learning, but they are only of value if they are followed through to implementation, and it was clear from evidence to us in the Select Committee that that did not happen at Mid Staffs.

Publication of complaints data must be obligatory for all care providers, including foundation trusts and private providers with NHS contracts. We must move away, as the hon. Member for Southport (John Pugh) said, from the blame and victim culture and reduce the emphasis on disciplinary procedures. We must put more emphasis on retraining and risk management.

We should enshrine accountability for patients at board level, making boards more diverse, not just comprising the usual suspects. Private providers, as my right hon. Friend the Member for Leigh (Andy Burnham) said, are not subject to FOI; they must be. The register of GPs’ interests must be open to clinical commissioning groups. It should not be up to the public to ask whether GPs have declared their interests. Every decision must be associated with a list of GPs’ interests.

I have spoken to the chief executive of the Royal Orthopaedic hospital, who said that he ensures that doctors, nurses and managers are all on an equal footing, which is an example of good practice. His phrase is that there should be “no gap between board and ward”. He puts his patient groups on the board, every ward gets rolling visits and board members even feed the patients.

In my own way, I have also been accountable and I have published on my website a table of all the complaints my constituents have come to me about so that they can see what sort of things are going on at the Manor hospital. The chief executive of the hospital is undertaking a patient survey and ensures that he looks at all the responses.

I hope that I have outlined some positive aspects as a way of moving forward and that we will continue to have an accountable, transparent and unique NHS that is the best in the world.

Medical Implants (EU and UK)

John Pugh Excerpts

Wednesday 6th March 2013 Commons Chamber

[John Pugh (Southport) (LD)]

With your indulgence, Mr Deputy Speaker, I should like to break some new ground in this debate on estimates day by talking just a little bit about the estimates. We have quite a lot to agree to. I do not know whether hon. Members have studied the papers for the day. We are agreeing to an extra £1.2 billion of expenditure in the revenue account and a reduction in the consolidated fund draw-down of £472 million. In previous debates we have debated similar figures for the Department for Work and Pensions, the Ministry of Justice, the Department for Communities and Local Government and so on. At the end of the day we will vote through £213 billion of Government expenditure and probably talk about none of it at all.

There is a reason for my raising the issue at this point. There is an odd gap between what we are notionally doing and what we are actually doing. A few months ago we had another estimates day when we voted through similar huge amounts but talked about Turkey. The nation’s finances were relatively undiscussed. It is odd procedure that the one thing we do not talk about on estimates day is numbers or estimates, but does it matter? It does in a funny sort of way, because Parliament is supposed to scrutinise the nation’s accounts and it clearly does not do so. I think the Government are aware of it. The hon. Member for Gainsborough (Mr Leigh) and I were tasked by the Chancellor of the Exchequer and the Chief Secretary to the Treasury with looking at how we scrutinise the nation’s accounts on occasions like this. It was announced at the Dispatch Box—

[Mr Deputy Speaker (Mr Nigel Evans)]

Order. I am giving the hon. Gentleman a little leeway but the matter under discussion is as on the Order Paper, so I would like reference to be made to that, rather than a general debate.

[John Pugh]

I am coming to that, Mr Deputy Speaker. In a way, that illustrates my point, because what we are actually debating is the supplementary estimate. My hon. Friend the Member for Gainsborough and I were tasked with looking at how the House debates supplementary estimates, and the answer we came to was this: not very well. Our report, a copy of which is in the Library for hon. Members to consult, testifies to that finding, and we produced adequate evidence for it, because the report was co-ordinated to some extent by the Treasury, which keeps a close eye on these things. I am suggesting that the work of examining the nation’s finances is boring, dull and, at times, anorakish, but it certainly needs to be done, and it probably should be done by Parliament, and on occasions like this.

[Mr Jamie Reed (Copeland) (Lab)]

On that point, which the hon. Gentleman is making very well, can he recall when the House last divided on an estimates debate?

[John Pugh]

I certainly cannot. There are occasions when we talk about general topics, but I think that I am right in saying that the reasons we have estimates days is so that Parliament, as well as the Treasury, can scrutinise the nation’s accounts. I regard that as highly desirable in this age of austerity, when we need to count every penny and record the overspend, underspend, virement and so on.

