Health Inequalities

Paul Beresford Excerpts

Wednesday 4th March 2020 Commons Chamber

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

I congratulate the hon. Member for City of Durham (Mary Kelly Foy) on her maiden speech. It was interesting; funnily enough I did not agree with a considerable amount of it, although that is to be expected.

I am the second working medical professional to speak, following my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter). We are both from the same party and speak with some knowledge of the difficulties that we face. The moment that this sort of debate comes up, health professionals from our own particular field have a go at us.

I was delighted that the Minister referred to child dental health, on which I feel a push from behind every time there is a health debate. When I first came to this country, I worked in a really deprived area of east London. Trying to treat children there was like trying to fill a bath with the plug out. The statistics for child dental health are still grim today: 23.3% of five-year-olds have tooth decay, rising to 33.7% in deprived areas. The rate drops to 13.6% in less deprived areas, but it is still bad. Tooth decay is the single greatest reason for hospital admissions for five to nine-year-olds. Last year, 25,702 children went to hospital because of tooth decay. Worse than that, 45,000 children and young people aged up to 19 went to hospital because of tooth decay.

The estimated cost of treating these children in hospital is about £50 million annually. Virtually all children will require a general anaesthetic. Every anaesthetic, especially for little ones, carries a risk—an unnecessary one. The cost is made worse because those cases occupy trained health professionals and hospital facilities that could be used for other NHS services. It makes me very cross because dental caries, as the Minister has said, are virtually entirely preventable. Put simply, the cause is acid from sugar and dental plaque. Britons eat about 700 grams of sugar a week—an average of 140 teaspoons. That intake is not spread evenly; it is higher in the north and lower in the south-east. As Members might expect, teenagers have the highest intake of all age groups, consuming, probably, about 50% more.

The Government are taking action and the sugar tax is helping. Sara Hurley, the chief dental officer, along with many charities and organisations, has a drive to teach children, even down to day nursery children, how to brush their teeth. It is helping but, as the Minister mentioned, far and away the best proven method to reduce tooth decay among children—and even, to some degree, among adults—is the fluoridation of the water supply. Fluoride increases the resistance of tooth enamel to decay dramatically. In the United Kingdom, approximately 330,000 people have naturally occurring fluoride in their water supply. Traditionally, another 5.8 million in different parts are supplied with fluoridated water. But that covers only 10% of the total population. The cover in the United States is about 74% and rising. In Canada, it is 44% and rising, in Australia, it is 80% and rising, and even little New Zealand has managed 70% and rising.

We do have fluoridation legislation, but it is left to local authorities to instigate the process and to compel water companies to fluoridate their water supplies. There is no financial advantage for local authorities if they take such action, but the savings that come through to the NHS are considerable.

The second problem with the legislation is that few local authority boundaries are coterminous with the boundaries of the water companies, which means that the direction and implementation get difficult, complex and sometimes nigh on impossible. To my mind, the simple and sensible answer would be for the application to be put into the hands of the Department of Health and Social Care so that the policy could be applied step by step across the country, going for the most deprived areas first. That is a big ask and it will require a brave Government, but from reflecting on the Labour party’s previous position on fluoridation, I would hope for Labour’s support.

Whenever I raise the issue of fluoridation, the green ink flies. Letters come in and broomsticks whizz around my house as people come up with extraordinary contrary points. The latest Department of Health figures show that the odds of experiencing dental health decay in fluoridated areas were reduced by 23% in five-year-old children in the less deprived areas, and by 52% in those living in the most deprived areas.

Water fluoridation reduces hospital admissions for dental extractions for children by 59%, and in deprived areas by as much as 68%. We have the opportunity to be world leading, to give our children this chance, and to combat health decay and children going to hospital.

[Several hon. Members rose—]

Health and Social Care

Paul Beresford Excerpts

Thursday 16th January 2020 Commons Chamber

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

I thought, Madam Deputy Speaker, that immediately I stood up you would announce that the time limit was down to three minutes.

The number of medically trained professionals who have come into the House has apparently risen dramatically. I am one of them, but I have been here a wee while. I warn the new ones that their profession will lean on them to put the case until they are driven to it, as I am today.

I wish to pick on child dental health in particular. For decades, the statistics have been absolutely appalling. Deciduous teeth—baby teeth—are particularly susceptible to decay: their enamel is much thinner than that of permanent teeth. Before SNP Members stand up to tell me about it, I should say that action has been taken on care and education, particularly in schools, and to some degree it is working, but those children for whom it does not work, or works only partially, will require extractions. I can remember looking at little kids in east London with appalling mouths—broken-down teeth, abscesses—who were crying and having sleepless nights, and having to refer them to hospital for a general anaesthetic.

The statistics today are terrible. Last year, more than 45,000 children and young people aged up to 19 were admitted to hospital because of tooth decay. They included 26,000 five to nine-year-olds, making tooth decay the leading cause of hospital admissions for that age group. Last year, there were more than 40,000 hospital operations and extractions for children and young people. That is 160 a day. It is a complete waste of money, it is completely preventable and it is occupying space in our national health service.

