Dermatology Funding

Paul Beresford Excerpts

Wednesday 4th December 2013 Westminster Hall

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

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

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

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

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

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

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

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

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

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

[Mrs Gillan]

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

[Sir Paul Beresford]

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

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

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

--- Later in debate ---

[Mr Jamie Reed (Copeland) (Lab)]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Sir Paul Beresford]

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

[Mr Reed]

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

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

--- Later in debate ---

[Jane Ellison]

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

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

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

[Sir Paul Beresford]

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

[Jane Ellison]

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

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

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

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

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

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

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

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

Mental Health

Paul Beresford Excerpts

Thursday 14th June 2012 Commons Chamber

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

It was beginning to look like a Whips’ cabal in the Chamber. I was quite worried. A number of hon. Members, particularly the hon. Member for Strangford (Jim Shannon), who is busy disappearing from the Chamber, mentioned care for, and the mental health of, veterans—[Interruption.] I am making a plea to keep my small audience. To my delight, the shadow Secretary of State mentioned a famous organisation in that field: Combat Stress—[Interruption.] He is also leaving the Chamber the moment I mention him. He can read my speech in Hansard as he has obviously been urgently called away.

Combat Stress was supported by the previous Government as it is by this one. Combat Stress clients—ex-servicemen, or veterans—suffer from the appalling conditions of post-traumatic stress disorder, depression or anxiety, or all three. Anyone who has seen such individuals with such conditions will recognise that they are exceptionally debilitating. They destroy the normal life of victims and those around them.

Combat Stress has three centres—the main one is in my constituency—an outreach service throughout the nation and a liaison team. It has been making a difference for some considerable time. Some 83.5% of Combat Stress clients are ex-Army. Three per cent. are female. Most of the veterans contact the Combat Stress service themselves or through family referral, but only 3.6% are referred by general practitioners, 6.9% by community health teams, and 0.3% by a hospital service. I hope the Minister thinks about that.

To make access to those services more available, Combat Stress set up a 24-hour helpline in March last year. It may interest the House and the Minister to consider statistics from the helpline from March 2011 to January 2012. Combat Stress received 6,279 calls, including voicemails. A few people hung up—a tragic few calls were silent, which I think says a lot.

Of the callers who were contacted, 74% were male and 26% female. Army veterans made a total of 2,248 calls. The second largest group of callers were family, friends and carers of the victims, who themselves were therefore victims. Seventy-seven per cent. of callers called about themselves. Perhaps tragically—I hope the Minister makes a note of this—just 6% of callers were given the number and contact details by a health professional. The call centre seems to be catching on. In March, it received 286 calls, but that doubled to 604 the following January. The organisation is funded by the Government, and I plead with the Minister to keep the funding going. I am sure he will.

The average post-service delay is a staggering 13 years. The Minister should be aware that after such a delay an individual’s condition will have developed in complexity, meaning that their recovery treatment can last for years, whereas if treatment is early, it can last just weeks and months. Early diagnosis and referral can lead to faster and cheaper treatment, and greater success, and can mean that the potential side effects of alcoholism, drug problems, which have been mentioned—[Interruption.]

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. Will the Minister wait while the hon. Gentleman is standing? The Minister was right in my line of vision, and it is not fair to the person speaking. This is the third time it has happened.

[Sir Paul Beresford]

As mentioned by several Members, the result can often be imprisonment, yet all these side effects could be avoided. On average, it takes veterans just over 13 years from service discharge to first approach Combat Stress. This is an ongoing issue for veterans.

Community outreach teams across the country now provide much support for veterans. They provide support and advice in veterans’ own homes and nearby community-based clinical care. Yesterday, we made much of the Falklands war, which ended 30 years ago today, on 14 June 1982. Of the 4,800 veterans Combat Stress is helping, 221 served in the Falklands war. The youngest is 46 and the oldest is 74, and on average the Falklands veterans have waited 15 years before going for help. Last year, 18 Falklands veterans contacted Combat Stress for the first time, and this year, to date, 10 have contacted it. But of course the case load is not just from the Falklands. Of the 4,800 ex-service men and women being treated, 589 served in Iraq and 228 served in Afghanistan. Between 1 April 2010 and 31 March 2011, Combat Stress received 1,443 new referrals.

Having set the scene, I shall touch on a few key points for the Minister to consider. First, all the UK Governments must acknowledge the ongoing need. Most of the Governments contribute considerably towards Combat Stress and its costs. Combat Stress estimates that in 2012, 960 service personnel will leave the armed forces with the likelihood of suffering from PTSD. I shall follow up a point made by the hon. Member for Strangford. We must persuade the MOD to look specifically at their decompressing veterans-to-be and, if there is any suspicion, to refer them to Combat Stress. It would make treatment by Combat Stress easier, because it would be given earlier, and all the pain and suffering of these men and women could be reduced to a tiny fraction of what it is for many of those in Combat Stress now.

That brings me to the crux of the problem, which has been touched on. Because mental illness is not a physical but a mental wound, a stigma is attached to it. A lot of Members have mentioned that. Combat Stress tells me that 81% of veterans with a mental illness feel ashamed or embarrassed, which often prevents them from seeking help—it certainly delays them seeking help—and sadly one in three veterans are too ashamed of their condition ever to tell their families about it. As a result, many of those families break up. Among the other side effects are crime, disorder and alcoholism. This is a mental health problem, then, that could and should be alleviated early.

Much has been done to raise the profile of the condition and the availability of help, so that those individuals do not feel that they are unique or, perhaps, weak. Much needs to be done to encourage them and their families to seek assistance. We need to put these valuable individuals back on their feet—and they are valuable: they have already performed valuable service, and there is still valuable service available if we can do that. Amazingly, there appears to be a considerable lack of understanding among GPs. Research conducted in September 2011 showed that only 5% of the veterans receiving help from Combat Stress had been referred by their GP. Perhaps those GPs failed to recognise the condition or were unaware of the existence of Combat Stress—or, more likely, both. I urge the Minister to ensure that the word is spread among our GPs. Combat Stress has done a clinical audit, and it would appear that approximately 80% of the veterans who come to it for clinical treatment tried to get help from their GPs or other specialist services first, and did not get it. Appallingly, that support and treatment was not forthcoming. It should be.

I hope that the Minister will consider joining me in a visit to Combat Stress, to see the value of the work first hand, to understand its difficulties and to help to build on the opportunity to prevent some of the tragedies that we see. We need to remember that for those veterans the physical war is over, but the battle is still raging in their heads.