I will now turn to the subject that appears to be the subject of this debate but is not actually on the Order Paper: medical devices and implants. I would like to make a few observations on what the hon. Member for Ellesmere Port and Neston (Andrew Miller) calls post-market surveillance, which we agree needs to be improved. That is obviously wholly desirable because it will eliminate problems, improve patient security and so on. I would not disagree with a single word voiced by him or his Committee. I agree that there should be more transparency and more feedback from patients and clinicians so that devices are safe and do exactly what they are supposed to do. However, we can improve regulatory vigilance. The MHRA has done a good job so far, but it obviously could do better. There is clearly a role for increased manufacturer responsibility. That is all very important.

The simple point I want to make about implants—I am not allowed to talk about the huge sums of money we are voting through—is that detecting failings is quite a complex matter. It is not as simple as it was with the breast implants, which was a case of the wrong substance being provided, which is fraud. I will illustrate my point with a real-life example. I am familiar with a case in Nottingham involving a number of unfortunate episodes that followed heart surgery in which a particular type and brand of stent was used. A number of people were called back for second operations because the stents leaked. I believe that there were a number of deaths and some litigation. Initially it was thought that the device was at fault, because it looked as though the people who had the device experienced certain problems and complications, and there had been other problems with it elsewhere. It was subject to a court case and prolonged investigation. Ultimately, the blame was attributed—this bears out the point made by my hon. Friend the Member for Truro and Falmouth (Sarah Newton)—to the surgical procedure, rather than to the device itself.

Therefore, there is a particular problem when it comes to post-market surveillance. Is it the equipment or how it is used that is responsible, because the equipment is only as good as its user? That is a particular issue in surgery, because surgeons up and down the land are very particular about what bits of kit they use and what type of equipment they work with.

[Andrew Miller]

The hon. Gentleman is making a perfect case for a proper registry. If a proper registry were maintained, one would be able to see whether the patterns of failure related to a location, which would mean it was a surgical failure, or a particular type or brand of product. He is underlining one of the Committee’s key recommendations.

[John Pugh]

I am grateful to the hon. Gentleman and pay tribute to his Committee for the work it has done. My simple point is that post-market surveillance is complex, because devices need to be judged alongside the patient experience and the clinician experience, and that gets more complex and difficult if the market for a particular device is relatively small. In the Nottingham case, the patients could not get fully informed feedback because it was neither in the manufacturer’s nor the surgeon’s interest to incriminate themselves. There was the added problem, as there is often is, that the manufacturer was in a different country from the user of the device. That is partly why products that have been found over time to be faulty in one country can still be used in another country because its regulatory body has not picked up on the problem.

This is not an easy matter, and I applaud the Committee’s efforts to get things right. I am slightly disappointed that we cannot have a wider debate on the nation’s finances. I hope that the Minister will explain what the £1.2 billion of expenditure that we are agreeing is all about, because that will be a blessing to the House.

--- Later in debate ---

[Norman Lamb]

It would be absolutely in order for a procurement officer to do that. The more searching their inquiries, the better, given the importance of what we are trying to achieve. We welcome the hon. Gentleman’s opinions on this issue and will consider how the system can be further strengthened. He makes a valuable contribution to our considerations.

The Government agree with the Committee about the need to improve the environment for clinical trials in this country, and we are doing a lot of work on that already. Things such as the life sciences strategy are making it easier for patients to get involved in research, and we have also set up the Health Research Authority, which is simplifying the approval process for ethical research.

To return to a point made by the shadow Minister, we wholeheartedly agree on the importance of transparency, which brings numerous benefits. I have always strongly believed that it empowers patients, informs and liberates health care professionals and builds trust in industry, notified bodies and public authorities. The proposed new European regulations will increase transparency, giving the public, patients and clinicians access, first, to clear information on the safety and performance of devices; secondly, registration information on devices and the companies that make, distribute and use them; and thirdly, information on the electronic traceability system for devices.

Furthermore, the outcome of peer reviews between different national authorities—reports from each member state on how they have monitored their notified bodies and statements from notified bodies on their independence and impartiality—will also be made public. The hon. Member for Ellesmere Port—I apologise for abbreviating his constituency—drew attention to concerns about the quality of different authorities across the EU, so this is an important step. The UK is already pushing for improvements in transparency in negotiations with other member states. For example, as we highlighted in our response, we would like to see clinical data from post-market surveillance published, so that the available information on the safety and performance of devices always remains up to date. We can do more as well. The Government’s public consultation on the proposed regulation closed on 21 January. It provided us with a lot of useful ideas, which we are currently considering in detail.