Education is starting to make a difference, but far and away the best-proven method to reduce tooth decay among children, and even more so among adults, is fluoridation of the water supply. In the United Kingdom, approximately 330,000 people have naturally occurring fluoride in their water supply. In addition, another 5.8 million in different parts of the country are supplied with fluoridated water. But that covers only 10% of the total population. The percentage covered in the United States is 74% and rising; in Canada it is 44% and rising; in Australia it is 80% and rising; and even little New Zealand has managed 70%. We have fluoridation legislation, but it is left for local authorities to instigate and compel companies to fluoridate their water supplies. There is no financial advantage for the local authorities, but the savings to the NHS would be considerable.

The second problem with the current legislation is that few local authority boundaries are coterminous with the boundaries of the water companies. That makes direction and implementation complex. The sensible answer is for legislation to apply nationwide. That is not in the Queen’s Speech. It could be put into a Queen’s Speech, but it will take a brave Government, I hope supported by the Opposition, to include and implement that. I warn that whenever I speak about fluoridation, the green ink letters fly and broomsticks whizz around my house as people complain. However, it works for child dental health care, which is deplorable in this country.

[Madam Deputy Speaker (Dame Rosie Winterton)]

It is a great pleasure to call Amy Callaghan to make her maiden speech.

Health Infrastructure Plan

Paul Beresford Excerpts

Monday 30th September 2019 Commons Chamber

[Edward Argar]

I will not stray into the politics of the NHS in Scotland. The hon. Gentleman asks specifically about Barnett consequentials. I can confirm that they will apply, and if it would be helpful I will write to him with details.

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

As my hon. Friend might guess, I am delighted by the announcement about Epsom and St Helier University Hospitals NHS Trust, which will find favour with hon. Members on both sides of the House. We have been talking about it for a long time, and this is the first genuine movement.

I have a tiny, slightly off-the-wall additional request. As my hon. Friend is aware, I have a declared interest in dentistry, which means that every time the word “health” comes up, I get prodded in the back by my colleagues. In most western nations, 60%, 70% or 80% of the public water supply is fluoridated. It is a proven caries prevention. Would he include in his plans the infrastructure to greatly expand the fluoridation of our water supply? It would bring benefits in terms of prevention and, in due course, cost.

[Edward Argar]

As he said, my hon. Friend showed some dexterity in asking that question, but I am happy to reassure him. The Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Bury St Edmunds (Jo Churchill), is looking at this matter, and I am sure that she will be happy to discuss it with him further.

NHS 10-Year Plan

Paul Beresford Excerpts

Tuesday 19th February 2019 Commons Chamber

[Stephen Hammond]

My hon. Friend makes a good point and urges me to take up the issue, which I will. He is obviously an expert in this field and will know that the Government have asked the NHS to come forward with proposals for legislative reform to support the long-term plan’s ambitions, and I will reflect on his comments in my thinking.

By 2021, every part of the country will be covered by integrated care systems, which will bring together local organisations, including local authorities, to redesign care and improve population health. They will become the driving force for co-ordination and integration across primary and secondary care. Any claim that such reforms might lead to privatisation are misleading. In fact, the Chair of the Health and Social Care Committee said that the proposals

“will not extend the scope of NHS privatisation and may effectively do the opposite”.

The NHS will invest more in preventing ill health and stopping health problems getting worse. That includes offering tobacco treatment services to all in-patients and pregnant women who smoke, establishing new alcohol care teams, and offering preventive treatments to more people with high blood pressure and other risk factors for heart disease.

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

As my hon. Friend is probably aware, I have a part-time job in which I deal with a preventable disease: caries. In dentistry we spend £34 million to £38 million on this preventable disease. Will he consider looking seriously at how we could persuade local authorities to put fluoride in the water supply to prevent caries?

[Stephen Hammond]

My hon. Friend will know that the plan has much on prevention in primary care and public health. I offer to meet him, and I will listen carefully. He tempts me down a line that I would rather not go down tonight.

The long-term plan marks a huge step towards parity of esteem between mental and physical health. In the next five years, the budget for mental health services will increase by at least £2.3 billion in real terms. This additional funding will be used to fund a major expansion of mental health services for both children and adults. In addition to piloting four-week waits for children and young people, we will test waiting times for adult and older adult community mental health teams, and clear standards will then be set. Specific waiting times for emergency mental health services will take effect for the first time from 2020 and will be set to align with the equivalent targets for emergency physical health services.

Prevention of Ill Health: Government Vision

Paul Beresford Excerpts

Monday 5th November 2018 Commons Chamber

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

As my right hon. Friend is aware, I am a very part-time dentist and I am also a supporter of the British Fluoridation Society. Probably the very biggest reason for children attending hospital for general anaesthetic is to extract decayed, rotten, abscessing teeth caused by dental caries. Fluoridation of the water supplies is a very effective means of prevention. Does he support fluoridation of the water supplies, and what can he do to actively promote it, because, at the moment, it is in only 10% of our supplies?

[Matt Hancock]

My hon. Friend is of course a dentist, and I would love to listen to him speak in more detail about what we can do to get this right.

Oral Answers to Questions

Paul Beresford Excerpts

Tuesday 24th July 2018 Commons Chamber

[Matt Hancock]

The hon. Gentleman makes an important point. Funding is available from lots of sources, not just taxpayers. Nevertheless, he will have noted that I have already started talking about the importance of getting funding out into the community, whether that is through social prescribing or wider public health efforts, to make sure that we try to tackle health problems at source and keep people out of hospital as much as possible, rather than spending all the money on sorting things out later in hospital.

