Tuesday 17 July 2007
[Mr. Peter Atkinson in the Chair]
Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Watts.]
I last initiated a debate on immigration matters in this House on 18 March 2003. The then Minister for Citizenship and Immigration, who is now the Minister for Children, Young People and Families, dismissed pretty much out of hand the serious and detailed points that Conservative Members made to her. Events have proved that she was totally wrong to do so, for this is a matter of the greatest and most profound concern to all our constituents, and I very much regret that it has been often inadequately and always insufficiently addressed in the House of Commons. I am thus grateful for this opportunity to return to a matter of such gravity for the country.
I was taken by an article in The Observer on Sunday by Henry Porter. He correctly made the point that our British way of life is
“tolerant, spirited and full of humour.”
We often forget that Britain is a successful and largely good-natured society despite having to absorb 2 million or more people from scores of countries around the world over the last 10 years.
He went on to state:
“If you ever wanted to see the accumulated virtue of British culture you might start with the humour, consideration, tolerance, generosity and all-round nous to be found in any mixed gathering anywhere in these islands.”
We should all rejoice at that, but ahead lie some dangerous shoals that could threaten the harmony. The issues must be dealt with and debated more regularly, in a calm and sensible manner.
There have been many debates about asylum but it is no longer the main issue. The principle of asylum for genuine cases is not disputed in this House. In any case, those numbers are now, thankfully, coming down: asylum now accounts for only some 6 per cent. of net foreign immigration. Nor is the debate about our existing legal immigrant communities. They are a valued part of our society, and they have enriched and often greatly enhanced it.
The serious issue for this House and for our country is the sheer scale of immigration that is now taking place. It is utterly misleading to claim, as some do, that people became used to immigration in the past and will do so again. The present scale of immigration is absolutely without precedent in our history. There have been only two major waves of immigration since the Norman conquest in 1066: the Huguenots in the late 17th century, and the Jewish refugees in the 19th and 20th centuries. Both those migrations were spread over 50 years, and both amounted to less than 1 per cent. of the population of Britain at the time. With foreign immigration currently running at 300,000 a year, we are now receiving an additional 1 per cent. of our population every two years. In other words, annual net foreign immigration is now 25 times higher than it has ever been in the past, even at the two peaks.
Talk of Britain as a nation of immigrants is absurd. It would be much more accurate to describe us as a nation of emigrants. Indeed, the number of emigrants exceeded the number of immigrants until the 1980s. Net immigration is a new phenomenon and initially was quite small. Between the mid-1980s and the mid-1990s, it hardly exceeded 50,000 a year. Since 1997, however, it has quadrupled to some 200,000 a year. Even that number makes little allowance for immigration from eastern Europe. In 2005, it was assessed as a net inflow of 64,000—a figure that today looks remarkably low. None of those numbers include any allowance for illegal immigrants, who are believed to comprise at least half a million people.
The sharp increase in immigration is no accident. To suggest, as Ministers do, that it is all a result of the fall of communism or of globalisation is, frankly, bizarre. The numbers point clearly to a massive increase since the present Government came to power in 1997. Part of the increase is due to their failure during their first five years in office to get a grip on asylum claims, of which more than 60 per cent. were eventually judged to be unfounded. Another part is due to their decision to allow a massive increase in work permits, which have trebled since 1997. At the same time, their decision in June 1997 to abolish the primary purpose rule has led to the number of spouses admitted to Britain doubling from 20,000 to 40,000 a year.
Those policy shifts have had a substantial impact on our population. Just over 1 million people have been granted British citizenship in the past 10 years. Net foreign immigration during that period was more than 2 million people, or 600 a day. That rate of immigration cannot be sustained without the most profound changes occurring in our society.
The first time. We have an additional 300,000 immigrants each year. At the same time, we have a Government who are paying to keep out of employment about 17 per cent. of the potential work force, and we have a critical housing shortage. Does my hon. Friend link those matters together, and does he think that policy should control them?
I am always grateful to my hon. Friend for his interventions, but, if I may, I shall come to those matters in my own time.
Looking ahead, the Government’s projections anticipate that we will add 1 million to our population every five years. Of that increase, 83 per cent. will be due to new immigrants and their descendants. Even that forecast is based on the cautious assumption that immigration will fall by about 30 per cent. from its present level and remain flat. It is still too early to judge how many east Europeans will turn out to be temporary visitors and how many will stay on as immigrants. However, it is at least possible that they will sharply increase the pressure on our population.
If proof were needed, consider the Prime Minister’s speech to the House last week. After 10 years in government, he has discovered that there is a housing crisis, particularly in respect of affordable homes. Why? Because for years, demand has outstripped supply. The Government have permitted—indeed, encouraged—the arrival of 2 million immigrants since 1997, but have completely failed to build the necessary houses or the wider social infrastructure that is so vital. They have not even built enough social housing to match the number of grants that they have made of asylum and other forms of protection. All those people qualify for social housing and many, but not all, will take it up.
