Dermatology Funding

Paul Beresford Excerpts

Wednesday 4th December 2013 Westminster Hall

[Sir Paul Beresford (Mole Valley) (Con)]

I congratulate my hon. Friend the Member for Gainsborough (Sir Edward Leigh) on obtaining this debate. I have tried quite often and failed, so he obviously gets on better with Mr Speaker than I do or has better luck in the ballot system. I also congratulate him on producing many of the statistics and conclusions that the all-party parliamentary group on skin has come up with, which has two advantages: the Minister has heard them, and I do not have to repeat many.

This is an important and reclusive area in the national health service, but I must start by making some declarations of interest, as we are supposed to do. First, as part of clinical practice, I have seen and referred patients with a number of skin conditions. The treatment of some has been urgent—my hon. Friend mentioned melanomas—and some semi-urgent, such as basal cell carcinomas. Such carcinomas are commonly called rodent ulcers and are just chopped out, but when I was in Palermo a few years ago I saw one that had been left on the side of a gentleman’s face and that looked something like a small, underdone McDonald’s hamburger. We do not see such things here, so whatever we say about the condition of dermatology in this country, that has gone—thank goodness. There are a number of common and disfiguring conditions. My hon. Friend touched on acne and a number of other chronic diseases, such as psoriasis, all of which some people do nothing about, but for which help is available if they look for it.

Secondly, I am chairman of the all-party parliamentary group on skin. I must admit that, shortly after the election, I was pressurised, bullied, pushed and dragged, kicking and screaming, to accept the post. One problem with many things that we do in this House is that, once close to something, it is hard not to get drawn in. It is a fascinating and complex area with a definite recognition problem. It is just not seen and accepted. My hon. Friend talked about funding but also touched on his family’s clinical problems; I shall resist doing so as my sons would never allow me. The area could do with more money, but more could be done more effectively with what we have. Much improvement can be made through education, which my hon. Friend touched on, a change in service approach and, most of all, a recognition of need.

One of the first really quite shocking points that was made to me as chairman of the APPG was that, while skin conditions account for the greatest proportion of patient visits to GPs, undergraduate education in such conditions for doctors, including those who will become GPs, is minuscule. I risk repeating my hon. Friend’s point, but it is worthy of repetition. Many student doctors spend a few weeks, possibly only one week, studying skin diseases and conditions. I am not sure whether it still applies, but I believe that education in skin conditions is optional in some medical schools. If someone wants to become a GP and opts not to learn about such conditions, they are in for one heck of a shock or run the risk of doing their patients a disservice. It is quite staggering considering that dermatologists are expected to manage over 2,000 different diseases of the skin, hair and nails.

Reputedly, as has been mentioned, 54% of the population are affected by skin disease each year, and, as my hon. Friend said, some 4,000 deaths are attributed to skin disease annually in the UK. Generally, the horrendous malignant melanoma is the main cause. The incidence of melanomas has increased by 50% over the past 13 years. The hot spots are many and varied and include Glasgow and areas of Surrey. I do not know why that is and I am not sure that anyone does. Skin cancer is the most common cancer and is the second most common cancer causing deaths in young adults. Prevalence of basal cell carcinoma equals that of all other cancers combined and increased by 133% between 1980 and 2000. Hand eczema is one of the most common reasons for disablement benefit in the United Kingdom, yet skin disease hardly ranks in the education that goes towards the basic medical degree.

As has been mentioned, we have 780 funded posts for consultant dermatologists in the United Kingdom, which is a positive. That would be impressive, but, as has also been mentioned, 180 to 200 vacancies need to be filled. To add to the difficulties, many of the posts are filled by locums who are not fully accredited dermatologists. Even more concerning is that there are few specialist facilities, which are not ordinary hospital facilities but those that provide specialist dermatological treatment, including dedicated dermatology psychology practitioners. It is little recognised that many skin diseases are always present or threatening to be present and can cause devastating effects on a person’s physical well-being and can lead to serious psychological problems.

The all-party parliamentary group on skin has produced evidence that highlights the extensive impact that skin disease can have on all aspects of patients’ lives, such as school, work or personal relationships and, as a result, self-esteem. Such conditions often affect career choices and even such basic things as where an individual can go on holiday. Who would want to sit on a beautiful beach or to go swimming from it when hit by eczema, psoriasis or any of the various pigment conditions? It just does not bear thinking about. Some conditions can obliterate what many of us would expect to be normal social, sexual or leisure activities. According to the British Skin Foundation, approximately 50% of people who suffer from skin conditions have been victims of verbal abuse—we can imagine a child with psoriasis in a school. One in six has self-harmed and 17% have contemplated or attempted suicide.