Oral Answers to Questions

Paul Beresford Excerpts

Tuesday 21st February 2012 Commons Chamber

[Mr Burns]

As the hon. Gentleman knows better than I do, the running of the NHS in Scotland and Wales is a matter for the devolved authorities. I speak for the English NHS, and I can tell him that that we have guaranteed that the budget of the NHS in England will be a protected one for this Parliament in which there will be real-terms increases, albeit more modest than in the past. But we have seen in Wales in particular a fall of just over 8% in funding. That is the decision of a Labour Welsh Government. The moneys that are saved in the health service in England through cutting out bureaucracy and through greater effectiveness in delivering care will be totally reinvested—100%—in the NHS in England.

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

I may have an interest—a remote one—in this question. I expect my right hon. Friend would agree that every patient who chooses to have private health care rather than national health service care, for whatever reason, is one less case on the national health cost and care bases. Does my right hon. Friend agree that it may be appropriate for the Treasury to do a cost-benefit analysis so as to consider a tax encouragement for individuals, especially those over 65, to take out private health insurance?

[Mr Burns]

I do not want to disappoint my hon. Friend, but I am afraid I do not agree with that. What the Government have to concentrate on is giving the maximum amount of resources within the protected budget to the provision of health care in this country, to ensure, enhance and improve the quality of care for patients in England. That is the priority, not providing tax relief in any shape or form for people who use their choice for private health care.

Oral Answers to Questions

Paul Beresford Excerpts

Tuesday 12th July 2011 Commons Chamber

[Mr Lansley]

On the contrary, with the progressive transfer of responsibilities to the NHS commissioning board there will be much more consistency in contracting for access to NHS dentistry, which at the moment is often a lottery in different places across the country, with the amounts paid per unit of dental activity varying dramatically between neighbouring practices. The new pilots are intended to achieve something that was not achieved under either of the two previous dental contracts, by securing a much stronger preventive approach based on capitation and registration for dentists. It has been welcomed by the dental profession and it promises a great deal for a new contract.

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

You will be aware, Mr Speaker, that I have some slight interest in this subject. Access to NHS dentistry is related to what is on offer. Does the Secretary of State agree that with the huge advances in dentistry, we should be reviewing what is and is not available, and what should or should not be available, from NHS general dental practitioners?

[Mr Lansley]

My hon. Friend will know that under the new dental contracts, I want to arrive at a point where everybody who wishes to has access to NHS dentistry. I was pleased to see that when we set out the details of the piloting proposal, the chair of the British Dental Association’s general dental practice committee, Dr John Milne, said:

“we are encouraged that the Department of Health is to begin testing new ways of delivering care. We are pleased that two principles that we believe are particularly important—quality of care and a continuing care relationship between practitioner and patient—are central to what is being piloted.”

As in other areas, we are moving from a system that simply incentivises activity to one that is much more focused on quality and outcomes.

Variant Creutzfeldt-Jakob Disease

Paul Beresford Excerpts

Thursday 28th April 2011 Commons Chamber

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

I thank my hon. Friend the Minister for his attendance. I know that he has been looking forward to this Thursday afternoon with two and a half hours ahead of him in a warm Chamber. Looking at his smile, he is not taking that too seriously. I need to declare an interest in case there is any knock-on effect from the debate. If the Government were kind enough to go ahead with some of the suggestions I might make, there could be a negative financial effect on me personally, as I am a very part-time dentist.

I have been interested in this issue for a number of years, and I have raised it through questions and in an Adjournment debate. I am hoping that now we have a new Government and a fresh set of eyes on the issue, we might get some progression towards a little more prevention. Variant Creutzfeldt-Jakob disease—commonly known as variant CJD, and it will be from now on so that my tongue can get round it—is a fatal neuro-degenerative disease originating from exposure to bovine-spongiform-encephalopathy-like prions. Prions are small particles of protein. Prion infections are associated with long and clinically silent incubations and cause a spongy degeneration of the brain with a horrible and untimely death. There is no cure. The number of asymptomatic individuals with vCJD prion infection is unknown. It poses a risk to others via blood transfusion, blood products, organ or tissue grafts, and contaminated medical and dental instruments.

The emergence of vCJD and the confirmation that it originates from exposure to BSE raised a glut of public health concerns affecting endoscopy, surgery, dentistry, organ transplantation and blood transfusions. Exposure of the UK population to BSE was widespread, with over 181,000 cases in cattle and estimates of total infections of 1 million to 3 million cattle beasts. About 200 people, mostly from the UK, have been infected, although many more could be. Because of this, the UK is the largest reservoir of vCJD prions in the world. Much of the UK population born before 1996 has potentially been exposed to BSE-contaminated food, and the number of people who carry the infection but remain healthy is unknown.

The issue is particularly relevant in the light of recent deaths. For example, Jonathan Simms, who died aged 26 in Belfast, was given only months to live following his diagnosis in the summer of 2001. He had won a High Court battle which enabled him to receive controversial treatment with an experimental drug called pentosan polysulfate. He remained disabled, but his family and doctors said that his condition had not declined any further, and a slight improvement was recorded. However, he finally lost his battle in March.

From 1990 to February 2011, 170 people in Britain died from vCJD. Although the current wave of vCJD is apparently fizzling out, after peaking in 2000 with 28 cases, a big worry is whether there will be further waves a considerable time in the future.

I wish to touch on three topics in this short debate, and I assure the Minister that my speech will be short. The first is the development of a new blood test for vCJD; the second is the approval of a red blood cell filter that can catch vCJD, which we seem to be running around in circles about without coming to a conclusion; and the third is the use of cold sterilisation solutions on surgical and dental instruments, of which three are potentially available, including Rely+On. I would like to ask why those are not being used.

First, on the new blood test, the number of asymptomatic individuals with vCJD prion infection is unknown. Because of that, it poses a risk to others via blood transfusions, blood products, organ or tissue grafts, and contaminated medical instruments. A blood test for vCJD has been an important goal of medical research laboratories and companies around the world for many years. It has been very difficult to achieve because the infectious agent that causes vCJD has unique features that mean that the sensitive methods that doctors usually use to detect the presence of a germ, or other such agents, do not work.

Professor Collinge and others at the Medical Research Council’s prion unit have recently developed a blood test to detect vCJD, or at least the prions. It exploits the powerful attraction between abnormal prion proteins and some metals, in particular some stainless steels. The test was applied to a number of patients, including those with vCJD, sporadic CJD and a number of other neurological diseases that are easily confused with vCJD, and to a number of healthy blood donors. As vCJD is rare, only a relatively small number of samples were available for testing. When the new test was run on 21 samples from different vCJD patients, 15 of the 21 samples from people with clinical CJD tested positive. So far, all samples from other neurological diseases or healthy blood donors have tested negative. The test is quite dramatic. Although it is at an early stage, it is able to correctly identify the majority of patients with symptoms of vCJD and has not yet given any false results for patients with other brain diseases or for healthy individuals. That is important both for early diagnosis of the disease in patients and for the development of a screening test that may detect silent infection in healthy individuals.