My hon. Friend is making an important point. I wonder whether he heard the Prime Minister interviewed by John Humphrys on the “Today” programme last week. The Prime Minister said that he recognised that demand was outstripping supply, but completely ignored Mr. Humphrys when he suggested that immigration may have played some part in that. Does my hon. Friend think that the Prime Minister is in denial in respect of the points that he so rightly raises?
I do not know whether the Prime Minister is in denial, but it is a fact that the Government persistently refuse to discuss the matter in public. They adopt what I understand is called in America the “ostrich” defence.
Looking ahead, the Prime Minister trumpets his plan to build 3 million houses by 2020. Many of them will have to be on greenfield sites. What he omitted to mention was that 1 million of them will be not for existing immigrants, who are now a valuable part of our community, but for new immigrants, and that even that vast number depends on the Government’s assumption that immigration will fall by 30 per cent. from present levels, and stay flat thereafter.
Housing is vital to the future of every family in this country. It is now unaffordable for key workers in many parts of the country, and millions of young people are unable to get on the housing ladder. The Government’s record on housing is a miserable tale of incompetence and is a complete failure of joined-up government. That record has largely resulted from their failure to face up to the practical consequences of mass immigration, but it is also a result of the failure of Members to talk about key national issues in the House in a sensitive and intelligent manner. That failure is reflected in the media, including the BBC, which reported the proposal to build 3 million houses without even mentioning the I-word. The BBC’s present work on impartiality should lead it to ensure that the basic facts about immigration are clearly and accurately set out. Dodging sensitive issues is simply not good enough, either for the BBC or for us.
The infrastructure of schools, hospitals and roads must also be considered because immigration levels mean that we are committing ourselves to building a city the size of Birmingham every five years. International migration flows are predominantly to England—the most densely populated part of the United Kingdom—which is already four times as crowded as France and 12 times as crowded as the United States. Pressure on public services will also inevitably grow. The health service is facing additional strain, not only because of numbers and the need for interpretation services, but because some of our new arrivals require major treatment. Immigrants have certainly contributed a great deal to our health service. However, although the flow of indigenous doctors and nurses has improved, they now have difficulty securing entry-level positions because they have been filled by immigrants.
The pressure on our education system has also increased, not only because of the numbers of immigrants, but because many pupils arrive with no English. Clearly, the local authorities most affected must be helped to deal with those problems. However, it has become abundantly clear that our statistical information is completely inadequate to trace the flow of migrants around the country. Indeed, the Minister and I have been in protracted correspondence about the Government’s absolute failure to formulate any idea of how many people fail to turn up after they have been granted temporary admission, and then fail to show again. In any case, the only effect of central Government subsidy is that the taxpayer, rather than the ratepayer, pays. The costs still fall on our society.
Understandably, there is also major concern about, and question mark over, social cohesion. Migrants now arrive at a rate of nearly one a minute. All those people need to be integrated into our society, and it is clearly impossible to achieve that at the present rate and in the current situation. Indeed, some immigrants choose, for entirely understandable reasons, to join people of their own origin. Unfortunately, that leads to the development of parallel lives. In September 2005, Trevor Phillips, when he was head of the Commission for Racial Equality, said that we are “sleepwalking into segregation”. He has since warned that the degree of segregation in parts of our country is wholly unacceptable.
The follow-up report on Oldham, which was written five years after the riots in that town, expressed similar anxieties. Its key finding was:
“A major factor in building community cohesion in Oldham over the next two decades will be projected population change within the Borough and, in particular, the relative growth in the Pakistani and Bangladeshi heritage population. The potential risk is that pace of change in building community cohesion may be overtaken by the potential for population change to generate division and conflict.”
What lies behind that is that, in the next 15 years, the Pakistani heritage population is expected to increase by 50 per cent. and the Bangladeshi population by 70 per cent. Meanwhile,the white population will decline slightly. That is just one example of the pressure building up in some of our cities
The Government claim that massive levels of immigration are justified by the economic benefits. Certainly, there are some benefits: wage inflation has been held down, interest rates are lower than they might have been, and economic growth is slightly faster. However, most of the benefit goes to immigrants themselves. The benefit to the native British population in terms of gross domestic product per head is extremely small, even according to the Government’s own calculations. They keep changing their story, but they now claim that immigration adds 15 to 20 per cent. of trend growth which, in turn, is now 2.75 per cent. The arithmetic shows that that amounts annually to around 73p per head per week, at the most. Similar results have been found in major studies in the US, Canada and Holland. I challenge the Government to produce any evidence that immigration makes a significant difference to GDP per head, and therefore to the indigenous population.
