Hernia Mesh in Men

Nadine Dorries Excerpts

Thursday 5th September 2019 Westminster Hall

[The Parliamentary Under-Secretary of State for Health and Social Care (Ms Nadine Dorries)]

It is a pleasure to serve under your chairmanship, Mr Hanson. I was alarmed when you walked in, because I think you have held more ministerial posts than anyone else in the House of Commons—or you are pretty close to holding the record, anyway. So to have you in the Chair, judging me as a Minister, is quite daunting.

I thank the hon. Member for Strangford (Jim Shannon) for bringing up this important debate. You always bring debates to the Chamber that you are heartfelt and passionate about. That is so important. It is a delight to be opposite the hon. Member for Washington and Sunderland West (Mrs Hodgson). We have both been in this place for 15 years, and I know that you also bring the same passion and commitment. You always speak from your heart. We might be a bit similar in that way.

[David Hanson (in the Chair)]

Order. “You” refers to me.

[Ms Dorries]

Of course, Mr Hanson. I am amazed that after 10 years in the Chair I make these mistakes—it is because I am nervous. I am delighted to serve opposite the hon. Lady; it will be great.

This is a serious subject. It is incredibly important to hear the voices of patients who have suffered as a result of inguinal hernia mesh repair operations, because without allowing those patients to be heard, we cannot move forward to find solutions to deal with this issue. I will go off-piste from my speech, because there has been some conflation during the debate of vaginal mesh repair for the purpose of urinary incontinence and inguinal mesh repair for an inguinal hernia. The two operations are entirely different and have completely different outcomes. Vaginal mesh repair is for urinary incontinence. Inguinal mesh repair is for hernia, and without repair, there is a possibility of death. That is because of the pattern of development of an inguinal hernia. It is due to a break in the muscle wall. The hernia is a part of the bowel that comes through the muscle wall, and it can quickly strangulate and develop into peritonitis. The result of that can be death.

[Andrew Griffiths (Burton) (Con)]

I join the debate late on, but perhaps I can be the example the Minister is looking for. I had a double hernia just a few months ago that was treated at Queen’s Hospital in my constituency, where I received fantastic care. Mesh was used to repair a double hernia, which I got as a result of doing too much exercise—I am not as fit or strong as I thought I was. I was nervous about having mesh because I had heard all the rumours about how damaging it could be, so I questioned the consultant and surgeon. For me, it was brilliant: it meant keyhole surgery and a quicker recovery. I say to all those men out there who might be going in for a hernia operation: do not dismiss mesh, because it makes the operation simpler and the recovery time quicker. I recommend it.

[Ms Dorries]

I thank my hon. Friend for his absolute honesty and openness in bringing forward his own case.

The bowel can come through the opening in the muscle wall, strangulate and develop into peritonitis, with dire consequences. The fact is that the alternative method of repair—just to stitch the muscle wall—is nowhere near as effective, and the same dangers can present. There can be a rupture, and the hernia will present again with the same complications.

[Mrs Hodgson]

The Minister, with her medical knowledge, can give the details on hernia repairs in men that otherwise would have been missing from the debate. The hon. Member for Burton (Andrew Griffiths) speaks from his experience. Although I do not want to be a harbinger of doom, for him it is very early days; often the pain that comes in 10% to 15% of cases appears a few years later, as the hon. Member for Strangford said in his speech. The Minister rightly points out that it is a good operation for what is a life-threatening condition in men, as opposed to stress incontinence in women, but still in 10% to 15% of cases we are talking about real pain. I would like her to elaborate on what we should do about that.

[Ms Dorries]

The hon. Lady is absolutely right. No one should suffer with chronic pain. There is a difference between acute and chronic pain, with acute pain happening immediately post operation and the chronic pain continuing afterwards. In inguinal mesh repair operations, the chronic pain is due to the mesh—like a small piece of net curtain—rubbing up against nerve endings and causing inflammation. For many men, the pain is quickly cured by an injection of local anaesthetic such as lignocaine with a steroid, which reduces the inflammation and takes away the pain completely. For many men who present back in out-patients, their pain is quickly sorted.

I do not want it to sound as though I am trivialising in any way the problems of those who continue to suffer pain. I believe that the Cumberlege report covers mesh as a wider issue, as well as issues related to the use of mesh, so we may gather more information from the report that will inform the debate on inguinal hernia mesh repair.

There are, however, other options. The best practice is shared decision making between the patient and the clinician, with the clinician fully explaining the operation to the patient, what is involved and what the options are. One option for patients who present with a hernia is for the clinician to reduce it in the clinic back in through the muscle wall. At that point, the patient may know how to handle it and manage it by not over-exercising and being careful when they cough. The patient will be registered as having had a hernia reduced and, if they want it operated on, they just ring up and go straight on to the operating list. That is a good option for many men if they think they can carefully and responsibly manage the hernia and come back to hospital only if it gets worse, if it pops again or if they need immediate attention. Whatever happens, they will be registered as having had an inguinal hernia and seen a clinician and therefore in need of treatment should it reoccur.