If I have one major ask of the Minister, it is that she go to one of the few—but top—skin clinics, particularly one that includes psychological treatment as a norm. She should talk to some of the patients with psoriasis or a number of other such disfiguring diseases. They are not necessarily death-causing, but they totally obliterate normal life. She can see how they are handling their conditions, as well as how modern medicine can improve their lives, in particular if they get psychiatric help. Most can be helped to keep their conditions at bay, but part of the package should require psychological help—we have an APPG paper on this. I ask the Minister to meet those patients, who range from the very young—babies—right through to the very old, and watch and listen to how they cope. That should encourage a national rethink on how the NHS treats this massive and often unrecognised area of medicine.

When the Minister visits new clinical commissioning groups, which she does, I hope that following our debate and in particular the point made by my hon. Friend the Member for Gainsborough, she will ask some pertinent questions about how commissioners draw up local service specifications for the bidding process for dermatological services. The parameters of dermatology bids need to be drawn up with expertise and experience, which many CCGs do not have. I hope that the Minister can encourage, bully, push and cajole those CCGs to buy in, pull in and seek expertise when drawing up the specifications. The British Association of Dermatologists recommends that, before carrying out a service tender, commissioners should undertake a health care needs assessment and a review of the current service provision and, most importantly, consult service users and local clinicians, especially those who know something about the conditions.

[Mrs Gillan]

I pay tribute to my hon. Friend as chairman of the all-party group on skin—however reluctantly he took the post, he does a good job and I am pleased to be a member of the group. Is he familiar with the teledermatology service pilot in Buckinghamshire where a short history and photos of a patient are sent to consultants who can then provide advice to GPs? If he is not aware of it, would he like to know more? If he is aware of it, will he recommend that the Minister look at it while examining what we do in this area? It could be a valuable addition to the tools available to help people with dermatological conditions.

[Sir Paul Beresford]

I thank my right hon. Friend. In answer to her first question, which was whether I was aware of the pilot, the answer is no. Would I be interested? The answer is yes. As for the Minister, I saw that she was writing the details down, so I do not think I need to repeat them.

The greatest change necessary is to encourage education. That has already been touched on at some length. The lack of knowledge among practitioners and clinicians is the problem. We need better education in the under- graduate curriculum and further improvement in post- graduate training, perhaps with a continuing professional development requirement. Training is also required to produce more consultants, more doctors and psychologists with a professional interest in dermatology and more specialist nurses. That is not a big ask, considering the size of the problem.

This is an area where investing more on education at every level, with better provision of specialist clinics should, in due course, ease some of the costs and pressures, in particular on primary care. There would therefore be a positive payback. I reiterate, however, the importance of the Minister seeing things first hand. I would be delighted to arrange an appropriate visit and join her if she is willing.

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[Mr Jamie Reed (Copeland) (Lab)]

As always, Mr Turner, it is a pleasure to speak under your chairmanship. I extend my sincere thanks to the hon. Member for Gainsborough (Sir Edward Leigh). I understand that dermatology is extremely close to his heart, and the personal testimony that he shared with the House today was a frank and honest account of what many of our constituents live with daily.

I can scarcely remember a health debate in this place when the hon. Member for Strangford (Jim Shannon) has not been present and made a tremendous contribution. He did so again today, as did my hon. Friend the Member for West Lancashire (Rosie Cooper) and all hon. Members. If only the House could speak with such unanimity of purpose on other issues. The chairman of the all-party group on skin, the hon. Member for Mole Valley (Sir Paul Beresford), also made a telling contribution.

This might be the first time I have debated with the hon. Member for Gainsborough. I was supposed to have debated religious freedom with him at the Oxford Union in 2005 when I was a young Back Bencher, but under pressure from the Whips, I was unable to attend, so we will never know whether that exchange would have been contentious. However, I am delighted to debate the issue before us today.

“Dermatology” is a wide-ranging umbrella word covering more than 2,000 conditions of varying severity, all of which have a detrimental impact on the quality of life of those who are affected. “Cancer” is also a wide-ranging word denoting many different types, including basal cell carcinoma, squamous cell carcinoma, malignant melanoma and others such as Kaposi’s sarcoma and cutaneous T-cell lymphoma. Dermatology also covers skin rashes, skin infections and acne. Acne and skin rashes may not seem to be serious medical issues and do not often cause such serious complications as other skin conditions may do, but they are far from trivial, as we have heard, and may have a huge impact on the psychological well-being of the individuals who suffer from them.