The initial studies provide a prototype blood test for diagnosis of vCJD in symptomatic individuals, which could allow development of large-scale screening tests for asymptomatic vCJD prion infection. If a screening test can be developed, it will be possible to estimate the number of infected carriers in the UK population and potentially to reduce the risk of accidental transmission of infection through medical and surgical procedures such as blood transfusions, and through dental instruments, which I must mention.

Variant CJD has predominantly been diagnosed when the patient has had the disease for some time and has developed symptoms that are coupled with extensive damage to the brain. The early symptoms of the disease, such as anxiety, depression and tingling pains in the legs, are regularly mistaken for many more common causes. Understandably, doctors do not jump to the serious conclusion of vCJD until other symptoms show forth, such as difficulty with movement or balance and loss of mental abilities.

Due to the rapid and crippling nature of the disease and the length of time it takes to carry out the series of tests required to reach a diagnosis, more often than not the patient’s symptoms are well advanced before a definitive diagnosis is reached. A blood test will enable patients to establish a diagnosis early, or at least earlier. Although there is no cure yet, experimental drugs are being developed at the MRC’s prion unit and elsewhere, with a view to holding clinical trials in the next few years. The unit wants to try such treatments on patients at an early stage, before irreversible brain damage has occurred. Early diagnosis would also give the patient and their family a quick and definite answer, allowing them to use the time that they have left as best they can.

Although the blood test is a monumental step forward in the fight against vCJD, it is important to be mildly cautious about the news. The results so far are encouraging, but further research needs to be taken forward. The researchers need to examine blood samples from much larger numbers of healthy people and those with other brain diseases, to get a better idea of how specific the test is in practice. That is vital before a version of the test can be considered for the routine screening of healthy blood donors.

Two steps need to be taken now that the blood test has been tested successfully in the initial study. The first is the planned testing of 5,000 American blood donors, which I understand has been set up. That will enable Professor Collinge and his team to eliminate the possibility of false positives. However, there is a stumbling block—a lack of funding. As I understand it, the Government are not keen to fund the research. There is a possibility that the MRC will fund that stage of it, but then the researchers would need to move on to seek funding for the next step, which would be to test 50,000 UK donors. That would give the Government an indication of whether vCJD was as widespread as feared, which would make it possible to consider whether the costly procedures that are currently in place to offset its spread are really necessary, or whether their use should be increased.

From the answer to a recent question by the hon. Member for Colchester (Bob Russell), we know that the Government have taken a number of steps to offset the spread of vCJD, including the removal of white cells from donated blood; the massively expensive importation of plasma used to manufacture fractionated blood products; and disallowing recipients of blood transfusions from acting as blood donors. Those are all extremely expensive steps, and at a time of spending cuts it would make sense to spend a little bit of money to get the test that I have described moving, to discover once and for all whether vCJD is as widespread as feared, and in turn whether those expensive procedures are really necessary.

Whether the test on 50,000 UK donors shows a prevalence of vCJD prions or a lack of patients with them, it is a crucial step in the fight against vCJD and should, without doubt, be a priority for Government funding. At the moment, the test does not work on other forms of prion disease such as sporadic CJD, but there is some hope that with further work, it will be available for such conditions in future.

I move on to the issue of blood filtering. Following an anonymous study of archived tissue specimens, the Department of Health uses in its risk calculations the estimate that 1 in 4,000 individuals may be silently infected with vCJD prions. Professor Collinge and his team believe that there is considerable uncertainty about that figure, and that the true number could be significantly higher or lower. It is also unknown how many of those infected will actually go on to develop the disease, the problem being that the incubation period in humans can be as long as 50 years.

Those unknowingly infected individuals could be active blood donors, and they could pass on the infection to other people, including through medical and surgical instruments used on them. Although the National Blood Service has taken several actions to try to minimise that risk, such as removing white cells from blood, a process known as leucodepletion, and spending millions of pounds on importing blood serum from the US, it is uncertain how effective those methods are in reducing the risk, or indeed whether they will really be justified should the number of infected people turn out to be exceptionally small.

ProMetic and MacoPharma are two firms that strongly recommend that the Department of Health implement the CE-marked P-Capt prion reduction filter as a matter of urgency, to safeguard the UK blood supply. It is a tailor-made medical device that has been developed by the medical technology company MacoPharma. It is a blood filter that removes all infectious prion proteins that carry vCJD, thereby dramatically reducing or eliminating the risk of transmission through infectious prions and ensuring as far as possible that all blood is safe for transfusion. It has been proved safe and effective and is ready to use, with more than 350 patients having been transfused with P-Capt filtered blood with no adverse effects. The filter has been CE-marked since 2006, meaning that it has passed the EU safety and efficacy test required for it to be used in the UK. The filter has been designed to work with existing technologies and procedures used by the UK National Blood Service, and its introduction would be simple and probably cost-effective. The P-Capt filter could also be used to protect against other transmissible spongiform encephalopathies, including prion diseases that have not yet been identified and named. However, the previous Government appear to have stalled on introducing prion filtration, which is proven to protect people against vCJD transmission through blood transfusions.

Blood contamination is a disaster well known to thousands in this country. Many people with haemophilia were infected with HIV and hepatitis in the ’70s and ’80s because they received contaminated blood from the NHS that was not particularly well screened, or not screened at all, for those viruses. Not only were people infected, but they unknowingly passed the infections to their families. Nearly 2,000 individuals have died as result of that blood calamity, and the figure is increasing.

The vCJD situation is potentially a ticking time bomb—a similar blood disaster could be waiting to happen. Like those who were infected with HIV and hepatitis, those infected with vCJD could be unwittingly passing it on to others, including those who receive their donated blood. To date, at least five people have been confirmed as contracting vCJD after receiving contaminated blood and blood products.

A number of researchers in the department of haematology at Cork university hospital investigated the filter’s operational use and the quality of the filtered components, as well as whether the filtration resulted in any significant changes to blood group antigens. They found that 99% of “top-and-top” units, and 58% of “bottom-and-top” units, had a haemoglobin content of more than 40 grams. Haemolysis increased immediately after filtration, but units remained within UK specification throughout storage. Prion reduction resulted in the loss of 7 to 8 grams of haemoglobin, and reductions in haematocrit of 6% to 9%, due to the filter containing 40 ml of saline, adenine, glucose and mannitol. There is no evidence of any immunologic changes of clinical relevance to the red blood cells membrane after filtration.

The Cork university researchers concluded that prion filtration does not appear to have a detrimental effect on basic in-vitro measures of red blood cell quality or on blood group antigens as assessed by in-vitro methods. However, prion filtration using the P-Capt filter results in some loss of haemoglobin, as I noted. The researchers also found during their study that the filter provides encouraging data on the safety of filtration, which means that it could be used, as was planned and recommended, in adults and children, but particularly the latter.

