NHS Winter Crisis

Philippa Whitford Excerpts

Monday 8th January 2018 Commons Chamber

[Mr Dunne]

I am grateful to my right hon. and learned Friend for making those points. He brings to the House considerable experience of what it is like to be responsible for the NHS. He is absolutely right: the number of over-80s who are presenting to hospital A&Es is going up exponentially each year. Hospitals need to adapt the way that they treat such patients to try to keep them as healthy as possible so that they can live independently for as long as possible. That is why many hospitals are now introducing frail elderly units close to or at the front door of A&E departments so that they can turn around patients and avoid admissions. My right hon. and learned Friend is also right to point to the increasing integration between the NHS and social care that is necessary to encourage more people to live independently out of hospital and leave emergency departments for those people who are urgently ill.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, pay tribute to staff across all four health services, where the normal pressures have been added to this winter by freezing weather and influenza. Scotland still leads in A&E performance across the UK, but we do not need to see four-hour data to understand the stress that NHS England is under. Thousands of patients have been held in ambulances for more than an hour outside A&E before they can even get in, which means that ambulances could not respond to other urgent calls, and that has obviously put other patients in danger. We have heard about patients being held in corridors for hours at a time, causing not just suffering and danger to patients, but enormous stress to those staff to whom we are paying tribute.

The Minister talks about the elderly population. We need to have beds for that population. England has halved its number of beds in the past 30 years, and now has only 2.4 beds per 1,000 population, compared with four in Scotland. Will he and the Secretary of State make sure that there are no further cuts in the sustainability and transformation reorganisation, and will they look at how they replace the money that has been cut from social care so that when elderly patients are ready to go home they can do so and free a bed for someone else?

[Mr Dunne]

As I have already said, the social care funding has gone up very significantly this year, and there is a second billion pounds to go into social care over the next two years. The hon. Lady is right to point to Scotland having a slightly better A&E performance than England, and the two countries are far better in performance terms than any other country that we regularly monitor, but she has to be a little careful when she talks about how Scotland is performing so much better. She talked about waits. It is the case that the over-12-hour trolley waits in England for November were half the rate of over-12-hour trolley waits in Scotland. We are providing information, and we are increasingly trying to be more transparent about the impact of winter on our health service in England. I strongly encourage her to take back to her colleagues in the Scottish Government the amount of data that is being published in England and to see whether they can try to match it.

Draft Pharmacy (Preparation and Dispensing Errors - Registered Pharmacies) Order 2018

Philippa Whitford Excerpts

Monday 4th December 2017 General Committees

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, and the Scottish Government welcome the order, as does our Scottish chief pharmaceutical officer. This is an anomaly that is being corrected, and the key thing is that it leads to more reporting. We understand that there were almost 21,000 reported errors in 2016, but it has been suggested that a considerably higher number were not reported. I echo the argument that risk to patients is increased if pharmacists are not flagging up simple things such as poor labelling, things that are difficult to read or mistakes that someone else has made. That is where everyone wants to get to.

I am keen to support the shadow Minister’s point that the obligation to report should be formalised, rather than pharmacists just having to contact the patient. That is how they will be able to utilise the defence, as they must show that they have taken every possible action to contact the patient and correct the mistake. That changes a defensive reason to hide errors into a reason to report errors, but it really needs to happen through a reporting system. I am interested in what the national reporting system will be and whether it will be across the UK, so that lessons can be shared as widely as possible.

The order will amend sections 63 and 64 of the Medicines Act, which contain a power that has hung over pharmacists, even though it has rarely been used. The Secretary of State for Health talks a lot in the Chamber about getting away from a blame culture and moving to a learning culture. I do not think there is any argument about that, but I want to know how mistakes will be reported.

I also echo the point about information sharing. In Scotland, we have had community pharmacies providing minor ailments treatments and other treatments, including a chronic medicine service, for about 10 years. We are moving to a point where patients are registering with their community pharmacy, in the same way they do with their GP and dentist, so that records are shared. We also use e-prescribing widely in general practice and hospitals. That technology helps to reduce errors right from the prescriber, which is what I used to be, to the patient. The system simply flags up the danger of prescribing penicillin to someone who is allergic, using the wrong dose or bad interactions. Using technology in that way, to prevent system errors right through from the prescriber to the patient, needs to proceed as quickly as possible. A lot of that comes back to data sharing and getting the confidence of the public back.

I agree with the shadow Minister’s call for the Minister look at other areas of pharmacy. If we start to have a single system through e-prescribing, that will become easier. Although it is suggested that that will be brought forward early next year, the legislative burden in this place is a tad heavy at the moment, and I certainly would not like to see it delayed for another five years. In essence, we welcome the order but want to know exactly what the reporting system will be and when the move to things such as e-prescribing will be made.

Maternity Safety Strategy

Philippa Whitford Excerpts

Tuesday 28th November 2017 Commons Chamber

[Mr Hunt]

I do not have that information to hand, but I will find out for my hon. Friend and let her know.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Last month’s debate on baby loss has been mentioned, and I too took part in it, although I have thankfully been spared the pain suffered by some Members of the House. Such a debate really helps to bring out for everyone on both sides of the House how important this issue is, and I do not think there will be anyone who does not welcome this statement and the ambition it shows.

In Scotland, we had a higher stillbirth, neonatal and perinatal death rate in 2012, but our new chief medical officer was actually an obstetrician, and that may have led to the change of focus in 2013, when she established the maternity and children quality improvement collaborative and the national stillbirth group—all as part of the Scottish patient safety initiative—as well as the neonatal managed clinical networks across Scotland. That has enabled us to drop our stillbirth rate by more than a quarter, and to drop our neonatal death rate by 50%.

This has been achieved despite the challenges we face of really difficult geography, including getting people off islands. It is easy to spot the woman who has a history of difficult births or to spot a woman with comorbidities, such as obesity or diabetes, but anyone who has been involved in birth knows that even the healthiest pregnancy can go wrong at the last minute. For us, as in rural parts of the north and west of England, there are transport issues in relation to how women with problems during labour are identified and transported if a higher specialism is required, and those issues must be looked at.

This is very much about the provision of neonatal services, including the movement of patients, and the availability of expertise and of neonatal intensive care units. However, as came out several times during the debate on baby loss, another issue is that of pre-term birth and stillbirth, so this is also about trying to change some of those things. After Scotland’s recent review in February, the focus will be on the consistent monitoring of growth, as a failure to thrive can identify a third of impending stillbirths; the continuity of care, which the Secretary of State has referenced; and especially smoking. Although the Secretary of State mentioned getting smoking rates down—and in Scotland, sadly, they are higher—the rate in the most deprived communities is more than four times that in the least deprived communities. That has an impact on every level of child loss.

Finally, on research, it is important that we learn, for example from the new information about women sleeping on their side in the last trimester. We need to fund the research to learn those things and then share the information—

[Mr Speaker]

Order. I have the highest regard for the hon. Lady, who is a considerable medical authority. I gave her a little leeway, but I say very gently that not only did she exceed her time by a minute, but she pursued her usual, rather discursive approach. In these situations, what is required is a question or a series of questions with a question mark or a series of question marks, rather than general analysis. We will leave it there for now. I say that in the most good-natured spirit to the hon. Lady.

I call Antoinette Sandbach.