As I have said, the reality is that most of the economic benefit goes to the immigrants themselves, which is, of course, why they come. The Government persistently duck the central issue of benefit to our own community. There are, of course, benefits that cannot be measured, such as those of a social and cultural nature, and perhaps a greater propensity for people to innovate. Social costs are becoming more widely understood, and a survey that the Institute of Directors conducted of its members in February this year noted that 85 per cent. agreed that immigration policy should take account of the impact on public services and housing. Some 80 per cent. agreed that it should also take account of the effect on social cohesion.
It is often argued that immigration fills skills gaps and thus contributes to the smooth running of companies and the economy. There is something in that, but in the long term, immigration cannot be the answer to skills shortages. As the Confederation of British Industry recognises, the key must lie in training and retraining our own work force, which consists of some 30 million people. Only recently, on 5 June 2007, the director general of the British Chambers of Commerce warned that
“skilled, work hungry migrants are masking the tragic lack of skills so many of our school leavers have.”
Other arguments put forward by the Government are simply false. The suggestion that immigration is of any significant help in paying our pensions was dismissed out of hand by the Turner commission, which reported that:
“Only high immigration can produce more than a trivial reduction in the projected dependency ratio over the next 50 years. It is important to realise that this would only be a temporary effect unless still higher levels of immigration continued in later years.”
The public sense that there are falsehoods in the Government’s arguments. Two thirds of people simply do not believe them, and 75 per cent. want an annual limit on immigration. That is the point to which I shall now turn. I believe that an annual limit is the key to restoring public confidence in our immigration system, which is now at rock bottom. My first proposal is that the level of net foreign immigration be managed downwards until it is close to the level of British emigration, which is running at about 100,000 a year and has doubled under this Government. Such a policy would mean that we were no longer adding to our population through immigration, and would relieve the pressure on our infrastructure and public services. That would require a reduction in the number of work permits, a tightening of the regulations on family reunion and much stronger efforts to remove failed asylum seekers.
It is important to recognise that limits cannot be applied to citizens of the European Union—which is not, as some allege, a matter of racism, but a consequence of treaties signed by British Governments of all political persuasions. The tough immigration policies that I advocate are not a matter of race. They would, for example, apply in the same way to Ukrainians and Ugandans, and to Americans and Indonesians. Fortunately, the omission of EU citizens from a new immigration regime would not be too serious. Migration to and from the EU14 is pretty well in balance. There was a blip when Spain, Portugal and Greece joined, but the numbers have now declined to a mere 22,000 a year. In the longer term, we can expect migration to and from the 10 new EU members to come into balance as their economies approximate to ours. Long-term pressure on immigration will come from the third world, where populations are rapidly expanding and employment opportunities for the young are sadly lagging well behind those in the EU. One measure of that is that visa applications have increased by 50 per cent. in the past five years.
Any immigration system is only as good as its ability to remove. We now find that the international human rights framework, which was established half a century ago and was brought into domestic legislation by the Human Rights Act 1998 nearly 10 years ago, has many serious unintended consequences. For example, it is making it extremely difficult for the authorities to remove from Britain people who have no right to be here and who, frankly, are abusing the hospitality and good will of our country. My second suggestion, therefore, is that a fundamental review of our membership of the European Court of Human Rights must be part of a new approach to immigration control.
My third proposal concerns the entitlement of non-EU citizens to welfare benefits. Under the transitional arrangements for the accession of eight EU countries, the Government sharply curtailed access to the welfare state for the first 12 months, but that will fall by the wayside at the end of the seven-year transition period, if not before. However, I believe that we should adapt this principle for wider use. We should deny full benefits to anyone who has not become a British citizen, or who has not worked in the UK for five years and been granted indefinite leave to remain. In other words, to enjoy the full benefits of the welfare state, a migrant would have to contribute significantly to the welfare state before being entitled to all its benefits, and/or have shown a commitment to becoming a British citizen by learning English and passing the citizenship test. Such a regime would go some way toward defusing the very strong sense of unfairness felt by those who have paid into the system for many years, but seen others benefit more or less on arrival.
To sum up, we need a fundamental rethink of our immigration system. Muddling on as we are will only add to the pressures building up in our society. I have made three proposals: an annual limit to immigration close to the level of emigration, a fundamental review of our membership of the ECHR, and a restriction of welfare benefits for those who have not contributed for five years. Finally and very importantly, we need more of an effort in this House and more widely in Britain, and we need to have a cool, sustained and serious debate on immigration, which has been long-promised but is long overdue.
