Childhood Cancer Outcomes

Caroline Nokes Excerpts

Tuesday 26th April 2022 Commons Chamber

[Caroline Nokes (Romsey and Southampton North) (Con)]

With a all the moving stories, this is a difficult debate to listen to, but I congratulate my near neighbour, my hon. Friend the Member for Gosport (Dame Caroline Dinenage), on securing it. Hampshire is a small community, so it can be no surprise that nurses who treated Sophie live in Romsey and Southampton North and that her family have friends who live in my constituency. I have heard from them about Sophie’s bucket list and what her mother Charlotte wants to secure for children suffering from cancer, and that very much echoes comments made to me by my constituent Jane O’Brien, who lost her son George to teenage cancer some years ago. The O’Brien family have dedicated their time to setting up George’s trust, to raising funds to bring the first ever teenage cancer unit to Southampton General Hospital and to raising funds for the world-leading immunology centre in Southampton. Of course, we have heard today that too little of that research and money goes to childhood cancers, which are not as rare as we would like to hope.

George’s family have made a really important point to me about when he was diagnosed. When he went to the doctor’s surgery on the Tuesday, nobody recognised how serious his symptoms were. He died on the Friday, a matter of days later, but they felt strongly that the support was not there for them as a family. They did know what George had died of. They were not given the same level of support and assistance that other bereaved families might have received in similar circumstances.

[Justin Tomlinson (North Swindon) (Con)]

My right hon. Friend is making a typically powerful speech and she makes a key point. We must be better at linking up parents so that they have crucial peer-to-peer support as they go through the unimaginable horrors they face in such situations.

[Caroline Nokes]

That is a really important point, not just for parents but for the wider family and siblings who also need such help.

When I was a very new MP, I remember being contacted by my constituent Pip Armitage, who came to see me with Sacha Langton-Gilkes—the most amazing woman—to talk about the charity HeadSmart. They made a point that we have heard several times in the Chamber: we need a joined-up strategy and public awareness. We have heard about the meningitis campaign that has seen hugely improved awareness among families, parents and the medical profession and enables the condition to be identified early. In George’s case and that of too many childhood cancer victims, the condition is diagnosed too late because GPs do not have the awareness and the family do not know what signs to look for.

Sacha ran the most phenomenal campaign to put awareness cards, particularly on brain tumours, into schools and local authorities, and that was really effective. As part of the children’s cancer mission that my hon. Friend the Member for Gosport is rightly calling for, we need to have that same level of public awareness campaigning on childhood cancers. We need better referral guidelines for doctors, so that doctors such as George’s GP, who I levy no criticism at, spot the signs and refer children quickly and efficiently to the brilliant hospitals that are there to treat them.

This is such a crucial subject. As we can see this afternoon, there is enormous cross-party support for something to be done. I know that the Minister is listening hard and I look forward to what she will propose.

--- Later in debate ---

[Tom Tugendhat (Tonbridge and Malling) (Con)]

I was going to make quite a different speech, but I am going to start by saying that, from Kirkcaldy to Kent and from Gosport to Glasgow, we have heard such a strong message of support for so many families in this great country, and I have to say that I am incredibly moved. My hon. Friend the Member for Sevenoaks (Laura Trott) and many others have recounted stories of great sadness and great tragedy, but what I am going to take away from this is not the tragedy or the sadness but the extraordinary love, courage and strength that so many families across the United Kingdom have shown, wherever they are from, whatever their background and however cancer has affected their young lives. They have shown extraordinary resolve and determination to be together as a family, to strengthen each other, to hold together and to really make a difference, even if lives are brief and even if the cancer is brutal. They have shown amazing determination to be so united in the face of such a horrific disease.

I am going to talk about a wonderful family I am privileged enough to represent. Claire Scott is just the most extraordinary woman—forgive me, I know that there are others in the Gallery, but Claire is a remarkable individual. When she was just about to give birth to her second child, Kylie, she found out that her first, Liam, had neuroblastoma. She had that extraordinary, horrific moment that so many families have had, of having to take in news that nobody would wish on anyone—not even their worst enemy in this place. We would all rather that these incidents never happened, but the truth is that they do. What Claire did when she heard the news was motivate herself and mobilise her friends around her to raise money to support the care that her son was receiving and also to take him to the United States to try an experimental vaccine. I am very glad to say that Liam is still with us. He is currently in remission and I very much hope he stays that way.

There is clearly an extraordinary amount of innovation coming through pharmaceutical routes and various other routes, and we really need to encourage that. We need to invest in it, we need to welcome the scientists and we need to celebrate the achievements of so many who are working on this right now. I am delighted to say that my right hon. Friend the Secretary of State for Health and Social Care met Claire recently and was able to talk to her about the possibility of looking at the various forms of treatment that are available and that may come in.

[Caroline Nokes]

There is clearly a challenge, in that therapies that are available abroad are not yet available here. Would my hon. Friend agree that more work needs to be done on that?

[Tom Tugendhat]

My hon. Friend is absolutely right, and that is exactly the commitment we got from my right hon. Friend the Secretary of State. We need to look hard at the various forms of treatment, and to encourage the NHS and NICE to look further into the many areas that offer hope for some. It is sadly not the hope for all that we sometimes read about in the papers, but these areas could possibly be the future for so many.

The House is united and strong today, and I hope we will be able to urge, encourage and persuade the Government to push forward with greater research, greater investment and greater support. Most of all, the House has spoken as one in celebrating the families, the love, the courage, the determination and the strength that have supported so many through this extraordinarily difficult time.

Smokefree 2030

Caroline Nokes Excerpts

Tuesday 26th April 2022 Westminster Hall

[Bob Blackman]

I thank the hon. Lady for that intervention. Vaping has its purpose, which is to encourage people to quit smoking and take up vaping. I am concerned that people may take up vaping and then escalate to smoking. We do not yet have medical evidence on the long-term effects of vaping on health, so I am cautious. Clearly, it is better to vape than smoke, but let us not encourage people to take up vaping as an alternative to stopping smoking completely.

The all-party group has encouraged the “polluter pays” approach. The situation is very frustrating. The Government recognised in the Green Paper three years ago that budgets are tight and new sources of funding are needed. As recommended by the all-party parliamentary group, which I chair, the Government agreed to consider the “polluter pays” approach to funding. They also acknowledged that there were precedents, and that the approach had been taken by other countries, such as France and the USA.

Only months after the consultation closed in October 2019, the pandemic struck and put the prevention strategy on the back burner. It soon became clear that an effective prevention strategy was essential to build back better from the pandemic. It is also essential to deliver on the Conservative manifesto commitments to level up, reduce inequality and increase healthy life expectancy by five years. Those commitments are baked into the levelling-up White Paper and, the Government have said, will be enshrined in statute.

On the anniversary of the Green Paper’s publication, on 22 July 2020, the all-party group held a roundtable to examine the actions needed to deliver the smokefree ambition. The then Public Health Minister, my hon. Friend the Member for Bury St Edmunds (Jo Churchill), and her opposite number, the hon. Member for Nottingham North (Alex Norris), were the keynote speakers. The Minister gave her commitment that the Department would continue to explore further funding mechanisms with the Treasury, as had been promised in the Green Paper.

On 30 March, the former Public Health Minister, my hon. Friend the Member for Winchester (Steve Brine), challenged why the commitment to consider a “polluter pays” approach had not been fulfilled. The response at the Dispatch Box from the Health Minister, my hon. Friend the Member for Charnwood (Edward Argar), was:

“My understanding—although my recollection may fail me, so I caveat my comment with that—is that this was initially looked at that stage, but was not proceeded with.”—[Official Report, 30 March 2022; Vol. 711, c. 867.]

My hon. Friend the Member for Charnwood might like to check his recollection. The all-party group on smoking and health, following its initial recommendations, put forward detailed proposals to Government in its June 2021 report about how a “polluter pays” levy could operate. I shared a copy of the report with Health Ministers at that time and wrote to the Secretary of State in July 2021, and again in December, asking for a meeting to discuss the levy. In September, I wrote to the Chancellor about the proposals. However, to date I have not had the courtesy of a reply to any of those letters.

If the “polluter pays” levy has been seriously looked at and a decision has been taken not to proceed, that was certainly not communicated to MPs or the all-party parliamentary group. That is precisely why officers of the APPG tabled amendments to the Health and Care Bill calling for a consultation on the levy. The amendments would not have committed the Government to going ahead, but would have ensured that they fulfilled their commitment to consider a “polluter pays” approach and that our proposals get the consideration they deserve. Our amendments were carefully considered by the other place and passed by a majority of 59—the greatest defeat the Government suffered on the Health and Care Bill. However, to the great disappointment of the APPG, the Government opted to oppose our amendments when they returned to the Commons for consideration. That leaves us without a mechanism for funding the smokefree 2030 ambition, with only eight years to go.

It appears that when the noble Lords met Ministers and Treasury officials to discuss the amendments, it was the Treasury, not the Department of Health and Social Care, that objected to the proposal to consult on a levy—not to introduce one, but to consult on the principle. The Treasury has a philosophical aversion to anything that smacks of hypothecation—raising funds to be put to specific purposes. Its preference is for funds raised to go into one big pot—the Consolidated Fund, from which all Government spending flows—that it controls and allocates, thereby giving it ultimate control. However, there are already numerous exceptions where hypothecation has been justified. One is the health and social care levy, which has just come into force. Another is the pharmaceutical pricing scheme, which the Department of Health and Social Care uses to raise funds for the NHS and provides a model for how our proposals could be implemented.