Medicines Regulation

Philippa Whitford Excerpts

Tuesday 21st November 2017 Westminster Hall

[Helen Goodman]

The hon. Gentleman truly is a gentleman, and I agree with him entirely. We want to see continued UK participation in EU regulatory and medicine safety processes as well. The ABPI has also said, reasonably enough, that it wants to maintain trading terms equivalent to being a full member of the customs union, and to have a common system for VAT.

In May, the EMA and the European Commission issued a statement saying that if the United Kingdom does not stay in the single market, stick with the EMA, or join the EEA—the European economic area—but goes for a clean break, drugs made in the United Kingdom will no longer be authorised for use in the European Union, and drugs made in the European Union will no longer be authorised for use in the UK. Tackling that would involve costly and time-consuming checks. It could even mean that the availability of drugs would diminish dramatically.

What response have the Government made to that statement? What practical steps have Ministers taken? All we have seen is a letter from the Secretary of State for Health and the Secretary of State for Business, Energy and Industrial Strategy to a newspaper, which said that they want a “close working relationship” with the EU, and that patient safety matters, as does certainty, long-term stability, and innovation. The letter said that Ministers will set up a regulatory system with competitive fee pricing. This afternoon, we would like the Minister to explain that.

Currently, the UK Medicines and Healthcare Products Regulatory Agency—MHRA—contributes to the EMA’s work, and the UK pays approximately a fifth of the overall costs. It is universally acknowledged that the MHRA could not take on the task of licensing all drugs without astronomical costs for the industry and the taxpayer.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Is part of the problem not that there appears not to have been a specific assessment of all the health-related impacts of leaving the EU?

[Helen Goodman]

I agree entirely. We tabled amendments when the article 50 legislation went through requesting impact assessments on many things, including the effect of possibly leaving the EMA, and we have not heard about them. That is extremely alarming, because it gives the impression that Ministers are basing decisions not on fact and analysis, but on prejudice and assertion—not a very good basis when it comes to health or economics.

This issue matters because life sciences and pharmaceuticals is one of the UK’s most successful industries. The combination of first-class scientific research in our universities and high-quality manufacturing means that we have been exceptionally successful. The life sciences employ 220,000 people—of which pharmaceuticals accounts for 90,000—in good quality, well-paying jobs. They are careers, not gigs. The industry is innovative and internationally competitive. In fact, it has the highest manufacturing gross value added, which means that every employee contributes £330,000 to the British economy every year. The value of our exports is £30 billion. Obviously, the industry wants to continue in those collaborations and develop new medicines.

One of the major costs in pharmaceuticals is research and development; another is complying with regulations. Inspections take several days, and internationally there are two dominant regulators: the EMA, which looks at about a quarter of all drugs globally, and the American FDA, which looks at about a third. Clearly, we do not want regulatory complexity, because that would simply add to costs. As Andrew Witty, the former head of Glaxo said, when the regulatory systems of 27 European countries were unified into one, that was a big deal.

Ministers need to keep in mind that the pharmaceutical industry is international and highly mobile. There is world-class production in France, Switzerland and America, and generics are made across the globe, in China and India. Senior executives answer to their shareholders; if it is cheaper to move, they will, so we need to do everything we can to keep costs down in this country. Quite honestly, I cannot understand why Ministers do not just commit to staying in the EMA—it is so obviously the cheapest and simplest solution—but their crazy ideological obsession with escaping the European Court of Justice means, to quote the Secretary of State for Brexit, “putting politics above prosperity”.

What is even worse is that Ministers are cutting across their own stated principles and are creating a highly uncertain environment. Business needs certainty to invest. For example, in my constituency, a new production facility was started a year ago. It will cost £120 million and will take four years to come into production. We are now only 16 months away from 1 April 2019, but yesterday, AstraZeneca wrote to Members of Parliament to say that it needs a transition period of two to three years.

The Prime Minister made things worse—I do not think she intended to, but she undoubtedly did—when, in her Florence speech, she said there would be a transition period. Everybody imagined that there would be time to look at what the post-Brexit regime would be, to have clear negotiations and to make a plan—to go through everything in a systematic way. Her insistence on putting the March date into legislation shrank that time overnight, from 40 months to 16 months.

Industry is taking decisions now. One plant has already closed in Southampton. GSK is implementing its contingency plans nationally, which include relocating some members of staff to other European Union countries. In Barnard Castle and Ulverston, it is reviewing the production of cephalosporins, which my hon. Friend the Member for Barrow and Furness (John Woodcock) will talk more about later in the debate.

But this is not just about jobs; it is also about health. Every month, the United Kingdom sends 45 million medicine packets to Europe and we receive 37 million medicine packets from Europe. Some 80 million people need those medicines. Border delays in the medical supply chain will affect not just the final product but intermediate production, especially where we are talking about time and temperature-sensitive drugs, such as for cell and gene therapy. More than 2,600 final products have some stage of manufacture in the UK. Delays as they cross the border during production could mean the loss of lives. That is why the Association of the British Pharmaceutical Industry and its European counterparts wrote a joint letter to Monsieur Barnier, the European negotiator, and the Brexit Secretary of State, to sort this out promptly. Ministers should put patients and public health first, and should start co-operating with the European Union on solving this problem. Given the long lead times, they need to speed up the work and sort out the transition phase.

I have seven questions for the Minister. Will he rule out introducing a freestanding, new, regulatory structure? Will he rule out incorporating the MHRA into the American FDA? Will he confirm the Government’s stated aim of keeping British regulation aligned with the EMA’s European regulation? Will he tell us what moving the EMA and setting up a new regime will cost? Will he set out the legal basis for our continued co-operation and participation in the EMA system from 1 April 2019? Will he say how he intends to legislate? And will he commit to more than another 90-minute debate on an affirmative statutory instrument? If he cannot even do that, half of the debating time that Parliament will have on this important subject will be this afternoon.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I too congratulate the hon. Member for Bishop Auckland (Helen Goodman) on securing such an important debate. Unfortunately, it is competing with the main arena, so this Chamber is not full.

I do not think that people yet recognise what the impact of Brexit on medicines regulation will be. The EMA represents all the countries within the European economic area, their drug-licensing bodies having come together in 1995, and it has been based here in London. That has been of huge benefit to London, not only as a result of the 900 jobs mentioned but as a result of world pharmaceutical industries—especially Japanese and other Asian ones—basing their European hubs here.

There is no question that the biggest challenge will be the impact on patients. The EMA assesses and licenses new drugs, and safety-monitors all drugs. It provides the service of pharmacovigilance. Recently we have had debates on the Primodos and valproate syndrome situations, where things have not been spotted early enough. For us to end up outside the European pharmacovigilance system will be a real danger.

The hon. Member for Lewisham East (Heidi Alexander) alluded to the possible delay. As I raised in Prime Minister’s questions way back in January, countries such as Canada and Australia get access to new drugs approximately six months to a year after the UK. The reason why we get early access is that we are part of a market of 500 million, on a similar scale to America. Without that, we slide way down the pecking order.

I am hearing from pharmaceutical firms that it is not just the size of the UK population but the fact that accessing the NHS in the UK takes several years. Given the budget impact assessment that has been added for new and expensive drugs, some firms are beginning to say, “Well, it won’t just be six months to a year; it might be several years, because what’s the point of paying to go through the process early but getting knocked back?” We might have to wait until our price has dropped, in which case Canada, Australia, Japan and so on will all be ahead of us.

Patients get access to new drugs that are expensive through the cancer drugs fund or the New Medicines Fund for rare diseases in Scotland. They also have opportunities through individual patient treatment requests. If the drug is simply not licensed in the UK, however, accessing it would be really problematic.