The Health Protection Agency findings that up to 40,000 people in the UK may be incubating vCJD without knowing it highlights the ongoing threat of prion diseases and the need to filter transferred blood to ensure that donors who are carrying latent prions do not infect recipients. P-Capt has been extensively and independently tested for more than three years. It has been proven not only to work, but to be safe and effective, for a wide range of prion proteins, and its implementation has been recommended by an independent UK safety committee.

As I mentioned, deaths from vCJD continue, and I suspect that there will be more. Only last year, researchers from Case Western Reserve university in the US identified a new human prion brain disease—similar to vCJD—that is also associated with a fast-advancing form of dementia. It is now more than a year since the UK’s Advisory Committee on the Safety of Blood, Tissues and Organs—SaBTO—recommended that the Department of Health adopt the P-Capt filter. It is abundantly clear that those crucial safeguards against that vicious disease should be implemented without delay.

The SaBTO recommendation of the use of the P-Capt filter was subject to the completion of the prion-filtered versus standard red cells in surgical and multi-transfused patients study, which is known as the PRISM study. For those who are not aware, PRISM is the third safety study that has been performed on the filter. The two previous investigations, both of which demonstrated the clinical safety of P-Capt, showed absolutely no adverse events. The PRISM process was initially due to conclude in spring and summer of 2009, but it appears to have dragged on for much longer, which has caused considerable concern. The process should be progressed much more rapidly.

A recent parliamentary answer suggested that the tests would not be expected to conclude until mid-2012, although the original deadline was 2009. An interim report is due this summer and I hope that the Minister will confirm that. As the filter has been deemed safe for use since 2006, such a delay seems unnecessary and potentially dangerous for those currently receiving unfiltered, and therefore unprotected, blood.

Following the publication of SaBTO’s recommendations, the Department of Health informed MacoPharma that an impact assessment was being prepared for Ministers, to help make a quick decision on implementation. This was in October 2009, but the impact assessment appears never to have been published and it has been increasingly difficult to understand the decision-making process. Given the potential impact of failing to protect the blood supply from vCJD contamination, such a lack of transparency is deeply worrying.

In Ireland, P-Capt is being used routinely in one pilot hospital and is currently undergoing a health technology assessment in relation to national policy and adoption. Of all places, Macau has a blood transfusion service that has started to use P-Capt to remove vCJD from red blood cell concentrates donated by Caucasians thought to be at risk of carrying the prion. Globally, over 90 million blood units are collected annually and MacoPharma is committed to providing solutions that safeguard this blood supply. The present process of leucodepletion used on UK-donated red blood cell concentrates is not sufficient to prevent people from being infected with vCJD. It is shown to remove only 42% of the total transmissible spongiform encephalopathies infectivity.

In terms of the financial costs of the filter, full implementation to filter all donated blood would cost around £1 per person in England. I think—and I hope that the Minister agrees—that that is a small price to pay considering the consequences if the problem escalates. Despite the fact that some people’s genetic make-up may protect them from this disease, at least 89% of the population may be susceptible to vCJD if infected.

Lastly I would like to discuss briefly the situation relating to dental and surgical instruments. As we have seen recently in the news, there have been two separate incidents—one at Queen’s hospital in Essex and another in Wales—in which patients have been told they have been put at risk of contracting CJD through surgery. Details have not been released about the case in Wales. However in the Essex incident, the mother of a patient who had an operation in the same operating theatre as those who have been contacted had developed an inherited form of CJD. That patient has since been tested and found to be carrying a gene that meant that she too could go on to develop the disease. Although the risk of the individuals concerned actually developing the disease is probably very small, it is of course extremely distressing for them, and in the interest of public health safety they will not be allowed to donate blood, organs or tissue.

Professor Collinge and his team believe that such incidents are not uncommon and that although the risk to patients from contaminated surgical instruments is believed to be small, it has not yet been quantified. His research team, working with Dupont, has recently developed an effective prion deactivation soak called Rely+On. However, despite actually having a commercial partner, it is not being used in hospitals and in fact DuPont is no longer manufacturing Rely+On. This soak is one of three—another was developed at Edinburgh university and another was produced by the Government-sponsored Health Protection Agency. None has been used in a hospital setting. The reason for this is that the Government have not given hospitals or commercial partners the incentive to use and invest in these products. If the hospitals were under pressure and the cleaner was provided at a commercially viable cost, the cost would be lower because there would be a huge market to sell it to and production could recommence. The Government need to give commercial firms the green light to go ahead by explaining to the companies that they will have a commercial market. That will inspire them to carry out the final tests and make changes to make the product more viable for hospitals to use. I understand that a qualified clearance has been given to Rely+On. It is qualified only at the second level because it froths in washer disinfectors. If a commercial green light was given, I am sure that DuPont and others would produce a product that did not froth. A future requirement could be set through a change to health technical memorandum 01-05 or even through the dreaded Care Quality Commission.

I ask the Minister to act now on these issues and not to let this valuable research sink without trace or these products go to waste. We are lucky in that vCJD does not seem to have had an enormous effect on our generation. However, it is the next generation and the one after that we should be thinking of and trying to protect. They are the ones who could well feel the ghastly effects of this crippling disease and who will be pointing the finger at our generation—and perhaps specifically the Minister—and asking why we did not get stuck into the problem and introduce more prevention now.

[The Minister of State, Department of Health (Mr Simon Burns)]

I congratulate my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing this important debate and on his thoughtful and well-informed comments on a matter of public concern and genuine importance. I also pay tribute to his ongoing commitment to keeping the issue of variant CJD in the public consciousness, not least through his various debates on the Floor of the House and his questioning of Ministers.

My hon. Friend asked about the Government’s response to vCJD, and I am happy to have this opportunity to update the House. Thankfully, the incidence of cases of clinical vCJD in the UK remains at a very low level, with a total of 175 cases recorded. Since a peak of 29 onsets in 1999 and 28 deaths—sadly—in 2000, the trend has fortunately been continuously downward. In 2010, there was only one new case. There have been no cases presumed to be associated with surgical or dental procedures and no known transmissions presumed to be associated with blood since 1999. The reality contrasts with some predictions that surrounded early discussion of vCJD in the late 1990s. Some people forecast large numbers of infections and deaths far in excess of what has come to pass. However, this is perhaps understandable given the uncertainties that still remain around the disease.

Although we can be pleased that the worst-case scenario has not materialised, we must remain vigilant and continue to do all we can to reduce risks to patients through potential transmissions via blood or surgical procedures. Many aspects of this condition remain unknown, and because of the unusual nature of the presumed infectious agent—the prion—are likely to remain so, as my hon. Friend alluded to. Existing measures have been put in place to reduce the risk of secondary vCJD infection passed from person to person, and it is vital that these are maintained unless evidence becomes available to indicate that they are no longer necessary or are otherwise ineffective.

