Tobacco and Vapes Bill (Third sitting)
Rachael Maskell ExcerptsWednesday 1st May 2024
(1 week, 1 day ago)
Public Bill CommitteesRead Full debate Tobacco and Vapes Bill 2023-24 View all Tobacco and Vapes Bill 2023-24 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 1 May 2024 - (1 May 2024)
Kirsten Oswald
Q
Professor Sir Chris Whitty: I think we are all very keen for the Bill to get through in the time that remains in this Parliament, so none of us would want to complicate this, but as Sir Gregor says, what we really want is for sports to be very firmly in the area of things that promote health. This is one of the areas that I do not think any of us would suggest is promoting health, so in broad terms we would agree, while not wanting in any way to complicate the Bill that is before Parliament at the moment.
Rachael Maskell (York Central) (Lab/Co-op)
Q
Professor Sir Chris Whitty: I wonder whether Sir Michael might want to go first, and then Sir Frank.
Professor Sir Michael McBride: We have to start somewhere. What we actively want to do, at this point in time, is encourage those individuals who smoke to quit smoking. We recognise that there are nicotine replacement products other than vapes that are very effective and that individuals successfully use, but for some individuals, as has been stated already and as is outlined in the relevant NICE guidance, vapes can be effective and are safer than smoking. It is about finding the sweet spot—hence the powers to consult.
We need to get a balance to ensure that we are absolutely not creating circumstances in which vaping is attractive to young children, starts a lifetime of addiction to nicotine and is potentially a gateway to smoking tobacco, as I think your question is suggesting. But at this point in time, this is an important step to ensure that the next generation are protected from smoking tobacco. We need to support those individuals who currently smoke or are currently addicted to nicotine to gradually move away from that addiction. That includes supporting smokers who currently smoke to quit, but we are increasingly seeing individuals who wish to quit vaping and are finding it difficult.
We are at the start of a journey. As Sir Chris has said, we do not want to delay this Bill and this important step change, in terms of making very significant progress. Sir Frank, do you want to add to that?
Sir Francis Atherton: Very briefly. The principle of alignment is a positive one. Keeping it simple for the public is in the interest of messaging, as a general point. In Wales, we did try—in 2016, I think it was—to align smoke-free and vape-free public places. Personally, I think that there is merit in that, but we have to be careful, because some of the arguments are different. The arguments around smoke-free public places are based on passive smoking, but we do not have a lot of data on passive vaping; many people see it as a nuisance, but that is a very different argument. We need to be a little bit cautious about that, even though I would personally be in favour.
The important thing is to remember that we really need to keep vapes as the quit tool. Your point about moving towards a nicotine-free next generation is absolutely right; that is really what we want to do. If we can make it less acceptable and less prevalent that children take up vaping, we should move towards that. The reality is that over the last three years we have seen a tripling of vaping among our children and young people. That is just unacceptable. The measures in the Bill will help deal with that and lead us, we hope, towards the nicotine-free generation that you talk about.
Nickie Aiken (Cities of London and Westminster) (Con)
Q
Professor Sir Gregor Ian Smith: My view on the Bill as it stands is that it is a starting point for how we take this work forward. It is adequate in that sense because this is a really important area. For me, the absolute priority has to be to remove young people’s ability to access vapes and so begin the journey to nicotine addiction.
I am not in favour of criminalising the possession of these products, but I am certainly in favour of banning their sale to younger people. If we can achieve that at this stage, and, as Sir Michael said in his previous answer, if we can begin to shift the culture so that people do not start to use vapes and begin to become addicted—potentially also by using other nicotine and tobacco products—for me that will be a good job done.
If we do things that way, it will allow us to protect the useful use of vapes: where people with a lifelong addiction to tobacco can use them as way to help them stop. That is the only justification that I can see now for the way we have set this up and for continuing to use vapes in society: as a useful tool for those with a pre-existing addiction to tobacco, so that they can reduce the harm and gradually stop using tobacco—through formal cessation services, as well.
Professor Sir Chris Whitty: I agree with Sir Gregor. To reiterate, the Minister wanted to get a balance and most people would agree that criminalising people for individual possession is a step further than anyone would want and is needed. I do not think there is a clamour for that from anybody, and I think it would not help the Bill.
On prescription vapes, I would like to see those available for use at the moment. So far—I will go into the reasons for this on another occasion—no products are available that we can prescribe. We would all very much like those products to be there so that people can prescribe them. That is different from saying that they should be only on prescription; at this point, we do not even have any products to prescribe at all. If we did, that would be a very firm step in the right direction, but it depends on the industry coming forward with products.
Speaking directly to the industry, I should say that I do think there is a very important niche for prescription vapes. They would be very useful for some people, particularly those on low incomes who, for other health reasons, have free prescriptions. I encourage anyone from the industry who is listening to think seriously about bringing forward a prescription vaping product appropriate for aiding people to quit.
Steve Tuckwell (Uxbridge and South Ruislip) (Con)
Q
Professor Sir Steven Powis: I have already highlighted some of the short-term impacts, and there will undoubtedly be short-term impacts. Some conditions are exacerbated by smoking, with asthma in children being an obvious one. I have talked about mental health conditions and the way that smoking exacerbates conditions such as depression and chronic mental health illness.
We will start to see immediate effects, but those effects will grow over time. I have given you some of the conditions that are impacted on by smoking—there are well over 100 of them—but I can give some more stats. By stopping children from ever starting to smoke, we estimate that we will prevent about 30,000 new cases of smoking-related lung cancer every year. More than 1.4 million people suffer from chronic obstructive pulmonary disease, which is a chronic disease of the lungs caused by smoking—it causes nine out of every 10 cases. As I said, that is a disease that clinicians commonly see. A common cause of admissions to emergency departments, through the winter particularly, is other respiratory infections on top of COPD—these are diseases that future clinicians will see rarely. They will not see them in the way that clinicians of my generation have had to manage them. The impact will begin immediately, but over time that impact will get greater.
Rachael Maskell
Q
Professor Sir Stephen Powis: As I outlined earlier, the impact on the NHS of vaping at the moment is relatively small compared with the impact of smoking. Nevertheless, there is an impact, and we are seeing growing numbers. I have highlighted the number of admissions per year, but they have doubled over the past few years, so that impact is becoming apparent. For example, yellow card reporting to the MHRA is a mechanism for reporting harm, and again the number of incidents related to vaping is increasing, although still in relatively low numbers.
As I said earlier, however, what is important here is that the evidence base, although emerging, is growing. This is an opportunity for us not to get into a position where, in years to come, we regret that we did not take the steps early on to change the trajectory. Instead of seeing rising impact on the NHS—small at the moment, but with the potential to be greater—that trajectory should be changed. This is a golden opportunity for parliamentarians to step in early and to prevent further pressure building over time on the NHS, while recognising that the evidence is still emerging.
I agree with the chief medical officers you heard earlier: I do not believe that vaping is safe. It is undoubtedly safer than smoking, which is why we support its use as a means of smoking cessation, but beyond that the evidence is building that it is not safe. Unquestionably, it will have a building impact on the NHS.
Angela Richardson
Q
How much do we know about the difference between the impacts of smoking and vaping? Thinking of the impact of vaping on babies, is vaping still an okay thing for pregnant women to be doing? Do we need to specifically address the impacts of vaping and smoking on pregnant people in the Bill?
Kate Brintworth: If we start with the evidence, as we have heard this morning there is a limited evidence base around vaping, but that does not mean we should be complacent. We know there is evidence around the transfer of chemicals and the reduction in lung capacity, which we see. As Chris said, while that is an improvement against the very, very low bar of smoking, we would see it as one step on a journey—an interim measure to being nicotine and tobacco free. On that basis, I do not think I would frame it as being okay to vape. We would see it as a tool—a means to an end—to reach the position of being nicotine and smoke free.
We will absolutely support research monitoring the impact of vaping. We cannot be complacent that it is going to be all right. However, at the moment, vaping is absolutely better than smoking, with the very well documented impacts that I have described on not just the mother but the baby and the future health of the family; we know that children born into households where smoking occurs are likely to start smoking themselves.
Dame Andrea Leadsom
Thank you very much. One last question: do you think the financial incentives for pregnant women and their partners would help?