The EMA has obviously been a driver and organiser of research. As was also mentioned by the hon. Member for Lewisham East, in particular with rare diseases, we would be trying to recruit for research from a population of 50 million instead of 500 million—there is no comparison from the point of view of getting answers. Purely because of such research, breakthrough drugs for rare diseases, in particular children’s congenital and rare diseases, have come on stream over the past 10 years.

The EU is the biggest research network in the world because of Horizon 2020 and all its forerunners. Until last year, the UK was its biggest beneficiary, but we have already slipped down the pecking order to behind Germany. People who lead international research teams are already being asked to step aside; they may take part and co-operate, but they may no longer be the principal investigator. The whole drive of academic, medical and clinical research in the United Kingdom is sliding down. The impact of that is significant.

There are a whole lot of different reasons. We have been talking about certainty, but universities and EU nationals need certainty. We have seen disruption to the EMA, which estimates it will lose 20% of its staff. Many have already left because they have been in limbo, like my husband, a German GP, for the past 16 months. They have therefore jumped before they might be pushed. Others might not choose to move to Amsterdam, even though it is quite an attractive place. As a member of the Scottish National party, I wish the people of Scotland had voted yes in 2014, because Edinburgh and Dundee would certainly be bidding to be a site for the new EMA, as we are also major pharmaceutical researchers.

The loss of the EMA from a business point of view is significant, but the main thing is the impact on patients and people. We will become a third country, and the idea that we can somehow leave the EU and yet keep all the bonuses that we have had is frankly naive. In my constituency I have Merck, a pharmaceutical company that develops drugs, although its main role is providing materials to other pharmaceutical industries—cell growth medium. It is therefore involved in all sorts of complex supply chains. This is just like aerospace. Components and ingredients move backwards and forwards as the drugs are constructed.

The other parts of Merck’s business are quality control and lot release. When drugs arrive in huge quantities they have to go through strict quality control testing, again under the EMA. Up until now such work has been carried out only inside the EU. Merck has three big BioReliance centres in Scotland, which carry out work for other firms. Other firms in my constituency such as GSK—again, I have a big plant—do that in-house. If they have to start moving some of that work to Europe—many pharmaceutical industries are already looking at having bases in Europe for their lot release work—other jobs tend to trickle after them, because gradually the refrain becomes, “We would do better to put everything in one place.”

I am sorry for the hon. Member for Barrow and Furness (John Woodcock), who is losing such a great production centre in his constituency. I wish him well in finding a solution, but in the current uncertainty it is really hard to see what kind of pharmaceutical business will open a new plant in this country. For the big global multinationals weighing up where to put future centres, they might put a small centre in the UK, but sadly they are likely to put their main centres on mainland Europe. We need to deal with these things going forward.

The issue of quality control means we could have drug shortages as well as job losses. Anyone on medication—I put my hand up; I am on multiple medication—will often be handed something in the pharmacy that could be in any one of the EU languages with a little sticker in English on the top. That is because drugs move around all the time. The most important thing is to ensure that we do not get into a no-deal Brexit. Ultra-Brexiteers keep standing up and saying that World Trade Organisation rules are not so bad and would be quite good and advantageous—but that is not the case from the point of view of drugs supply.

The 0% tariff drug list has not been updated since 2010, so on any new drugs developed in the past seven years there would be automatic tariffs. The potential of trying to hang on to things such as BioReliance jobs would simply be impossible because there would be no chance of negotiating mutual recognition agreements or parallel agreements. Going forward we need an assessment of the impact of Brexit on health: everything from EU nationals, the potential threats to health, reciprocity, right through to research networks and how we get our drugs.

What will the MHRA do? It provides about 25% of the assessments for the EMA and it therefore has expertise, but it would need funding if it was to replace the EMA for drugs within the UK. How would we attract big global firms to go through the process when they might not sell any real quantity to the NHS for several years? Would it be suggested that we simply would not charge them? If that were the case, how would we fund it? I assume that in the position of getting a sensible deal around Brexit, the MHRA would try to mirror everything from the EMA, but that simply would not solve all the problems.

We are still in a separate situation. The strength has been in co-operation. There was no discussion before the referendum and no recognition of the benefits we have had from the EU in the past 40 years. Those were never discussed and are being thrown away. The EMA did not increase bureaucracy, but decreased it. Imagine a small firm trying to go through 27 regulatory agencies in multiple languages. That will not happen. The EMA created one thing. The trials regulation system, due in the next year or so, does exactly the same for research: one trials portal.

We also have to tackle the issue of data protection and data sharing. If the UK sees Brexit as the potential to go off the reservation and cuts standards or is sloppy around data and sells the data or does not protect it, we will become a pariah, which will not do our patients any good. The issue is ideologically driven. Nobody with any sense of what brings the biggest benefit for patients within the United Kingdom would think of leaving the EMA. It is driven, as was said in the Health Committee in January, by the need to leave the European Court of Justice, the decision to leave the single market and the decision to leave the customs union. I have a simple plea: why don’t we just not do that? Why not just stay in the single market and accept that we need an arbiter, and that the ECJ is as good an arbiter as any other? We should hang on to the fantastic benefits that we have had from Europe for 40 years.

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[Steve Brine]

I think it is the latter, but I will check and come back to the hon. Lady on that point.

[Dr Whitford]

The veterinary medicines division is part of the EMA, so it comes under that—I am not sure whether that is what the hon. Member for Bishop Auckland (Helen Goodman) was asking.

[Steve Brine]

I thank the hon. Lady; she is always there when we need her.

As I was saying, those skills and expertise have allowed the MHRA heavily to influence global practice and regulations, which is why I say it is a world leader. A majority of medicines available in the UK—around 90%—already receive a national UK licence issued directly by the MHRA. It also leads the assessment of more than 20% of new medicines licensed by the EMA, with particular expertise and specialism in more complex new drugs that come to market. Similarly, on medical devices, five of the EU’s 55 notified bodies are in the UK, and they undertake a disproportionate amount of work. We estimate that they assess between 50% and 60% of the highest-risk devices on the EU market—a big player.

The strengths of our world-leading regulator are similarly reflected in the UK’s life sciences sector. The UK has one of the strongest and most productive life sciences industries in the world, with more than 5,000 companies, more than 233,000 employees, and an eye-watering turnover of more than £63.5 billion each year. It also provides products that the NHS and patients rely on every day—I know that the constituency of the hon. Member for Bishop Auckland has seen the benefits of that productive industry.

GlaxoSmithKline announced this year an investment at its Barnard Castle facility in Teesdale, as part of a wider £140 million investment in the expansion of manufacturing HIV and respiratory medicines. However, we cannot be, and are not, complacent, and we must continue to work hard to support the industry, and we have done just that. The industrial strategy Green Paper was launched in January this year, and it set an “open door” challenge to industry to come up with proposals to transform their sectors through various sector deals.

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[Steve Brine]

I know that the hon. Gentleman asked that question. I cannot confirm that today—I am sorry—but when I can, I will.

A couple of Members, including the hon. Member for Central Ayrshire, talked about the absence of impact assessments of the health implications of leaving the EU. I fully concur with Members’ concern that complex discussions about the future of medicines regulation were not at the forefront of the referendum campaign. That is obvious. That is the problem with referendum campaigns. That is about as far as a diplomatic Minister can go. Sadly, the subject did not feature on the side of any buses. However, as part of our work on preparing to make a success of our departure from the EU, we are carrying out a full suite of economic analyses, as any Government would be expected to do. That means looking at 58 sectors, including life sciences, and at cross-cutting regulatory, economic and social issues. It will of course take time to collate that information and ensure that it is informative and accessible. We will provide it to Parliament as soon as possible.