The noble Lord Stevens, formerly chief executive of the NHS, pointed out that the pharmaceutical pricing scheme was put in place by a Conservative Government in 1957 and has been sustained ever since with the support of Conservative, Labour and coalition Governments. He also said—and who could disagree?—that if it is deemed appropriate to have a form of price and profit regulation for the medicines industry, which delivers products that are essential for life saving, it is not much of a stretch to think that an equivalent mechanism might be used for an industry whose products are discretionary and life-destroying. I completely agree with him on that approach.

The Government already accept the principle that the polluter should pay to fix the damage they do. The extended producer responsibility scheme, which comes into force in 2024, is another good example. It requires producers of packaging waste to pay for its collection and recycling. Lord Greenhalgh, the Housing Minister, said:

“The reality is that we cannot keep looking to the Treasury to keep bailing everybody out—we have to get the polluter to pay.”—[Official Report, House of Lords, 5 January 2022; Vol. 817, c. 566.]

I could not agree more, and that principle applies even more strongly to smoking, which, as the chief medical officer pointed out, is a deadly addiction created and marketed by companies for profit.

There were objections because we were part of the European Union, but when speaking for the Government on Report in the House of Lords, the noble Lord Howe stated:

“the tobacco industry is already required to make a significant contribution to public finances through tobacco duty, VAT and corporation tax.”—[Official Report, House of Lords, 16 March 2022; Vol. 820, c. 297.]

However—this is the key point—tobacco companies pass on the cost of tax increases to smokers, which means that it is not the tobacco industry that contributes to the public finances but ordinary smokers, who have little choice but to buy cigarettes to maintain their deadly addiction. Indeed, when HM Treasury consulted on and rejected a levy in 2015, it was on the grounds that it would add an extra tax burden to smokers. That may have been true in 2015, but it is not the case today.

In 2015, we could not prevent tobacco manufacturers from passing the costs on to consumers because we were in the European Union. We are no longer part of the European Union, and therefore by capping tobacco prices and controlling profits, the Government can ensure that tobacco manufacturers bear the full cost of the levy, helping incentivise the industry to move out of combustible products and make smoking obsolete by 2030. I can think of few better Brexit dividends than making tobacco companies pay for the damage they do.

To quote my noble Friend and fellow APPG officer Lord Young of Cookham, speaking in the other place, our proposed levy will allow the Government to

“put the financial burden firmly where it belongs, on the polluter—the tobacco manufacturer—and not the polluted—the smoker.”—[Official Report, House of Lords, 16 March 2022; Vol. 820, c. 290.]

The reality is that this levy could raise £700 million a year from the profits of the tobacco companies—money that could be applied to smoking cessation services.

There is public support for this measure. It has been endorsed by more than 70 health organisations, including Cancer Research UK, Asthma + Lung UK, the British Heart Foundation, the Royal College of Physicians and the Health Foundation. It is also supported by three quarters of the public, including those who voted Conservative in the 2019 election, with fewer than one in 10 being opposed to the levy. What could be better than introducing a tax that the public support?

If we want to achieve a smokefree 2030, it is vital that we tackle high rates of smoking among our most deprived communities, pregnant women and people with mental health conditions. As the Government have said, this will be “extremely challenging” and cannot be achieved on the cheap. Health Ministers in both Houses have said that they do not want to prejudge the review, and therefore could not accept amendments calling for a consultation on a levy. However, as I have said, that review will report very shortly—in the middle of next month—and the discussions I have had with the chairman of the review make it very clear that the measures he will be recommending will need investment, and will be radical.

Once Javed Khan has reported back to the Government, there will need to be serious consideration of how the funding to deliver the smokefree 2030 ambition can be found. That will need to be done in parallel with decisions about what interventions are needed, as interventions cost money and can be delivered only if the funding is found. Pressure on budgets has only worsened since 2019, with the covid-19 pandemic wreaking havoc on our nation’s health and on Government finances. The Government made it very clear in the spending review that there is no new money for public health, so an alternative source of funding is urgently needed. With only eight years to go before we reach 2030, the Government need to decide where that money is coming from.

The existing funds are not sufficient, and our proposals provide a new source of funding in addition to tobacco taxes. If the Government are unwilling to accept our proposals, they must come up with an alternative solution that will match the scale of their ambition. As such, my question to my hon. Friend the Minister is this: if the Javed Khan review recommends a levy, will she commit to meet with us as APPG officers and with independent experts to discuss our proposals for a “polluter pays” levy to provide the investment that is needed to deliver the Government’s smokefree ambition?

My final point is that this review also needs to look at shisha tobacco, chewing tobacco and snus. Unfortunately, those areas are completely unregulated at the moment, but are extremely damaging to people’s health. I look forward to hearing the contributions of other Members and of the Front Benchers.

[Caroline Nokes (in the Chair)]

I will call the Front Benchers at 10.40, so perhaps Back Benchers could try to limit their contributions to about six minutes.

[Mary Kelly Foy (City of Durham) (Lab)]

It is a pleasure to serve under your chairmanship, Ms Nokes, and I wish my hon. Friend the Member for Harrow East (Bob Blackman) many happy returns. I declare an interest as a vice-chair of the APPG on smoking and health; I hope, therefore, that I can speak for a little more than six minutes, if that is okay.

The north-east is the most disadvantaged region in England, with high rates of smoking and all the harms that it brings. However, I am proud to say that in the last five years, the fastest declines in smoking rates have been in the north-east. Credit goes to our local authorities, which prioritised tackling smoking and banded together to fund Fresh—the longest-running and most effective regional tobacco control programme in the country. However, the north-east started with much higher smoking rates than the rest of England, so we have further to go to achieve a smokefree 2030.

More than 4,000 people died prematurely from smoking in our region last year, with 20 times as many suffering disease and disability caused by smoking, yet there is also an economic cost to our already disadvantaged communities. Smoking costs the north-east £685 million in lost productivity, £125 million to the NHS and £67 million in social care costs to local authorities. We simply cannot afford this strain on our economy.

When the smokefree 2030 goal was launched nearly three years ago, the Government acknowledged the scale of the challenge, admitting that it would be extremely challenging and promised bold action to finish the job. Since then, however, the Government have sat on their hands. Rather than stepping up their efforts to achieve the smokefree 2030 ambition, the Government have failed to announce a single new policy to that effect, while the £1 billion cut to public health funding since 2015 appears to be baked in.

The Minister knows that half the difference in life expectancy between the rich and the poor is due to differences in smoking rates. The Government’s lack of action threatens our ability to achieve not just the 2030 smokefree goal, but their levelling-up mission to narrow the gap in life expectancy between areas where it is highest and lowest by 2030 and to increase healthy life expectancy by five years by 2035.

Today’s debate was originally secured to discuss the recommendations of the independent review. The fact that the review was delayed made the debate even more necessary. The Secretary of State committed, when he announced the review in February, that it would report back in April. Javed Khan said he would report back on 22 April, so we were very disappointed that the Secretary of State told Parliament last week that he hoped it would be published in May, with no commitment that that would be the case. That is just the latest of many delays and missed opportunities, which we want to put on the record.

We want a commitment from the Government that they will accept no further delays in bringing forward a plan to achieve a smokefree 2030. Let us start with the Green Paper that announced the Government’s goal of a smokefree 2030, which was launched with much fanfare in July 2019. Further proposals included considering the “polluter pays” levy, which my hon. Friend the Member for Harrow East mentioned, and giving the ultimatum of making smoked tobacco obsolete by 2030. Cabinet Office guidelines say that Departments should:

“Publish responses within 12 weeks of the consultation or provide an explanation why this is not possible.”

The Green Paper consultation ended in 2019. In July 2020, on the anniversary of the Green Paper, the then public health Minister, the hon. Member for Bury St Edmunds (Jo Churchill), told the APPG that work was under way to publish the further proposals envisaged in the Green Paper, and that she was keen to work with us to explore whether the current regulatory framework was sufficient. Since then, we have heard nothing.

The lack of an outcome on the Green Paper was disappointing, so in November 2020, we held a debate urging the Government to commit to publishing a new and ambitious tobacco control plan. We were therefore delighted when the then Minister committed in December to publishing a new tobacco control plan in 2021. The APPG commissioned Action on Smoking and Health, working in collaboration with SPECTRUM, the academic public health research consortium, to provide us with a report setting out our recommendations and the measures that the Government needed to take to achieve their 2030 ambition. The then Minister attended the launch of our report, welcomed our recommendations and committed to publishing the plan by the end of 2021. We are understandably disappointed by the delay in its publication.

There were other opportunities that could have been seized but were not. The Government were legally required to review the impact of existing tobacco product regulations, including those on standardised packaging, health warnings, product standards and e-cigarette regulations. The regulations set out in law a deadline for the review to report by May 2021. To that end, the Government launched a consultation last January to assess whether the objectives were still appropriate and whether the regulations were fit for purpose. Those regulations predated the Government’s commitment to a smokefree 2030, and it was blindingly obvious that they needed to be strengthened to match the scale of the Government’s new goal.

Since the regulations came into force, it has been clear that there are serious loopholes. The menthol ban relies on subjective rather than objective measurements to determine whether the regulations are being adhered to. An investigation by the Express newspaper revealed that the industry has exploited that loophole in the law and that Britain’s biggest tobacco giant sold £1 billion-worth of cigarettes flavoured with menthol in the year after the ban came into force.