Professor Turner: I think this is extremely contentious, but the evidence is that it does—sorry, you did ask me about pregnancy before. Pregnancy itself can be one of those opportunities to quit. Those parents who continue smoking—12% in Cumbria—feel terribly guilty. Anything we can do for that person, who has been addicted since she was 15 or 16, can help them to quit. There is no doubt—in Dundee, the trials have shown that, if you give mums incentives, in terms of vouchers rather than money, it helps them to quit, particularly if they are from deprived communities.
Rachael Maskell
Q
Professor Hawthorne: I am not a nicotine expert, but my understanding is that there is a risk from vaping, but it is about 5% of the risk from smoking. That is the best I can do in comparing the two. When I talk to patients about stopping smoking, vaping is one of the things we talk about as an alternative, with a view to eventually stopping vaping as well. Of course, there are all the other products: we use patches and chewing gum—all the usual things. It is difficult to quantify exactly how much less dangerous vaping is than smoking.
Professor Turner: Just to supplement that, as a user—if that is the right word—or a customer buying a vape, you can select the dose you want. There are doses that are equivalent to cigarettes and doses that you can wean yourself down on.
You asked whether we would be missing an opportunity if we do not introduce a smoke-free generation. I think we would absolutely be missing an opportunity. If we look back, the legislation on smoke-free public spaces across the UK was landmark. We all remember the days when you went on a plane and there was a smoking bit up front and a non-smoking bit at the back. If we were to go back and say there would be no smoking areas, we would think, “Wow, that would be transformational.” We have come on a journey, and the legislation has been part of it. I see a smoke-free generation as the logical next step, and I really think we have to take it.
Rachael Maskell
Q
Professor Turner: To me, smoking and nicotine are two sides of the same coin. Nicotine addiction is smoking.
The Chair
I just want to advise the panel that we have about 13 or 14 minutes to go, and four Members want to ask questions, so be kind to your colleagues.
Tobacco and Vapes Bill (First sitting)
Rachael Maskell ExcerptsTuesday 30th April 2024
(1 week, 2 days ago)
Public Bill CommitteesRead Full debate Tobacco and Vapes Bill 2023-24 View all Tobacco and Vapes Bill 2023-24 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 30 April 2024 - (30 Apr 2024)
Rachael Maskell (York Central) (Lab/Co-op)
Q
Dr Johnson
I want to ask about the passive effect of vaping. We know that if you are proximal to someone vaping you can smell the blueberry flavour, or whatever it is. Do you have any evidence on the passive health effects of vapes?
The Chair
We have five minutes left and I do not think there will be time for any further questions. I may have missed it, but I am not sure whether anybody responded to Rachel Maskell’s points. In responding, could you cover those as well?
Deborah Arnott: Can I just confirm, Rachael, that your question was about public health messaging, restrictions and smoke-free laws?
Rachael Maskell
Including where people can vape, yes.
Deborah Arnott: To go to that one first, I think it is really important—the chief medical officer has said this too—to make the distinction between smoking and vaping. Smoke-free laws were implemented after very strong evidence about second-hand smoke causing lung cancer and heart disease. We do not have that for vaping. It is important that regulations are in place, and we are seeing that—you cannot vape on public transport or aeroplanes or in most workplaces, and that is fine—but making it legislative implies that it is equivalent to smoking.
On the point about displays and promotion, our surveys show that children are most aware of the promotion of vapes in store and online, and that is where the priority has to be in strengthening the legislation. Restrictions on how products are displayed, and the packaging and labelling stuff that we have already talked about, are really important.
In terms of additional measures, on the vaping side, there is one thing that I would say is vital. At the moment, clause 63 does not allow for a change in the product requirements set out in the Tobacco and Related Products Regulations, following on from the EU tobacco products directive, which was designed in 2013, over 10 years ago. We need the Government to have powers to change the general product requirements, not just ones related to branding, and that is the other amendment on vaping that I think is really important. There are other things, but I have possibly run out of time, so we can share those with the Committee separately.
The Chair
That would be helpful, thank you. We are up against the clock, but is there anything additional that either of the other two witnesses want to say very briefly?
Sheila Duffy: Thank you for your time. ASH Scotland supports an increasing European movement towards SAFE—smoke and aerosol-free environments—for the sake of health. I would say, on the evidence base on tobacco, that we have 100 years of scientific evidence, and it took 30 to 60 years to see the heaviest health impacts from tobacco. We should be more cautious about e-cigarettes as recreational products. The World Health Organisation, in its call to action in December last year, suggested that they should be carefully handled as cessation products, not as a whole-population approach. We would support ambient advertising and sponsorship being closed down. In terms of what further the UK Parliament could do, use the powers you have to regulate things like social media and be very aware of the massive commercial influences on thinking, which far outweigh any resource that small third-sector advocacy organisations can bring.
Michelle Mitchell: We need to keep our eye on the big prize. We have talked about the evidence and statistics relating to smoking. This would be a world-leading piece of legislation, and we urge you in Parliament to pass it in full with the scope recommended by the Government. I think you would be leaving an incredible legacy of health, wealth and a healthy country for future generations.
Preet Kaur Gill
Q
Dr Griffiths: As Deborah from ASH said, vapes are a fairly new product, so the research and evidence base, which we have in abundance for tobacco and smoking, is still forming for vaping. However, there are indications that it is not great for health. We are cautious and worried about the long-term implications. What we do know is that vaping can be an important cessation tool for those trying to quit smoking, and that many do want to quit, so we strongly encourage anything that stops smoking, but the people who are turning to vaping as an alternative to smoking for the first time is of deep concern to us. We do not understand the long-term health implications, but the addiction to nicotine deeply concerns us.
Sarah Sleet: We strongly agree. It is a very delicate balancing act between stopping the harm caused by smoking and looking to the long-term with regard to vaping. Quite clearly, smoking is far more damaging for adults and children. Anything that can steer people away from smoking will be healthier than continuing to smoke in the long run, but we do recognise that more attention and more research need to be put into vaping.
Rachael Maskell
Q
Sheila Duffy: As I said earlier, it is a delicate balancing act. We need to move people away from smoking, and anything that does that is a good thing, but we need to look at the long-term effects of vaping. The balancing act in the proposals around restricting access to vaping—making sure that nobody under-age gets access to vapes, denormalising them by taking them away behind the counter and so on—all of those are good measures to reduce the number of children moving on to vaping, but they need to be enforced. We need to make sure that we have the right enforcement action in place to make sure that that actually happens.
Dr Griffiths: You gave a great example of early science that causes us concern, and it perhaps will not surprise you to know that as a body that is based in science and evidence, we at the BHF take statistics incredibly seriously. We are worried that the body of evidence will grow. We would hugely support and welcome a position where vaping was available to people as a cessation tool, but absolutely would discourage anyone else from taking it up as a starting point for nicotine consumption.
Steve Tuckwell (Uxbridge and South Ruislip) (Con)
Q
Dr Griffiths: It has a huge impact, and thanks to some of the previous legislation there have been some improvements that we can measure and track with great certainty. Second-hand smoke is undoubtedly a cause of cardiovascular disease, and for those people unfortunate enough to be exposed to it, it is a serious issue. Just over 15 years ago, there was a study that looked at coronary heart disease and cardiovascular disease in men. It showed a significant uplift for those exposed to second-hand smoke on a regular basis that was roughly the equivalent in risk of smoking nine cigarettes a day. So there is a very clear basis for saying that second-hand smoke causes heart and circulatory disease.
Sarah Sleet: I would add the legislation on smoking in closed places—there was of course the legislation back in 2015 about children and smoking in cars—was based on very good evidence and was introduced for very good reasons. It proved to be a popular measure. Second-hand smoke in this context as well is an important additional factor to consider in terms of the harms balanced against the need to restrict these particular products.
Rachael Maskell
Q
Matthew Shanks: Yes. I absolutely agree.
The Chair
That is really helpful.
Patrick Roach: I am not going to add to that, partly because I am here representing the interests of our members. The issue is about how we can control access to products, particularly illegal products, for school-age pupils. We therefore think that it is absolutely right that the Bill has identified the need to secure robust measures to protect the health and wellbeing of children and young people.