The wide-ranging nature of dermatological practice means that episodes of treatment for conditions are extremely common. Skin cancer is one of the most common cancers in the world, as we have heard, and the NHS estimates that there are around 100,000 new cases of non-melanoma skin cancer in the UK each and every year. Thankfully, through excellent research and brilliant work by professionals and charities alike, skin cancer is becoming more and more treatable, but it is not “job done” and we must continue to strive for even better patient outcomes. I am sure that all hon. Members agree.

Skin diseases represent more than one third of diseases in children. One in five children in the UK have eczema. The British Association of Dermatologists, in its recent evidence to the Select Committee on Health, stated that children with serious skin conditions have their quality of life impaired to the same extent as those with chronic illnesses such as epilepsy, renal disease and diabetes.

Acne is a very common skin disease and affects many people. It is often trivialised as a passing phase for teenagers, but that is not the case and it can continue throughout their 20s, 30s and even 40s. The scarring left by acne is permanent and may have lasting effects on the psychological well-being of those who are affected. The British Association of Dermatologists says that it may have a major impact not just on someone’s relationships, but on their employment prospects throughout their life.

In this very Chamber yesterday afternoon, hon. Members debated the side effects of a drug, Roaccutane, used to treat acne. It is very effective in clearing up acne and is often prescribed to those who suffer the condition. It can be prescribed only by a specialist dermatologist because of its associated side effects, which, it is said, can range from relatively minor issues such as dry lips and chapped skin to serious mental health problems linked to depression and suicidal thoughts, as well as physical conditions such as diabetes and kidney problems.

When a significant number of people rely on such treatment to improve their quality of life, Government of all colours must give a commitment properly to fund research and development for new treatments. Many thousands of people rely on drugs such as Roaccutane and face the many risks associated with them. We must commit to developing new and safer drugs. Will the Minister give that commitment today? Will the Government help to facilitate the development of new medicines and new treatments for these conditions?

In 2009, the previous Labour Government legislated to introduce a ban on under-18s using sunbeds. That ban was an important step in protecting people of all ages from what can be harmful tanning practices. Will the Minister, who is responsible for public health, tell us what steps she is taking to increase awareness of the risks of using sunbeds? I certainly hope that she will retain the previous Government’s focus on the issue.

Other skin complaints have an impact on many millions of people in the UK and continued work is essential for progress to be made. I again thank the hon. Member for Gainsborough for securing this debate because at a time when funding and commissioning in the NHS have been thrown into turmoil—some clinical commissioning groups will have their funding slashed in the next couple of days—it is crucial that treatments and research are properly funded.

The funding of dermatology services in the NHS has been made ever more complex by the Health and Social Care Act 2013 with some treatments now being commissioned by NHS England on a national scale and others being left to local clinical commissioning groups, resulting in a fragmentation of services and a poorer experience for patients. The British Association of Dermatologists said:

“Provision of the type of care affected people need is under resourced, fragmented and of variable quality in terms of manpower and facilities. This is exacerbated by poor teaching and training of dermatology in medical schools and general practice, and underfunding of relevant research.”

These very serious concerns have been raised by a well-respected charity with unparalleled expertise in this area. Will the Minister tell us whether they have been raised by anyone else with her Department, and what action the Government are taking to tackle them?

The resources available for dermatological purposes are majorly overstretched. It is estimated that skin conditions result in 13 million consultations each year in general practice—I think we heard that figure earlier. If we had the pro rata equivalent of dermatology consultants in Germany, France, the USA and elsewhere, we would need almost 10 times as many as we have currently. Will the Minister also tell us whether there are recruitment plans in place to ensure that this highly specialised discipline is adequately catered for throughout the national health service? Not only is access to dermatological expertise in the UK subject to a postcode lottery in terms of quality, but the resources and the necessary work force are simply not there to care for the patients who rely on those services.

We have heard many testimonies today, and not just those of hon. Members here. When hon. Members speak of their own circumstances and difficulties, we achieve a better quality of debate and tend to edge towards better policy outcomes. In the light of the testimonies we have heard today and of what our constituents, patient groups, charities and professionals tell us, it is clear that the evidence points to a specialism under severe strain. It is underfunded, understaffed, under-resourced and, as a result, under immense pressure. The profession’s staffing levels are clearly a major problem.