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

5. What assessment he has made of the potential merits of extending the provision of the HPV vaccine to boys.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

Our expert group, the Joint Committee on Vaccination and Immunisation, issued its final advice on HPV vaccination for boys on 18 July. I have carefully considered its advice, and I wanted to tell the House first that the Government will introduce a nationwide HPV vaccination programme for adolescent boys. This will bring clear health benefits for boys, providing them with direct protection against HPV infection and associated disease, including a number of cancers.

[Sir Paul Beresford]

I declare an interest as a very, very part-time dentist.

I am delighted by the response, but given the importance of head and neck cancer prevention for both sexes, but especially for males, who are twice as susceptible, will the Minister supplement this programme with a catch-up programme, as was done for girls in 2008, to make the vaccine available for 14 to 18-year-old boys?

[Steve Brine]

I thank my hon. Friend for welcoming this. The British Dental Association has been key in lobbying on this issue, as has—I give credit where it is due—The Mail on Sunday, which has campaigned on it for a long time. I have asked NHS England and Public Health England to work together to advise me on the implementation of the programme, including with regard to the issue that he raises, which makes a lot of sense and for which there is precedent from the girls’ programme. I will of course consider the advice and confirm the implementation plan as soon as possible.

Children’s Oral Health

Paul Beresford Excerpts

Tuesday 31st October 2017 Westminster Hall

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

I congratulate the hon. Member for Birmingham, Selly Oak (Steve McCabe) on going through all the statistics, which means that I can cut my speech down immensely; I will put him up for an honorary degree as a dental therapist.

The hon. Gentleman is right: the statistics on child dental health are horrific. Deciduous teeth, or baby teeth, are particularly susceptible to decay as they have thinner enamel than permanent teeth. That is a contributing factor, but the problem is basically one of education, and it has gone on for decades. When I first practised dentistry in this country, in the NHS in east London in the early ’70s, I was struck by the appalling state of child dental health. Every Thursday afternoon, either I or a principal of the practice, with an anaesthetist, ran general-anaesthetic sessions. When I look back on them I am horrified, because the risks were considerable and such treatment is now banned. The children would all go to hospital now.

Those sessions were packed, and were almost entirely about extracting teeth from little children. It is appalling to think of it, but not as appalling as seeing those little children coming in, in pain after sleepless nights due to dental decay. If one wandered down to the local supermarket in east London, the stacks and racks of biscuits and sweets were considerable; the stacks and racks of what we would call wholesome food were minuscule. It was an education problem.

Prevention must be the way forward, because of the cost reductions. If one realises that Britons eat around 700g of sugar a week—an average of 140 teaspoons—one can see that reduction is needed. The intake is not spread evenly; it is higher in the north, lower in the south-east, and teenagers have the highest intake of all age groups, consuming some 50% more sugar on average than is recommended. That is another education issue.

The hon. Member for Birmingham, Selly Oak mentioned Childsmile—the set of Scottish tactics and methods for teaching kids—and that is very successful: more than 90,000 nursery schoolchildren take part. It is a programme of supervised tooth brushing, which has made some quite staggering gains; it has been mimicked in Wales and now here. England has an enthusiastic new chief dental officer, Sara Hurley. She and I will be arranging for every English MP to be invited, region by region, to meet her and others to discuss tooth decay problems among children and understand how we can move forward.

I have a few suggestions for the Minister, some of which have already been mentioned. We need a national oral health programme, such as that in Scotland, which should target poorer areas and areas of poor health, although this is not about poverty—it is about education. Sara Hurley is well on the way with a number of campaigns and areas where that is working. She, I and others have been working with local health and wellbeing boards to move into schools to run a check system that ensures that children, particularly in primary schools, visit their dentist once a year. If children had a little book, every child could be required by the head of the school to come back with an appointment card signed by a dentist to show that they had been once or twice a year. That should be a standard policy in schools.

Not just dental healthcare professionals but all healthcare professionals, such as midwives, health visitors and pharmacists, need to be given training. I remember an occasion when one of my kids visited a healthcare professional. The child was tiny. My wife had to listen to the healthcare professional say that fluoride and fluoride toothpaste were poisonous. I could not believe the ignorance!

Dental associations and groups should wake up—they are starting to—and should help dentists to help tooth-brushing campaigns and programmes. Such practices could be and sometimes are adopted in schools. The dentist does not have to go, but the hygienist and the nurses can. Toothbrushes and toothpaste can come from providers for free, and education can be linked. Kids—little kids especially—love brushing their teeth. Sara is trying to bring that into primary schools and nurseries, and perhaps to children as young as between one and two.

Far and away the biggest proven method of reducing tooth decay among children, and ultimately adults, is fluoridation of the water supply. As part of the health professional programme, the use of oral fluoride for children should be promoted by health workers. It is not, and it should be, because it makes a dramatic difference. My father was a dentist in New Zealand. I remember him saying that before fluoride arrived, trying to treat children with tooth decay was like trying to fill a bath with the plug out. Fluoride has dramatically changed the situation, and education and tooth brushing will change it even further.