That was not the only loophole; although e-cigarettes can be sold to those aged 18 and above, it is completely legal to hand them out free to children. While the advertising, promotion and sponsorship of e-cigarettes are heavily regulated, packaging and labelling are not. That has allowed the use of sweet names for vaping products, with cartoon characters and garish colouring, all of which appeal to children. Those are clear gaps in the law that need to be fixed without further delay.

The consultation was well timed to feed into the Health and Care Bill. ASH and SPECTRUM provided the Government with detailed and well-evidenced proposals for a number of improvements that would strengthen regulations and fix those loopholes. When the outcome of the review was not published in May 2021, as was required, we hoped that the Health and Care Bill would contain the further proposals the Government had promised to bring forward. Imagine our disappointment when the Bill was introduced to Parliament last July. Although it included measures on prevention and public health, there was nothing on tobacco or smoking, despite the Government’s much-trumpeted smokefree 2030 ambition.

That is why, in Committee, I tabled a set of amendments for increased regulation on tobacco, based on the APPG’s recommendations. The amendments included requirements to consult on a “polluter pays” levy; introduce pack inserts containing quit information; put warnings on cigarettes; close loopholes in the existing regulations on menthol and e-cigarettes; and consult on raising the age of sale to 21—a measure that has been proven to reduce smoking rates in the population at large by 30%. That measure has also been shown to reduce inequalities, because it has the greatest impact on the poorest and most disadvantaged communities. Throughout the passage of the Bill, Ministers in both Houses have repeatedly said that the Government were sympathetic to our aims and amendments, and that they would be considered for the next tobacco control plan. However, the tobacco control plan has already been delayed by a year and still does not have a publication date.

If the Government had supported those amendments, we would now have the foundation in place for a comprehensive strategy to end smoking by 2030. Instead, the Government have chosen to reject the amendments and, yet again, to kick tobacco control into the long grass. Now we are waiting for the tobacco control plan. Before the plan can be published, we have to wait for Javed Khan’s independent review, which will be followed by a public health disparities White Paper in the spring, which will in turn be followed by the tobacco control plan. That will leave only seven years to deliver the smokefree 2030 goal.

Since evidence first emerged of the harms caused by tobacco in the 1950s, smoking has killed more than 10 million people in the UK, and it continues to kill hundreds more every day. Up to two thirds of those smokers die prematurely from their addiction. There is a crucial message around children: every day, 280 children start smoking—that is more than 280,000 since the smokefree 2030 ambition was launched. Smoking is highly addictive; two thirds will go on to become daily smokers. With that in mind, can the Minister assure us that the tobacco control plan to deliver the smokefree 2030 ambition will be published no later than three months after the independent review? Will she also assure us that the Queen’s Speech will include a commitment to bring forward legislation in the next Session to deliver regulatory measures essential to delivering the Government’s ultimatum to the industry to make smoked tobacco obsolete by 2030?

I end with a comment from the chief medical officer. He pointed out that one in five people who die from cancer will die from lung cancer, and went on,

“the reason that people like me get very concerned and upset about it is that this cancer is almost entirely caused for profit…a small number of companies make profits from the people who they have addicted in young ages and then keep addicted to something which they know will kill them.”

[Caroline Nokes (in the Chair)]

I shall now put Members, starting with Hywel Williams, on a formal time limit of six minutes.

Health and Care Bill

Caroline Nokes Excerpts

Consideration of Lords amendments
Wednesday 30th March 2022 Commons Chamber

[Dame Diana Johnson]

I am talking about women’s experience, so I will continue, if the hon. Gentleman does not mind.

The woman may have to make arrangements if she has childcare or caring responsibilities, or she may have to take time off work. In the case of a coercive and controlling relationship, she would have to explain where she is going to a perpetrator, such as the Mumsnet user who said she had to visit a hospital to access abortion care and was “terrified” of her abusive ex-partner finding out where she was. She spoke of having to construct “various lies” about where she was that day and why she had to have someone look after her children.

I referred to NICE and the World Health Organisation in an intervention, but we should be aware that since telemedicine was introduced the risk of complications related to abortion has reduced, as women are able to access care much earlier in their pregnancy. I will rehearse the long list of supporters of the measure continuing: The Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of General Practitioners, the British Medical Association, the Royal Pharmaceutical Society, the Faculty of Sexual and Reproductive Health, the TUC, Women’s Aid, Rape Crisis, Karma Nirvana, the Terrence Higgins Trust, End Violence Against Women, Mumsnet, and many others. What I find most disappointing is that the Government are going against a wealth of robust and widely accepted peer-reviewed evidence from medical professionals and women’s charities, and appear to give greater weight to anecdote, erroneous opinion and misinformation focused on campaign groups with extreme views who bombarded a consultation. Sadly, that further emphasises that this is not an evidence-based policy decision.

[Caroline Nokes (Romsey and Southampton North) (Con)]

Will the hon. Lady give way?

[Dame Diana Johnson]

I want to address the issue of safeguarding. Let me be clear: creating more barriers to access does not help women; it helps abusers. The End Violence Against Women coalition and other major VAWG organisations reject the claim that telemedical abortions put women at greater risk of coercive abortions. The fact is that coercive pregnancies are far more common than coercive abortions, and since the introduction of telemedical abortions providers have seen a rise—a rise—in safeguarding disclosures, highlighting that the system provides a safe space for women to come forward if they are being coerced. Nurses are highly trained to assess safeguarding issues, and if concerned they will ask the women to come to the clinic for face-to-face assessment.

Finally and crucially, women themselves strongly favour keeping telemedicine for early medical abortion. A clear majority want it to continue.

As a country, we have an opportunity to be seen to be a shining light for women’s reproductive rights around the globe at a time when those rights are being rolled back elsewhere. The weight of the evidence in favour of maintaining this essential women’s healthcare pathway is overwhelming. I ask Members to support the amendment in lieu.

Oral Answers to Questions

Caroline Nokes Excerpts

Tuesday 1st March 2022 Commons Chamber

[Gillian Keegan]

I thank the hon. Lady for her question. She raises an incredibly important point. As a Government, we are determined to tackle long autism diagnosis waiting times. We are investing £2.5 million as part of the NHS long-term plan to test and implement the most effective ways to reduce autism diagnosis waiting times for children and young people across England. That is vital, because we know that the earlier children get the support, the better the outcomes are for them. We are absolutely determined to work on this, but the diagnosis pathways are sometimes quite complex.

[Caroline Nokes (Romsey and Southampton North) (Con)]

16. What plans his Department has to take steps to permanently implement the telemedicine service for early medical abortion.

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

The Government will end the temporary approval put in place at the beginning of the pandemic. We have extended the temporary approval for six months until midnight on 29 August 2022. From that point, abortion services for early medical abortion will return in line with pre-covid regulatory requirements. As with any healthcare service, this measure will be kept under review.

[Caroline Nokes]

Can my hon. Friend explain how the decision to end telemedicine for early medical abortion supports women who responded to the Department’s own consultation, how it works in line with the Royal College of General Practice, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives, and what the dangers are in ignoring their advice when pulling together a women’s health strategy?

[Maggie Throup]

The temporary approval was put in place during the pandemic to address a specific and acute medical need to reduce the risk of transmission of covid-19. It was recognised that without it, significant numbers of women would not have been able to safely access abortion services. Thanks to the success and impact of the national vaccination programme, the situation is now very different. In making this decision, the Secretary of State has considered all the risks and benefits regarding the temporary approval.

Cumberlege Report

Caroline Nokes Excerpts

Thursday 3rd February 2022 Westminster Hall

[Caroline Nokes (Romsey and Southampton North) (Con)]

My right hon. Friend has made that point a number of a times during his speech, and it is worth highlighting. I know that my hon. Friend the Minister will do some great work on the women’s health strategy, but time and again my right hon. Friend has said that women’s voices are being ignored and dismissed. They are told that they are imagining things and that it is in their heads. It is not good enough.

[Alec Shelbrooke]

I completely agree with my right hon. Friend. In fact, I will later make a couple of points on what I have discovered about women’s health. The way women are treated is quite appalling.

Another person says:

“I had my TVT in Exeter 12 years ago. Exeter consultant in 2020 told me I couldn’t be referred to Bristol. He said he would refer me to UCLH but I never heard from them, I rang in 2021 to be told UCLH hadn’t received any referral but they then put me on their wait list from when I’d been told the referral was made. I then heard nothing from them for ages so I paid for a private consultant at Bristol to be told I could have been referred to Bristol on the NHS in the first place. Bristol requested NHS tests in Exeter which were done in August 2021 and they referred me back to Bristol in October, so I am now on Bristol NHS list for removal”.

Somebody else says:

“Took 4 years to be referred to specialist mesh centre, after a lot of pushing and pushing for it, referred to Royal Victoria Hospital in Newcastle upon Tyne. The mesh centre was no better, more lies, gaslighting and a really appalling treatment and total indifference, lots and lots of mistakes, cancelled appointments and no regard for any pain or suffering.”

Another person says:

“Told too dangerous to remove…left in agony...self-catheterising, lost job, pain management referral but they are behind 12 months …invisible and invalid is how I feel…is this my life at 54?”

Somebody else says:

“I went for a consultation for removal in 2020 had a scan then asked to contact his secretary when I’d had an MRI which I did in December 2020. Now still waiting for them to contact me. I leave messages and nothing happens.”