[Sir Paul Beresford]

The biggest problem is education. It takes a very long time to give someone expertise, particularly in this area with around 2,000 diseases or variations of them. Will the hon. Gentleman think carefully and recognise that any unfilled consultant place goes right back to a lack of education under his Government?

[Mr Reed]

I am grateful for that intervention. I make the point repeatedly every time hospital doctor statistics are mentioned by Ministers. I absolutely recognise the hon. Gentleman’s point and welcome his making it: he is absolutely right to say that education is surely at the core of the problem.

Staffing levels in the profession are clearly a major problem. Will the Minister give an assurance today that those who need the services of a specialist dermatologist will have access to them? If not imminently, when? Should the Government bring forward effective proposals, I give the Minister the assurance that they will have the Opposition’s support. Where the Minister cannot answer my concerns, I would appreciate a written reply.

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[Jane Ellison]

I am very happy to give a commitment to take that point away and I will certainly bear it in mind in other discussions that I have.

I am glad that some hon. Members have taken the opportunity offered by the debate to highlight the growing issue of malignant melanoma. It is absolutely right to say that we need to make more people aware of the dangers of skin cancer. I was struck by the point made by my hon. Friend the Member for Romsey and Southampton North about the regional variation and the fact that in her area it is a particular problem.

The Department has funded Cancer Research UK to continue to test approaches to encourage, in particular, men over the age of 50 to visit their GP if they have signs of skin cancer. I have to say that, if anyone can come up with a magic way of making men over 50 approach their GP about anything, that would be very welcome and they would be rewarded by all parts of the NHS.

[Sir Paul Beresford]

There is a largish American community in Surrey, just outside my constituency. They are very aware of skin protection, to such a degree that there is a slight recurrence of rickets.

[Jane Ellison]

That is perhaps a debate for another time, but I note the concern. There is a happy medium to be struck.

Hon. Members might be interested to know that in autumn 2013 Cancer Research ran a campaign in south Devon, utilising text message communications, phone consultations with specialist nurses and volunteer community outreach to try to address some of the barriers to getting harder-to-reach groups to seek advice about skin concerns. Between 2003 and 2011, Cancer Research also collected data via the Office for National Statistics monthly omnibus survey to measure awareness, attitudes and reported behaviour of adults in relation to sun protection. The Department is funding a repeat of that survey in 2013, so that Cancer Research can track changes over time. I think that the results will be very interesting.

Public Health England, in partnership with the Department, NHS England and other stakeholders, proposes to run a local “Be Clear on Cancer” pilot campaign in early 2014 to encourage the early detection of malignant melanoma. The South West Strategic Clinical Network will host that pilot. It will build on evidence from the work in this area that I have just described.

This is a sizeable challenge. We can only, as individual Members of Parliament, take every opportunity that we can to encourage people to seek help from their GP and not to put that off, because for some cancers, the only thing that explains different outcomes for men and women is the fact that men refer themselves later and therefore do not benefit from early diagnosis.

With regard to the point made by the shadow Minister, the hon. Member for Copeland (Mr Reed), on sunbeds, I can respond to him separately on some of the specific things that he asked. I will make the point that the figures that I have seen for the problems associated with sunbeds are highly regionalised and that is one reason why public health is now devolved to local government. Some local government areas are giving the issue real attention and making it a priority. It is perhaps better suited for that sort of local and regional priority than it is for a national campaign, but I take the point that he makes.

A range of support is in place to help GPs to identify malignant melanoma. There is NICE guidance, “Improving Outcomes for People with Skin Tumours including Melanoma”, and there are the “Referral guidelines for suspected cancer”. We cannot highlight them too often.

I would like to take this opportunity to recognise the hugely important role that patient support organisations play. As has been said, they sometimes operate on a shoestring. They make an enormous contribution in helping patients to understand and cope with their conditions. Sometimes, knowing someone who can stand alongside us and say, “I know how you feel and this is how we have learned to cope with it,” is very important as a supplement to clinical guidance.

I again congratulate my hon. Friend the Member for Gainsborough on securing the debate and raising the profile of what is an important issue. As I said at the outset of my speech, I have learned a lot in researching my response to the debate, and I will now have these important issues firmly in my mind in my meetings and visits, where I can raise them. I pay tribute to the work that my hon. Friend is doing and to the all-party group. I assure the House that I will make NHS England and all the relevant bodies that I have mentioned today aware of the issues raised in the debate and the depth of feeling expressed about them.