Let me turn to the issue of notified bodies and pre-market assessment. Strengthening the quality of notified bodies is absolutely one of the most important ways to improve the regulatory system. The Government agree with the Committee’s recommendations in this area. We are pleased that the Commission’s proposal goes a long way towards addressing the current weaknesses in the system. Competent authorities will review each other and share ideas on how to improve the way in which they monitor notified bodies. The Commission can take action in response to a member state’s concern about a particular notified body. There is significantly more detail on the criteria that notified bodies must fulfil, and teams of experts from different competent authorities will audit notified bodies every three years. The Government agree with the Committee that a new layer of European bureaucracy is not the solution to problems with notified bodies. We need to focus not on who carries out pre-market assessment, but on how it is carried out.

Regardless of all that, we cannot just sit back and wait for the revised legislation to come into place—it is some way off yet. As I outlined previously, we are acting before then to ensure that notified bodies improve as soon as possible. Interim action is being taken across Europe. It includes, first, joint audits of notified bodies on a voluntary basis. The first of these took place in the UK in January and many more are planned for 2013. Secondly, all member states are auditing the quality of their notified bodies that assess high-risk devices. Thirdly, rules on notified bodies and how they audit manufacturers, including undertaking unannounced inspections, are being put together.

While we strengthen the pre-market assessment of devices, it is equally important that adequate post-market surveillance and vigilance procedures are put in place. My hon. Friend the Member for Southport (John Pugh) entertained us and educated us on some important issues. He drew attention to the complexity of identifying the cause of a problem and whether it is the equipment or how it is used. That is not always easy, and the court action he referred to very much drew attention to the complexity of these issues. I am afraid that I am unlikely to be able to satisfy him on the £1.2 billion, but I liked the effort on his part.

[John Pugh]

I hope the Minister did not think I was being awkward in any way, but the original purpose of estimates day was clearly not to discuss medical implants. However, I have now learnt not only that we do not talk about estimates on estimates day, but that we are not allowed to talk about them.

NHS Commissioning Board

John Pugh Excerpts

Tuesday 5th March 2013 Commons Chamber

[Norman Lamb]

The Leader of the House was absolutely correct in stating—[Interruption.] If the hon. Lady will listen to my answer, she may benefit from it. The Leader of the House made it absolutely clear in the House last week that the regulations would not introduce compulsory competitive tendering. We are amending them because there was legitimate and understandable concern about the impact of some of the provisions. We will make the position clear so that the policy intent of the Health and Social Care Act is implemented faithfully in these regulations.

[John Pugh (Southport) (LD)]

The Labour regulations are not perfect, and neither the regulations introduced by Labour nor those initially proposed by the coalition Government in section 75 will do in any sense. Do we not need regulations that embody the assurances given to peers and to GPs themselves during the passage of the Health and Social Care Bill, and not a charter for privatisation?

[Norman Lamb]

We will make absolutely sure that the amended regulations meet faithfully the commitments given in the Upper House during the passage of the Bill, and in the letter sent to clinical commissioning groups by the former Secretary of State following the legislation.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 26th February 2013 Commons Chamber

[Mr Hunt]

I know that the hon. Gentleman asks a lot of questions about radiotherapy. We use a strict evidence base before we make any investments. We also want to embrace innovation, but our absolute priority is to save as many lives as possible from cancer. He will know that we are in the lower half of the European league tables when it comes to cancer survival rates, and that is something that we are determined to put right.

[John Pugh (Southport) (LD)]

On collecting performance data, has the Secretary of State seen the NHS Confederation publication “Information overload: tackling bureaucracy in the NHS”, which points to a great deal of duplication in information? What is his reaction to it?

[Mr Hunt]

There is far too much bureaucracy in the NHS, which is why I have asked the chief executive of the NHS Confederation to report to me on how we could reduce the bureaucratic burden on hospitals by a third. If there is a lesson from the Francis report on the tragedy at Mid Staffs, it is that we need to free up the time of people on the front line to care, which is what they went into the NHS to do.