Tobacco and Vapes Bill (Second sitting)
Rachael Maskell ExcerptsTuesday 30th April 2024
(1 week, 2 days ago)
Public Bill CommitteesRead Full debate Tobacco and Vapes Bill 2023-24 View all Tobacco and Vapes Bill 2023-24 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: Public Bill Committee Amendments as at 30 April 2024 - (30 Apr 2024)
Dame Andrea Leadsom
Q
Cllr Fothergill: Specifically on vaping, we support the move to plain packaging, moving them away from the counter and restricting flavours—we support all those things. I have to say that we recognise the role of vaping in helping people to give up smoking, but where children and younger people are involved, we want to move the vapes away and make them less accessible. Trading standards will enforce that, as long as there are clear definitions of what can be sold, where it can be sold and who it can be sold to. A lot of the work that they do is evidence-led, so they will work on people who are giving them tip-offs or where they are seeing that there is a trend in an area where those products are being sold. As long as we are resourced and we recognise that a lot of that evidence-led work is required, it is entirely achievable.
Greg Fell: I have a fairly similar view. Largely, trading standards do this work now. The easier and simpler we can make it, and the more we make sure that it is resourced appropriately, the better, but they largely do this job now pretty well.
Rachael Maskell (York Central) (Lab/Co-op)
Q
Greg Fell: Hopefully only illegal vapes contain cannabis or Spice, and not legally produced ones—I sincerely hope that is the case. I have mixed views on vaping in public. I think that Prof McNeill will talk later this afternoon. It is worth reading her evidence review for the Office for Health Improvement and Disparities, which has a whole chapter on the passive inhalation of vapes. The ADPH does not have an official position on the passive inhalation of vapes, but my personal view is that in open spaces I am not too worried about it. In enclosed spaces, I might be, particularly for people who have pre-existing respiratory conditions, but I do not think that the evidence supports it being as big an issue as people think. However, that is definitely a question for Prof McNeill, who is the expert on such matters.
Steve Tuckwell (Uxbridge and South Ruislip) (Con)
Q
Cllr Fothergill: I have already said that we believe the amount of the fine needs to be reviewed. We believe it is right to do it by a local penalty notice, which is issued locally and can be enforced. We do not believe that £100, reduced to £50 if it is paid within 14 days, is sufficient. It will not have the effect that it needs to have and it should be reviewed.
We are also keen, as part of the Bill, for a review of whether we should be brought into line with Scotland on age verification. Scotland has very clear guidelines that legally, people have to produce identification that they are of an age to buy, and we think this is an opportunity for us to bring that in as well. There are two things where we would like to see enforcement strengthened: mandatory age verification and an increase to local penalty notices.
Rachael Maskell
Q
Greg Fell: I do not know that there is a lot of evidence on the gateway effect of switching from vaping to smoking. Again, there are proper experts, some of whom are sitting behind me. It might be something that you want to test them on later, but I do not know that there is lots of evidence of that. Nobody thinks it would be a good thing to do. I think it is fair to say that there is widespread misunderstanding, and occasionally misinformation, about the dangers of vaping in much of the popular press. When we read a study about immensely high doses of vape in the lungs of mice, that leads to awfully lurid headlines, and that causes people to have misunderstandings and misinformation about the relative risks and benefits of vaping compared with smoking. Sadly, I cannot stop that, but it is a problem and I do not think there is an easy solution, because the media like to publish good headlines. I get that; I understand it, but it often skews us away from what the science is actually telling us.
Dame Andrea Leadsom
Q
Kate Pike: The Bill will have enabling regulations on vapes, with powers and criminal sanctions. That is good, but the specifics around where the vapes are positioned in store will be down to the next stage. We get calls all the time from people saying, “There’s a shop in my area called Toys and Vapes—do something about it!” There is actually no legislation that we can use to tackle that.
If you do not want the vapes next to the sweets, legislate for it. We will enforce what it says in the legislation, but we cannot make it up. People are always saying, “That’s not right,” but we cannot enforce morals. We can only enforce the law, so get it in there. If you do not want the vapes there, for very good reasons, give us legislation and we can enforce it.
Rachael Maskell
Q
Kate Pike: Illegal drugs are not a trading standards issue. If drugs are consumed via vape or by injection or rolled up in a roll-up, that is not our issue; that is a police issue. We can only enforce the law around the products where the enforcement is given to trading standards. We have no role whatsoever in illegal drugs in vapes. But there is a huge amount of enforcement around illegal drugs in this country, with the police, and the public health approach, about ensuring that people do not use illegal drugs. However they consume them, it is really important that they are on board—
Rachael Maskell
Q
Kate Pike: If you have intelligence around a vape seller selling an illegal drug in a vape, or in any other sort of format, that should be reported to the police. The police will take action against illegal drug sales, or Border Force at the ports and borders. There is a huge enforcement body around illegal drugs.
John Herriman: It is the market surveillance point again. If you have the right level of market surveillance, which is down to capacity, you will have trading standards officers, as well as those from other agencies, out and about who will detect the stuff. Then you can take the appropriate enforcement activity by whichever agency is appropriate at that particular point.
I take the point that was made earlier. I was walking down Hackney high street with trading standards just a couple of weeks ago. About every third or fourth shop, regardless of whatever the main thing it sold was, was also selling vapes on visible display. It is about making sure that we are aware of the level of vapes being sold, and that we therefore take the appropriate action, which is what the Bill should enable us to do.
The Chair
Colleagues, we might be voting fairly soon, so short questions, please, and concise answers.
Hospice Funding
Rachael Maskell Excerpts(2 weeks, 3 days ago)
Commons ChamberRead Full debate Read Hansard Text Watch Debate Read Debate Ministerial Extracts
Rachael Maskell (York Central) (Lab/Co-op)
I congratulate everyone who has spoken in the debate. The House has come together to highlight something that I am struggling with: when people are at their most vulnerable, they are having to beg for money to fund important services. That should not be the case, yet here we are with an NHS that is clearly not functioning and other services are also feeling the pain. The reorganisation of the NHS devolved powers to ICBs, but we must remember that it is the responsibility of the Government to ensure that the structures function. That is not happening at the moment, and our constituents are losing out. A word that keeps echoing in my mind, rolling off our lips as it always does, is the NHS: the “national” health service. Yet we are hearing about a postcode lottery, where different areas have different experiences, with different ICBs funding to different tunes and where you live accounts for how you die. Surely, we are better than that? In the words of one clinician about the extraordinary provision at St Leonard’s Hospice in York:
“Having worked with people at the end of life through my career, I didn’t know care like that was possible.”
However, as with all hospices, if funding is not addressed, such care will not be possible.
It was this Parliament that inferred the duty, through the Health and Care Act 2022, to address the inequality in access to palliative and end of life care, so that everyone can have the best clinical and holistic support possible, if the right funding is stabilised and put in place. Currently, however, we know that many people—Hospice UK says one in four—are not accessing palliative care. That is 150,000 people every year who die without the support they require. That number is set to rise 25% by 2048 and, according to Marie Curie, by 13% in the next decade. This debate cannot just be about what happens now, but what happens in the future.
In York, the hospice ran an £800,000 deficit last year. The hospice at home funding has remained static for the past seven years, while demand has doubled and the ICB has provided just a 1.2% increase. Sue Ryder believes that the real cost increase over the past year was 10%. Hospice UK figures released say there has been an 11% increase for the payroll this year to around £130 million. Martin House, the local children’s hospice, costs £9.9 million to run. With a total income of £8.6 million, it had a £1.3 million deficit. Only 18% of its funding came from the statutory sources, £1.1 million came from the national children’s hospice grant and £700,000 came from the ICB. Hospice UK estimates a £77 million deficit for the financial year just past—the worst for 20 years.
As demand and costs are rising, the funding is not rising to match. As of 12 April 2024, St Leonard’s hospice in York did not know how much money it was getting from the ICB: left to carry all the risk and left to depend on its reserves, and that, of course, not guaranteed for the future. Martin House, which is also using its reserves to expand its services, knows that it will have only six months of reserves. It certainly does not know what is happening with its funding after this financial year.
The children’s sector, yes, has received a grant, but what comes next? We cannot just run our hospices by running marathons and running charity shops. It is driving inequality. In areas of greater deprivation, fundraising is even harder and therefore the hospices are getting even less money.
Ms Rimmer
I thank my hon. Friend for giving way and I thank the hon. Member for Hastings and Rye (Sally-Ann Hart) for securing the debate. It has been a wonderful and sincere debate, but does my hon. Friend agree that there should be more equality between care at home—hospice at home—and care at the hospice? There is no doubt that there is nothing better than care in a hospice—absolutely no doubt. I have nursed four members of my family at end of life, and getting clinical support at home when it was needed was always a problem—my brother had to search for morphine at night. Does she agree that staff are funded even less and are on the minimum wage?