[Dr Whitford]

Is the Minister aware of whether an impact assessment is being done with regard to health, not as part of the economy but as a benefit to people in the UK?

[Steve Brine]

There is a huge body of work going on in the Department about the impact of Brexit on every single area of every single Minister’s responsibility.

[Steve Brine]

The hon. Lady asks me to visualise all the different scenarios for the current negotiations. We have been clear that we want a comprehensive deal. A number of Members mentioned that no deal is some sort of ideological obsession for some Government Members. That may be true, but they do not speak for Government policy. We are not looking for no deal; we are looking for a comprehensive deal.

The hon. Member for Barrow and Furness (John Woodcock) asked about meeting my colleague Lord O’Shaughnessy. I cannot speak for my colleague’s diary, but I will speak to him. If he cannot meet the hon. Gentleman and his taskforce, I will. The hon. Gentleman always speaks passionately for his constituency, and I am more than happy to try to sort that out for him.

The hon. Member for Central Ayrshire raised a concern about safety data. That absolutely should always be shared at a global level. The MHRA leads about a third of the EU’s pharmacovigilance work. The EMA already shares data with third countries. It is in all our interests for that to continue. If we are outside EU regulatory procedures, we will ensure that the UK remains an attractive market and that regulation does not delay patient access. A number of Members expressed concern about that, and it is a concern of mine, which is why it is a priority for us.

[Dr Whitford]

Does the Minister recognise the data protection issue? Some people have suggested that the UK will be in a position to follow its own line on utilising data. Ending up on the outside as an untrusted country—or as an untrusted set of countries within the UK—would obviously kill our ability to take part in clinical trials and research.

[Steve Brine]

It would. That is why, as the hon. Lady knows, we are working extremely hard not to be in that position. As ever, she makes her point well.

Whatever our future relationship with the European Union on the regulation of new drugs, the MHRA, our world-leading regulator—I have mentioned some of the reasons why it is world leading—will be empowered to protect patient safety both in the UK and internationally. We will also ensure, as everyone said, that patients are at the forefront of our thinking and do not get new drugs any slower than they do now.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 14th November 2017 Commons Chamber

[Mr Dunne]

My hon. Friend is right to say that there has been a long-standing tradition of this country welcoming professionals from outside, through various waves of migration that go back several decades. It is important to point out to him that the Secretary of State announced a year ago a 25% increase in the number of doctors in training in this country and earlier this autumn a 25% increase in the number of nurses to be trained in this country, so that we become less reliant on overseas clinicians at a time of a shortage of some 2 million worldwide.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Being a member of the European Medicines Agency has allowed UK patients early access to new drugs, and it also plays a crucial role in quality control and safety monitoring, so what solution has the Department come up with to ensure not only timely access to new drugs after Brexit, but that any complications are spotted early?

[Mr Dunne]

As I indicated in response to the hon. Member for Glasgow South West (Chris Stephens), finding an appropriate relationship with the EMA post-Brexit is one of the core strands of work the Department is doing. As the hon. Lady will be aware, next Monday the other EU nations will vote to decide which country will host the new EMA. It is our intent, as we have made clear to the EU negotiators, to seek mutual recognition.

[Dr Whitford]

With the World Trade Organisation not having updated its drug list since 2010, all new drugs developed in the past seven years could incur tariffs. What contingency plans have been made to avoid shortages and increased costs in the event of a no-deal Brexit?

[Mr Dunne]

As the hon. Lady will be aware, we are looking for a relationship with the EU to ensure that we have tariff-free access to the single market, including for drugs and medicines, because the life sciences industry is such a critical element of our economy. Contingency plans are being put in place for a no deal. She will have to wait, as will the rest of us, to see whether or not that eventuality happens. Of course we do not want it to occur—it is not our intent.

Children’s Oral Health

Philippa Whitford Excerpts

Tuesday 31st October 2017 Westminster Hall

[Andrew Selous]

I agree with that. Some of the food companies set a lot of store by their links with sport. Of course sport is a good thing—we should all take more exercise—but the key is good oral preventive hygiene and consuming less sugar. When we consider that five-year-olds are consuming their own weight in sugar, we begin to see the scale of the problem. I agree with the point made by the hon. Lady.

I have the pleasure of serving on the Health Committee with the hon. Member for Central Ayrshire (Dr Whitford), who will shortly be speaking for the Scottish National party. She has often told us that Scotland has got certain things better than England, and some of the time she may have been right. On this issue, we can learn from what is happening in Scotland, as my hon. Friend the Member for Mole Valley said as well.

Chapter 3 of the report from the Royal College of Paediatrics and Child Health, which I quoted from earlier, includes some graphs that show improvement in children’s oral hygiene. Somewhat irritatingly, the graphs end in 2013, but the rate of improvement in Scotland is clearly shown to be superior to the rate in England, Wales or Northern Ireland, as a result of the Childsmile programme, which I understand costs £17 per child. Set that cost against the £836 average cost of a child tooth extraction and, for my money, I would rather put more focus on prevention. I want to see the English treated as well as other parts of the United Kingdom.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The hon. Gentleman cites a figure of £17. That is an average and is obviously not how the money is spent. It is very much targeted at children in areas of deprivation.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Let us admit that, before Childsmile, Scotland’s children started with much worse teeth than those in England and Wales—seeing people in Glasgow with no teeth at all was a common sight. I was quite shocked when I attended a dental health meeting in Parliament after being elected: I met a dentist carrying a bag of more than 100 children’s teeth that she had removed that day. That was when I first realised the difference between the approaches in Scotland and in England and Wales.

Although there were some pilots and proposals in 2005-06, the Childsmile programme kicked off in December 2007, so we are coming up to the end of the first decade. It has transformed dental health in Scotland, although there is no question but that we have further work to do. Overall, extractions have gone down by a quarter, while extractions in England have gone up by a quarter in the past decade. That has to be looked at. Children losing their teeth must be seen as a health failure.

The core Childsmile programme consists of all nursery school children undergoing education about cleaning their teeth, and undergoing supervised teeth cleaning every single day. Provision of 30 hours’ childcare in Scotland is being rolled out to all children, not just the children of working parents, and that gives us access to even more children, including vulnerable two-year-olds.

The core programme, which, as was mentioned, includes 90,000 children, is the main driver, but we also have a practice programme, which involves all NHS dentists in Scotland. That programme links dentists with health visitors and public health nurses. If a health visitor is aware that a family is not registered with a dentist and is not active in preserving its dental health, they can refer that family and its children to a dental health support worker, who will follow a child up from the age of three months and ensure that they attend a Childsmile-registered dentist. That is crucial.

We hear that 80% of one to two-year-olds and 42% of children aged 16 and 17 in England do not attend a dentist, even though the advice is that children must have attended by the age of one and that they should get an annual check. It is crucial that that changes. It is also important that, as well as their dental check, children access twice-yearly fluoride varnishing, which makes a key difference.