Some measures put in place to protect against the transmission of vCJD also provide additional benefits to patients. One example is the continual improvement of decontamination practices across all of health care. This is vital to ensure that care is delivered safely with low levels of infection risk from all manner of infections, including vCJD, bacterial, protozoal and viral risks. The maintenance and improvement of existing, and the development of new, decontamination systems are essential for maintaining patient safety.

The Government take high-quality decontamination very seriously, and I can announce today that the Department of Health is commissioning a new programme of decontamination-related research. The Department will make available £2.4 million over the next four years to fund this research, which will include support for the development of cold plasma decontamination technologies, specifically for use in narrow channelled instruments such as endoscopes. Another study will aim to optimise the effectiveness of automated washer disinfectors used to wash and sterilise surgical instruments. Other projects will address new methods for detection of residual protein contamination on instruments following routine washing and disinfection.

In addition to decontamination, another vCJD risk-reduction measure that provides additional health benefits is the removal of white blood cells from all blood for transfusion. The removal of white blood cells not only reduces the risk of vCJD transmission, but reduces the risk of cytomegalovirus transmission, transfusion-associated lung injury and transfusion-related fever, and has other benefits. The provision of synthetic clotting factors for the treatment of all patients with bleeding disorders such as haemophilia is another measure associated with both reducing the risk of vCJD transmission and improved patient care.

[Sir Paul Beresford]

I thank my hon. Friend for his announcements and I note his repetition of some of the points that I have already made. Does he accept that there are already three commercially available materials that can be used for cold sterilisation—but which are not being used and to which the Government have given only semi-recognition—and could also be introduced extremely quickly? Secondly, I note his point about white cell depletion, but a filter has been available since 2006 that would take red blood cells out as well, greatly improving the restriction of the prion.

[Mr Burns]

I am grateful to my hon. Friend for that intervention. If he bears with me, I will come to both those points. I want to outline what the Government have been doing, but towards the end of my speech I have a number of comments to make in response to some of the valid points that he raised in his speech.

As I was saying, the provision of synthetic clotting factors for the treatment of all patients with bleeding disorders such as haemophilia is another measure associated with both reducing the risk of variant CJD transmission and improved patient care. Those products, although not suitable for all patients, eliminate all variant CJD and other blood-borne infection risks to those patients.

All the health care actions taken to reduce the risks of person-to-person transmission of variant CJD have costs. Estimates of the annual cost of blood-related protection measures alone amount to approximately £40 million. However, many costs that are badged as variant CJD risk-reduction measures would be incurred even without that specific risk. Without a variant CJD risk, many of the blood-related measures, including leucoreduction and the use of synthetic clotting factors, would continue because of the wider safety and other benefits that they confer. The Government also continue to support payments to those affected by clinical variant CJD through the Variant CJD Trust. The trust has paid out approximately £39 million to patients and their families over the last 10 years.

In the latter part of his speech my hon. Friend talked about the risk of contamination via dentistry, which I would like to address now. There have been no known, or indeed suspected, cases of variant CJD transmission arising from dental procedures. However, there are still considerable scientific uncertainties that prevent us from quantifying the specific potential risk. The Department of Health has focused on improving standards of dental decontamination over the last decade, as the risk from blood-borne viruses—especially hepatitis B and C, and HIV—is a recognised risk in dental practices. Approximately 500,000 people in this country are infected with those viruses, and there are more than 1.5 million patient contacts every week in NHS dental practices. It is essential that the quality of local decontamination in practices must be of the highest standard.

The available equipment for and knowledge about decontamination is constantly changing, as my hon. Friend is aware. We update our policies to keep pace with those technical and scientific developments. An essential feature of the British Dental Association guidance, published in 2004, was the importance of both the sterilization and pre-sterilization cleaning components of the decontamination process. Indeed, the essential quality requirements in the Department’s guidance, as set out in “Health Technical Memorandum 01-05”, were similar to those in the British Dental Association’s original A12 document.

Guidance from the Department of Health states that all dentists should use automated washer disinfectors as part of best practice. There are three reasons for this. First, they provide a consistent and reliable cleaning and disinfection process. Secondly, they contain the washing and disinfection process within a sealed unit, which helps to minimise the risk of spreading microbiological and chemical hazards. Thirdly, there is strong evidence that automated washer disinfectors are effective in removing the worst of the contamination from dental instruments and that they deliver a much greater degree of consistency in cleaning. This will reduce the worst-case risks to subsequent patients.

Also, following the recently commissioned research on optimising the efficacy of washer disinfectors, we expect their performance to improve significantly in the coming years. Initial research indicates that the use of automated washer disinfectors can reduce general protein contamination on instruments by a factor of up to 10,000. The reduction in hydrophobic proteins, similar to prion proteins, is roughly a factor of 100. Automated washer disinfectors are therefore very useful in improving the quality of instrument cleaning and reducing risk.

--- Later in debate ---

[Sir Paul Beresford]

I was not picking on dentistry specifically, because washer disinfectors are also used in hospitals. They are an excellent idea. They are very expensive, but we are going down the right road. The problem is, however, that the prion sticks to certain stainless steel instruments used in dentistry and elsewhere in hospital services, and the washer disinfector will not remove it. However, if the Rely+On, or one of the other two products, were utilised either in the soak beforehand or in the washer disinfector, that would make the process much more effective as far as the prion is concerned.

[Mr Burns]

Again, if my hon. Friend will bear with me, I will come to these points when I deal with a number of the issues that he raised in his speech.

The guidance encourages the purchase of automated washer disinfectors. However, no time frame has been stipulated and they were not part of the essential quality requirements that all practices had to meet by the end of 2010. A 2009-10 national survey on policy, equipment and procedures used by local dental practices in the decontamination of their instruments showed that more than 70% were at or above the standard required by Department of Health guidance. That figure is likely to improve further, as many other dental practices are close to the required performance level.

The British Dental Association was fully involved in the development of the guidance, and is supportive of the principles underpinning it. The guidance is also consistent with the BDA’s advice sheet A12, “Infection Control in Dentistry”, published in 2004, which states:

“CJD and related conditions raise new infection control questions because ‘prions’, the infectious agents that cause them, are much more difficult to destroy than conventional micro-organisms, so optimal decontamination standards need to be observed. As a universal precaution, all instruments should be thoroughly cleaned before autoclaving, in order to remove as much matter as possible.”

During 2006-07 and 2007-08, the Department of Health made £100 million of capital funding available through PCTs for use in primary dental care. One of the areas identified as suitable for that money was the improvement of standards of decontamination in primary dental care. Many PCTs have provided grants to practices to support the roll-out of automated washer disinfectors in primary dental care.

These and other variant CJD risk reduction measures will remain in place and we will continue to consider all other options where there is evidence of their overall efficacy, safety and cost benefit. For example, we closely follow the development by commercial and academic organisations of potential blood screening tests. While recent progress—as exemplified by the recent publication in The Lancet of the Government-funded prion unit’s development of a prototype diagnostic test—is promising, there remains no test suitable for screening blood donations.