I congratulate the hon. Member for Mid-Sussex (Mr. Soames) on calling this debate. I am pleased that this Minister will be replying because he is by far and away the most impressive Minister on immigration, and shows all the signs of attempting to turn around this huge oil tanker, although those who navigate such ships tell me that it takes time.
I shall begin on a slightly discordant note. The debate on immigration is rated by constituents as one of the most important. And yet look! Although I am grateful that the hon. Member for Mid-Sussex is being supported by three Back-Bench Conservative Members, no Liberal Democrat Member is here to support their spokesman, the hon. Member for Sheffield, Hallam (Mr. Clegg). I do not know whether the Parliamentary Private Secretary, my hon. Friend the Member for Wrexham (Ian Lucas), will be frog-marched into contributing to this debate, but no other Labour Member, besides the Minister, is present. Yet this is, for our constituents, one of the key issues that we are facing, and they think that we should represent their views more adequately.
I disagree also with the hon. Member for Mid-Sussex on his very firmly fixing the culture of blame to the Government. I would throw the net wider, although he would reply, “Well, he would say that”. However, I believe also that we are fighting, in the political classes, a frame of mind that is unwilling, perhaps, to suggest that it might have been mistaken in what it has prattled about for the last 30 years. Indeed, perhaps the Minister would take a message back to his Cabinet colleagues. In the statements of relief that the last bombing episode had not wrought the evil on innocent people that had been intended, Cabinet Ministers told us to be vigilant. The report back from my constituents in Birkenhead market was: “What a damned cheek that they should lecture us on vigilance!” If the political class had been a little more vigilant in the past, and responded to their regular doubts and worries about the level of immigration, we might not, they said, be listening to such statements from Cabinet Ministers. So a little less from the political leadership about those on the receiving end of that lack of vigilance from the political class would be much welcomed.
While the right hon. Gentleman is talking about political leadership, there is the small matter of deportation, which relates to immigration control. I believe that he was in the Chamber when the Home Secretary told me that, over the last two years, only nine people had been deported from this country on national security grounds. Was the right hon. Gentleman astounded by that? Does he think that that shows a failure of political leadership, given that currently almost 2,000 people are under surveillance in this country for possible terrorist activity, and that so many leave our prisons each year?
The hon. Gentleman knows perfectly well that I was in the Chamber at that time, because I asked whether we would track those leaving this country to go to terror camps abroad, and prevent their re-emergence in this country. The Home Secretary’s view was that the Government had not yet contemplated such a move, which I think suggested a lack of urgency that might haunt her as time goes on. But if I may, I shall return to that matter.
I am grateful, for another reason, to the hon. Member for Mid-Sussex for calling this debate. I wanted to present the information that he did—I shall not repeat it—in a slightly different context. We need a debate on both our national identity and, linked to that in a horrible way, our national security. I represent a seat little affected by those early waves of Commonwealth immigration. However, it includes many vulnerable people, and many others who are not vulnerable, who feel that without any debate or consultation with them, what it means to be English and to have an English identity in this country is changing. As a political class we can of course pretend that that is not happening below the surface, but we must not be surprised if, at the end of the day, events overtake us the consequences of which might shock us. The charge against all of us, not only this one Government, is that we have remained so confident about our national identity that we feel that it does not need to be renewed.
That is the case on a macro level, but we have done the same on a micro level. We have taken it for granted that just because in the past this country was very successful in nurturing children, we do not really have to pay much attention to it in the future. Well, we jolly well need to pay attention to how we nurture children, so that they become first-class citizens and contribute to the community. Likewise, we need to think much more carefully about the very nature of Englishness or, as the Prime Minister, for obvious reasons, would prefer us to call it, “Britishness”—although most people are not fooled by that and insist on Englishness, because after all we are still the majority in this country, despite figures that we have heard.
My constituents are appalled by the way that we treat citizenship: our lack of regard, our failure to think that citizenship should be treasured and nurtured. They reject totally the dominant view among the political classes that have ruled this country for 30 or 40 years that citizenship is like a trip round the supermarket—the idea that we can pick up the bits that we want and reject those that we do not like. That is not to condemn any of those who have behaved in that way. The condemnation is against us, in that we could have acted otherwise but failed to do so. I am sometimes shocked when I hear colleagues criticising groups that have arrived here more recently for their behaviour. Given that in the past we did not care tuppence how they behaved, it seems a bit rich that we should now be getting upset about some of the ways that they present themselves visibly in our community. The debate is of course about numbers, but it is also about what it means to create and maintain a community. If the Government do not change track very smartly on this issue, the sense of national identity might be lost, and then we are in totally new territory. None of us knows what it will be like to try to govern, or what the consequences of failing to be able to govern will be.