In the United Kingdom, approximately 330,000 people have naturally occurring fluoride in their water supply at the optimum level. In addition, some 5.8 million people in different parts are supplied with artificially fluoridated water. That is about 6 million, out of a total population of 64 million—about 10% of the population. The percentage in the United States is 74%; in Canada, it is 44%; in Australia, it is 80%; and in New Zealand, it is about 70%.

The answer has to be a combination of fluoride in the water supply, fluoride in toothpaste—especially where there is none in the water supply—and, as the hon. Member for Birmingham, Selly Oak has said, using the opportunity to get out into schools and teach the kids. If we teach the kids, we teach the mothers. Dental decay is preventable; let us prevent it.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Member for Birmingham, Selly Oak (Steve McCabe) on securing this debate. As always, it is good to have the pleasure of the vast experience and knowledge of the hon. Member for Mole Valley (Sir Paul Beresford) on this subject. I thank him for his contribution.

I am the Democratic Unionist party spokesperson for health, so this issue is very much on my radar. I will give some stats—the hon. Member for Birmingham, Selly Oak gave some, but I will give different ones. That does not make me any more of a statistician or an honorary member of any statistical organisation, but they are important for me because they are from my own region.

I can remember, as a child, my mother taking me to the bathroom and scrubbing the life out of my teeth; we can all probably remember something similar. When I was old enough to brush, but perhaps not old enough to know the importance of brushing, there were mouth checks, which reminded me of checking a horse’s mouth to see the health and age of the horse. Rather than understanding why it was essential that we brushed our teeth, I was probably more afraid of not having my teeth brushed and my mother doing it for me. The hon. Member for Mole Valley mentioned an increase in that among young children, which is good news. I am afraid that we do not see all the stats and realise the importance of that in Northern Ireland.

I believe that we are all fearfully and wonderfully made, as it says in Psalms, and that the intricacy of our body does nothing other than point to our creator God. Why else would we have two sets of teeth—the baby teeth that we probably abuse, which decay and fall out, and then the adult teeth? I know some adults who probably wish that they had a third, and possibly even a fourth, set of teeth.

I commend the previous Health Minister, David Mowat, who launched the new programme in January this year. I look forward to the present Minister’s response, which I know will be equally committed. A briefing I received for the debate made very interesting reading, and it all points to prevention. Tooth decay is the most common reason why five to nine-year-olds are admitted to hospital. In Northern Ireland, some 5,300 children were admitted to hospital for tooth decay and extractions, with 22,000 baby teeth removed. Moving on to 12-year-olds and teenagers, the signs of decay in permanent teeth are significant.

The hon. Members for Birmingham, Selly Oak and for Mole Valley have both referred to the need to control the intake of sugary drinks and foods. As a diabetic, I am well aware of the need to control sugar. Coca-Cola used to be one of my favourite drinks, but it is not any more—not because I dislike it, but because it was doing more harm than good and I had to stop drinking it. We need to have that control, and parents have a role to play.

There are significant regional and socio-economic differences in dental health across England—the numbers of those with tooth decay in the south-east compared with the north-west, for example; the difference is almost double. Perhaps the Minister will reply on that north/south difference. In some areas, seven times as many children are affected than in the best performing areas, where only 8% are affected.

Northern Ireland is at the bottom of the league table for oral health. I am not at all proud to say that, but it is a fact of life. We have a lot to do, in what is a devolved matter in Northern Ireland—at least until we find out where the Assembly is going, in which case the role over here might become greater. The 2013 children’s oral health survey showed that Northern Ireland had the worst oral health outcomes in the UK, and highlighted the difference in the figures compared with outcomes in England. Some 72% of 15-year-olds have signs of decay in Northern Ireland, compared with 44% in England and 63% in Wales. We have a lot to do, and we need to start that in primary school. The hon. Member for Birmingham, Selly Oak suggested education at primary school breakfast groups as a way of doing that. I think that would be excellent.

Of the 4,000 parents questioned in the Simplyhealth professionals oral health survey, 51% said that getting their child to brush his or her teeth for the recommended two minutes twice a day was a challenging task. Well, I think children are always challenging, but that is certainly one of the things that we need to do. The view has been echoed by members of my staff, who said it is as tough to get the seven-year-old grandchildren to do a good job as it is the two-year-old. That is a battle many parents face and they will do many things to try to encourage children. There are even such things as singing toothbrushes, as one method that may encourage children. It may help set the timespan, but the quality of brushing during that time could be questionable. To listen to the sound of a singing toothbrush is one thing, but brushing teeth has a purpose and we need to focus on that.

Children who experience high levels of oral disease, and are treated with fillings and other restorations, will require complex maintenance and treatment of new oral problems as they grow older. We are all aware that dental treatment is a significant cost to the NHS, with spending in England amounting to £3.4 billion. Some £2.3 billion is spent on private dental care. The NHS spends £50 million on tooth extractions for children, the majority of which are due to tooth decay. Shockingly, 42% of children did not visit an NHS dentist in the year ending 31 March 2017, even though such check-ups are free. The National Institute for Health and Care Excellence recommends that children see a dentist at least once a year, but 80% of children between the ages of one and two did not visit a dentist in the 12 months to the end of March. Those statistics are important, because they show us where we need to focus our attention.