Another possible technology is, as my hon. Friend mentioned, prion filtration, which aims to remove the presumed variant CJD infective agent from blood. In early 2012 on completion of a clinical trial, Ministers will consider the possible use of prion filtration in addition to leucoreduction to reduce further the potential risk of infection from red blood cells. I trust that that helps to answer one of my hon. Friend’s points.

--- Later in debate ---

[Sir Paul Beresford]

I thank my right hon. Friend again for giving way, and for his tolerance. His statement is interesting, although under the previous Government there was a demand by the Department to provide an impact assessment on the P-Capt filter, which should have been ready for Ministers in October 2009. Will he inquire whether that is available, and if so have a look at it? It would speed up the decision making.

[Mr Burns]

I can answer my hon. Friend instantly on that. I said just before his intervention that we expect the trial results in 2012, and the impact assessment will be completed only when the trial is completed. The impact assessment, then, will not be available until 2012 when the trials have been completed. I hope that that explains it, and satisfies my hon. Friend.

I would like to enter a note of caution that, as with all new technologies, it is important to consider all the potential costs and benefits to ensure that, as far as possible, the benefits they offer and the costs they incur—both financial and clinical— are fully understood. One example was when single-use tonsillectomy instruments were introduced in 2001 to reduce the risk of variant CJD infection. The instruments were withdrawn within a year, after the death of a number of patients. This clearly shows that no matter how good the intentions, there can, sadly, sometimes be unintended consequences with the introduction of thoroughly assessed new technologies.

My hon. Friend raised a number of issues, which I would like to go through methodically. He talked knowledgeably about prion filtration and effectively asked what was the Government’s position on its use to reduce the risk of variant CJD. I can advise him that the independent Advisory Committee on the Safety of Blood, Tissues and Organs considers that there is evidence that a particular filter is able to reduce potential infectivity in a unit of red blood cells and has recommended—subject to satisfactory completion of the clinical trial—the introduction of filtered blood to those born since 1 January 1996. The Government are undertaking an evaluation of the costs, benefits and impacts to inform a decision on whether to implement that recommendation. As I said to my hon. Friend a few moments ago, that is expected to be completed in 2012, when we will also have an impact assessment, which could be studied.

My hon. Friend raised the issue of funding. The current funding by the Department is for studies led by Professor Collinge. Between 1996 and 2012 the Department of Health will have provided more than £18.2 million for studies led by Professor Collinge, which is in addition to his funding by the Medical Research Council. Through the RDD policy research programme, the Department currently funds two studies that underpin and are integrated with the MRC Neuropathogenesis Unit funding. The National Prion Monitoring Cohort funding is worth £3.04 million between 1 April 2008 and 31 March 2012. Secondly, the development of an effective treatment for prion infection by humans is funded to the value of £7.2 million from 1 February 2006 to 30 June 2012, in partnership with GlaxoSmithKline.

[Sir Paul Beresford]

First, I am astonished that the PRISM trials have taken so long. They were supposed to finish in 2009, and they have dragged on for a further three years. We really should be worried about the potential development of infection in the intervening period.

Secondly, the Minister has delighted us with the research figures, but they pale into insignificance in comparison with the volume of expenditure by the national health service on imports of blood products and blood serum from the United States in particular. Collinge’s team have produced the test and one of the three soaks, so he has achieved positive results. It would be a mistake to stop now, rather than investing a little more funding to support the next stages of the test so that the tree that was planted initially can bear fruit.

[Mr Burns]

I always welcome any justified lobbying for extra funding, especially if it is for research. I do not think it appropriate for me to promise my hon. Friend the earth from the Dispatch Box this afternoon, but I will promise him that I will ensure that his request and his justification for the provision of further funds are drawn to the attention of the Under-Secretary of State for Health, my hon. Friend the Member for Guildford (Anne Milton). No doubt she will consider what he has said and write to him in due course.

[Sir Paul Beresford]

rose—

[Mr Burns]

I feared that that might prompt another intervention.

[Sir Paul Beresford]

I thank the Minister sincerely, because it is unusual for Ministers to give way with such regularity. Perhaps it is also unusual for them to receive requests.

I understand that the Under-Secretary of State has considered the matter, and is looking to the private sector to fund the advances and further testing. The private sector is unlikely to do that because it has no incentive, but, as a Minister in the Department of Health looking after the nation’s health, my right hon. Friend has every incentive, as has the Under-Secretary of State.

[Mr Burns]

I admire my hon. Friend’s persistence and congratulate him on it, but I fear that it will not push me any further at this moment. I hear what he says about the meeting between my hon. Friend the Under-Secretary of State and Professor Collinge. I cannot comment on that, but I reiterate yet again that I will draw my hon. Friend’s comments to the attention of my hon. Friend the Under-Secretary of State so that she can reflect on them. No doubt she will be in touch with him once she has had time to do so.

My hon. Friend mentioned the three decontamination products. They have not yet been proven suitable for use in the standard decontamination cycle in health care, and we must therefore await the conclusion of the research. Once we have seen the results of that research and, in one case, the impact assessment, we shall be able to seek to make positive progress.

Let me reassure my hon. Friend that the Government take the risks of variant CJD very seriously indeed. Because of the uncertainty surrounding it, we cannot be satisfied that we can stop looking for ways of improving and enhancing the protection of members of the public, and minimising the development and spread of this particularly horrendous medical condition. Successive Governments have introduced a wide range of precautionary measures focused on reducing risk to protect public health. I assure my hon. Friend that we will maintain them and keep them under review as new evidence emerges, and that we will ensure that any new measures under consideration are effective, safe and appropriate.

Question put and agreed to.

NHS Reform

Paul Beresford Excerpts

Monday 4th April 2011 Commons Chamber

[Mr Lansley]

Thank you, Mr Speaker. I shall not go through a long list, but many services in the NHS have improved and continue to improve. Our objective is very clear: it is to support that improvement, including improvement in waiting times. For example, last year the median wait in January for non-admitted patients was 4.8 weeks, whereas last year it was 4.9 weeks. For diagnostic tests, the average wait this year is 1.6 weeks, exactly the same as last year. Meanwhile, many other factors are continuing to improve as well.

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

As the Secretary of State may know, I still have a faint link with the NHS and medicine in general. The GPs I have met in my constituency and elsewhere are very much in favour of the proposals. In contrast, the complaints are circular letters that have been well organised. Does the Secretary of State agree that GPs will be devastated if there is any reversal and backtracking?

[Mr Lansley]

I am grateful to my hon. Friend for his remarks. He and other Surrey Members will be aware of that primary care trust’s past failure to manage effectively within its budget. The GPs in Surrey are, like many others across the country, coming together and demonstrating that they can achieve much greater service improvement within NHS resources—and those resources will increase in future years.