I could go on and on and on, and I am sure that many other right hon. and hon. Members will be raising similar cases. What I want the Minister to comment on in today’s debate is this. There is now, from the relevant royal colleges, the “Purpose Statement for the Mesh Complications Management Training Pathway”. That statement outlines several areas, but I will highlight just the “Mesh Complication Management credential”. Its subheading is “Professional Identity: Clinical Expert” and it states:

“The doctor has the knowledge, skills and attitudes required for clinical assessment of patients presenting with suspected mesh-implant complications…The doctor is able to investigate mesh complications, and interpret the results of tests, appropriately…The doctor is competent in non-surgical management of mesh complications…The doctor is competent to undertake mesh removal surgery as part of a multidisciplinary team”.

This is progress, but I think we can all understand that there is going to be a long time around that, so I say this to the Minister. Can the House please have regular updates on how this training process is going, within the royal colleges, for surgeons, because we need to understand what the process is and how long it is taking to try to deal with the main issue?

That brings me to the other parts of recommendation 5 in the report of the independent medicines and medical devices safety review. The written ministerial statement in response said:

“Recognising the need for enhanced data collection on pelvic mesh, the Government in 2018 announced the provision of £1.1 million for the development of a comprehensive database of urogynaecological procedures, including vaginal mesh, to treat pelvic organ prolapse and stress urinary incontinence. I can update the House that the pelvic floor information system has started to receive live data, including historical data from July 2017 onwards, with an initial focus on supporting specialist services to report every pelvic floor and comparative procedure to this national database.

The report of the IMMDS review also recommends that the information system is accompanied by a retrospective audit of mesh procedures, and by the development of a patient reported outcome measure (PROM) or patient reported experience measure (PREM). I am pleased to announce to the House today that the Government accept both these recommendations. NHS Digital has been commissioned to scope and deliver the retrospective audit. Subject to receiving high quality research bids, a new validated PROM for pelvic mesh procedures will be commissioned through the National Institute of Health Research in 2022.”—[Official Report, 21 July 2021; Vol. 699, c. 73WS.]

Again, I ask the Minister whether she can update us on progress in these areas and, after today’s debate, could she speak to her Department about ensuring, even if it is just through a written ministerial statement, that there is a regular update on the progress being made?

I will give a summary of the points that I have made. GPs are unaware of mesh complication centres and the referral process. Many patients are denied access and offered physio and pain management instead. They pay thousands of pounds for private care. They experience extremely long delays for appointments. Many women end up seeing their implanting surgeons, who then dismiss them. That leads to further deterioration in their physical and mental health. There is a lack of experience, particularly in mesh removal. There are only around four to five surgeons in the UK who can do mesh removal. There is no post-op aftercare.

More positively, on recommendations 6 and 7, the Government announced that the MHRA

“has initiated a substantial programme of work to improve how it listens and responds to patients and the public, to develop a more responsive system for reporting adverse incidents, and to strengthen the evidence to support timely and robust decisions that protect patient safety.”

Recommendation 7 was:

“A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation. This can be linked to specifically created registers to research and audit the outcomes both in terms of the device safety and patient reported outcomes measures.”

The Government accepted both recommendations. Again, I ask the Minister for an update.

Recommendation 8 states:

“'Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors' particular clinical interests and their recognised and accredited specialisms. In addition, there should be mandatory reporting for the pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians.”

The Government said that they accepted the recommendation in principle:

“We agree that lists of doctors’ interests should be publicly available, but we do not think that the GMC register is the best place to hold this information”,

so “publications of interest” should be held by healthcare providers. Having approved the recommendation, how is that progressing and how easy is patient access?

Finally, we get to recommendation 9:

“The government should immediately set up a task force to implement this Review's recommendations. Its first task should be to set out a timeline for their implementation.”

The Government accepted the recommendation in part.

Having probed the recommendations to open the debate, I ask the Minister whether she and her Department are able to say positively that they are meeting recommendation 9. Are the recommendations being implemented properly and is she revisiting the recommendations rejected by the Department initially? We can all recognise from the examples that I have given that the mesh centres are not working, that people’s lives have been destroyed and that they will need to support throughout their lives. We cannot just draw a line, have a year zero and say that we hope such things do not happen again. We have to move forward.

Drawing on what my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) said and on my research, it is clear to me that the NHS is constantly failing women. During the pandemic, I read a report—unfortunately, I have not been able to reference this since, so it is open to challenge—stating that gynaecological surgeons were taken off their operating theatres for longer than any other surgeons, being kept on the frontline of the covid wards.

That says exactly where the problem in the NHS lies. That comes up not just in this debate, but next week, in another debate, on problems with endometriosis. It seems that the NHS is—I do not say this in a positive way—gender-blind to the needs of women and the complications that occur. It is an attitude, a built-in psychology, that we will have to address, and we can only start to do so if we take all the aspects of this report seriously.

Although men have mesh issues too, this debate is dominated fundamentally by women’s health. It speaks to that wider assessment of NHS priorities on women. We have to start doing something about that. We must stand up and say that we are not afraid to criticise areas of the NHS, because I am sure that as we go through the debate we will have example after example from which we can draw only one conclusion: women are being failed.

My hon. Friend the Minister, as a practising nurse, will know the importance and vocation of patient care. With her professional eyes, will she allow the NHS to ignore the plight of people who are suffering every day? To be blunt, her predecessor appeared to. I ask her to apply her considerable and dedicated professional expertise to get the Government to direct the NHS to adopt the recommendations, or at least to mirror them. That is the least we can do for the terrible and horrific damage that the NHS has caused to so many people. To finish: the NHS did this, so the NHS must fix this.

--- Later in debate ---

[Caroline Nokes (Romsey and Southampton North) (Con)]

It is a huge pleasure to speak in this debate. I extend my congratulations to my right hon. Friend the Member for Elmet and Rothwell (Alec Shelbrooke) on opening the debate in an incredibly sensitive and thoughtful way. I hope that I can follow his lead and not get angry at the Minister. I do not blame her for this, and I know that she has a very real and personal commitment to the women’s health strategy, which we will see come forward in the spring—I was grilling special advisers on that only this morning. However, I urge her to listen carefully to the voices she has heard today, and to recognise that Members of Parliament speak up on behalf of their own constituents. We hear in our surgeries, week in and week out, about the issues that are affecting women and impacting their wellbeing and health. I urge her to ensure that those voices are listened to ahead of the final strategy being published.

We have heard it all today: sodium valproate; Primodos; mesh. I always hear “the victims of mesh”, and I absolutely regard them as that; they are victims of a surgical process that has left them in absolute agony. Each of us here this afternoon has a different perspective and interest. It is absolutely right that we all have highlighted the particular areas of concern to us.

Of course, I have victims of mesh living in my constituency. I also have a wonderful family whose daughter has been the victim of Primodos. Her story is one that always resonated with me, because she is exactly the same age as I am, and has been living with her disabilities since 1972. However, I really want to talk about sodium valproate. I do not know why that issue stuck with me so clearly, other than the fact that it was through the contribution of two amazing women—Emma Murphy and Janet Williams—who came to see me when I was a very newly-elected MP, and spoke to me about valproate. I am not an evangelist for banning the use of valproate—it is such an important drug, and has a valuable impact on those patients with epilepsy who need it to support them and manage their conditions well—but it is imperative to recognise that the dangers of valproate were known for many decades but not articulated to those women who were taking it and were of child-bearing age.

We have, for decades, had really effective pregnancy prevention programmes for various drugs. I always highlight—as my right hon. Friend the Member for Hemel Hempstead (Sir Mike Penning) pointed out, we have been here before—the use of Roaccutane, which I remember taking probably 30 years ago. I had to sign all sorts of bits of paper promising not to get pregnant. Then, when my daughter was prescribed it as an 11-year-old, she had to have a pregnancy test every single month— at 11—to demonstrate that she was not pregnant and that it was therefore safe to give her the drug. The same measures were not put in place for valproate.

Emma and Janet went digging around in archives; they have made endless freedom of information requests, and they have had their work recognised by the World Health Organisation. The pressure that they put on Members to convey the importance of a proper investigation to people like my right hon. Friend the Member for Maidenhead (Mrs May) brought forward the Cumberlege report, which was so valuable.

I will give a bit of a timeline: on 8 July 2020 that report was published; on 9 July, I was in the House for the oral statement on the Cumberlege report. I can remember my hon. Friend the Minister’s predecessor, the then Minister of State at the Department for Health and Social Care, my right hon. Friend the Member for Mid Bedfordshire (Ms Dorries), actually giving us hope and confidence.

I listened to her, that day in the House, and thought that she had the tone of her response absolutely right. She promised to take away the issues that we were all raising. She promised to look at all of the recommendations that the Baroness had brought forward so competently and effectively. I had hope, as did the campaigning women from In-FACT, and the hon. Member for Bolton South East (Yasmin Qureshi), who is on the APPG. We all had hope that the recommendations would be accepted and acted on with speed.

Then, on 21 July 2021, a whole year later, rather than having an oral statement in the House, when we could ask the Minister what was going to happen, and what action was going to be taken on the recommendations, the Government snuck out a written ministerial statement on the last day before recess so we had no opportunity to bring forward the concerns that we had on so many of the recommendations either being rejected or only accepted in part. Those campaigners felt despair—not the hope that they had a year before, but despair.