I am conscious that other hon. Members wish to speak, so I will conclude with this. Drastic action must be taken, but for that to happen we need a funding regime so we can do more for children in schools and through the healthcare system. More needs to be done in socially deprived areas, because there is a north-south divide when it comes to those affected by tooth decay. We must ensure that parents prioritise oral healthcare and are able to access a dentist for their child easily and without fear that they will be judged or told off. Something needs to be done. We must ensure that there is not another generation of people in agony due to their teeth. Having had toothache, I know my heart goes out to those who suffer from it. Tooth decay is preventable, so we must do all we can to prevent it in our children. We should start as we mean to go on.

[Sir Paul Beresford]

On a point of order, Mr Bone. I was so enthusiastically carried away by the opening speech that I cannot remember whether I declared that I am a very part-time dentist. If I did not, I have now done so.

[Mr Peter Bone (in the Chair)]

I think hon. Members knew that, but thank you for putting it on the record. We have got about half an hour to go, and five Back Benchers wish to speak. I work that out to be roughly six minutes each.

--- Later in debate ---

[Sir Paul Beresford]

I hear what the hon. Lady says. The success in Scotland has been dramatic, and the importance of dentists is dramatic—I would have barbs in my back if I said anything else, as she can imagine—but the biggest success has been the prevention programme with schools, nurseries and so forth. That outweighs everything else. That has been the reason for the Scottish success.

[Dr Whitford]

I thank the hon. Gentleman for that intervention. I was not trying to give any other impression. I said that the core programme is the education of 90,000 children about how to clean their teeth and discussions with their parents about that. The problem is that we waste an opportunity if we stop there. There needs to be a link between health visitors, nurseries and dental practices, and there certainly needs not to be a contract that punishes and penalises dentists for investing in patients. The fact that dentists do not have long-term registered patients means that they do not look at patients with a long-term view and say, “If I do more work now, they will have better dental health later.”

In Scotland, 92% of the population is registered; the number of people who are registered has risen from 2.6 million to 4.9 million. Registration is actually higher in deprived areas than in rich areas. Unfortunately, attendance is not always higher, but people are at least already registered with a practice.

Oral Answers to Questions

Paul Beresford Excerpts

Tuesday 4th July 2017 Commons Chamber

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

I declare an interest which is probably fairly well known.

The Minister will be aware that the answer is early-years prevention. A huge campaign, which is making progress, is being led by the chief dental officer, for whom I have considerable admiration. Is the Minister prepared to meet me and the chief dental officer to discuss that progress? In advance of that appointment, will he look at the possibility of providing additional funding from the annual dental clawback?

[Mr Speaker]

New Members probably will not know that the hon. Gentleman is a dentist.

O’Neill Review

Paul Beresford Excerpts

Tuesday 7th March 2017 Westminster Hall

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

I am delighted to serve under your guidance, Mr Streeter, and I congratulate my hon. Friend the Member for Thirsk and Malton (Kevin Hollinrake) on securing the debate. A disadvantage of being the only practising dentist in the House is having to remember that the Commission is watching, so I have to declare it, Mr Streeter.

As the right hon. Member for Rother Valley (Sir Kevin Barron) will know, as a dentist I am instantly lobbied by the likes of the British Dental Association, and I will stick to that area. As he said, around 10% of the antibiotics that are dispensed are for dental pains and dental problems. Hundreds of thousands of people swarm into GP surgeries and A&Es and they are given pills like lollipops to take away, but the solution is only temporary and does not solve the problem. To ask the Minister one small thing, will she think about working on a system to increase the number of emergency dentists that are available, because dental action, not pills, is needed?

Dental action can take many forms. Part of stopping the broad provision of antibiotics is straight prevention. In the case of dentistry, that is relatively simple. The cause of the majority of dental pain requiring antibiotics is decay and that is totally preventable. I am delighted that Sara Hurley, the new chief dental officer, is really moving on that issue. She is making changes so that kids are taught, from the moment that their teeth arrive right the way through to their school years, about brushing their teeth and using fluoride toothpaste to prevent decay. Many of the hundreds of thousands of patients who go into A&E are children suffering from swollen faces, pain, sleepless nights and so on. They are given antibiotics to tide them over until they have teeth taken out. In England, some 900 kids a week are given general anaesthetics to have their teeth out. That is appalling and preventable. I encourage the Minister to work with the chief dental officer, the health and wellbeing bodies and charities to prevent the need for any antibiotics—or at least, to reduce the antibiotics used—in dentistry by simply preventing dental decay.

Variant CJD and Surgery

Paul Beresford Excerpts

Tuesday 29th November 2016 Commons Chamber

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

I am delighted to see the Minister in her place, and I am sure that she is delighted to be here—or at least she is trying to smile under the circumstances. She has probably been made aware of my long-term interest in, and deep concern about, this subject. I am sorry to inflict it on her this evening, but she is bearing up. I also declare a potential interest, as a very part-time dentist.

Variant CJD is a fatal neurodegenerative disease originating from exposure to bovine spongiform encephalopathy-like prions, prions being small particles of protein. Variant CJD prion infections are associated with a very long and clinically silent incubation, but when the disease strikes, it causes a fast, spongy degeneration of the brain, followed by a horrible and untimely death. It is probable, but not certain, that carriers might not produce the disease themselves, but it appears to have a potentially decades-long incubation. The long incubation period means that some will die of other causes first, but, as we live longer, we cannot be certain that in time —after decades—the disease might not strike all carriers, if they survive long enough. Carriers might also unwittingly pass on the prion through blood transfusion and via surgical instruments.