I thought that the hon. Member for Mid-Sussex was modest in the figures that he gave—they do not tally with the figures that I have tried to compute in this area—but he is right to say that we are at a loss to know the precise numbers of people coming and going. One would have thought that that would be a first requirement of those who have a duty to defend our borders. The rate is certainly speeding up, as the hon. Gentleman said. In the last three years for which we have data, the number of people coming to this country is about 2 million and the number leaving is about 1 million. I do not subtract one from the other and say, “Oh, there is a net increase of only this sum.” Those figures are changing the stock of people in this country. Therefore, one has to bear in mind both those forces.
In these circumstances, what might the Government do? I return to the intervention by the hon. Member for Castle Point (Bob Spink): we need to regain control over our borders on a much sharper timetable than the one that the Government have announced for action on this front. We should do so with the sense of urgency that most of our constituents have. I look forward very much to hearing what the Minister says on that.
I do not exclude, as the hon. Member for Mid-Sussex did in opening the debate, movements from eastern Europe. I beg him to look at those figures again and not merely to mock those clever people who told us that when we opened the borders only 13,000 people would come from Poland and other countries. Poland has an honourable history of supporting us in times of need and I am not one to disregard that lightly, but with all those who do not have to register for work because they are self-employed and those who are bringing families here, we may have had, from that first wave of immigration when we opened our borders, about 1 million people coming from eastern Europe. I do not believe that is sustainable, nor do I believe the line that the apologists trot out that most people are going home, because we now know that most people are not going home. Of course, it is a huge compliment to this country that people want to come here, want to stay and want to contribute. I do not doubt any of their motives or their good intent, but I return to the question whether it is sustainable at this level.
Of course the Government could say, as the hon. Gentleman did, that we signed treaties, but we signed treaties about the free movement of people in a single market when the countries with which we were signing those treaties had similar standards of living to our own. We have now extended our borders, for good reasons but also political reasons, and it is not sustainable to have those open borders within Europe when some countries will not begin to approach our current living standards until a time when all hon. Members who contribute to this debate have long since ceased to exist in this world. The Government have to begin a conversation with our partners in Europe about whether they think, along the same lines as some of us in this debate, that the future of the European Union is an unsure one if we continue blindly to turn our eyes away from what is now a mass movement of people within Europe, as well as what the hon. Gentleman talked about, which was people coming from beyond the European borders.
That is my first plea, which links to the point that in a sense the hon. Member for Castle Point allowed me to make as a result of his intervention. We need, as a matter of urgency, to be able to trace people from this country into Europe and from Europe to the terror training camps, which are largely but not exclusively in Pakistan. Not to do so now, given the number of warnings that we have had, will reflect—let me put it euphemistically—very badly on the Government who are in power. That is my second point.
My third proposal is that we should insist that anyone coming here should speak English; that should be one of the requirements. I say that because I believe that it is crucial that people participate and, unless we do that, we are allowing people to be subjected to all sorts of evil forces to which they should not be subjected. People who cannot speak English find it very difficult indeed to escape oppression once they are here if they are also restricted not by evil people, but by a different language.
I was waiting for the right hon. Gentleman to clarify what he meant by a requirement to speak English for those coming here. Would that cover people who came here temporarily as well, or is he talking only about those who seek to settle here permanently? If he is talking about the latter, I totally agree with him. I wonder whether it is realistic to suggest that anyone who comes through the terminals of Heathrow airport should speak English.
No, but as the hon. Gentleman knows, there are different categories here and we do have a group of people who—let us put it kindly—come here for a temporary stay and decide that it is so nice that they want to stay longer than that. Of course we do not want to test people who come into Heathrow and are to leave in a few days’ time, but insisting on an English language test would show how important our national identity is and is also important in terms of the way in which we wish to welcome people and our wish that they should be fully integrated into our community.
Fourthly, will the Government please become real about how immigration undermines other aspects of their policy? The hon. Member for Mid-Sussex touched on some of them. We all know that in our constituencies there are large numbers of people who, unless we radically change our approach to housing, will never, ever, ever have a decent home—and they scale down all the time what they mean by decent, given the terms of trade under which they have to barter. It is absurd for the Government to say that they are trying to increase significantly the amount of affordable housing for people here if we have an open-doors policy and are adding significantly to the number of people who, naturally, want to live in decent circumstances and whom we would wish to live in decent circumstances. There is clearly a conflict there.
There is also a conflict with the totally proper wish of the then Chancellor of the Exchequer and now Prime Minister to take this country’s skills base upmarket. If only employers would behave differently. If there is an endless supply of cheap labour—although the labour may in the workers’ own countries be deemed skilled—there is no incentive whatever to try to raise the skills base in this country and match that new skills base with an increase in the capital formation. If we do not do that, this country’s long-term future is doomed. There is no way that most of our younger constituents will find work over the coming decades if we do not significantly raise our game, but there will be no pressure to do so if employers have an endless supply of willing and hard-working cheap labour.