Rachael Maskell
I am really grateful to my hon. Friend for raising those points and I will come on to the issue of hospice at home. We know it is absolutely vital that people can choose where they die. Not everyone wants to die in a clinical setting—indeed, a hospice is barely a clinical setting—but many choose to die at home and they should be able to receive the care they need. She is right. We must have integration with the rest of the NHS. A district nurse may not be able to push palliative care to the extent that a palliative care specialist would in providing pain relief and the support somebody needs at the end of life at home. We need it to be timely and we need to ensure it is fully funded. The Health and Social Care Committee found that when it visited Royal Trinity hospice, as part its assisted dying inquiry. The point was made that we need to ensure we have the training so that clinicians have the competencies and the confidence to administer the pain relief and the palliative care that is necessary, and to ensure that the service is available universally. It is not and that must be addressed.
In York, of the 1,000 people who benefited from St Leonard’s hospice last year, 50% received hospice care at home. That number will grow over time and we need to ensure those services are there as they are needed. Of course, we know that if people are not on that pathway they end up in the acute service. They are put through the trauma of A&E, costing the NHS goodness knows how much, and then they do not get the care they need. Trinity Hospice talked about what it was doing to divert people away from that pathway and into proper care, either at home or within its wider services. There is much still to secure on that front.
If I may, Mr Deputy Speaker, I will raise just one more major point before I close, which relates to inequality. We know there is real inequality at the end of people’s lives. Some of it is based along socioeconomic lines, and some of it is emphasised within minority communities. We need to deal with that to ensure we have universal provision, address the death literacy of our nation, and ensure the support is there when it is needed. I am particularly concerned about the lack of comprehensive funding for our palliative care services.
I urge the Minister to look at funding staffing costs, which are 69% of all funding. It has been suggested by Marie Curie that 70% of funding come from the state, and I think that is about right. We can phase that in, but we need to ensure we address the inequality that is driven through the system. We need to put in the research that is needed, so there is better data on who is accessing care and who is not, and we need to ensure that we are pushing palliative care as far as we can. If we do not, and we debate assisted dying, I am worried that people will be fearful that they will not be able to access the care that could be possible should that service be properly funded. I really urge the Minister to make that a priority before that debate takes place. Mr Deputy Speaker, I will end on that point.
Several hon. Members rose—
Tobacco and Vapes Bill
Rachael Maskell ExcerptsTuesday 16th April 2024
(3 weeks, 2 days ago)
Commons ChamberRead Full debate Tobacco and Vapes Bill 2023-24 View all Tobacco and Vapes Bill 2023-24 Debates Read Hansard Text Read Debate Ministerial Extracts
Victoria Atkins
I am going to make some progress and then I will give way.
As I have said, the tobacco industry questions the necessity of the Bill on the grounds that smoking rates are already falling. It is absolutely correct that smoking rates are down, but as I said, there is nothing inevitable about that. Smoking remains the largest preventable cause of death, disability and ill health. In England alone, creating a smoke-free generation could prevent almost half a million cases of heart disease, stroke, lung cancer and other deadly diseases by the turn of the century, increasing thousands of people’s quality of life and reducing pressure on our NHS. An independent review has found that if we stand by and do nothing, nearly half a million more people will die from smoking by the end of this decade. We must therefore ask what place this addiction has in our society, and we are not the only ones to ask that question of ourselves. We know that our policy of creating a smoke-free generation is supported by the majority of retailers, and by about 70% of the public.
The economic case for creating a smoke-free generation is also profound. Each year smoking costs our economy a minimum of £17 billion, which is far more than the £10 billion of tax revenue that it attracts. It costs the average smoker £2,500 a year—money that those people could spend on other goods and services or put towards buying a new car or home. It costs our entire economy by stalling productivity and driving economic inactivity, to the extent that the damage caused by smoking accounts for almost 7p in every £1 of income tax we pay. As Conservatives we are committed to reducing the tax burden on hard-working people and improving the productivity of the state, which is why this Government have cut the double taxation on work not once but twice, giving our hard-working constituents a £900 average tax cut. That is a moral and principled approach.
Having celebrated the first 75 years of the NHS last year, I am determined to reform it to make it faster, simpler and fairer for the next 75 years, and part of that productivity work involves recognising that we must reduce the single most preventable cause of ill health, disability and death in the UK. This reform will benefit not just our children but anyone who may be affected by passive smoking, and, indeed, future taxpayers whose hard-earned income helps to fund our health service. Today we are taking a historic step in that direction. Creating a smoke-free generation could deliver productivity gains of £16 billion by 2056. It will prevent illness and promote good health, help people to get into work and drive economic growth, all the while reducing pressure on the NHS.
Victoria Atkins
I have already taken an intervention from the hon. Member for North Antrim (Ian Paisley). I will take one more, from the hon. Member for York Central (Rachael Maskell), and then I will make some progress—although I will give way to my hon. Friend the Member for Dartford (Gareth Johnson) in a moment.
Rachael Maskell
The Secretary of State has talked about addiction to nicotine. If, as she has suggested, vaping is a pathway to stopping smoking, why does she not envisage a vape-free generation arriving in parallel with a smoke-free generation, so that we can have a nicotine-free generation across the board? Why does she not expand her legislation to ensure that young people take up neither smoking nor vaping?
Victoria Atkins
The House has already legislated to ensure that vapes cannot be sold to people under 18. However, as we are seeing in our local shops, the vaping industry is finding ways of marketing its products that seem designed for younger minds and younger preferences. Once the Bill has been passed, that age limit will be maintained for vaping but, importantly, from January 2027 onwards we will not see the sale of legal cigarettes or tobacco to those aged 18 or less.
Rachael Maskell (York Central) (Lab/Co-op)
Let me first put on record that I worked in respiratory medicine for 20 years before coming to this place, and every single patient I treated regretted being where he or she was. Let me also put on record my thanks to Javed Khan for his excellent report. It is important for us to follow the science and the facts in this debate, and to ensure that we take the harm reduction approach that is so necessary.
The Bill is both bold and the right thing to do. Smoking kills one person every five minutes in the UK, and kills 7.69 million people globally every year. It is a leading cause of preventable death and disability and is responsible for one in four cancer deaths, alongside heart and circulatory diseases and strokes. We must do everything we can to prevent the tobacco industry from exploiting another generation to max out its profits, leaving people financially impoverished and in poor physical health.
Public health teams need the resources that are necessary to support adults into a smoke-free future, and I echo what the hon. Member for Dewsbury (Mark Eastwood) said: we need a focus on resourcing to achieve that. In my constituency 9,100 people continue to smoke, and they deserve better. We need a targeted approach, because passive smoking is still costly to people’s lives. We know that smoking in pregnancy is harmful to the unborn; we also know that it targets the very poorest in our society, driving greater health inequalities, and affecting people with mental health conditions as well. It is urgent, indeed imperative, for the Government to turn their attention to addressing the inequalities that are seen in all areas of healthcare.
Let me now turn to the issue of vaping. York’s schools survey showed that 19 % of children had tried vaping, while 5% in the city vaped regularly. Schools are battling to stamp out the practice. While much of the detail in the Bill will be set out in secondary legislation, I urge the Government to go toe to toe with the approach taken on tobacco products: plain packaging, health warnings, and no designer products, attractive flavours, descriptions or colours. When it comes to sales, the approach should be no less stringent, putting products out of sight and out of mind. The aim must be to create a vape-free generation too. I urge Ministers to address the reasons why Gen Z have turned to vaping on a large scale, to develop the interventions that are needed to help them make better choices, and to expose the blatant exploitation by vape companies that profit from the creation of a new generation of addicts. We are yet to know the extent of the translation of non-nicotine vaping to nicotine-based products, but researchers are examining the relationship between vaping and moving on to tobacco products, and it is extremely worrying. Clearly, the industry has worked out the correlation. To profit, it needs the next generation to be addicted to its goods—to nicotine—so non-nicotine vapes must be seen as the first step for those moving into forms of nicotine addiction.
Where I believe the Bill falls short is in its approach to adults taking up vaping. As the Minister recognises, vapes are seen as an important public health measure to stop smoking, so there must be greater ambition to prevent people over 18, as well as those under 18, from starting vaping, yet the Bill is silent on that. We know that vapes are not harm free, and I urge the Minister to broaden her ambition for a nicotine-free generation by instituting vaping cessation programmes through a public health model.