Variant CJD is an appalling disease with no cure. The number of asymptomatic individuals with variant CJD prion infection is unknown, but recent research estimates that the carriers number about one in 2,000 adults, which is a staggering number. The disease poses a risk to others, via blood transfusions, blood products, organ or tissue grafts and contaminated medical or dental instruments. The response of this and previous Governments has been bipolar. To give an exaggerated simplification, the first position of this bipolar response is that as we have not had many recent cases, there is no problem—but considering the long incubation period and some recent changes, this is a dangerous assumption. The second position is that there might be a problem so we should apply the precautionary principle in some areas. We cannot have both. I believe that waiting and an occasional application of the precautionary principle really do not hit the problem. If the Minister takes no action, I hope she will recognise that the absence of evidence is not evidence of absence.

As I have said, research says that one person in 2,000 is a carrier. The incubation period may well be decades, and some individuals appear to be more susceptible and some less so, although in time this could be proven wrong. A death from variant CJD in Edinburgh in January this year showed a potentially deeply worrying change. People are of various genotypes: they can be VV homozygotic, or MM homozygotic or MV homozygotic—and for the sake of Mr Deputy Speaker, I will not explain that. Until this case of the Edinburgh patient, all cases of variant CJD had been MM. The Edinburgh patient was the first MV patient that we have seen. It was thought that being MV or VV might offer some resistance, but this does not seem to be the case. We should bear it in mind that about 45% of the population are MV.

There is still no conclusive evidence, but there is a possibility that patients with the MV genotype may have a longer incubation period, which could lead to a second wave of variant CJD. The real point is that until recently it was hoped that MV patients might not show clinical signs, but in these early days this appears to have been put in deep doubt.

Research also shows that prions are transmissible by blood products and contaminated surgical instruments, and as the prions resist decontamination from stainless steel, we have a problem. Over the years, a precautionary principle has been applied—it is still being applied, but only partially. Much has been done slowly over many years. Leucodepletion was introduced, and synthesised clotting factors have been provided for haemophiliacs. A prion unit was set up at Queen Square. Single-patient use of stainless steel endodontic reamers was made mandatory, which I find quite interesting and will return to in a few moments. Non-UK blood supplies were sourced for those born after 1 January 1996.

What I found curious about the endodontic reamers is that if a patient requires endodontics, it is possible to use the stainless steel reamer but singly; but if the patient for some reason does not have endodontics, the tooth will have to be extracted using a stainless steel instrument that is used repeatedly, called a pair of forceps.

Very early on the Government established, through Medical Research Council funding, a prion unit at Queen Square under Professor Collinge. This unit was tasked with finding a test, finding ways of stopping or reducing transmission and hopefully even finding a cure. The prion unit with DuPont has produced a RelyOn soak, which deactivates the prion on stainless steel surgical instruments. Following the soak, there is then decontamination and a washing machine—a dishwasher-type machine—and then a full-blown steriliser, particularly a vacuum-based one. These instruments will bring about total sterilisation, from which the prion will be lost.

DuPont is no longer producing the soak, because there is no market. And there is no market simply because hospitals, clinics and surgeries in this country are not required to use it; if they were, there would be a market. That is quite extraordinary considering that this country has the greatest deposit, if I may use that term, of people carrying the prion.

In a surgery washer, the disinfectant would do the job. Recently, Professor Collinge became aware that the Department of Health had announced funds for research into prion-disinfecting stainless steel instruments. I believe the prion unit has applied and will hopefully get a grant. The problem with the wash was that it meant an extra stage, which slowed everything down in the hospital, but if DuPont or another manufacturer could produce it in the form of a tablet, a powder or a liquid that would go into the dishwasher without frothing, that step would be taken away, we would get rid of the prion and there would be no time wasted. Those instruments would be prion-free.

Incidentally, the Minister may be aware that there is some evidence that a protein may—and I stress the word “may”—be responsible for the occasional transmission of Alzheimer’s disease. If she wants a little bit of help on moving with RelyOn, I can tell her that RelyOn would disinfect instruments with this protein as well.

Another major failure relates to the sourcing of blood products. People born after 1 January 1996 who needed blood products—for instance, a transfusion—could get non-UK-sourced plasma that was almost certainly prion-free. Those born before that date would get UK plasma, and would have to pray earnestly that the donor was not the one in 2,000. As a parent, I can imagine having two children born on either side of that date. If for some horrible reason they both needed blood transfusions, one child would get the prion-free plasma and the other would take the risk, as would elderly people like us.

With a test, we could be fairly sure of excluding that one in 2,000. Professor Collinge and his prion unit team have developed such a test. They tried it out in this country and subsequently went to the United States, where they checked it with an extensive research programme to make sure that it produced no false positives. They were successful. They then returned to this country. The final stage of the research needs to be tested on a large batch of anonymised UK blood samples, but the Medical Research Council will not fund it. At least, that is the case so far.