The third date that I want to highlight—this is where I will provide some air cover to the Minister—is 15 September 2021. Rarely in a Member’s career does the opportunity come along to ask question No. 1 at Prime Minister’s questions, and on 15 September is was my turn. It will probably never happen to me again, so I carefully considered what issue to raise. We all have brilliant constituency issues that we want to raise or things that we have been campaigning on, and suddenly, in a Zoom call with Emma Murphy and Janet Williams, I went, “Do you know what? I have question No. 1 on Wednesday.”

I used my question to ask the Prime Minister about the specific issue facing the parents of children impacted by foetal valproate syndrome: their children have learning difficulties and additional needs. Some are born with spina bifida, a cleft palate, heart defects or limb malformations. They have all sorts of additional challenges, which are expensive. They need redress and specialist centres where their children can get the support they need, to lead as full a life as possible. Guess what? Their parents also need respite. They need be confident that their children are being properly looked after, cared for, supported and helped to counteract all the challenges they face, and they need a break, but they have been offered none of those things.

So, in September 2021 I asked my right hon. Friend the Prime Minister if he would recognise that there was an additional cost—a fiscal impact—on these families and if would he commit to making redress available. He responded by indicating that the Government was

“committed to making rapid progress”—

I emphasise the word rapid—

“in addressing all the areas that”

the Cumberlege report

“mentions, including the one that my right hon. Friend covered today.”—[Official Report, 15 September 2021; Vol. 700, c. 964.]

Yet we are still waiting for redress and for the specialist centres, and the families are waiting for an acknowledgment that they face additional costs, day in, day out, and they want help with them.

I want to ask a specific question of the Minister, which was provoked in my mind by my right hon. Friend the Member for New Forest East (Dr Lewis), who sadly cannot be with us for the conclusion of this debate. He made the point about disability and the women who have had mesh implants whose ability to work is impacted forever. I remember being a Minister at the Department for Work and Pensions. We did a lot of work around people who had long-term conditions and whether they should have to go through the reassessment process.

This would be an excellent opportunity for my hon. Friend the Minister to outline to us what work she is doing with the DWP to ensure that these women can be included in that group, so that they do not have to go through endless reassessments time and again to establish whether they are still suffering pain from mesh. That is an important point, because that would give them a sense that we are making some sort of progress. That is my specific question for the Minister, which I hope she will be able to answer.

I will not take credit for my final, really important point, which should be given to my right hon. Friend the Member for Elmet and Rothwell, who passed me a note midway through the debate. We have to make sure that this stops. We must not continue to ignore the voices of women who say they had a procedure that has damaged them, but who are told it is a mental problem and it is all in their head. We cannot have a situation where people continue to be ignored, or where drugs come on to the market and are left in use and circulation for decades, before somebody recognises that there is a problem. If we go back to thalidomide and valproate, it was decades before people recognised that there was an issue.

The point was made earlier that the aircraft and airlines industry has a no-blame, no-consequence reporting system for errors, so that if someone finds something that is wrong, it will not come back on them in their career. As my right hon. Friend said, the career of the doctor who discovered the problem with Primodos was impacted by that discovery, for the rest of her career. We cannot have that situation. Just as the airline industry has a no-blame reporting system, can we also have that in our NHS, so that people have the confidence to report, knowing it will not come back upon them? Then we will not have medicines and devices that do harm, in the same way that we no longer have planes that simply drop out of the air.

--- Later in debate ---

[Maria Caulfield]

I will come to that point. The Government have apologised on behalf of the health and care sector for the time it took to listen and respond. We are doing more than apologising: we are changing the healthcare system so that it responds to women in a much better way.

As the hon. Gentleman has just raised the issue of redress, I will touch on it now. It is not just these cases where it is often difficult for patients to get redress and compensation. I gave evidence to the Health and Social Care Committee this week on the issue of clinical negligence. This week, we announced a fixed recoverable costs scheme, meaning that, for low-value claims, we can speed up the claims process, reduce legal costs and ensure that, whatever clinical negligence they have experienced, patients are able to get compensation as quickly as possible. The findings of the Cumberlege report highlight mesh, Primodos and sodium valproate. However, across the board, it is very difficult for patients to get redress, regardless of the clinical negligence they have suffered.

[Caroline Nokes]

I do not want to be too difficult, but I do not think it is any excuse to say that because it is difficult for everyone to get compensation, we should not try here.

--- Later in debate ---

[Maria Caulfield]

Specifically on Primodos, there is pending litigation so it is difficult for me to comment while that is in progress, but, depending on the outcome, the Government will respond to that.

[Caroline Nokes]

I will go for valproate, because there is not pending legislation about that. Have I understood the Minister correctly? Is she saying that if the Primodos case is successful, the Government will review it, and the women who have had mesh implants or who are the victims of sodium valproate will not be expected to have to go down that legal route?

[Maria Caulfield]

If I touch on the points in my response, hopefully I will be able to reassure colleagues on the progress being made.

Skin Conditions and Mental Health

Caroline Nokes Excerpts

Tuesday 25th January 2022 Westminster Hall

[Caroline Nokes (Romsey and Southampton North) (Con)]

It is a pleasure to serve under your chairmanship, Mr Gray. I pay tribute to the APPG, and to my right hon. Friend the Member for Gainsborough (Sir Edward Leigh) for securing this important debate. I will try to keep my comments brief, but the challenge is that there is so much to talk about.

I, like the hon. Member for Swansea East (Carolyn Harris), pay tribute to Changing Faces, which has done incredible work to promote the cause of those with visible difference, who too often in our lives face discrimination and bullying. We know that 55% of young people will be bullied about their appearance. With the skin the largest organ of the body, it is almost inevitable that those who have a visible difference, such as eczema, cystic acne, scars or burns, will face some horrendous bullying at school—the sort of bullying that means that they do not take part in the ordinary activities that other children do. When I say “ordinary activities”, I mean that they do not want to take part in PE or put their hand up in class in case attention is drawn to them. Is it any surprise that children who have conditions that require medical treatment also need psychological help to overcome all of that?

I pay particular tribute to the most amazing man in Southampton, Professor Keith Godfrey—a dermatologist at Southampton General Hospital who runs the paediatric dermatology service.

Nobody likes talking about acne. I have been in this Chamber when I have heard Members say to me, “Nobody died of a few spots.” But actually, we heard my right hon. Friend the Member for Gainsborough highlight acts of self-harm in young people who feel so bullied and pressured because of the state of their skin that they do not leave their bedrooms and do not want to take part in school activities. Tragically, some do take their lives; they lose their lives because of “a few spots”. That is why it is so important that they are given the psychological help they need to get through their conditions.

Sometimes this is terribly controversial and upsets people, but I want to pay particular attention to the drug Roaccutane, which in itself can cause low mood. It is therefore important that young people who are prescribed it get the support they need when under prescription. We are terribly good at ensuring that young girls who are taking that drug go on the pregnancy prevention programme, but terribly bad at ensuring that the young men who take it get the support they need to get through low mood swings and the depression that some—I am quick to emphasise, not all—feel.

The Women and Equalities Committee last year conducted our inquiry into body image and the pressures that young people face. Of the evidence that we took, particularly from witnesses put forward by Changing Faces, two stick out in my mind. Tatyana, who was a burns victim when she was a very small child—she was at primary school when she was disfigured—gave us the most incredible evidence, in which she spoke about the importance of being open and talking about her skin condition.

Tatyana also spoke about the importance of role models. Pretty much everybody we see on social media today—those influencers of young people—is seen through a filter, so they look perfect at all times, yet young people look in the mirror and do not see that same perfection. Tatyana drew attention to Katie Piper, who she said was the only person she saw in public with visible burns who she could hold up as a role model. She said that she talks about it because she wants that young boy or young girl in their bedroom to see somebody who looks like them who is prepared to speak up publicly and ensure that other people have the courage to take part in everyday life.

I conclude with a plea from Changing Faces, which provides a brilliant, charity-run service that includes its skin camouflage clinic and one-to-one counselling support. Changing Faces would love to work with the Government. My plea to the Minister is: please, go and talk to the people there, listen to the lessons that they have learnt and the support that they can give, and work out how we can bring them into the NHS and help clinical commissioning to ensure that the psychological support is available for those who need it.

Eye Health and Macular Disease

Caroline Nokes Excerpts

Tuesday 11th January 2022 Westminster Hall

[Caroline Nokes (in the Chair)]

Before we begin, I remind hon. Members that they are expected to wear face coverings when they are not speaking in the debate. This is in line with current Government guidance and that of the House of Commons Commission. I also remind you all that you should have a covid lateral flow test before coming on to the parliamentary estate, and give one another plenty of room when entering and leaving the Chamber. I call Jim Shannon to move the motion.

[Jim Shannon (Strangford) (DUP)]

I beg to move,

That this House has considered the matter of eye health and macular disease.

Thank you, Ms Nokes. This is a very important issue. I suppose all issues are important, but this one is very important, as I shall illustrate in my speech. I place on the record my thanks to the Backbench Business Committee, as always, for agreeing to schedule this debate, and to the Macular Society, which is working with Fight for Sight and Roche pharmaceuticals in the Eyes Have It campaign group—we say “The Ayes have it” in the House many times, and the eyes have it literally this time—for its support in securing the debate.

I thank all the hon. Members who are here for taking the time to discuss this important issue. I have spoken to some of them, and they will all bring their individual comments and contributions to the debate. I am very pleased, as always, to see the shadow Minister, the hon. Member for Denton and Reddish (Andrew Gwynne), in his place, and it is a particular pleasure for me and for all of us to see the Under-Secretary of State for Health and Social Care, the hon. Member for Lewes (Maria Caulfield) in her place. We look forward to her response as well.