My last proposal, which takes us back to one that has already been made, is that we should be much more serious about welfare, not because we want to crack down or be unpleasant to people, but because the feeling of having contributed to the building up of certain institutions and provisions and, therefore, the feeling of owning them are part of being English, Welsh or Scottish. We are undermining one of the cornerstones of our society by allowing Tom, Dick and Harry to qualify under certain conditions—perhaps for the best reasons in the world—when others believe that one should first make a significant contribution to the community and that they have done so either as individuals or through their families. Not requiring people to make a contribution strikes against other people’s sense of fairness. In the long run, those with sharper elbows will not defend the institutions that are crucial to the poorest members of our society if they feel that those who come to this country are getting as good a deal as, or a better deal than, the English, Scottish, Welsh and Irish people who have been resident here for a long time and who—either as individuals or through their families—have contributed to those institutions.
I am grateful that we have had this debate, but I end on the note on which I began—
Before the right hon. Gentleman finishes, will he allow me to make one more point? I was waiting for him to raise one more issue, but he has not. Unless the Government and the House address the implications of immigration issues, we will see the rise of fundamentalist parties, which will fill the vacuum. [Interruption.] That would be an extremely bad thing, not only for our society, but for the excellent immigrants who come here.
Clearly, the hon. Gentleman was being prompted, but he responded very well.
I end by saying that I am appalled that the Chamber is not so full of people demanding to speak that there is standing room only. One advantage of that would have been that we would more adequately have reflected our constituents’ worries and concerns, but it would also have meant that I would have had to speak much more briefly.
I, too, heartily congratulate my hon. Friend the Member for Mid-Sussex (Mr. Soames) on securing the debate. Migration is, of course, a sign of economic success. It is also of great benefit to migrants themselves, as a recent World Bank report underlined.
As a London Member of Parliament, it is important that I contribute to the debate because London receives more than double the total amount of inward migration into the rest of the UK. It is particularly important that I contribute because the Border and Immigration Agency and the Electric house reporting centre for migrants are based in my constituency. Indeed, 40 per cent. of my casework relates to migration, and I am extremely grateful for the Minister’s assiduous responses to the cases that I raise with him.
It is important that Parliament should debate this issue. In other places, the approach has been weak and pusillanimous. Colleagues will know that I am also a member of the London assembly, and it is a great criticism of that organisation that it has felt unable during its seven years to conduct a proper investigation into what is such an important issue for London and that it has decided to have only a watching brief on it.
Migration and human trafficking are also important to me as a Croydon Member of Parliament, because Croydon Community Against Trafficking is a strong campaigner in my locality on the issues of human trafficking and the local sex industry, which is driven by human trafficking. The group has done good work to identify just how high a proportion of women in Croydon’s brothels are trafficked from overseas, and the figure is, indeed, 84 per cent. It also does important campaigning to raise awareness of the issue with the police and other public bodies. In addition, it is strongly campaigning to encourage the Croydon Advertiser and the Croydon Guardian to remove adverts based on the sex industry and human trafficking. It is unacceptable that those newspaper groups should secure profits on the back of such activity.
Important points have been made in the debate about the implications of migration policy for housing and worklessness. Worklessness among London’s indigenous population is an important issue. Where borders are relatively open in terms of migration, the combination of benefits payments and poor training among the indigenous population means that it is almost economically logical for others to be drawn into the London economy to provide the skills that are not available. That can lead to those in areas of great under-privilege becoming significantly resentful of the approach taken by those of us in the political classes, as the right hon. Member for Birkenhead (Mr. Field) stated, and there is a great danger that we will be unable to engage properly on this issue or to give voice to it.
As a candidate in the last general election, I referred to the London plan and the recognition that housing pressures exist as a result of migration. I was concerned that that should have resulted in a complaint by my political opponent and that I should be spoken to by the local police service about the matter. When authorities make such directions to prevent mainstream politicians from having a reasonable, studied and careful debate about migration, that is an invitation to electors to support parties of the far right. That is why it is so useful and such good news that my hon. Friend has secured this debate.
Obviously, it is important for us to work with our European partners to deal with migration. It is good news that the European Union tries to discourage migration from outside the EU by opening up our markets to those in, for example, the Maghreb. In that way, we are likely to be able to ensure that incentives to migrate to the EU are reduced. It is also good news that there are EU initiatives on education and work and on encouraging the return of illegal migrants to outside the EU. However, I am glad that the Government are sceptical about giving up unilateral control over our own borders.