Where people are allowed to vape should be no different from where they can smoke. Indeed, people who already have poor respiratory health are impacted by vaping. Therefore, let us make things simple by introducing one set of rules for public places such as bars and so on, and for private vehicles where they are children..
May I urge the Minister to look again at the enforcement proposals? I support investment in strengthening local authorities’ trading standards teams. The team in York have just seized 1,000 vapes, worth £13,000. They need funding and the tools to do their work. I question the paucity of the fixed penalty notice, which is just £100. This is not a sufficient deterrent for illegal traders, and I urge the Government to increase the amount and review it annually. Placing that in secondary legislation would enable more flexibility.
That takes me to my last point about where I believe the legislation falls short. A vaping company came before the Health and Social Care Committee. It promoted its products through a relationship with Blackburn Rovers. The arguments it used for doing so mirrored those that the tobacco industry has propagated for decades. We saw right through them—we tested their reasoning and they failed at every turn. There must be an outright ban on all forms of vaping advertising for nicotine and non-nicotine products, and it should be no less stringent than the ban on tobacco advertising. We must legislate for a complete advertising ban, and I trust that the Minister will look at that when bringing the Bill into Committee.
The reason why I sound the warning bells is that the limitation on the available science does not mean that there is none. The Health and Social Care Committee has met academics at the University of London who have undertaken a study of 3,500 samples of tissue to show that vaping can cause changes in epithelial cells in the oral cavity. They want to look at lung tissue, but access is available only via a bronchoscopy. They observed DNA methylation changes, which provide a very early indication that cells will grow more quickly and are biomarkers for early identification of the onset of disease, such as cancer. In researching the impact of smoking on tobacco users, the researchers have also demonstrated the impact of vaping. This powerful, peer-reviewed research is the first of its kind. I urge the Minister to read the paper by Professor Martin Weschwendler and Dr Chiara Herzog.
Smoking kills, and while vaping may be less harmful than smoking, it is not without significant risk. We cannot use ignorance—the excuse used by past Governments—as a reason for getting this wrong. We must follow the science, be on our guard and recognise that where people are being exploited, it is the duty of this Parliament to protect them. This industry is driven by a profit motive—one of exploitation. It is our job to protect our constituents.
Oral Answers to Questions
Rachael Maskell Excerpts(2 months ago)
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Dame Andrea Leadsom
I have had a number of meetings with my hon. Friend and know that he is determined to resolve some of these long-standing issues in his constituency. I have assured him that ICBs have the freedom to increase capital for primary care in their region, so long as their plans remain within their overall capital allocation. I will certainly be happy to meet him again to talk about what more measures we can take to support his constituents.
Rachael Maskell (York Central) (Lab/Co-op)
Dame Andrea Leadsom
I am very surprised and disappointed to hear the hon. Lady say that. We are delivering 2.5 million more appointments through the new patient premium, which started last Friday. We will have information within a month to see which dentists have taken up this generous new patient premium to ensure that many more people get access to dentistry. Not only that, but we have golden hellos to attract dentists to areas that are underserved, mobile dental vans and, importantly, a new focus on Smile4life. That is going to ensure that all babies and young children have that fabulous smile for life.
NHS Dentistry: Recovery and Reform
Rachael Maskell Excerpts(3 months ago)
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Victoria Atkins
We have focused this plan on introducing the new patient premium—a bonus for new patients. Having discussed this carefully with professionals, we think that is one way that we can incentivise people into NHS practice. Dentists can already work up to 104% of the contract. Many do that, but some sadly do not, so we are trying to encourage those dentists who already have NHS contracts to go the extra mile and use the full slot available to them.
Rachael Maskell (York Central) (Lab/Co-op)
The Health and Social Care Committee took months gathering evidence and putting together a recovery plan, which the Government should have adopted. Dentists wanted that plan put in place. Central to it was reform of the NHS dental contract. However, the Secretary of State has completely failed to even mention reform of that contract. As a result, dentistry in my constituency in York, where constituents are waiting seven years to see a dentist, will not have the recovery that she talks about. Why did she not adopt our plan?
Victoria Atkins
I hope the hon. Lady will, as usual, be the help that I expect her to be to her constituents in publicising this plan. We are getting graphics and information out to all Members of Parliament, so that they can help their constituents understand what will be available in their area, because each and every one of us wants the very best for our constituents. She will be interested in the new patient premium, which is encouraging dentists back into NHS practice, or into NHS practice for the first time, and in the increased price for units of dental activity. Reform of the dental contract is part of our agenda, but we realised that we needed to give immediate help to communities such as hers.
Physician Associates
Rachael Maskell Excerpts(3 months ago)
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Dr Poulter
I completely agree with the hon. Member. He advocates strongly for his constituents, as always, and for the need to better retain our medical workforce in general, our junior doctors in particular. The Government will have heard his comments. I am sure that things can be done to improve the current offer to junior doctors in England. Indeed, things can be looked at in Northern Ireland, too, with the restoration of political arrangements.
An agreement could be put in place that will properly renumerate junior doctors, and also look at the other terms and conditions of employment that are important in respect of retaining the medical and healthcare workforce. These situations are not always about pay; it is also about wider terms and conditions. The Government could certainly look in more detail at student debt, for example, as the Times Health Commission outlined this week, which may incentivise people to stay in medicine for longer.
We have diverged slightly into the broader healthcare challenges, so I will return to physician associates, which was the point of this evening’s debate. There are concerns about the regulation and training of this particular group in the medical workforce. Physician associates and anaesthesia associates are not currently regulated. There have been a number of recent high-profile cases of patient harm as a result of being seen by medical associate professionals, including, sadly, some deaths. We know, for example, of the tragic case of Emily Chesterton from Salford who died of a pulmonary embolism having been seen twice and had her deep vein thrombosis misdiagnosed as a musculoskeletal problem by a physician associate at her local GP practice.
Anybody who watches the TV programme “24 Hours in A&E” may have seen some fairly enlightening scenes in respect of the clinical skills of some medical associate professionals, including physician associates. There are many examples of poor clinical diagnosis and judgment, including, for example, making initial decisions to send patients with compound fractures home without an X-ray when the patient actually required surgery.
In my own clinical practice, I have worked alongside some very competent physician associates, but there is a high degree of variability in their training and skills. Only last year, I was forced to directly intervene to prevent patient harm following a paracetamol overdose by a patient who attended A&E. The physician associate incorrectly informed me that they did not require N-acetylcysteine treatment because their liver function test was normal, in spite of the fact that they were over the treatment line as a result of their paracetamol overdose. Of course, at that time, the patient’s liver function tests were normal, but they would not have been for very long. The consequences of that diagnostic decision by the physician associate could have been fatal. The key issue for me is that many physician associates do not know or have the self-awareness to understand the limits of their knowledge and practice, but this is perhaps understandable in a health system that fails to adequately regulate and indeed define its scope of practice.
There are many other areas of concern that have been highlighted in a recent British Medical Association survey of 18,000 doctors, an overwhelming majority of whom work with physician associates. In November 2023, due to severe concerns around patient safety, the BMA called a halt to the recruitment of medical associate professionals to allow proper time for the extent of patient safety claims to be investigated and the scope of the role to be considered.
When the physician associate role was introduced, it was clearly seen as part of the solution to a shortage of doctors, which currently stands at in excess of 8,500. By freeing up doctors from administrative tasks and minor clinical roles, it allowed them to see more complex patients and get the training required to become excellent consultants or GPs.
Unfortunately, physician associates and anaesthesia assistants have been employed in the NHS in roles that stretch far beyond that original remit, and in many cases that were reported in the recent BMA survey that I mentioned, they appear to be working well beyond their competence. That has raised serious patient safety concerns—I gave some examples earlier—and led to calls to review the role, limit the scope of practice, and protect training for the doctors that the NHS desperately needs. When consultant time is taken by supervising physician associates, that is to the detriment of training and supervising junior doctors. That has not yet been addressed or even considered in the NHS England workforce plan.
Rachael Maskell (York Central) (Lab/Co-op)
I am grateful to the hon. Member for introducing this evening’s debate. I sat on the Committee that considered the Anaesthesia Associates and Physician Associates Order 2024. He is drawing out several issues. One is competency; another is patient literacy. A lot of new roles are emerging—technicians, assistants, associates, and advanced practitioners—and to the public this is now becoming a blurred space. People do not understand the competences that individuals possess, their scope of practice, and where they fit into the medical family, or indeed professions allied to health. Does he agree that we need to define those roles clearly, and that associate roles should be around professions allied to health, rather than associated directly with the medical profession?