Glasgow, which had the worst teeth in Scotland and probably the worst teeth in the UK, has improved dramatically. We still have more work to do—there is still inequality, and there are still more caries-free five-year-olds in England than in Scotland—but the proportion of caries-free five-year-olds in Scotland has improved by 50%, from 45% to 69%. There has been a one-third improvement among primary 7 children, who have their second teeth, from 59% to 77%. Inequality has reduced. Some 56%—more than half—of children in the most deprived areas of England have caries at the age of five. That just is not acceptable, and it needs to change.

It is important to drive education and to improve dental health, but the underlying problem is the difference in contracts. Since 2006, dentists in England have been paid for units of dental activity. There are three bands, from simple activity such as examinations, cleaning and advice, up to complex work at band 3, but dentists get only one payment for a band 1 unit of dental activity no matter how much they do. They are paid the same rate for doing an examination, providing advice and doing fluoride varnishing as they are for doing only a check-up. That means that they are not rewarded for prevention, whereas dentists in Scotland are paid for doing fluoride varnishing and fissure sealants. That situation in England undermines the basic principle.

In Scotland, there are also additional payments for children with disabilities or learning difficulties, because we know that they take dentists more time. Those payments mean that dentists invest in those children to try to prevent future dental ill health. Children with learning difficulties in particular tend to have very poor teeth, because we cannot just educate them to clean their teeth; the people around them need to commit to doing that.

Lack of registration is another issue. In England, people are not registered with a dentist for the long term, so why should a dentist invest in someone? Children turn up and try to access a dentist when they have problems. Recent BBC articles suggest that 40% of children in England are unable to access a dentist. If a dentist is paid the same for one filling as they are for 10 fillings, they will not want to take a child who clearly already has very poor dental health. Again, there is no sense of investing in the future.

[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.

[Steve McCabe]

The hon. Lady is making an excellent speech. I am conscious that this debate is about children’s oral health, but does she accept that, given the growth in the elderly population, the problems that she has indicated will only get worse if we do not have better registration and intervention?

[Dr Whitford]

I totally agree. In so many areas, the health of an adult—even an elderly adult—is actually laid down in their first five years. That is nowhere clearer than in dental health. Laying down good foundations in childhood is critical to allowing many more older people to have healthy teeth and, in particular, healthy gums—in the end, more tooth loss is due to gum disease—and to hang on to their teeth. Registration is important, because it gives people a relationship with a dentist. For people who are frightened of the dentist, knowing their dentist and having access to extra support such as hypnosis, if that helps, is valuable.

Childsmile costs £12 million a year in Scotland in terms of total dental health, but it has saved £5 million in dental treatments and extractions. We heard from the hon. Member for Birmingham, Selly Oak (Steve McCabe) about the money that is coming back. That could be used to set up a programme in England. I welcome the pilots, but those are in only 13 of the 23 worst areas in England. Why do the UK Government feel that they need to pilot? The evidence is there from 10 years of Childsmile in Scotland. If they just looked at the data and designed a national programme for England, in the end they would save not just money but children’s dental health.

--- Later in debate ---

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

I thank everyone who has spoken and the hon. Member for Birmingham, Selly Oak (Steve McCabe) for securing the debate via the Backbench Business Committee. He has proved once again that he is on his mettle. There are a number of things I want to get on the record and there are lots of things I want to respond to. We know that, as many Members have set out, poor oral health for children can lead to pain, poor sleep, days missed at school—the hon. Gentleman said that three days are missed on average, but the figures can be much higher—and impaired nutrition and growth. It is a serious business and we take it seriously.

The shadow Minister spoke passionately about the subject and the risk to our economy. I am glad that she recognises that there are no quick fixes. If there were, I suspect many of my predecessors would have quick-fixed.

It is a fact that the two main dental diseases of decay and gum disease—dental caries and periodontal disease—can be almost eliminated by a combination of good diet and correct tooth brushing, backed up by regular examinations by a dentist. They are preventable. It is worth putting it on the record—it is not all doom and gloom—that children’s oral health is in fact better than it has been for years. The most recent data from 2015 show that 75% of five-year-old children in England are now decay-free. That is good, but it clearly leaves 25% who are not. Between 2008 and 2012, the numbers of five-year-old children who showed signs of decay fell by approximately 10%. Improving children’s oral health and that of the adult population is a priority for the Government. Indeed, our manifesto earlier this year set out our commitment to improve coverage and achieve better outcomes, especially for children in deprived areas.

[Dr Whitford]

Will the Minister give way?

[Steve Brine]

I will once, but with the time I have got I am going to have to press on.

[Dr Whitford]

Does the Minister recognise that total dental clearances in children, of which there are approximately 25,000, have seen an 11% increase in the past five years, so it is not possible to claim that dental health in England is getting better?

[Steve Brine]

I said that there is clearly a long way to go, and the hon. Lady also said that about Scotland. I am just putting it on the record that there are some positive stats; it is not a counsel of despair.

In explaining what I started to say, let me talk about the extensive work being led by Public Health England as well the wide range of activity nationally in reforming the dental contract, which a number of Members asked about, and locally, in initiatives such as “starting well” run by NHS England, which a number of people referred to. First, it is important that I, as the Minister, acknowledge the vital role that dentists play in this. They are a brilliant part of the NHS. There are just over 24,000 dentists currently providing NHS dental care and their commitment and contribution is vital to delivering our wider health and public health aims. Overall, access to NHS dentists continues to increase in England. In the latest figures for patients seen by NHS dentists, 6.8 million children were seen in the 12-month period ending 30 June this year, which equates to just over 58% of the child population. Looking at adults, this year’s January-to-March GP patient survey results showed that, of those adults trying to get an NHS dental appointment, 95% were successful.

Although those numbers are an encouraging start, clearly more needs to be done—I am not pretending that it does not—to reduce the inequalities in access and oral health that remain as a result. Nationally, Public Health England has an extensive work programme to improve oral health, particularly of children. Improving that and reducing inequalities in oral health is a priority for PHE, which I meet regularly. It was in the office just last week, when we discussed this subject. So many Members have mentioned the sugar levy, which addresses some of the root causes of dental disease.

Social Care

Philippa Whitford Excerpts

Wednesday 25th October 2017 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

We have all seen the figures about everyone getting older. If we look over the lifetime of the NHS from 1948 to the predictions for 2030, we see that the number of people over 65 will double and the number of people over 85 will increase by 10 times, yet the number of funded places for care has gone down by a quarter. Those two things simply do not match up. As the Minister mentioned, those under 65 with disabilities or learning disabilities are also, thankfully, living longer. The problem is to provide them with care. As a doctor, I obviously tried to do my little bit for people living longer. We should not look at this as a catastrophe; we must celebrate it. We are all heading there, so it is in our own vested interest to ensure that the services will be there for us.

We know that a lot of people’s state of health in older age is laid down in the early years. In Scotland, we are focusing on the early years collaborative—from the baby box for every newborn child, the 30 hours’ early learning entitlement, doubling active transport and rolling out through schools what is called the daily mile. However, we will not get a financial return on that for 50 or 60 years, so we must also invest in our older citizens. In Scotland, we are trying to expand elective services to meet the demand for operations on hips, knees and eyes, but the King’s Fund reports that hip and knee joint replacements are being rationed, and we know that three quarters of trusts have set such strict limits on accessing cataract surgery that people are, in essence, losing their sight, and certainly losing the ability to drive, with half of the trusts fixing only one eye.