It is also important to recognise the significance of English, which my hon. Friend the Member for Castle Point (Bob Spink) raised in his intervention. There are real concerns about the effective integration of migrants into British society, given that support for English language training is being reduced for speakers of other languages. Such reductions are entirely counterintuitive, although I understand just how strong the demands on the service are. None the less, those reductions are themselves a reflection of the way in which there has been a loss of control over the numbers coming into the UK.
I strongly agree that it is time for us to consider constructively reducing the flows of migrants into the United Kingdom. Perhaps what is happening is the result of economic success; but economies go up and down, and it is quite reasonable for us, in our national interest, to be able to feel that we have some control over the amount of immigration into our country, and that that should be in the interest of our constituents.
More than a third of the present population of London were born outside the United Kingdom. It strikes me that the Government should have a view on what the percentage should be: does the Minister take the view that it should be the majority? The question whether the majority of residents of our capital city should have been born outside the UK strikes me as a fundamental aspect of public policy. It is important for us to regain control over our borders and reduce the rate of migration into the United Kingdom.
I congratulate the hon. Member for Mid-Sussex (Mr. Soames) on securing the debate. He may be surprised to learn that I agree with quite a lot of his analysis, although I do not share some of his conclusions. To highlight the fact that there has been a quantitative shift in the scale of immigration into the United Kingdom, with massive knock-on effects on the public policy debate, seems to me to be stating the obvious. Other right hon. and hon. Members have claimed that the political class as a whole has been living in denial of that fact, and I certainly join them in that view and acknowledge that when the facts around us change as radically as they have done a political response is required.
I shall repeat some of the facts that underline my point: global migration has increased dramatically in the past 20 years and there are now 191 million people living in a country other than the one where they were born; 7.5 per cent. of the British population were born abroad; net immigration has risen exponentially since the mid-1990s to reach about 185,000 in 2005 alone, which is the equivalent of about 500 more people a day; we have heard figures suggesting that up to 600,000 workers have come from the new EU member states, although we do not yet know quite how many have returned; and just over 32 million overseas visitors came to Britain in the year to April 2007, which is twice as many as 20 years ago. Infamously, the Home Office has estimated that there are anything between 300,000 and about 600,000 irregular or illegal immigrants living in the United Kingdom. The sheer scale of what I have described is striking and new and has had a dramatic effect on public opinion. We know, from one opinion poll after another, that the salience of the issue of immigration is now far greater than it has been for a generation.
I accept, therefore, that a major public policy challenge exists. However, I do not share the three-point conclusions that the hon. Gentleman reached. I have never heard anyone explain—but perhaps the hon. Gentleman’s Front-Bench colleague will do so—how to turn immigration on and off like a tap and pull up the drawbridge for the nth new immigrant who arrives beyond the quotas unilaterally set by the Government of the day. I simply do not see how that is practicable. Equally, I understand that the perceived constraints placed by the European convention on human rights on the deportation of a very small number of individuals to countries where, let us remember, the relevant concern is that they will be tortured, is a raging preoccupation for many Conservative Members; however, given that the constraint applies, if at all, to a tiny handful of people, it is irrelevant to the issue of large-scale economic immigration to the United Kingdom.
There is a good and legitimate debate to be had about the restriction of benefits; as to some of the premises of that debate, about making distinctions between the benefits for those who have contributed to the system over a lifetime, and the benefits for those who have not, the issue may develop into how to determine the appropriate period of time to qualify a person for full benefits. It should be borne in mind—the Minister may be able to elaborate on this point—that qualification for or entitlement to benefits is already much more restricted than many people, I think, imagine, certainly for non-EU citizens.
Having said all that, it is worth recalling that there are still more British citizens living abroad than non-UK nationals living in this country. If people with second homes who spend a significant part of every year abroad are taken into account we are talking about nearly one in 10 of the British population living abroad permanently or for part of the time; it is a two-way process. One of the dangers of the kind of political debate that we could have about this subject, framed purely in terms of the threat that large-scale immigration poses, is that we may remain oblivious to the fact that British citizens benefit enormously from the mobility that now exists, particularly in the European Union. We would not want to deprive British citizens of that freedom, so we should not lightly deprive others of it.
The hon. Gentleman is noted for having an optimistic view of events; I have a slightly pessimistic one. Does he not also think that the growing number of people leaving these shores to live abroad are doing so because they are appalled by what is happening to their mother country?
No. I do not share for a minute the idea that a Victor Meldrew-style disgust is leading to that outflow of people. It has been much to our credit that we are a people who have for decades—for centuries—travelled and lived abroad. We are an outward-looking, travelling and explorative nation, and that is a good thing. Perhaps issues such as climate weigh heavily with the large numbers of pensioners who seek sunnier climes in their retirement. I do not subscribe to the right hon. Gentleman’s enormously pessimistic view, but I have sympathy with him as a sufferer from it.