Dr Poulter
I fully agree with the hon. Lady, and I will expand on that a little later. There is certainly confusion among the public about what a physician associate is. Many members of the public assume them to be doctors or other healthcare professionals. They therefore lack a much greater degree of competence. Given that it is envisaged that the role will be significantly expanded, the public understanding and awareness of it, and people’s expectations when being treated by somebody in that role, are really important. That needs to be better addressed through the current proposals for regulation, which I will come to in a moment.
I will talk briefly about general practice and the additional roles reimbursement scheme. Through the ARRS, the Government have provided funding to GP practices that can be used to pay for physician associates and other clinical staff, but not for hiring additional doctors and nurses. That is quite extraordinary, and results in GP practices having physician associates rather than fully qualified GPs. Currently, most physician associates in general practice are funded through the additional roles reimbursement scheme: an NHS scheme that funds primary care networks to support recruitment across a very limited set of eligible roles. The current rules for ARRS funding are causing inefficiencies as they are not flexible enough to respond to locality needs for healthcare staff. In particular, the rules do not allow practices to hire primary care nurses, practice nurses, or indeed GPs, as I mentioned.
Over the past year, there have been many developments in how the Government and the profession view the roles of physician and anaesthesia associates, but it seems extraordinary that when we are talking about supporting general practice in developing the right skills and competences, and delivering the right service for patients, one of the key funding schemes does not allow for the hiring of the GPs and practice nurses that are needed, and is skewed towards physician associates. I wonder whether the Minister might take that away, look at the scheme, and help to provide additional flexibility, which general practice would like and which seems eminently sensible, to allow recruitment at a local level, in line with patient need.
There are significant concerns connected with the roll-out of the anaesthesia associates project. While the GMC addressed some of those issues in its recent letter to NHS England, a number of concerns remain. In particular, the NHS long-term workforce plan suddenly projected a huge expansion in the number of anaesthesia associates, but no expansion in the number of doctors in anaesthesia—or, as we are talking about position assessments, in the number of doctors in other specialities. To many, that looks like a replacement of doctors with anaesthesia associates, rather than anaesthesia associates being employed to complement the anaesthesia team, which was the idea previously portrayed.
There are many examples of medical associate professionals in the wider sense working in ways that have caused concern, as we have discussed in this debate, particularly with regard to their scope of practice. Anaesthesia provision in the UK must continue to be led and delivered by doctors, who are properly trained and properly regulated. Anaesthesia associates are valuable members of the anaesthesia team in addition to doctors, but they are not a solution to the challenges of low workforce numbers in anaesthesia and growing waiting lists.
The answer is to expand consultant numbers, an expansion in training scheme places for doctors in anaesthesia, and the development of the large number of speciality doctors and locally employed doctors already in post. Creation of speciality and specialist doctors and consultants via the General Medical Council’s new portfolio pathway could result in our having many more independent doctors in anaesthesia and other medical disciplines. It seems extraordinary that we are not looking at that first, given that we have a properly regulated and properly trained profession, rather than at expanding a workforce that is not subject to proper regulation to date, does not have a certified training pathway, and has been associated with a significant number of adverse patient outcomes and incidents.
Regulation ensures consistent standards for training, and for the practice of physician associates and anaesthesia associates. It maintains standards and, critically, contributes to patient safety. As per the recent Anaesthesia Associates and Physician Associates Order 2024 laid before the UK and Scottish Parliaments, those associates will be registered with the General Medical Council. However, there are increasing concerns that that could further blur the distinction between doctors and anaesthesia associates.
In response to those concerns, the GMC has said that physician associates and anaesthesia associates will be issued with a registration number format that distinguishes them from doctors. That is to be welcomed. However, it must go further and present doctors on a separate register from physician associates and anaesthesia associates, whether we are talking about a register online or in print—that aligns with the point that the hon. Member for York Central (Rachael Maskell) made—so that it is very clear that the different professions are regulated under separate registers. That is important for both accountability and transparency, and it is important that patients understand that.
There should be a clear distinction between the register of doctors and other registers. That is necessary to provide absolute clarity for patients and others who wish to access the registers, and it is essential to protect everyone from accidental or deliberate misrepresentation. With modern information technology systems, there is no legitimate reason why that cannot be done. It would be simple, and it is about transparency, openness and patients better understanding the difference between the responsibilities of doctors, and those of physician associates and anaesthesia associates. I hope the GMC is listening to this debate and will ensure properly separate registers. That does not cost much, but is very important.
Perhaps the crucial point in this debate is the scope of practice. There should be a national scope of practice for physician associates and anaesthesia associates, both on qualification and after any post-qualification extension of practice. Any future changes to scope of practice should be developed in conjunction with the regulator and should be agreed at national level. I understand that currently the GMC will not regulate extended scopes of practice, which is very regrettable. For example, we are aware of whether a doctor is on the GP register or a specialist register, or just has a licence to practise. Those levels of expertise are part of the regulatory framework. It seems extraordinary that although the GMC has been asked to look at regulating physician associates, there is no understanding of the scope of a physician associate’s practice. That needs to be properly mapped out and explored.
Rachael Maskell
I am grateful to the hon. Gentleman for making those points. It is particularly concerning that a prescribing nurse, say, could become a physician associate, but perhaps without the ability to prescribe. That would create even greater confusion. Does he agree that we need clarity and distinctions to be drawn on those kinds of issues?
Dr Poulter
I fully agree; the hon. Lady is absolutely right. I was going to address that very point about prescribers a little later. There is clear agreement on the challenges. Those issues should be thought through before a workforce plan is brought forward, and before there is a significant expansion of the workforce, for reasons of patient safety, particularly as concerns have consistently been raised about the scope of practice and adverse incidents. It is rather putting the cart before the horse to say, “We want to expand the workforce without dealing with the important issues of how that workforce is trained, how it can properly be regulated, and what its scope of practice is.” That is unfortunately a regrettable failing of NHS England’s plan, which I hope it will consider.
If the GMC cannot regulate extended scopes of practice, they should be devised according to a national framework. There needs to be an understanding of what that should be. It is unacceptable for employing organisations in the NHS to devise their own extended scopes of practice without reference to at least some national framework—one that has the confidence of regulators and standard setters—so that we know and understand what good practice looks like.
Doctors should be directly involved in devising any changes to the scope of physician associate and anaesthesia associate practice, whether on qualification or at extended level. There should be no extension of roles beyond the scope of practice on qualification until national guidance is issued. Where organisations are planning such an extension, it should be paused for reasons of patient safety. Where physician associates or anaesthesia associates are already working in an extended role, it should be recorded on the healthcare organisation’s risk register, and the organisation should ensure that it has full confidence in its standards of supervision, access to support, indemnity of the anaesthesia or physician associate and the supervising doctor, and patient information and consent. Anaesthesia associates have a role to play as part of the wider anaesthesia team, but it is important to ensure that it is a complementary role as an addition to the workforce, not as a replacement for doctors and nurses, as the hon. Lady rightly underlined. Expansion in the number of anaesthesia and physician associates should not be at the expense of expansion in the number of doctors in specialist posts.
Let me come briefly to assessment, which is another area that has not been well thought through. It is important that assessment for anaesthesia associate roles is standardised at national level. The Royal College of Physicians does a national exam for physician associates, but a national body needs to be established to undertake the assessment process for anaesthesia associates if we are to ensure confidence in their competencies. It may be possible for that to be delivered locally, if there are stringent controls in place to ensure consistency. However, before the anaesthesia associate workforce is expanded, there needs to be some process for assessing competency.
On indemnity, which was also addressed by the hon. Lady, further information is needed around indemnity cover for both physician associates and anaesthesia associates, as well as for any doctors supervising them. “Good medical practice” expects all doctors to ensure that they are fully indemnified. The same standard should apply to physician associates and anaesthesia associates. Many doctors in anaesthesia, in general practice and in emergency departments are already worried about medicolegal liability when working with physician associates, and clear guidance is urgently needed. Although reference is made to accountability, more information is required in this area, given the challenges that we know have arisen.
The hon. Lady mentioned prescribing rights. Some physician and anaesthesia associates—for example, those with a nursing background—may already have those rights from their parent profession. The Commission on Human Medicines is responsible for deciding which professions are able to prescribe, and it is important that it is clear in its guidance and reasoning in respect of physician and anaesthesia associates before there is a wider roll-out of those roles.