If we had that test, blood donors who were carriers would be sorted out and their blood not used, and special measures could be taken for surgery patients who proved to be carriers. In respect of the latter line, the Minister’s Department introduced new guidance in July this year. I understand that it requires separate instruments to be used on high-risk tissues in the case of patients born before and after 1 January 1997 respectively. That is sensible reasoning, because it is thought that people born since 1 January 1997—I thought that it was 1996—have had less exposure to prions via the food chain. Those people form a group who are at lower risk of prion diseases, and thus less likely to contaminate surgical instruments with prions.

The instruction from the National Institute for Health and Clinical Excellence on a risk-reduction strategy requires every hospital and clinic to have separate pools of instruments to be used for high-risk surgery. It distinguishes between patients who were born before 1 January 1997 and those who were born on or after that date. The instruments must be kept separately, and notated. Although I consider that instruction to be eminently sensible, it will add greatly to the costs to hospitals of instrument provision, storage, and the required regular re-sterilisation. Tracing and tracking of instruments has also proved costly, and some hospitals are etching all instruments with identification numbers to ensure that they can carry out the process properly.

I have only been able to obtain one figure, but I understand that since, I think, July, observing the new guidance has cost the National Hospital for Neurology and Neurosurgery in Queen Square an extra £120,000. A little further down the road, the cost to a hospital specialising in children will be considerably higher. If RelyOn were developed so that it could be used, that difficulty would be removed.

I have three small asks of the Minister. First, we must recognise that all patients need to be treated equally in respect of blood products. As one person in 2,000 is thought to be a carrier, until we have a variant CJD test everyone should receive non-UK plasma. Secondly, rather than chasing a new product for sterilisation, the Department of Health, through whatever means, should fund the manufacturer of RelyOn to produce it in a more user-friendly form. If NICE or the Care Quality Commission made the use of such a product mandatory, there would be a market potential, which might be sufficient to persuade DuPont or some other manufacturer to produce such a user-friendly product without the need for funding, because it would be sold and used every time sterilisation pouches went through the dishwasher. Thirdly, funding the last stage of the testing of the prion unit system for prion detection would enable carriers to be taken out of the blood transfusion pool, and would also ensure a more sensible separation of surgical instruments. The cost savings would be vast.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Gentleman on making such a compelling case for those with CJD. In 2001, the Government set some money aside for a compensation scheme for UK victims of variant CJD. A trust fund was set up in April 2001 and compensation payments of £25,000 were made to the most affected families. Does the hon. Gentleman feel the Government should reconsider the compensation scheme and upgrade it for 2016 for those who, clearly from what he says, will probably fall into that category—although I hope not—in years to come?

[Sir Paul Beresford]

The hon. Gentleman makes a good point, but what I would really like to do is get the Government to take some action that is sitting, waiting, readily available to prevent it; otherwise, in time to come I believe we are going to have a chance of a considerable flood of variant CJD disease, but we do not know, and if this test was there we would know if the figure of one in 2,000 is right or wrong, or if we can separate patients out, so that those who have it have special instruments and the rest of us are all right, and we can also start using blood products in this country, because we will only be using products that do not have the prion on board.

In effect, the Minister needs to think about this: I do not want my grandchildren to be the generation that sees the re-emergence of variant CJD and for them to turn to me, if I am still around, and say, “Why didn’t we do something about it?” That is not a very big ask.

[The Parliamentary Under-Secretary of State for Health (Nicola Blackwood)]

I congratulate my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing this important debate on variant CJD and surgery. It is clearly an area on which he has a great deal of knowledge. I recognise that prion disease is the causative agent of transmissible spongiform encephalopathies such as variant CJD. It remains in many ways obscure and there are many aspects of these rare diseases that we are still in the early stages of researching. However, one thing I am confident about is that the UK system for ascertaining CJD case numbers has been for the past 20 years reliable and accurate. Our national CJD research and surveillance unit, which is based in Edinburgh and funded by the Department and the Scottish Government, leads pan-European work and has leadership from expert clinicians and scientists who, in 1996 following BSE, were the first to identify variant CJD as a separate form of the condition.

The Department recognises the potential seriousness of secondary—person-to-person—transmissions of vCJD and has since the late 1990s introduced a series of measures to reduce the risk of such spread, whether by blood transmission or by surgery. We are reassured that there have to date been no cases attributable to surgical transmission and only three cases of clinical disease attributable to blood transfusions, all of which occurred in or before 1999. However, our risk assessment models, which we use in our impact assessments of potential risk reduction measures, continue to take into account the potential for secondary—person-to-person—transmissions by both routes, in people with all genotypes and over potentially very long incubation periods, which my hon. Friend mentioned. This is why the scientific advice we have is that the surgical instrument measures in place are sufficient irrespective of the genotype.

My hon. Friend was right to mention the recent case. It was always anticipated on the basis of a wide body of published scientific work that, following the BSE epidemic, further cases of vCJD, including MV cases, might arise from time to time. We have seen that with similar diseases, such as kuru in Papua New Guinea, and studies suggest MV cases could be seen in small numbers for more than 30 years after exposure. Having reviewed the information about the case of vCJD in a patient with MV genotype, the Advisory Committee on Dangerous Pathogens has advised that no changes in the current risk reduction measures are needed at present. It advises that the measures in place are sufficient, irrespective of genotype, although of course the matter will remain under review.