Doing such things means driving people into their own homes and into isolation, as well as increasing their need for care and increasing the speed, or lowering the age, at which they need care. It really does not make sense. Age UK points out that 1.2 million people are not getting the care they need, and that matches almost exactly the 1 million family carers who are actually providing the bulk of the care required. In Scotland, we have already committed to raising carer’s allowance from £60 to match jobseeker’s allowance, but that is pretty paltry for someone working, in essence, seven days a week, while 40% of them are reported not to have had any respite or break in a year.

Such a situation arises because the statutory system is not supporting carers, and we need to look at this. Care homes are closing because of the extra costs brought in by the national living wage, and part of that is simply because the price paid is being driven down. As has been mentioned, over half of local authorities are seeing either home care providers or nursing and care home providers closing. The thing is that we need to pay people a decent wage—not the national living wage, but the real living wage. This needs to become a profession that attracts and retains people. Who would we like to look after us or our mother or father—someone who is doing it only for six months until they can get something better, or someone who actually believes in looking after our older population with the greatest possible love, care and dignity?

We need to put in the funding. The Minister talked about the better care fund, which has indeed put in extra money, but that is at the cost of the new homes bonus in England, while local authorities are also being told to build more houses. What are they meant to do? We need to put this on a sustainable footing. We also need to address the issue of those under 65. In Scotland, our programme for government includes a commitment to the under-65s with what is called Frank’s law, in honour of a football player from Dundee who developed early dementia. We have people aged under 65 with the same needs—those with early dementia, multiple sclerosis or motor neurone disease. Why should their birth date dictate whether or not they get help?

[Christine Jardine (Edinburgh West) (LD)]

The hon. Lady is painting quite a rosy picture of the social care system in Scotland, but does she not accept that it has serious problems as well? In my constituency, I know of a gentleman who was in hospital 150 nights after he could have been transferred because no care package was in place. Freedom of information inquiries have shown that people have spent 400 nights in care when they could have been transferred. Does she accept that the picture in Scotland is not entirely rosy?

[Dr Whitford]

I totally accept that the position is not entirely rosy. I said many times in the Chamber before the hon. Lady entered the House that we face the same challenges. Those challenges are increased demand, workforce needs—they will be made significantly worse by Brexit—and the fact that money is tight. We face exactly the same challenges. Some of the patients she refers to will have had particularly complex needs that it was a struggle to meet. We are talking about the fact that we are funding free personal care—it is not based on means-testing—and we are working towards providing it for under-65s.

Everything happening in England at the moment will seemingly be solved by the sustainability and transformation plans, yet they have been set backside forwards, with designers having to work backwards from the budget line, which is made the predominant thing. That will not produce the desired result, and it must be recognised that supporting people at home and in the community is desirable in its own right. None of us wants to be stuck in a hospital or in a care home if we could be looked after in our own home; that is the choice we would all make. That will not necessarily cut the money required by a hospital. The nurses will still be there, the lights will still be on. What it might mean is that that bed can be more effectively used and waiting times for surgery or other treatments can be achieved, and they are not at the moment.

On the news yesterday, there was talk about the inefficiency of operating lists, and the former president of the Royal College of Surgeons clearly said that this comes down to beds. The number of beds in England has been cut in half over recent decades, and the problem is that if a patient cannot be put in a bed before or after the operation, the operation cannot be done. That is often discovered only the day before, and we cannot just drum up another bed.

All sorts of things, not just delayed discharges, are driving inefficiencies within the system. The thing generating the biggest pressure on the NHS has been the cuts in funding to social care that mean that by 2020 in England a funding gap of more than £2 billion will have to be met. We all want to look forward to a dignified older age. We hope that we will be independent and healthy. We need to invest in that, yet public health spending has gone down 5%. Should we need care, we will also want care that is dignified and decent. That has to be funded.

Valproate and Foetal Anticonvulsant Syndrome

Philippa Whitford Excerpts

Thursday 19th October 2017 Commons Chamber

[Norman Lamb]

I thank the right hon. Gentleman for that, and he is right in what he says; I, too, feel that there is a sense of inertia. For goodness’ sake, for as long as women are not getting told about this, more such babies are being born. That is the awful horror of this.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Many of us in the House have been approached by constituents or groups about several of these drug scandals, which represent a paternalistic time, when the patient was not part of a team in an open discussion with the doctor. I am sure there are many of these, so should they be looked at together, as the principles of them all are the same?

--- Later in debate ---

[Paul Flynn (Newport West) (Lab)]

It was heartbreaking and infuriating to read the news that 68% of the women who are taking valproate today were not aware of the risks. That is a failure for all of us. We debated this issue in March 2013, and we have put down early-day motions. There was a television programme, chaired by Huw Edwards, in which the victims took part. We thought we had cracked it: we thought we had advertised enough so that no one, after 2013, could be in the position of not realising the terrible risks caused by taking valproate in pregnancy.

I am not making any criticism of anyone, except the MHRA, and we must look at our relationship with the regulatory body. The former Minister, the right hon. Member for North Norfolk (Norman Lamb), did all he could. He has a great and honourable record as a compassionate campaigner on many issues. It is a shock to all of us in that we did not expect there to be compensation, but it should now be coming along. It is not compensation in any serious way, but it is some admission that a terrible mistake has been made—not by the mothers, but by the system.

It is helpful to look back at what happened with thalidomide, which I remember vividly. There were 2,000 cases of birth defects in the United Kingdom; there were 20 in the United States. Why? The reason is that we went on prescribing Destobel for a year after the birth defects were suspected, because the drug company was adamant about it. It had tested the drug on animals, including pregnant animals—pregnant rabbits, even—and only when it went back to do another test of a particular strain of the drug on pregnant rabbits were the birth defects reproduced. That shows the limits of animal testing. The real difference was that the regulatory body in the United States would not accept thalidomide in that form, and its use produced a very small number of cases: 20 compared with 2,000.

We have had the effect of a drug called Vioxx for arthritis sufferers. According to the Food and Drug Administration in America, it caused 60,000 deaths; imagine it—60,000 deaths. How many bad reactions did the MHRA have in this country? About six. We would still be using it if the FDA had not discovered that death was one of the side effects of the drug, which was taken by millions.

GlaxoSmithKline in America has been fined—it is hard to believe—$3.5 billion. What was the fine for? It had suppressed the evidence of the trials it had carried out. It did not publish any of the negative results of the trials it carried out, and only the ones that were neutral or favourable. Drugs that were killing people were getting on to the market—this is a British company. What did the MHRA do in this country? Nothing! I wrote to them saying, “For goodness’ sake, you have to act against GlaxoSmithKline.” It is no coincidence that the person who chaired the regulatory body for more than a decade was a previous employee of that company. I am not saying that in this instance the body did absolutely nothing; it did produce the tools and provided advice, but that clearly did not work—how could it have done if 68% of the women still taking the drug did not know?

This issue applies to all Governments; it has been raised many times before. What we need is a regulatory body that is not paid for or controlled by the pharmaceutical industry but is independent and controlled nationally. Some years ago in Italy, the system changed. The pharmaceutical industry still pays for running the body, but for the past 20 years each Government have said that they would not have a fully independent body because they did not want to pay for it, although it was fine if the burden was taken by the pharmaceutical industry itself.

I do not want to say that we are all against the pharmaceutical industry, which has produced miraculous results this century. Valproate is a very good drug: everyone I have spoken to who has used it says that it is very effective and that it reduces seizures, epileptic fits and the incidence of bipolar disorders. We do not want to stop its use at all and we want to appreciate its quality, but after these four years, when the evidence from parents who have suffered has been there, clearly nothing has worked. We must look to reform our regulatory system, appreciating the value of the drug but at least setting up a fund that can express the sorrow of the country and the regret that we have not sorted this matter out or given warnings to future parents. We must make sure that the reforms suggested by the right hon. Member for North Norfolk proceed as a matter of great urgency.