As someone who had glasses from a young age—eight years old—and who has had diabetes for the last 15 years, I can say that eye health is a matter of great personal import, as well as a constituency issue that affects a huge swathe of my constituents. Every day, 250 people start to lose their sight. At least half of all sight loss is avoidable. That is the key issue in this debate, because if sight loss is avoidable, the question is what steps we take to ensure that people do not lose their sight. With that in mind, I look forward very much to the Minister’s response.

More than 2 million people have sight loss, and 350,000 people are registered blind or partially sighted. Age-related macular degeneration is the leading cause of blindness in adults, leading to 50% of blindness. The hon. Member for Great Grimsby (Lia Nici), when we spoke last night, told me that she herself has this. Therefore the contribution from the hon. Lady, out of everyone in the House, will be particularly poignant and relevant to the debate.

I was shocked to learn that more people in the UK are living with macular disease than with dementia. We hear lots of stories—I am not saying we should not, by the way—about dementia, but just to give an idea of the magnitude of the subject of this debate and its importance, there are more people with macular disease than there are with dementia. Macular disease is a particular risk for the nearly 4 million people in the UK who, like me, are living with diabetes. I have long been instructed that poor control of blood sugar and insulin levels can damage the blood vessels of the eye, causing fluid retention in a condition called diabetic macular oedema. About one in every 14 people with diabetes develops DMO, which will result in a noticeable loss of vision.

Why should this topic be flagged as urgent for every Member of the House? Well, the issue is not just the physical health problems but the financial costs. The cost of eye conditions to the UK economy has been estimated at £25.2 billion per year, and without action, that is forecast to rise to £33.5 billion per year by 2050, so there is clearly a financial equation to this issue. It is about prevention and about reducing the costs for the health service as well. But cost is not the only important factor. The fact is that it is an awful thing to lose one’s sight and—for many people—one’s independence. Members across the House will know—perhaps through their own experiences or those of a loved one, or perhaps through the stories shared by their constituents, which we see in our constituency offices each and every day—the impact that sight loss can have. Loss of vision can have an impact on quality of life by undermining patients’ ability to live and work independently. For example, I recently met a member of the Macular Society, Bryan, who was diagnosed with age-related macular degeneration in 2012 and told me that something as simple as catching a bus can become very challenging.

Sight loss can also have a profound impact on emotional wellbeing. Sight is considered by many people to be the most important sense. Patients with macular disease, who are at risk of losing their sight, report feelings of isolation, shock, anger, anxiety and hopelessness. Those feelings may grow as individual sight deteriorates, with patients increasingly cut off from the world as they had previously experienced it. Losing one’s eyesight makes one particularly lonely; those who lose their eyesight do not know what is happening around them. I often think that, of all the senses that one could lose, eyesight is—with no disrespect to those who have lost other senses—the most important.

At the same time, macular disease can put pressure on the family members, friends or neighbours who act as carers for people with macular disease. This means that, although macular disease is more common among older people, its effects can be felt across the working-age population as well. Such feelings are understandable.

Without treatment, sight loss can be rapid. For example, wet age-related macular degeneration—wet AMD, where blood or fluid from abnormal blood vessels leaks into the macula, causing scarring—can cause significant sight loss within a matter of weeks. That is why this is so urgent. It is vital that patients are diagnosed and treated as quickly as possible. Can the Minister tell us what has been done to achieve the early diagnosis of AMD? It is so important that sight loss is addressed urgently. Other hon. Members in the debate will reiterate what I am saying shortly.

--- Later in debate ---

[Lia Nici (Great Grimsby) (Con)]

I thank the hon. Member for Strangford (Jim Shannon) for securing the debate. As he alluded to earlier, I have macular disease, and I want to speak about what macular disease is and its effects.

When I was diagnosed 20 years ago, my eye specialist told me that I was going blind. Anybody who does not really understand about going blind might think that one day the lights will switch off, but that is not actually the case. The macula is a particular part of the retina that deals with detail. Over time, it becomes very difficult for people to see in the centre of their vision; there is difficulty reading, recognising faces and writing. It poses a number of challenges, but there is life after a macular disease diagnosis. Hon. Members will notice that I am using my iPad—technology performs a huge service to people with issues such as mine.

I would like to talk about some of the causes. We have talked about diabetes and age-related macular degeneration, but it also happens to younger people. It happened to me when I was young, as secondary to high myopia. Councillor Daniel Westcott, a colleague and constituent of mine, was diagnosed at the age of 17 with Stargardt disease, which is a loss in the macular area of the eye. Despite it ending his career as a plasterer—he could no longer see enough detail—he trained as a teacher and is now working as both a personal trainer and a councillor. Those people who experience the shock and concern of being diagnosed can certainly still have a very positive life that contributes to society.

I want to talk about the importance of going to the optician. We have talked about ophthalmology, but as the hon. Member for Strangford said, it is going to the optician regularly that spots these serious issues. With the retina in particular, speed is of the utmost importance. I went to my optician because when I was reading I noticed that the lines on the page of my book had a dip in them. I went to the optician not thinking anything of it, but it was actually the start of the back of my eye bleeding and causing a bubble. Imagine looking through a window through a raindrop—that is the effect that starts to happen. If anybody hears of someone having that kind of issue, they must go to their optician, who will give them an urgent referral to the hospital. If they cannot get to the optician, they should go to accident and emergency straight away and explain; they will then get straight in to the eye specialist. My constituency is Great Grimsby—that is where I live—and Diana, Princess of Wales Hospital has a fantastic ophthalmology team. Mr Kotta, Mrs Bagga and the whole team are fantastic; the nurse specialists really are specialists, and they are fantastic at care and treatment.

It is incredibly important that we support technology companies being able to continue helping with this. In my case, 20 years ago there was no treatment for my eye condition. However, when it went into my second eye, there had thankfully been a lot of development in technology. I had 11 injections directly into my right eye in order to save my sight. Companies such as Regeneron and Novartis have produced medicines that go directly into the eye. If they had not been available, I would now be registered blind. The effects of those 11 injections meant that my eyes improved five lines on the acuity test. That is quite amazing, and it allowed me to continue to drive. I obviously still have some issues, and colleagues will know that they have to prod me because I do not always recognise them—especially on a dark night. Stem cell research is the real pinnacle, and will hopefully mean that people’s eyes will work better for them in the future.

I want to highlight computer technology, and in particular Apple computers. Twenty years ago Apple had the foresight to ensure that accessibility was built into their operating systems. If it was not for Apple’s technology and foresight, I could not have continued in my previous job of teaching, video production and camera operating. When a camera operator is told that they are no longer going to be able to see, that can be a little bit of a problem. Computer technology allowed me to continue to be able to do what I do, and Members can see that I am working with large text today. It is absolutely vital, and I say to other producers of computer operating systems and programming systems that they should really think about simple things to allow people to zoom in and to magnify. All those things are now on the market and they really do make a difference to people’s independence.

If someone does not lose all of their sight, it is very difficult for people to understand. They do not walk into things, and their peripheral vision is fine. It is the detail that is the problem. For a lot of people, that affects their independence. They can no longer read a telephone bill or look at something on the internet. If they love reading, they can no longer do that either. Writing is also affected because they cannot see what they are doing. There is much hilarity in our household when people say that I should become a professional prescription writer because they cannot read anything that I write any more.

Most important, for me, is the role of employers. When I was first diagnosed, my public sector employer—whom I will not embarrass by naming—was appalling. They were not supportive; in fact, they went into panic mode. I would like to say to employers that when somebody comes to you to say that they are having eye problems, do not go into panic mode, because they can continue to be a positive, important part of the team. It just means that they will need slightly different ways of working. I continued to run a television station, keeping a close eye on my editors and camera operators, who always used to say that I may have eye problems, but I could still see their mistakes.

The Royal National Institute of Blind People in particular was fantastic. Its staff will come and do a free assessment in the workplace and offer advice to the employer. I also thank the people at ACAS because when my employer was being downright dirty, they were fantastic in advising me in what I was able to do. Rather than people with eye or macular disease having issues and becoming vulnerable, they can actually become a positive and important part of the team—even more so than before their eye problems. I send this message out to employers: embrace the team member who has these issues, because they will continue to be a fantastic part of the workplace.

[Caroline Nokes (in the Chair)]

I thank the Member for that contribution. We now come to the Front-Bench spokespeople.

Health and Care Bill

Caroline Nokes Excerpts

Report stage
Tuesday 23rd November 2021 Commons Chamber

[Dawn Butler]

My hon. Friend makes a valid and valuable point. One way we can show our appreciation for nurses’ work is to protect their title, but we should not do that instead of addressing any of the issues she mentioned, along with ensuring that they receive a pay rise.

I thank the people who have petitioned for the change in my new clause for a number of years, including the former Secretary of State, the right hon. Member for South West Surrey (Jeremy Hunt), who is no longer in his place but supports my new clause; the Labour Front-Bench team; Ann Keen; the chief nursing officer for England, Ruth May; Professor Mark Radford, the chief nurse at Health Education England; the previous chief nursing officer for Northern Ireland, Charlotte McArdle; Andrea Sutcliffe, Matthew McClelland and the Nursing and Midwifery Council; Mr Paul Trevatt; Professor June Girvin; Dr Crystal Oldman; Ms Shamim Donatta Ayiecho; Ms Leanne Patrick; Mr Gerry Bolger; Ms Catherine Eden; and the Florence Nightingale Foundation leadership scholars. The Government know that there is a lot of support for new clause 12 and I hope it passes today.