I draw the Minister’s attention to key findings from the British Medical Association’s recent survey, which sought the views of over 18,000 doctors about the role of the medical associate professions. Almost 80% of respondents—that is well in excess of 15,000 doctors—had worked with or trained medical associate professionals, which means that contact with those professionals is widespread throughout the NHS. Medical associate professionals are currently unregulated and have a poorly defined scope of practice. The BMA survey respondents were very concerned about that, as well as about the fact that MAPs have been employed in the NHS in a variety of roles, which go well beyond what was originally envisioned as an assistant role. A staggering 87% of doctors surveyed believed that the way that physician and anaesthesia associates work in the NHS is a risk to patient safety. For the Minister’s benefit, that is the best part of 18,000 doctors who work with this workforce raising concerns about working practice and patient safety.
Rachael Maskell
Once again, I am grateful to the hon. Member for giving way. Doctors in training need a very clear career pathway, but because of the rise in anaesthesia associates in particular, but also in physician associates, the pathway to many more senior roles will be blocked. As a result, people will stagnate as doctors in training, as opposed to getting a consultancy. Does he agree that that is highly problematic, and that the career pathway needs working through before there is any increase in the number of physician and anaesthesia associates?
Dr Poulter
That is absolutely essential. At the moment, the prerequisite appears to be a biomedical science degree, which is incredibly variable—depending on whether a person went to Hull, Newcastle or a London university, a biomedical science degree could be very different—and then two years of study. A physician associate would then have to pass an exam set by the Royal College of Physicians, but when a person passes that exam, it does not necessarily mean that they had standardised or good training; potentially, it just means that they prepared well to pass their exam. The difference with doctors in medical school—and indeed the difference with nurses going through nursing school—is that they are consistently assessed, all the way through their undergraduate training. When they graduate at the end of that training, they are consistently assessed as they progress.
None of that exists in the training pathway for physician or anaesthesia associates; in fact, as we have discussed, there is not even an exam for anaesthesia associates at the end of the process. It is absolutely essential that those issues are addressed as a priority, and it is little wonder that patient deaths and adverse incidents are occurring on such a scale. Perhaps when the Minister is suffering from insomnia late at night, he may wish to watch old episodes of “24 Hours in A&E”. He will see the huge variability in the expertise of physician associates. Some are very good, but some are not, and we should not be dealing with variability in the British health system. That is what we are trying to address, so the hon. Member for York Central is absolutely right in everything she has said.
That highlights the last point I am going to draw to the House’s attention from the BMA survey of 18,000 doctors. Some 75% of respondents said that the quality of training among medical associate professions—physician and anaesthesia associates—was woefully inadequate; 84% said that the quality of their supervision when they are at work was inadequate; 91% outlined the fact that they work outside their competence; and 86% of respondents confirmed that the public would confuse them with doctors, as the hon. Lady outlined. This is not just a few hundred doctors; this is 18,000 doctors saying in a survey that they have serious patient safety concerns due to the variability in training of anaesthesia associates. There have been far too many adverse incidents where things have gone wrong, and it is time for the Government to give NHS England some clear direction that this area needs to be looked at, and some proper planning and consideration of the expansion of this workforce put in place.
These are the asks I have of my right hon. Friend the Minister. First, we should ensure there is a standardised and quality assured training programme for physician associates, anaesthesia associates, surgical care practitioners and all other medical associate professionals, and indeed that there is ongoing training and supervision to a nationally standardised level when that group is in the workplace post qualification. Secondly, we should ensure that the General Medical Council sets up a register for the regulation of medical associate professionals, separate from the register for doctors. Thirdly, as is the case with all other healthcare professionals, we should ensure that the scope of practice of physician associates is clearly set out to make sure that we can develop appropriate training pathways and supervisory pathways, but, more importantly, to ensure patient safety. Finally, the Government should support the introduction of a system with greater flexibility to hire GPs and general practice nurses using the ARRS funding. I thank the House, and I look forward to the Minister’s response.
Andrew Stephenson
My hon. Friend makes a valid point, and that is one reason why regulation is so important. The GMC has assured me that although draft regulations are out there, it will be consulting further on them later this year, so my hon. Friend, the BMA and various others can make strong representations about how the training framework should be provided. With that introductory regulation, the GMC will be responsible for setting, owning and maintaining a shared outcomes framework for physician associates, which will set a combination of professional and clinical outcomes. The outcomes framework will help to establish and maintain consistency, embed flexibility, and establish principles and expectations to support career development and lifelong learning. While at the moment there is significant variability in the system, I hope that the regulations we passed in this House on 17 January will help to provide that clarity and give the GMC the powers it needs to ensure that the training provided to physician associates is of the appropriate quality for the roles we are expecting them to undertake in our NHS.
Physician associates can work autonomously with appropriate support, but always under the supervision of a fully trained and experienced doctor. As with any regulated profession, an individual’s scope of practice is determined by their experience and training, and will normally expand as they spend longer in the role. That must be coupled with appropriate local governance arrangements to ensure that healthcare professionals only carry out tasks that they have received the necessary training to perform. Statutory regulation is an important part of ensuring patient safety, but that is also achieved through robust clinical governance processes within healthcare organisations, which are required to have systems of oversight and supervision for their staff.
NHS England is working with the relevant professional colleges and regulators, to ensure that the use of associate roles is expanded safely and effectively. That includes working with the GMC, royal colleges and other stakeholders to develop appropriate curriculums, core capabilities and career frameworks, standards for continual professional development, assessment and appraisal, and supervision guidance for anaesthetist and physician associates. NHS England will also work with colleges, doctors’ representative organisations, AAs and PAs to identify areas of concern. Specifically, the NHS has committed to working with the Academy of Medical Royal Colleges and individual professional bodies to develop and implement recommendations as a result.
Regulation will give the GMC responsibility and oversight of AAs and PAs, in addition to doctors, allowing it to take a holistic approach to education, training and standards. That will enable a more coherent and co-ordinated approach to regulation and, by making it easier for employers, patients and the public to understand the relationship between the roles of associates and doctors, help to embed such roles in the workforce. Indeed, regulation addresses many of the concerns that we have heard in the debate last month and today. The GMC will set standards of practice, education and training and operate the fitness to practice procedures, ensuring that PAs meet the right standards and can be held to account if serious concerns are raised. GMC guidance sets out the principles and standards expected of all its registrants, and that will apply to PAs once regulation commences. Those standards will give assurance that PA students have demonstrated the core knowledge, skills and professional and ethical behaviours necessary to work safely and competently in their areas of practice and in a care context as newly qualified practitioners.
Rachael Maskell
On that point, can the Minister clarify where the liability will sit if error does occur? Will it sit with the clinician or the consultant who is supervising them? I am not clear on that particular issue.
Andrew Stephenson
In many ways, it will be the same as with many medical professionals. Once we have the situation clarified in regulation, it will not be any different from the personal liability of a doctor or others working in an organisation. Those are the kind of things that the GMC will be consulting on and discussing with stakeholders in the coming months, and is important that all these points are clarified. The hon. Lady was in the debate we had in January, where the tragic case of Emily Chesterton was raised. In that case, unfortunately we saw a PA move from one practice to work in another, and we need to ensure that there is a proper, robust fitness-to-practice regime so that any medical professional can be held to account in such cases for what has happened and, if necessary, struck off the register and no longer able to practice.
Oral Answers to Questions
Rachael Maskell Excerpts(3 months, 2 weeks ago)
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Giles Watling (Clacton) (Con)
Rachael Maskell (York Central) (Lab/Co-op)
The Parliamentary Under-Secretary of State for Health and Social Care (Dame Andrea Leadsom)
I am determined to ensure that everybody who needs NHS dental care can receive it. We have already implemented a package of reforms to improve access and provide fairer remuneration for dentists. That has had an effect, with 1.7 million more adults being seen, 800,000 more children being seen and a 23% increase in NHS activity in the past year. We know we need to do much more, and our dentistry recovery plan will be published shortly, setting out a big package of change.
Dame Andrea Leadsom
As my hon. Friend will know, this is a local matter, and it is for his ICB to determine whether it wishes to support the excellent pilot proposal for overseas dental students in Clacton. At the same time, it needs to ensure that its actions are compliant with current legislation and within the delegation agreement with NHS England. I have just written to my hon. Friend about that, and my letter should address his concerns, but of course I would be happy to see him again if he has any further questions.