Dental Practitioners

Paul Beresford Excerpts

Monday 29th November 2010 Commons Chamber

[The Minister of State, Department of Health (Mr Simon Burns)]

indicated assent.

[Sir Paul Beresford]

The Minister is nodding sagely so perhaps I will believe him. The fire prevention regulations are enforced by the local fire authority and any CQC interest in that area is duplication. To my amazement, there is even duplication in the CQC requirements, some of which are addressed many times. For example, evidence that practices have appropriate confidentiality protocols in place must be provided to satisfy outcomes 1, 2, 6 and 21.

Dental providers must comply with 28 standards, but there is no guidance on what the CQC requires as evidence of compliance. Furthermore, it is unclear who the auditors of the process will be. To give an example provided by people who have lobbied me, the NHS Partners Network and the NHS Confederation state that generally, their members have been subject to mixed messages and unclear instructions from the CQC about what to expect from it. They say that in the current financial climate, such uncertainty is particularly difficult for their members and runs the risk of adding significantly to costs without yielding safety and quality benefits. The ultimate guillotine is having one’s practice shut down for failure to comply with a potential deadline of April next year, which is causing deep concern in the dental profession.

Finally, I turn to costs. The current situation is that there is no fee for CQC registration. In contrast, my fee to be paid this month to the General Dental Council is £576, the same as for the majority of dentists. However, the CQC is consulting on proposed fees, which it wishes to divide up depending on the size of a provider. The fees proposed are disproportionate, as the lowest fee is to be £1,500, for a provider with one location, such as my own small, part-time surgery, whereas £48,000 is to be charged for a provider with 101 or more locations.

One of the most glaringly ludicrous points is the extreme jump in fees from one level to another. For example, if a dental firm has 100 practices it will pay £24,000, but if it merely adds one more practice, its fees will double to £48,000. The situation has to be dealt with, and it is in the hands of the Minister and his colleagues to do so. The CQC is charging ahead blindly, apparently with little knowledge and with no response to concerns that have been expressed. It has finally agreed to sit down with the General Dental Council in the next week or two and discuss the potential duplications in registration costs.

I understand that there are organisations similar to the CQC in Wales and Scotland, and both appear to be working closely with the GDC without duplication. The result is that the annual cost to Welsh dentists for their organisation is not between £1,500 and £48,000, but probably in the region of £80 and certainly less than £100.

There is an opportunity for Ministers to act before it is too late, and before too much money is wasted. If necessary, the forthcoming Public Bodies Bill will enable Ministers to remove the CQC from its role of regulating dentists. I remind the Minister that all the problems that it is having with dentists, and dentists with it, are likely to be repeated, and more, in the case of general medical practitioners. They are next on the list.

I await the Minister’s considered response, and I hope that he will take a step back and promise to consider the points made by me and, in particular, by the many organisations that have lobbied on the matter. It would be helpful if there were a serious meeting between Ministers, the GDC, the CQC and the BDA. It is overdue.

[The Minister of State, Department of Health (Mr Simon Burns)]

I begin by congratulating my hon. Friend the Member for Mole Valley (Sir Paul Beresford) on securing this debate on an issue that I know is of some concern to him and other dentists throughout England. He said at the beginning of his comments that he was a friend of mine and hoped that he still would be by the end of my speech. I echo that, because I, too, hope that we are still on friendly, and hopefully speaking, terms by the end of the debate.

My hon. Friend will know that the coalition Government do not believe in regulation for the sake of regulation. However, there are areas in which regulation is important for the interests of vulnerable people who are less able than others to defend their own interests. The provision of health care and adult social care services is one such area, and since 1 April 2009, the Care Quality Commission has been responsible for regulating those sectors under the Health and Social Care Act 2008.

The Government support the role of the CQC in ensuring that providers of health care and adult social care provide services that, at the very least, meet the essential levels of safety and quality that every patient and service user has a right to expect. I am sure that my hon. Friend would not argue with that, or with the enforcement powers that the CQC can use when providers fail to meet essential levels of safety and quality. He will be aware that the Government are committed to strengthening the CQC’s role as an effective regulator of health and adult social care services in England.

At the moment, NHS and private health care providers are registered by CQC under the 2008 Act, as are providers of adult social care. From April next year, providers of primary dental care and private ambulance services will also be registered. From April 2012, providers of primary medical care will be brought into the registration system.

There are a number of reasons why it is right to bring primary dental care providers into registration and to require them to meet essential levels of safety and quality. First, the current regulatory systems for dentists focus on the competence of the individual. However, how organisations and systems are managed is just as important in protecting the safety of patients. CQC registration will provide the framework to ensure that the provider, as well as the individuals within it, meet essential levels of safety and quality.

Secondly, increasingly complex treatments are being provided in primary care settings. For example, it is likely that more oral surgery will be carried out in primary care in future, and the General Dental Council has seen an increase in complaints about harm caused to patients by the placing of dental implants. Those developments make it even more important to ensure that providers have adequate systems in place to protect the safety of patients. Registration with the CQC will allow potential problems to be identified and addressed before they result in harm to patients.

[Sir Paul Beresford]

The Minister mentioned the GDC and complaints about dental implants. There has also been an increase in poor endodontic work, all of which can be dealt with adequately by the GDC. The situation does not need a huge, monolithic organisation such as the CQC.

[Mr Burns]

I am very grateful to my hon. Friend for making that point. If he will bear with me, I will, at a slightly later stage in the course of my remarks, address whether working together can minimise the level of overlap so that there is no unnecessary duplication.

Thirdly, registering primary dental care providers will ensure that the same levels of safety and quality are met irrespective of where care is provided. One patient could be treated in hospital where the quality and safety of their care is regulated by the CQC, while another receives the exact same treatment elsewhere without that same guarantee. Wholly private dental providers, treating some 7 million patients, are currently subject to no formal scrutiny of the service that they provide.

Finally—I know that my hon. Friend has raised this subject in the past—registration will provide greater controls on the decontamination of used dental instruments. Guidance on decontamination is set out in “Health Technical Memorandum 01-05”. Although that has no legal standing, the CQC can monitor whether providers, including those in the independent sector, meet its requirements by enforcing the cleanliness and infection control registration requirement.

It is the view not just of the Government that the registration of dentists will bring benefits; that view is shared by the dental profession. Responding to the consultation on registration of dental providers with the CQC in June 2008, the GDC said:

“We broadly welcome the establishment of the Care Quality Commission…Whilst we are responsible for the registration and regulation of the whole dental team, whether they work in the private or public sector, there has been no additional means of regulating wholly private dental services…up until now. We believe that this role can be covered by the CQC and would further enhance patient protection”.