We are encouraging clinicians to have that conversation with patients. I do not know whether the clinicians treating my hon. Friend the Member for Burton (Andrew Griffiths) did, but clinicians should do so that patients can decide whether they want to go ahead with an operation.

[Andrew Griffiths]

I had exactly that conversation: it was my choice whether I had an operation and how I managed it. Also, it was just four months between seeing my GP and having the keyhole surgery at my local hospital, which took an afternoon. The service at the hospital was brilliant; I cannot praise it enough.

[Ms Dorries]

I am delighted to hear that.

I am pleased to say that shared decision making is set out in the NHS long-term plan and I hope we will see more of it in other areas. As the hon. Member for Strangford mentioned, it has the full backing of the Royal College of Surgeons and the Royal College of Anaesthetists. I know from my own experiences in the health service that the role of patient voices is critical at every stage along the treatment pathway. Indeed, as we have said, the Government have asked Baroness Cumberlege to lead a review on the theme of patients’ voices. I will say more about that later.

All of us, including Ministers, regulators and clinicians, must listen to patients, such as the constituent mentioned by the hon. Member for Strangford who has had an ongoing problem, when they raise concerns. Only by listening to those patients’ voices and understanding the issues they have after hernia repair can we learn and develop what we need to do to ensure that it does not happen to people in the future. We must strike a fine balance as we steer through innovation, emerging science, clinical advice and the voices of a multitude of patients.

Hernias are relatively common. One in five men will get an inguinal hernia in their lifetime and it is worthwhile briefly outlining why men are mostly affected. Inguinal hernias are a type of groin hernia, which are the most common type of hernia. Some 98% of them are found in men, as the male anatomy is particularly vulnerable in this region. The main reason to operate on a hernia is to reduce the risk of bowel obstruction or necrosis, which is tissue death. Both of these conditions require major emergency surgery, where there is a risk of death.

Hernia surgery is therefore often a necessity. I have been advised by clinicians that when an individual’s condition indicates surgery, mesh repair is the standard operation for adults with inguinal hernias. It is safer than non-mesh repair in the first instance and is less likely to lead to pain post operation. It is also less likely to lead to hernia recurrence. To address the point made by the hon. Member for Strangford, I hope he understands not only that this treatment is the most effective but that the alternative is more likely to result in complications. Mesh is therefore used in approximately 97% of all surgical inguinal hernia repairs in England.

All the expert scientific advice that Ministers have received does not support a ban. It is important to emphasise that internationally no other country has banned the use of mesh to treat hernias. According to the National Institute for Health and Care Excellence, approximately 70,000 surgical inguinal hernia repairs are performed in England each year, at a cost to the NHS of £56 million a year. These mesh repairs are performed by either open surgery or laparoscopic surgery, as my hon. Friend the Member for Burton described.

NICE has developed guidance which recommends laparoscopic surgery as one of the treatment options for the repair of inguinal hernia. The guidance states that it should only be performed by appropriately trained surgeons who regularly carry out the procedure. This evidence was reviewed by NICE in February 2016 and the recommendations have remained in place since then. The Medicines and Healthcare Products Regulatory Agency and others will continue to review the situation as further evidence and analysis emerges, and will take any appropriate action on that basis. That is why this debate and the recounting of the experiences of constituents is important. They have ensured and will continue to ensure the safety of patients who need treatment.

Unfortunately, no type of surgery is without risk, both during and post surgery. The right balance between risks and benefits for individual patients must be achieved, which places patient autonomy and consent at its heart. I stress that I am deeply concerned to hear about instances where these conversations may not have happened, or have not been conducted in a manner that sufficiently informs the patient. Every patient should expect to receive safe and effective care, and to have an opportunity to raise concerns and feel confident that they will be listened to.

I will talk about the pain and suffering experienced by some men after mesh surgery. The vast majority of patients who undergo surgery using mesh to treat hernias go on to live normal, independent lives. While we do not know the exact number of complications, we believe it is low. However, I understand that those who experience the most adverse outcomes are those who suffer chronic pain or long-term discomfort.

I have been advised that 10% to 12% of men experience moderate to severe chronic pain post surgery. While that number is high, it is lower than for those who have non-mesh repair. I have been advised that acute pain is normal during healing, but chronic pain is not normal. As I said, one example of pain management is to treat chronic pain by injecting local anaesthetic and steroid. Long-term discomfort or pain is fortunately rare, but can still occur in one in 20 inguinal hernia repairs. While this number is still concerning, and, I believe, too high, the risk is dependent on the circumstances of each case. For example, there is an increased likelihood of it where patients have small hernias and where the predominant symptom before the operation is pain. Patients present at the clinic with pain and continue to have the pain after the operation. Both these adverse outcomes—the severity and the longevity of pain—remind us that regrettably complications can arise when any person undergoes surgery.