[Caroline Nokes (Romsey and Southampton North) (Con)]

It is a pleasure to contribute to this debate and specifically to speak to new clause 1, tabled in my name and the names of the right hon. Member for North Durham (Mr Jones) and many other Members throughout the House. First, though, I pay tribute to my right hon. Friend the Member for South West Surrey (Jeremy Hunt) for his incredibly important amendment on the workforce. I also pay tribute to my hon. Friend the Member for North West Durham (Mr Holden) for his crucial new clauses on virginity testing and hymenoplasty. As the Chair of the Women and Equalities Committee, I was pleased to be able to support those amendments and am delighted that the Government have introduced their own new clauses on those issues.

I wish to talk specifically about aesthetic non-surgical cosmetic procedures, which may seem quite trivial in comparison with the important matters I just referred to, but I vividly remember visiting a doctor in my constituency and talking to her about her experience when a patient came to her after she had had far too much lip filler placed into her lips by an unqualified and inexperience practitioner. The poor girl’s lips had, frankly, exploded, leaving her permanently scarred and with the prospect of many years of corrective surgery to try to rebuild her face. That is the stark reality.

The hon. Member for Brent Central (Dawn Butler) spoke about people being able to call themselves nurses when they are not nurses; aesthetic cosmetic practitioners can not only call themselves that but perform all sorts of procedures, some of which we would find it bizarre and disturbing to talk about and, indeed, at some of which we might look with absolute horror when they are reported on the internet and in the pages of national newspapers. I am talking about semi-permanent make-up and permanent tattooing, which can leave people permanently disfigured. The semi-permanent variety can fade to leave people with bizarre blue eyebrows that require many different procedures to be put back to normal. The list is long: we are talking about tattooing, botox and laser treatment—just imagine the damage that high-powered lasers can do to somebody’s skin when in unqualified, untrained hands.

[Dr Whitford]

Along with the damage to patients who trustingly go for such procedures, is it not also about the fact that when they go horrifically wrong, as sometimes they do, it is the NHS that ends up having to pick up the pieces?

[Caroline Nokes]

I thank the hon. Lady for using exactly that term because she is right: it is about the NHS picking up the pieces and spending taxpayers’ money trying to correct something that should not have been done in the first place. If it is to be done to somebody, it should be done only by the qualified, trained and, as my new clause argues, licensed. I call today for some form of licensing or regulation. I absolutely accept that the Minister may view my new clause as deficient and not doing what he would want it to do. I appreciate the fact that he took the time to meet me and other Members last week to discuss the issue, because there are concerns throughout the House.

I pay particular tribute to my hon. Friend the Member for Sevenoaks (Laura Trott), who has done so much work on injectables in respect of under-18s and deserves absolute credit for getting her private Member’s Bill on to the statute book. That is amazing work and I really appreciate the fact that she has done it. Nevertheless, we need to do more and to go further.

I pay tribute to a number of my constituents who, following the work I did last year on the beauty industry, approached me on this issue. In particular, I pay tribute to Dr Chris Rennie of Romsey Medical Aesthetics, and to Dr Mitra Najafi, who has developed an incredible process by which plasma-rich platelets are extracted from a patient’s blood and injected back into them. It is a highly medicalised procedure and her big worry is that if it falls into the hands of somebody who is unregulated and unlicensed, it could be extremely dangerous indeed. Those with medical qualifications absolutely understand how they have to treat blood products; the stark reality is that those without do not.

I pay tribute to aestheticians—I struggle to say that word—such as Naomi O’Hara who came to me, as someone who practises, to call for regulation and licensing.

I pay tribute to a lady who is not my constituent but travelled to Romsey to see me: Tania Gough, who publishes the Image Directory. Her concern was that it is perfectly possible for someone to set themselves up in practice with next to no training whatsoever. She spoke to me of some of the horror stories that she herself had seen and some of the training courses she had gone on that she said were quite simply not worth the money she paid for them or the waste of her time. She said that certificates were issued at the end of such courses that gave the impression that people were qualified and trained when in fact they had had no more than a couple of hours—in one case it was 90 minutes—of training.

I also pay tribute to the Chartered Institute of Environmental Health and the Joint Council for Cosmetic Practitioners; they have been incredibly supportive and helpful in the drafting of new clause 1. The Joint Council for Cosmetic Practitioners says:

“The creation of a national licensing scheme for practitioners of aesthetic non-surgical cosmetic procedures would ensure that all those who practise are competent and safe for members of the public.”

To my mind, that is the abiding word: safe. We want those who receive these sorts of treatments not to be putting themselves in harm’s way.

I look forward to the Minister’s response; I know he is listening on this issue. He can expect me not to push my new clause to a vote, but I very much hope he can show us a constructive way forward that may take us to the regime that we want to see.

[Tonia Antoniazzi (Gower) (Lab)]

I could speak about so many aspects of the Bill—such as the U-turn on the social care cap, the lack of action to include health inequalities, allowing private healthcare providers to access our NHS and, frankly, whether a reorganisation of the NHS at this time of crisis is what we need to support all our healthcare workers—but I am sure that colleagues will more eloquently cover a lot of those points in their contributions. As the chair of the all-party parliamentary group on cancer, I will restrict my comments to the amendment on the NHS workforce tabled by the right hon. Member for South West Surrey (Jeremy Hunt).

Staffing is the biggest challenge facing the NHS. The Prime Minister claims to be building 40 new hospitals; if that ever happens, they will be of no use to anyone if there are not the doctors, nurses, radiotherapists, pharmacists, porters, cleaners and other staff to look after patients. As we have already heard, the NHS had 100,000 vacancies before the pandemic started. That, coupled with the intense strain and burnout that staff have suffered over the past 18 months, is causing a crisis in staffing that needs bold action now.

The Budget was a missed opportunity to invest in the people who make the NHS great, but amendment 10 would go some way to rectifying that. According to research from Macmillan, it is estimated that we need an extra 3,371 cancer nurse specialists by 2030—that is a doubling of the number of cancer nurses in just over eight years if we are to have any chance of providing the care and support that patients deserve. Macmillan has worked out that it would cost £174 million to train and develop specialist cancer nurses to plug the gap. Any increase in funding would be passed on to devolved Governments through Barnett consequentials. In the grand scheme of things, £124 million in England, £31 million in Scotland, £12 million in Wales and £7 million in Northern Ireland is not too much to ask of the Government—it is probably in the region of the amount of money spent on security for the Prime Minister’s trip to Peppa Pig World at the weekend.

Chronic Obstructive Pulmonary Disease

Caroline Nokes Excerpts

Wednesday 17th November 2021 Westminster Hall

[Caroline Nokes (in the Chair)]

Before we begin, I remind Members that they are expected to wear face coverings when not speaking in the debate, in line with current Government and House of Commons Commission guidance. I remind Members that they are asked by the House to have a covid lateral flow test twice a week if coming on to the estate, which can be done either at the testing centre or at home. Please also give each other room when you leave the Chamber.

[Mike Amesbury (Weaver Vale) (Lab)]

I beg to move,

That this House has considered support for people with chronic obstructive pulmonary disease.

It is a pleasure to serve under your chairmanship, Ms Nokes. I am grateful for the opportunity to lead the debate—and on World COPD Day itself, no less. Chronic obstructive pulmonary disease impacts many of our constituents, but it is simply not given the clinical priority in our health systems that it should have. I hope today, with the other parliamentarians present, to push the Government a step further and improve our fight against COPD on a few fronts: to push public health action to avoid our constituents contracting it; to improve diagnosis rates, so that it is caught at an earlier stage; to transform treatment to help patients manage their condition; and to invest in more research, so that we can develop groundbreaking diagnostics and treatments.

I am thankful for the hard work of the British Lung Foundation, which has campaigned tirelessly for better recognition and treatment of lung disease and which, ahead of World COPD Day, has highlighted the experiences of those living with COPD in their report “Failing on the fundamentals”, which I know some hon. Members in the room will have seen. I am also grateful to the all-party parliamentary group for respiratory health and those involved with the COPD national action plan for their work. I know that some Members present are involved in that APPG; I thank them sincerely. Many thanks also go to my constituent Sarah Jones, who has worked with the taskforce for lung health and pushed me to raise the fight against lung disease in Parliament after the sad loss of her father, John Jones, from idiopathic pulmonary fibrosis.

Chronic obstructive pulmonary disease is a group of lung conditions that cause breathing difficulties, including emphysema, which is a breakdown of lung tissue, and chronic bronchitis, the chronic inflammation of central airways. It is a disease chiefly caused by smoking, which causes nine out of 10 cases of COPD. Air pollution, childhood poverty and exposure to dust in workplaces are also contributing factors. I know that other Members in the Chamber will be very familiar with COPD and its constituent conditions. Many champion the cause of their constituents while others have direct experience.

In a case study provided by the British Lung Foundation, Chris highlights his desperation to breathe—something that many of us take for granted—the panic, the fear, the wheezing and in some cases the crushing sensation that he feels in depleted lungs. Those are just some of the facets of the debilitating disease known as COPD. Early signs are shortness of breath, a wheezing chest, tightness, chronic cough, lack of energy and weight loss. I encourage people with these signs to get an appointment with their GP.