[Dr Whitford]

Will the hon. Gentleman give way?

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

He has finished.

--- Later in debate ---

[Dr Whitford]

I come back to the point I made earlier. We seem to see these themes. Rather than having multiple separate inquiries, should we consider issues such as Primodos and valproate together? Common learnings need to come out of them.

[Mims Davies]

I absolutely agree. I hope to pull that issue together as I go on with my remarks. It is really important that we raise the case of sodium valproate, which, as we have heard, is still in use. All of these issues need to be looked at.

Common to this debate—and in all such cases, including Primodos—are the hidden, missing and lost documents, along with a delay in education and information. That was raised again today by the right hon. Member for North Norfolk. I pay tribute to Sky News for its exposés on valproate and Primodos, because this really matters to the families affected.

--- Later in debate ---

[Liz McInnes (Heywood and Middleton) (Lab)]

I am pleased that we are having this important debate, and I pay tribute to the right hon. Member for North Norfolk (Norman Lamb) for securing it and for setting out so clearly the issues involved.

My career before I was elected was as an NHS clinical scientist. Working in a biochemistry laboratory, I was very familiar with sodium valproate as part of the battery of anticonvulsant drugs for which we regularly tested patients to help their clinicians better monitor their treatment and ensure that their dosage was at the optimum level. Until I met Emma Murphy, however, and became aware of her campaign, I was not aware of what appeared to be a systematic failure to inform women of the potentially damaging effects of taking valproate during pregnancy.

Only after watching a television programme about foetal anticonvulsant syndrome did Emma herself became aware that her own children’s health problems were probably attributable to the anti-epileptic drugs she had taken while pregnant, which had been prescribed to her from the age of 12. Like everyone in the House, I pay tribute to Emma Murphy and Janet Williams for their great campaigning work.

The damage to the developing foetus is thought to be caused in the first trimester of pregnancy when the anti-epileptic drug crosses the placenta into the foetus, and the effects depend upon the dosage and the drug. Sodium valproate, or Epilim, is indicated in 80% of cases of foetal anticonvulsant syndrome. Experts such as Dr Peter Turnpenny, clinical geneticist at the Royal Devon and Exeter Hospital, say that Epilim may affect about 560 babies every year. He adds:

“About 10% of foetuses exposed to sodium valproate will have a major congenital malformation such as cleft palate. 12% are likely to be diagnosed with a neurodevelopmental disorder.”

Reports linking valproate to birth defects started to appear, most notably, in 1981, with a paper by H. Nau entitled “Valproic Acid and its Metabolites”. In 1983, the British Medical Journal published an article in which the Royal Liverpool Hospital cited two cases suggesting a link between birth defects and valproate taken during pregnancy. The American Journal of Medical Genetics cited seven cases in 1984 of children born with malformations to mothers taking valproate, and the Journal of Paediatrics cited 26 cases in 1986. The list goes on. It would appear that the evidence was steadily building up with the publication of more and more cases linking valproate to birth defects. The Committee on Safety of Medicines and the Medicines and Healthcare Products Regulatory Agency noted those reports, and, I hope, monitored the use of valproate, particularly during pregnancy.

[Dr Whitford]

We have heard about various scandals. In the case of Vioxx, which was mentioned by the hon. Member for Newport West (Paul Flynn), trials did not show a problem but real-world use did. Does the hon. Lady think that we need some kind of reform of the reporting system? There is something that we call a yellow card, and patients can now fill it in themselves, but many of them do not realise that. I feel that there is not enough “flagging up” when patients suspect that they are suffering from side-effects.

[Liz McInnes]

The hon. Lady is absolutely right. She and I are well aware of the yellow card system, because we have both worked in the NHS, but how many people out there know that they can report side-effects of drugs, or even suspected side-effects? We really have a job to do in conveying that message to the general public, and we also need people to collate the information and act on it.

A definitive paper stating that there was a clear link between valproate taken during pregnancy and birth defects was published in 1995. It was entitled “Foetal Valproate Syndrome”, and was written by geneticists at St Mary’s Hospital, Manchester. It is clear that the evidence has been building up for a long time, so why does it appear that women were not warned about the potential dangers of taking the drug in pregnancy?

--- Later in debate ---

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, pay tribute to the right hon. Member for North Norfolk (Norman Lamb) for securing this debate and trying to air this issue again. Epilepsy affects 1% of the population—600,000 people—and it is not a trivial condition. It is dangerous. As we have heard, 1,200 people a year die due to epilepsy, and we must not diminish that fact. At the lowest level, someone who has a fit after being well controlled suddenly cannot drive again, which can have quite a big impact, but at the other end of it there is death. We therefore must be careful not to send out a message that anti-epileptic drugs are bad, or even that Epilim is. It works really well, and it is one of the drugs that often can control the most dangerous seizure—the tonic-clonic or grand mal, as it used to be called—without the use of other drugs.

Almost all anti-epileptic drugs carry risk. Sodium valproate is the worst by far, but all the ones we have heard of in the past—phenytoin, phenobarbital, primidone and carbamazepine—carry some risk. We therefore have to recognise that it is not just as though the doctors prescribed the wrong drug. This condition is really hard to deal with, and we need people to have specialist input. We are really asking that from when girls reach puberty until they reach menopause or get into their 50s—when there is no risk of them having children—decisions are made with them by specialists.

As we have heard, there was obviously a recognition right back in the ’70s that sodium valproate could bring about congenital abnormalities, but what appears to have changed is the scale. If we look back, we see that people used to discuss a 2% risk of malformation and “some possibility” of developmental delay. We are now talking about 10% of children having a birth defect, which might be something like a minor cleft palate that can be dealt with, right through to spina bifida, meaning the child faces major physical disability. On a much worse scale, some 40%—almost half—of children face some form of developmental delay, which might mean an autistic spectrum disorder, learning difficulty or ADHD. That is a big change.

We heard earlier about the 1995 paper that started to bring these cases together. Before that, there were predominantly case reports—someone saying, “Oh, this is odd; I’ll write it up”—but we needed someone to bring things together. When we hear that 400 affected babies have been born in the year since the recent attempt to deal with this issue, we realise that had the yellow-card reporting system been working when we had perhaps 500, 600 or 700 cases a year, the situation would have been spotted much more quickly.

The system utterly failed to recognise a pattern and has to be reformed. If a woman gives birth to a child with a birth defect, or there is in the very early years recognition of some kind of major developmental delay, and she is on a drug, that should be reported, and I do not care what the drug is. Her GP may never have seen such a thing before and might not recognise that there could be an association, but someone sitting in the MHRA who is receiving 400 or 500 reports certainly ought to.

The obvious question is how to tackle this issue. The toolkit was put out in February 2016, because we have recently recognised the huge scale of the problem—the change is the recognition of the scale. It is therefore shocking and incredibly disappointing to hear that more than two thirds of women have not received any part of it. It is great that there is now some marking on packaging, but perhaps more of that needs to be combined, because we then do not have to depend on people remembering to hand something out or to pick something up. We would be empowering women to say, “Oh, what’s that? You’ve never talked to me about that,” and both sides would have the chance to have a discussion.