[Mrs Hodgson]

What we are establishing is that there are still many unknowns with regard to the numbers and when the pain occurs. That is what we need to drill down on. The hon. Member for Burton said that his surgery has been totally successful, however many months it is since it took place. However, the problem is not just post-surgery. Often, as we have heard, people are fine for two or three years and then suddenly, “Boom!”—they are hit with whole host of pain and autoimmune reactions. We need to drill down on that when we are looking at the problem. Will the Minister commit to trying to use the data to do that?

[Ms Dorries]

I am hopeful that the Cumberlege report will touch on that area to some degree. I will study the report in some detail, as will officials in the Department, and we will decide where we go from it, but I emphasise that the alternative of not having the mesh repair is more dangerous and has more complications, as we know from the data, than having it.

[Jim Shannon]

To follow on from the shadow spokesperson’s question, has it been possible within the investigation and review to understand why the vast majority of people can have the operation without any side effects, while a large number of people do? There were 400 such people in Northern Ireland. If we take that population across the whole country, that means about 24,000 people across the rest of the United Kingdom, so the figures show a large number of people who have had problems. Is it possible to say why, or to investigate and ascertain why those problems take place, as they did in Australia?

[Ms Dorries]

We will take that question away. I will come back to the hon. Gentleman, because that is a detailed question with more complexity in it than I could answer today. For those people who suffer from pain, is it alleviated by the steroid and local anaesthetic injection? Are those numbers just people who present back once with pain, or do they go on to have chronic long-term pain, and, as the hon. Member for Washington and Sunderland West says, come back three or four years later? Some drilling down into that data is needed.

Work is under way both within and independent of Government to improve safety and how we listen to patients, in order to gather the information to work with. In July, we launched the patient safety strategy, which sets out the direction of travel for future patient safety. It was developed through speaking to not just staff and senior leaders but, importantly, patients from across the country. As much as it looks at system improvements, such as digital developments and new technologies, it also looks at culture, so that the NHS becomes ever more an organisation with a just culture of openness to concerns, whether they are raised by patients, family members or staff. Concerns of all kinds should be welcomed, valued and acted on appropriately.

We are also waiting to hear back from the independent medicines and medical devices safety review, which is led by Baroness Cumberlege. The review examines how the healthcare system has responded to concerns raised by patients and families around three medical interventions, one of which is vaginal mesh. To do so, the review has focused on meetings with a broad range of stakeholder groups; I think the hon. Member for Washington and Sunderland West may have attended one of those with her mother.

I close by acknowledging just how difficult the subject matter is. No one should suffer from chronic long-term pain without every effort being made to reduce it and find out why it occurs in the first place. This is not an easy subject for men who are suffering from ongoing pain to speak about. We know that men are always very reluctant to come forward and go to the doctors about anything. I pay tribute to the many impassioned contributions of the brave men who have allowed their stories to be told, who have visited their MPs and contributed, because men are not good at sharing information when it comes to their health.

As I mentioned earlier, however, it is vital that the use of mesh to treat hernias continues. It remains the best course of action for patients where the appropriate treatment pathway leads to surgery. As with all treatment, shared decision making should be central to this process. It is vital that we continually examine the evidence together on the best means of treatment. Decisions in healthcare are often about weighing potential benefits against risks, and I thank those in our healthcare system who strive always to offer us the best treatment possible.

--- Later in debate ---

[Jim Shannon]

It was the hon. Gentleman’s quotation, so I am just quoting him again. He has personal knowledge of what has taken place. Again, to be fair, his operation has been successful. The shadow spokesperson, the hon. Member for Washington and Sunderland West, brought a lot of information to the debate. The problems are really real.

We set out two subjects in this debate: No. 1 was awareness, which is important, but No. 2 was that everyone should understand, before they have the operation, what the implications could be. That does not mean that they will not go ahead with the operation, but it ensures that they understand it. The hon. Lady referred to the “devastating” effect that this can have on lives. It is not a quick or cheap procedure, either, and patient safety is critical.

I thank the Minister for her response. She first confirmed in her contribution that we are raising awareness, and secondly referred to a safety review. I appreciate that and understand why. That does not in any way dismiss—no one can dismiss—those problems that have arisen out of the hernia mesh operations in men as not real. I ask her, if she has the opportunity, to perhaps look at the Australian investigation, although maybe she has already done so.

[Ms Dorries]

indicated assent.

[Jim Shannon]

There we are; the Minister is ahead of me there. Well done. That investigation might give us some ideas for what we could do here as well.

I also thank the hon. Member for Burton (Andrew Griffiths), as always when he turns up, for his contribution. I know many people who have had the operation successfully, but my job here is to bring to the attention of the Minister and this House the many others who live with the mental, physical and emotional problems. That is what this debate is about. I thank everyone for their contributions, and I thank you, Mr Hanson, for chairing the meeting admirably, as you always do.

Question put and agreed to.

Resolved,

That this House has considered hernia mesh in men.