The British Dental Association was equally supportive, saying:

“Wholly private providers are currently unregulated (beyond individual professional regulation) and we believe it is essential for this to be addressed.”

[Sir Paul Beresford]

I actually touched on that at the beginning of my short address. The Minister has to realise that the consultation came before the CQC moved into the area of dentistry, before the BDA realised what the CQC was going to do and before the monolithic and, what I called, almost cancerous growth of this organisation.

[Mr Burns]

I am grateful to my hon. Friend for that intervention. As far as I know, however, the BDA was aware at the time that dentists were going to be registered under the CQC, and as I see it, the comments on the consultation process were made in the knowledge of that information.

I know there has been concern among dentists about the potential impact of registration with the CQC, and my hon. Friend made an interesting and vigorous case highlighting what he perceived to be some of the problems. However, I have some sympathy with those dentists concerned that the process of registering with the CQC will be onerous and time consuming. I can assure him, however, that for the majority of dentists—those who already provide high-quality services—there will, to my mind, be no difficulty in meeting the essential levels of safety and quality.

The experience of HTM 01-05 demonstrates this point. Before the introduction of the guidance, dentists raised concerns about the burden that complying with it would place on them. Only today, we have published the results of the dental national decontamination survey, showing that when HTM 01-05 was published in November 2009, about 70% of practices were already meeting the essential quality requirements for decontamination, with approximately a further 20% of practices very near the essential quality requirements. The remaining small minority of practices were not.

This experience will, I believe, be repeated with CQC registration. Most dental providers already give their patients a high-quality service and will find that they already meet the registration requirements. In those relatively small numbers of cases where dentists do not meet essential levels of safety and quality, registration with CQC will force them to improve. This is the purpose of regulation, and such an outcome would result in safer and better dental care for patients.

My hon. Friend has spoken about the potential for overlap in the role of the CQC and the General Dental Council in the registration of dentists, and he raised it again in his first intervention on me. I would like to address that point now. I read with interest the recent letter from a number of dentists in The Daily Telegraph making the same point as him. The CQC and the GDC are working closely to ensure that the roles of the two regulatory bodies are closely co-ordinated. Indeed, the two regulators have agreed and set out a memorandum of understanding that explains how they will co-ordinate their activities and share information to ensure that they do not duplicate actions and therefore create any risk of double jeopardy. It is vital that CQC registration complements the professional regulation of dentists by the GDC. The important word there is “complements”.

[Sir Paul Beresford]

I spoke to the president of the GDC last week, and she said they are having a meeting to discuss this for the first time. So the Minister’s information might have gone a little awry.

[Mr Burns]

I take on board what my hon. Friend says. However, the information I have been given, as I said earlier, is that the two regulators have agreed and set out a memorandum of understanding explaining how they will co-ordinate their activities and share information to ensure that they do not duplicate actions. I trust that that action is correct, I trust that they work closely together to achieve that aim, and I will certainly get back to him if—despite what I have been led to believe—that is not the case.

My hon. Friend also referred to the proposed level of registration fees for dental providers. As he is aware, the Care Quality Commission is currently consulting on its proposals for annual registration fees, which will apply to all providers, including dentists, from April next year. I would like to emphasise that they are proposals for consultation. I would certainly urge all dentists in England to make their views known to the CQC through the consultation process as soon as possible, and certainly before it ends, on 17 January. I heard what my hon. Friend said, and I have seen the consultation document. I can only repeat—and repeat quite vehemently—that it is important that all dentists take part in the consultation process and ensure that the CQC is fully aware of their views before it ends. I should also add that the CQC’s final fees scheme is subject to the consent of the Secretary of State. It would obviously be wrong of me to prejudge the consultation process or what will happen at its conclusion. All I can do is advise my hon. Friend and the profession to ensure that they lobby the CQC as part of the consultation, so that it is left in no doubt about the views and concerns of dentists on the issue.

My hon. Friend also mentioned Criminal Records Bureau checks, which I know have been a particular issue for some dentists. CRB checks are important to ensure that those responsible for the delivery of services are fit to do so. In earlier registration rounds, CRB checks have revealed convictions that were not otherwise declared. Those dentists who already have a CRB disclosure countersigned by their primary care trust can use it for CQC registration. I know that there have been practical problems with getting the required CRB checks carried out, and I understand the frustration that this has caused for some dentists. As a result, the CQC has increased to 100 the number of post offices that can process CRB disclosures on its behalf. That will go some way towards helping to deal with some of the practical difficulties experienced in getting a CRB check. The CQC is also exploring with Post Office Ltd the possibility of extending the service to the entire post office network.

Although there is a degree of anxiety among dentists about CQC registration, I hope—although I am not convinced—that I have reassured my hon. Friend that the majority of dentists, who already provide good services, have no need to fear CQC regulation. For the small number who do not provide a safe service, registration will provide an effective mechanism to bring about improvements for patients. Indeed, that is the very purpose of regulation.

In spite of the concerns, I am pleased to have been told by the CQC that the registration of primary dental care providers is so far proceeding smoothly. More than 7,000 dentists, including nearly 1,600 who operate solely in the private sector, have enrolled in the CQC’s registration process. The CQC has now invited those primary dental care providers to submit applications. I understand that the first completed application was returned to the CQC within three hours and that more than 400 applications for registration had been returned by the end of last week. With what I believe has been a good start, I am hopeful that the task of registering dental providers with the CQC will be completed on schedule by 1 April 2011, and that patients will have the assurance that whichever dental practice they use, whether NHS or private, they will receive care that meets essential levels of safety and quality.

Question put and agreed to.

Oral Answers to Questions

Paul Beresford Excerpts

Tuesday 29th June 2010 Commons Chamber

[Anne Milton]

I cannot comment on the specific circumstances, but I would be happy to meet the hon. Gentleman if he would like. I must point out to him, however, that the number of people now seeing an NHS dentist remains lower than when the previous Government introduced the new contract in 2006. He mentions children, but there is no doubt that the inequalities in the oral health of children are scandalous.

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

rose—

[Mr Speaker]

Order. I hope that the hon. Gentleman will apply the ingenuity required to stay within the terms of a question relating to Chesterfield.

[Sir Paul Beresford]

Thank you, Mr Speaker. Given my declared interest, it was too great a temptation not to contribute.

Does my hon. Friend not agree that for dentists, the biggest disincentive to providing an NHS service in Chesterfield—and, in fact, in the rest of England too—is the contract that she just mentioned, with its targets, its “units of dental activity”, its clawbacks and so on? Will she ensure that any new system that she introduces enables and encourages dentists to offer a choice between national health and private dentistry, thus encouraging those who have opted out to opt back in again?

[Anne Milton]

I thank my hon. Friend for his question—he speaks eloquently and with much knowledge on this subject—and for highlighting the perverse incentives in the contract. It is absolutely critical that we take those out of any new contract.