Rachael Maskell
We were promised “before the summer”, we were promised “after the summer”, we were promised “before Christmas”, we were promised “soon” and now we have been promised “shortly”. The reality is that Labour has a plan and the Government have not. In York, we cannot get an NHS dentist either. Blossom Family Dental Care is just handing back its contract. My constituents have nowhere to go. What is the Minister going to do to ensure that my constituents can access NHS dentistry?
Dame Andrea Leadsom
As I said to the hon. Member for Oxford West and Abingdon (Layla Moran), I absolutely understand the challenge for some people. The situation has improved over the last year. Since the covid pandemic, where almost every dentist had to stop working altogether, we have not seen the recovery we want. We are putting in plans—not a paper ambition like the one Labour has put forward, but significant reforms that will enable many more people to be seen by NHS dentists. I say gently to the hon. Member for York Central (Rachael Maskell) that a recent Health Service Journal article states that Humber and North Yorkshire ICB
“have indicated in board papers that dentistry funding will be squeezed to help them balance their books.”
I encourage her to talk to her ICB about that too.
Draft Anaesthesia Associates and Physician Associates Order 2024
Rachael Maskell Excerpts(3 months, 3 weeks ago)
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Rachael Maskell (York Central) (Lab/Co-op)
It is a pleasure to serve on the Committee, Dame Caroline. Before I begin, I declare that I was a registered professional with the Health and Care Professions Council, and worked in the NHS for 20 years before coming to this place. I was also the head of health at Unite, so I have a strong background in understanding the regulatory frameworks in the NHS.
I understand the issues that the Government are trying to resolve, given the changing nature of the NHS, the emergence of new professions, and the need to protect patients. I agree that all NHS professionals must be registered, and regulatory reform is long overdue, including for anaesthesia associates and physician associates. When Agenda for Change was piloted in 2003 and fully instituted in 2004, a job evaluation scheme was designed for this very purpose, and was overseen by the formidable Sue Hastings. However, emergent professions cannot just be add-ons to existing regulation. They required their own registers, governance and accountability, not least to ensure professional competence. The order is the first expression of that, 20 years on.
Also, the knowledge and skills framework enabled people to grow in their professional competencies and provide a higher level of care. That could lead to hybrid roles forming. I remember Alan Milburn saying at the time that the NHS career framework should enable someone to move from the role of porter to neurosurgeon—I do not know if that has ever been achieved. It is important that at every stage there is protection for the professional and, most importantly, the patient.
The reality behind the order is that the professional silos of the last 150 years or more are rapidly evolving and morphing in new ways, and the regulatory framework has to capture that and catch up. I agree that we urgently need a system of statutory regulation for anaesthesia associates and physician associates. They are working at a significant level of decision making, and they have a duty to uphold professional standards, their training must be of the highest standard, and there must be a fitness-to-practise process through which they can be called to account. I agree with my hon. Friend the Member for Bristol South that we need to ensure that that is rigorous and upholds standards, but I also welcome the fact that they may be expedited within the new system.
I have been asked whether the GMC is the right regulatory body. I understand the arguments for and against. This is where a lot of the concern comes from, which is why regulation is important. The challenge to this order is the lack of clarity about titles, roles and the competencies associated with each role. It could be argued that, for greater distinction, the HCPC, for example, is a more relevant registrant. I believe that that should have been examined further, not least as AAs and PAs are professionals allied to health and sit within the “Agenda for Change” family.
The public are nearly universally unaware of different roles in the NHS, let alone what they can or cannot do. In a clinical setting, if someone with a stethoscope around their neck calls themselves part of the medical team and they assess, diagnose and treat a patient, it will generally be assumed that they must be a doctor. I remember that when I started practising, if you were a woman, you were a nurse, and if you were a man, you were a doctor, so I certainly know that the distinctions are not always there. However, some use the title “Dr” because they hold a doctorate in another field, and that needs to be looked at. Further, there is a new lexicon of technicians, assistants, associates, advanced practitioners, and no doubt many more. I urge the Minister to find a common language so that there is simplicity and accuracy, and so the public understand the distinctions between these roles and those of the established professions.
In talking to the British Medical Association, I heard how people are now working above their competencies as AAs and PAs—carrying the consultant’s bleep, for example. That is deeply disturbing and just reinforces the public confusion over the distinct identity and purpose of each clinical role. Boundaries must be clear and distinct and, for the sake of safety, defined nationally rather than determined locally.
While the Government are very much focused on vertical integration, which can exacerbate things such as skill mix, I urge the Minister to further consider the power of horizontal integration. We have seen some, for example with advanced practitioners reaching across professional silos, and in developing a focus on primary care it could bring strong benefits. We need to ensure that new regulatory frameworks address that. The blueprint for a future professional regulation framework must account for this opportunity.
As with all professions, medicine must not be exempt from looking at how it can be reshaped. However, when someone who has had two years’ training is paid more —ironically, 35% more; Members might recall that number—and assumes more authority than a doctor of seven years’ training with a higher level of competency, there is clearly a problem in the design of the role and cause for concern. We need to look at how we can move beyond traditional silos and create skills pathways that honour professions and the level of their skills, so that competencies can be gathered, tested and examined along the way. I believe that there needs to be a full job evaluation to understand the challenges between the professions—yes, across the two core NHS pay structures—and then a clear delineation of roles. For example, senior doctors in training in anaesthetics are now in a logjam, unable to progress to a consultant post due to the rise in the redeployment of anaesthetist competencies to AAs.
The same could be said of the Government’s prioritisation of PAs over, for instance, traditional senior house officers. There is serious concern about the diagnostic skills of PAs; there have been examples of failure, as we heard so powerfully about Emily Chesterton, the daughter of the constituent of my hon. Friend the Member for Worsley and Eccles South.
These functions need serious reconsideration and tight regulation. The GMC must ensure that their scope is clearly defined and that, before further role reforms occur, there are assurances that there will be no further scope creep. Clarity of role is really important in prescribing too. Some AAs and PAs may have transitioned from professions where they were already prescribers. We need to hear from the Minister how that situation will be managed, with clear delineation.
I want to touch on the issue of liability—where responsibility lies. With registration, AAs and PAs will be autonomous practitioners, liable for their own conduct and practice. How will the regulator ensure that liability is apportioned in the right way between them and those who provide supervision? Will they receive one-to-one supervision, and how far will liability carry on to, say, the consultant or senior registrar? That is a really important issue to consider in the immediate future, not only for AAs and PAs, but for doctors and doctors in training, who must receive supervision too. We need to ensure that a new generation of doctors in training are able to receive the support that they need, and that it is not all dedicated to AAs and PAs.
Furthermore, with the envisaged rapid expansion in the number of AAs and PAs, the GMC needs to determine that supervision is safe and appropriate, and at the level required to enable people to mature into highly skilled professionals. It must also ensure that there is not a spike in fitness-to-practise cases due to lack of investment. The call from the medical profession is for us to slow down and properly evaluate and understand the consequences, seen and unforeseen.
On part 3 of the order, which concerns the register, can the Minister clarify that the associates will be on a separate register to doctors at the GMC, and that they will have their own register, as identified in article 5(2)(a)? I note that AAs and PAs will be on one register, but in separate parts. Will he explain to the Committee exactly how that will operate? Holding information separately would enable greater access for the public to the information they seek with respect to the new associate roles. The register must be robust and easy to navigate and, like the register for doctors, provide the public with all the information that they require. I know that the GMC has agreed to put a simple prefix ahead of registration numbers, but the professions are calling for more distinction so that there can be no confusion.
I am mindful of the higher proportion of cases generated from AAs and PAs. Will the Minister ensure that the registration fees reflect that? It is vital that the Government and the GMC, in formally setting up the statutory register over the coming three years, work closely with the professionals to ensure that they are engaged in the process and that their concerns are picked up and addressed along the way. I am asking the Minister to commit to that today, as I know my hon. Friend the Member for Bristol South will when she has the opportunity later in the year.
Patients, the wider public and fellow clinicians need to understand these fine lines and distinctions for their safety and safe practice across the NHS. The culture of “get it right first time” must be central to this debate and all that flows from it. If regulation lands in the wrong place, the Minister and the GMC need to be candid and ensure that it is changed so that it is fit for purpose. I trust that Parliament will have further opportunity to scrutinise these developments.