According to the National Institute for Health and Care Excellence, 3 million people in the UK suffer from COPD. Shockingly, 2 million of are undiagnosed. As Sarah Woolnough, the chief executive of the British Lung Foundation stated:

“It is hard to imagine, for example, this proportion of cancer cases going undiagnosed”.

But that is the reality and it has to change. It is nothing short of a silent scandal.

To the Government’s credit, in response to campaigners and clinicians campaigning for respiratory disease, COPD is given priority in the NHS long-term plan. Yet, like all plans, the devil is in the detail and delivery on the ground is essential. It is vital to ensure that people with the disease are diagnosed early. Too often, diagnosis occurs only when the disease has considerably progressed, leading to greater risk of damaging flare-ups of COPD symptoms and greater risk of being one of the 30,000 people killed by the disease every year, making it Britain’s fifth biggest killer.

Of course, we encourage people to see GPs, but 9.8% of people in the north-west, for example, are struggling to get appointments. I am sure the Minister will refer to that in her reply. An important survey conducted by the British Lung Foundation—its largest ever of those suffering with COPD—found that 75% of those surveyed were missing out on the basic care recommended for the disease.

The theme of this year’s World COPD Day is “Healthy Lungs—Never More Important”. It aims to highlight the risk COPD poses against the backdrop of the pandemic, which has represented a higher risk for those suffering from lung disease and resulted in the additional demand on services created by the impact of covid-19. Even before the pandemic, it is clear that those with COPD experienced unacceptable delays in receiving a diagnosis—delays that can prove fatal.

Diagnosis rates, already far too low, plummeted further during the pandemic by 51%, meaning that nearly 50,000 of our constituents in England alone missed out on a diagnosis. Although the impact of covid-19 was widespread across our health service, this drop was more substantial than for comparable non-respiratory diseases, such as diabetes. Some GPs were advised during the pandemic to stop diagnosis breathing tests and they have yet to restart.

Does the Minister think that we should put in place a delivery plan with funding to get lung health strategies back on track and tackle the respiratory backlog so that another 50,000 people do not miss out on the diagnosis in the coming year? COPD already costs the health economy £1.9 billion. This could be an effective saving, not only of lives, but of essential financial resources.

Can the Minister confirm whether the new diagnostic hubs announced as part of the Budget will cover the tests needed to diagnose COPD and other pulmonary diseases? It would be useful to hear more detail on the part these hubs will play in the diagnosis of lung disease, and on an effective staffing and recruitment strategy.

The British Lung Foundation’s recent report on the experience of people with COPD also highlights shortcomings after diagnosis. It found that three quarters of people across the UK did not receive the five fundamentals of COPD care, as set out in the NICE guidelines. The problem is particularly severe in the north of England and in the devolved nations. Tackling this and ensuring that everyone is offered the five fundamentals of COPD care needs to be at the centre of the strategy. Those five fundamentals are a written management plan, access to pulmonary rehabilitation, help to stop smoking, management of co-existing medical conditions, and access to flu and pneumonia vaccinations.

As with many diseases, prevalence of COPD is linked with deprivation. Between 2019 and 2020 the life expectancy gap between the least and most deprived areas in England grew from 9.3 years to 10.3 years for men and 7.7 years to 8.3 years for women. Respiratory conditions are major contributors to widening health inequalities in the UK, with those living in the most socioeconomically deprived areas in England seven times more likely to die from respiratory disease compared with the least deprived areas.

In my constituency of Weaver Vale, 2.6% of residents are estimated to suffer from COPD, compared with 1.9% of people in England as a whole. Looking at the map of the prevalence in my constituency, we can clearly see that the most deprived areas have twice the proportion of COPD cases than the least deprived areas, and I know other hon. Members here will have the same experience. Eighteen of the 20 clinical commissioning groups in the worst areas for respiratory diseases and emergency responses are in the in the north of England.

If the Government are serious about tackling health inequalities and levelling up life chances, more work needs to be done to ensure that COPD is not overlooked as one of the major respiratory conditions driving health inequality in the UK. If this Government are really serious about levelling up, that should be a focus. Those living with COPD, as well as those living with other diseases, should have equal access to fast diagnosis, care and treatment, no matter who they are and where they live. I hope to hear from the Minister about how her Department plans to ensure that disparities in COPD prevalence, diagnosis and care are a major part of the national health inequalities strategy.

In most cases COPD is caused by smoking, so I would like the Minister to give an update on the new tobacco control plan, how it will focus on tackling health disparities and how she intends to plan and fund an effective, high-quality stop smoking service throughout the country. Over the past 11 years, many of those services have been cut, so I would be fascinated by her response.

Finally, I would like to raise the problem of awareness of COPD, lung disease more widely and the importance of lung health. Today’s debate has primarily focused on the lack of funding, the lack of real clinical and Government priority and the lack of awareness that extends beyond that. I would like the Minister to outline how, as part of getting lung disease the delivery prioritisation it desperately needs, her Department can promote greater public awareness of lung disease. Our shared interest must be to transform COPD care in the UK, while driving down the numbers who develop this condition in the first place. I look forward to this debate, and I certainly look forward to the Minister’s response.

Menopause (Support and Services) Bill

Caroline Nokes Excerpts

2nd reading
Friday 29th October 2021 Commons Chamber

[Caroline Nokes (Romsey and Southampton North) (Con)]

It is always a privilege to be in this Chamber to support the work of the hon. Member for Swansea East (Carolyn Harris). It is just over a week since we last debated the menopause in the Chamber, and I always say that in Parliament we should pick not just our battles but our allies. It is a pleasure to campaign, to hold a revolution and to be a warrior alongside her.

The reality is that all women will go through the menopause, but not all women will suffer symptoms. Only about 80% suffer symptoms and HRT—a brilliant, wonderful solution to some of those symptoms—does not work for everyone, and the same type of HRT does not work for every woman. That is why it is often a case of trial and error, going through many prescriptions to find the form of HRT that works for each woman and resolves their symptoms. We have to address the costs because women will be bearing the burden of prescription after prescription until they find the solution for them.

We have heard a little this morning about education, but no one has yet paid tribute to the brilliant work of my right hon. Friend the Member for East Hampshire (Damian Hinds), who made sure that, as part of personal, social, health and economic education, girls are not just taught about periods, not getting pregnant and contraception but are taught about what might happen when those periods stop. Of course, it is not just a matter for girls. Their male classmates and colleagues, their fathers and brothers, also need to be part of this discussion.

As we have heard repeatedly, there is too little knowledge in schools and in the workplace. I regard this place as a workplace and, until very recently, it was heavily male- dominated, but we are clawing it back, sometimes just one seat at a time. I pay tribute to the work of one of the foremost menopause warriors, Anne Milton, the predecessor of my hon. Friend the Member for Guildford (Angela Richardson). As Deputy Chief Whip, Anne Milton played the crucial pastoral, human resources role of helping many of us with conversations on all sorts of weird and wonderful health issues. It helped that she was previously a nurse, but she was an evangelist for HRT. When I spoke to her about it yesterday, she said, “Just go and get yourself a prescription, because this will solve those hot flushes at night and the fact you wake up in a puddle of sweat.” I still tried to say, “No, I’m sure that’s just my insistence on sleeping under a 13.5 tog duvet.” Apparently not.

I vividly remember being brutally asked by GB News, “What are your menopause symptoms?” I recoiled a little from the question, which I thought was a bit rude. And then I thought, no, I have to talk about it. I regard it as my duty to talk about it so that younger women know, whether it is brain fog, anxiety, hot flushes or night sweats, this is all normal and it can be addressed.

[Angela Richardson (Guildford) (Con)]

I had that conversation with my predecessor, the right hon. Anne Milton, quite a few years ago, and she completely changed my mind about HRT. My mother and aunt had to go through this 30 years before me—I am now 47—and they had difficult reactions to HRT. My aunt died from cancer that, anecdotally, was blamed on HRT.

It was Anne Milton who said to me, in a frank conversation, “This is what women need to live good lives.” I pay tribute to her for having the courage to have that conversation with me, and I pay tribute to my right hon. Friend the Member for Romsey and Southampton North (Caroline Nokes) for the courage she shows in talking about it, too.

[Caroline Nokes]

My hon. Friend has made the point—lead good lives—and that is what we want to do, whether it is at home or at work.

Something in particular has struck me during Menopause Awareness Month. I have spoken to many employers about the menopause workplace pledge, and have talked to members of organisations in the City of London about what they can do to support women. According to a survey carried out by the Fawcett Society, 50% of women working in financial services were not taking on additional responsibilities because they were worried about their menopause symptoms, while 25% were considering leaving work. Women at the height of their careers are potentially losing them, and not providing those brilliant female role models to which we all need to aspire in order to progress in our careers.

I make no criticism of my right hon. Friend the Member for Pudsey (Stuart Andrew), the current Deputy Chief Whip, but I issue a plea to all those in the Whips Office: make sure you have good, strong women in there who can provide advice when it is needed. I pay tribute to Claire Hattrick, who lives in Hampshire and runs the clipboardclaire.com website, providing impartial, informed advice for women when they are going through the menopause. Many of us simply do not know what the symptoms are. We do not understand them, and we do not know where to turn. Claire and many like her across the country provide that advice, free of charge and independently, giving us all hope that the symptoms can be dealt with.

Bills such as this mean that we will debate the issue on the Floor of the House as well as in the wider country. It is about having the conversations, about making sure that we understand, and, most of all, about joining the hon. Member for Swansea East and ensuring that we are all warriors and allies, and that we are going to bring about change.