It is important to stress that modern surgical equipment in the UK is very safe and that robust guidance is in place for the NHS on procedures and practices to reduce the risk of contamination of any kind, including the use of single-use instruments where possible and of decontamination practices. Where it is not possible to use single-use instruments in higher-risk procedures, there are processes in place to track the use of specialist equipment. As my hon. Friend will know far better than I do, there is a potential risk of vCJD transmission via dental surgery, and this has been recognised by the UK’s chief dental officers. In 2007, they issued letters to all dentists to advise that endodontic root canal reamers and files should be used as single-patient or single-use instruments.

[Sir Paul Beresford]

I am a little worried that the Minister appears to accept that surgical procedures are as good as they can be, given that the Department is inviting research to find a RelyOn equivalent, to improve the situation. The Department must therefore see a flaw in what we have at present.

[Nicola Blackwood]

My hon. Friend anticipates my next words as only an experienced Member of Parliament can do. I think it is right to say that there has so far been no evidence of any secondary, person-to-person, vCJD transmissions via surgery or dentistry. Nevertheless, we are maintaining and updating our precautionary approach. Surgical instruments guidance has recently been refreshed to support health organisations in delivering the required standard of decontamination of surgical instruments and to build on existing good practice to ensure that high standards of infection prevention and control are developed and maintained. My hon. Friend mentioned a number of these points.

The major change in this latest revision takes account of recent changes to the Advisory Committee on Dangerous Pathogens transmissible spongiform encephalopathy subgroup’s general principles of decontamination. This establishes a move towards in-situ testing for residual proteins on instruments. Residual protein is important because of the potential risk of the transmission of prions, though vCJD has not been shown to have been transmitted person-to-person in this way. The guidance provides information on how sterile services departments can mitigate the patient safety risk from residual protein with the objective of reductions in protein contamination levels through the optimisation of decontamination processes.

The ambition is that all healthcare providers engaged in the management and decontamination of surgical instruments used in acute care will have implemented this guidance by 1 July 2018. However, providers whose instruments are likely to come into contact with higher-risk tissues—for example, neurological tissue—are expected to give the guidance higher priority and to move to in-situ protein detection methodologies by 1 July 2017.

The chief medical officer has also recently written to NICE supporting the need to update its guidance on patient safety and the reduction of risk of transmission of CJD via interventional procedures, to ensure that it is fit for purpose, appropriately targeted, and can command the confidence of those who use it. We would expect this to take account of available evidence, including decontamination methods that are safe and effective against human prions; the epidemiology of CJD, including data on the prevalence of vCJD infectivity in the UK population from the appendix prevalence studies; and the availability and performance of single-use instruments in high-risk specialties. We would also expect the guidance review to be considered in the context of the latest research on prevalence, particularly for those born after 1996, who are currently considered unlikely to have been exposed to the BSE agent.

My hon. Friend is right, however, to say that adopting the precautionary principle alone is not sufficient. That is why successive UK Governments have been supportive of the development of new measures that might help in vCJD risk reduction. The Department of Health has provided over £70 million for CJD-related research in the last 15 years. That research has focused on infectivity, pathogenesis and transmission risk; decontamination of surgical instruments and the development of more sensitive methods to detect residual proteins to improve instrument cleaning; test development, treatment and diagnosis; and surveillance, screening, epidemiology and case finding.

[Sir Paul Beresford]

I accept everything that my hon. Friend says. However, a test solution is on the market and waiting to come through. The prion unit test has reached the point at which it just needs a final run to ensure that it does come through. I hope that I can count on the Minister to back me in persuading the MRC to support that last round of testing. If we could test blood, we would not have to import blood products from overseas. We could separate out the one in 2,000 or whatever the figure is and cut down on the costs of instrument storage.

[Nicola Blackwood]

That is one reason why the Department has continued in difficult financial times to ring-fence £5.5 million a year for CJD-related research. We are keen to see safe, evidence-based, cost-effective measures to reduce the risk of vCJD. At the moment, however, there is no validated diagnostic blood test that can be used before the onset of CJD symptoms to diagnose whether someone is infected or incubating the disease. We will of course take advice from the ACDP and the Advisory Committee on the Safety of Blood, Tissues and Organs on the use of any potential test in any proposed Department of Health-funded research study or deployment by UK blood services, but there are established systems for applying for research funds. We have put such funds out there, and any applications for those funds must go through the standard processes. To do otherwise would be to undermine the reputation for research excellence that the UK scientific community has fought hard to establish.

To that end, we recently launched an open competition, inviting proposals for research to further inform our risk-management and health-protection measures, including our understanding of vCJD infection in the UK population, the development of a test able to detect pre-clinical levels of infection in blood, and the development of decontamination technologies for reusable medical instruments. I understand that Professor Collinge’s RelyOn is one application that is currently going though that process, so it would be inappropriate for me to intervene.

I assure the House that the Department recognises the fatal consequences of all forms of clinical CJD and the devastating cost to individual patients, their families and carers, which my hon. Friend described movingly. That is why we set up the vCJD Trust in 2001 in recognition of their wholly exceptional situation and the fact that the Government are their last resort for help. The trust provides a no-fault compensation scheme for vCJD patients and their families, providing payments to be made in respect of 250 cases from a trust fund of £67.5 million. Over £41 million has been paid out by the trust to date.