We have predominantly focused on the results of using sodium valproate during pregnancy but, as the hon. Member for—

[Norman Lamb]

Strangford.

[Dr Whitford]

Sorry. I am not doing very well today. Six hundred and fifty names is hard enough; adding another 650 constituencies just does my head in!

As the hon. Member for Strangford (Jim Shannon) mentioned, by the time a women is pregnant—crucially, by the time she knows she is pregnant—it is too late, because these abnormalities happen in the first trimester: those first two months when the brain and spinal cord are forming and the arches of the face are combining. That is why we particularly see neural tube defects, brain function abnormalities and cleft palate. Many women who lead hectic lives may already be two months pregnant by the time they finally know, and that means it is too late. That is why the annual review is important.

Epilim is perfectly fine for a girl to use if it gives good control for grand mal seizures, but we need to flag up the fact that when she is expected to be approaching puberty, discussions need to start with her and her family. Family planning is important for all women, but for women on these kinds of drugs, which must be stopped in pregnancy, it is crucial. We need to have that discussion so that the alternatives can be considered. I echo the comment that if a woman is pregnant and did not plan for that, she should not stop the drug on her own. She should have emergency access to a specialist who is able to look at her type of epilepsy and discuss the options with her, such as whether it would be safe to take nothing or if it would be better to change to something else. It should be recognised that uncontrolled seizures in pregnancy can cause the loss of the mother and the baby. We must not have any kind of irresponsibility by not flagging that up.

We had a debate in this Chamber last week on baby loss. It was a very powerful cross-party debate on the anguish that people face, whether it is due to early miscarriage, stillbirth or neonatal loss. We talked about that loss and bereavement, but any of us—male and female—who have had children know of the expectation and joy that comes from waiting for a child. There is still exactly that bereavement when we know that our child will face a life of physical and mental difficulties, and of learning disabilities. We know that a child with a marked learning disability has only a 7% chance of working. For the parents, there is the stress of knowing that there will come a point when they are not there, and of wondering how their child—perhaps now a young adult—will actually survive facing a harsh world.

Financial support is absolutely crucial to give families peace of mind. We need an inquiry, but rather than holding multiple inquiries, we should recognise that bringing some of these common themes together into one would be a much more powerful way to get people to understand that we are talking about relentlessly repeating patterns. Let us try to reform the things that allowed this to happen and to ensure that we support the families and the children to whom, sadly, it has happened.

Oral Answers to Questions

Philippa Whitford Excerpts

Tuesday 10th October 2017 Commons Chamber

[Mr Hunt]

The hon. Gentleman is right to bring that up. One thing we can do a lot better is to improve the opportunities for flexible working. We have announced that we will be making new flexible working arrangements available to all NHS staff during this Parliament. We are also expanding programmes to encourage people who may have left the profession to come back into nursing.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I think everyone would welcome an expansion of nurse training places, but the Council of Deans of Health stated in June that no new extra places had been funded either in universities or, crucially, in hospitals, where 50% of the course is carried out. Will the Secretary of State clarify when that funding will be made available?

[Mr Hunt]

Next year.

[Dr Whitford]

Obviously we know that it takes quite some time to train a nurse, and one in 10 posts in England is vacant—that is twice the rate we face in Scotland. We also know that there is a 51% increase in nurses leaving the profession, a 96% drop in those coming from the European Union, and a limit on the use of agency staff, so where does the Secretary of State expect NHS England to find the 40,000 nurses it needs right now?

[Mr Hunt]

Let me just remind the hon. Lady that there are 11,300 more nurses on our wards than there were just four years ago, so we are increasing the number of nurses in the NHS. She mentions what is happening in Scotland. I gently remind her that nearly double the proportion of patients are waiting too long for their operations in Scotland as in England.

Baby Loss Awareness Week

Philippa Whitford Excerpts

Tuesday 10th October 2017 Commons Chamber

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I speak as someone who has not lost a child, but I remember what happened when I was working in Lebanon and was four months pregnant with my son. We had discussed the risks of going to Lebanon when I was pregnant and we thought I would only be there a few months; even if I was here there would be nothing that could be done, so I was not adding to the risk. But when I suddenly saw blood, all of a sudden I realised how paltry that word “miscarriage” is. I understand that we are predominantly talking about babies who have been lost later, but that term “miscarriage” sounds like “misstep”—like a bump in the road—and by four or five months, particularly once you have had that little ultrasound picture, which you thought was going to be the first of a whole lifetime of photographs, you realise you have already bonded with the bulge that means you need elasticated waistbands and is giving you heartburn or keeping you up at night, or even, a bit later, starting to kick the living daylights out of you at three in the morning. So I think it is really important, as my hon. Friend the Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron) said, that we think of those who are slightly outwith this debate. That is something that we must try to bring over to medical staff as well.

I acknowledge the discussion about bereavement midwives, and we always need champions and leaders when, trying to raise awareness, but as someone who has worked in breast cancer for over 30 years, I can tell the House that having a grumpy old surgeon and then sending the lady to the breast cancer nurse, who would be nice to her, is not a solution. In fact, with all midwives, all doctors, it only takes one person to turn the knife and make that heartbreak worse.

I had a friend who had three miscarriages before she successfully had two rather wild and lively boys—something for which I am sure she gives thanks every day. On her second miscarriage, a routine scan at 16 weeks revealed that the heartbeat had stopped. They thought she would miscarry, but she did not. The period between then and when she underwent surgery meant she knew she was carrying her own dead baby. That was really difficult. At the scan that made the diagnosis, she was simply sent back out to the waiting room after a couple of minutes. She was sitting there surrounded by women with their bumps discussing their plans, while she waited for almost half an hour to be taken into a room and just given leaflets. There is no point in having one person who knows how someone should be supported: every single member of every single team, from antenatal, perinatal and right through to early paediatrics, needs to know the language, the body language, the timing and the support that someone might need.

The number one thing as a doctor is to try to reduce the number of deaths. Scotland actually had higher perinatal, stillbirth and neonatal figures. About five years ago, there was a big discussion in the profession in Scotland saying that it needed to be tackled. It was not enough simply to collect data—whether the Scottish perinatal mortality data, which go back to 1977, or, now, in MBRRACE-UK. The cases had to be looked at. Regardless of whether that is done through a fatal accident inquiry, it must be done by the clinicians. As surgeons, we carry out morbidity-mortality meetings every couple of weeks to discuss cases that have gone wrong in a very open and frank way. We learn from them. Often, we will suddenly see a pattern that makes us want to change. Since 2013 in Scotland, our perinatal figures have dropped by 34%—a third—our stillbirth rate has dropped by 26% and neonatal has dropped by over 50%. That is what can be done if every single case is discussed.

Believe me, Scottish Members here know that the geography of Scotland makes providing perinatal care really difficult and challenging. It is easy to identify the difficult case with a past history of diabetes or a huge wain and a small pelvis, but any delivery can go wrong. One challenge we face, which is not faced in so many areas in England, is how to get people off our islands and how to cover hundreds of miles, yet we have managed to bring the figures down.

It is absolutely right that, even if we drop the mortality rate further, there will be children who are lost. We must not stop trying to do that and we must support people, in particular those whose babies are born and require extra neonatal care in a special baby unit. We know they have a higher incidence of post-natal depression. We know that, naturally, mothers who lose a child will have an increased incidence of post-natal depression. If we can get all our teams to try to get it right all the way through and support them, then maybe we can tackle both problems.