Perhaps I may take up a specific point with the right hon. Gentleman. He talked, and I agree, about the need for a debate about what it is to be British, or, more specifically, English. I could not agree more and I think that the challenges posed by large-scale immigration also throw up important questions about identity and integration and the values around which identity and integration are organised. I still happen to think, however, that openness to the outside world, tolerance towards others, acceptance of diversity, and an acknowledgement of the economic benefits brought about by economic immigration are part and parcel of a liberal identity that I cherish. It would be a crying shame if in our response to the new facts we were to throw the baby out with the bath water and not acknowledge that a liberal attitude to immigration is integral to what it is to be British.
Of course I accept what the hon. Gentleman is saying, but I want to probe further. Does he believe that that identity itself might lose out, given the current scale of immigration? Is it his view that we can and should do nothing to try to restrict it; that our means may be feeble but we should at least show the political will to do so; or that it is totally unimportant?
No, I do not believe that it is a process of policy neglect or that the response should be a throwing up of the hands and to take a laissez-faire approach. I do not suggest that we should simply allow large-scale immigration to take its natural course in an unmanaged fashion—quite the reverse. If any kind of halting consensus is emerging in this political debate, it is that, given the sheer scale of inward immigration, we must ensure that it is managed. I freely acknowledge that unmanaged immigration can have negative consequences, not only for the immigrants, who may be subject to illegal trafficking, criminality and discrimination, but to the anxieties, fears and, sometimes, prejudices, of the host nation. That brings me to the latter part of my comments and some of my questions for the Minister. How should we manage the process and ensure that immigration on that scale is a positive and managed process and not an uncontrolled, unmanaged and negative process?
There are perfectly legitimate circumstances in which we should refuse to allow certain people into this country for stated reasons. If I am a pessimist, it is in this respect: I have not yet heard of a system that is sufficient in its watertight rigour to do what the hon. Gentleman suggests and somehow set an arbitrary limit and then pull up the drawbridge at the Dover coast. I challenge him to explain exactly how he would do that. We are dealing with a global phenomenon of a mass movement of people across borders, which is altogether more complex, but that process can be managed if we have an efficient, fair and effective system. My criticism of the Government is to ask why it has taken them 10 years to introduce a points-based system and the Border and Immigration Agency—steps that I welcome. Why do they propose not to reintroduce the exit controls that were abolished in 1994, so that we at least know who comes in and goes out, until 2014? That seems a lackadaisical approach.
May I finish these points before we descend into a bilateral debate?
Why do the Government still refuse to accept the case that has been made by both Opposition parties for a properly resourced and integrated border force? The Minister and I have argued across the Floor of the House many times about the virtues and vices of identity cards. Does he seriously believe that they will provide a panacea to all our ills when it comes to managing immigration? Does he accept that if there are, by his own estimation, up to 600,000 people living illegally in this country, even if we had the best controls and the tightest identity checks on the planet, we would risk driving an increasing number of people out of sight and out of mind altogether?
I come to a point that the hon. Gentleman made: if we are to manage the process properly, we need to plan for the effects of inward immigration. Much has rightly been said about the foot-dragging with which the Government have responded to the massive housing crisis, and I am curious to hear the Minister’s responses to the points that have been put to him about whether the new Prime Minister’s latest plans will be sufficient to deal with the long-term demand for housing.
I return to the legacy of the large numbers of people living invisibly and illegally in this country. What are we to do about them? The Conservative proposal that we should somehow deport those 600,000 people is utterly fanciful. Is it not time for us all to accept that as part of a more honest, candid and straightforward management of the process, we must find some way of creating a route, not an amnesty, by which earned regularisation is introduced? Will the Government consider urgently what local authorities tell us—that in areas with large numbers of new immigrants, the Government funding formula for local government simply does not reflect their particular needs? Indeed, there is a time lag of about three years between such demands being placed on local authorities and the resources being provided to them by the Government.
I know that others wish to speak, so I shall make my final points. The issue of how to promote integration as well as immigration is all important. I agree with much that has been said about the need to tighten the requirements on proficiency in the English language. As the hon. Member for Croydon, Central (Mr. Pelling) said, it is clearly contradictory to advocate that at the same time as cutting resources for English language learning. It might be time to revisit the “Life in the United Kingdom” test that is applied to people who seek to settle permanently in this country. Perhaps it should be extended to those who apply for long-term visas. The test could be made more practical so that those people are given more practical guidance on how to live in this country rather than being stuffed full of historical facts that might not be relevant to their everyday needs.
Finally, will the Minister reconsider the way in which the money raised from work permit fees is used? Perhaps it could be recycled to provide training to British workers who feel that their sectors are under particular pressure from an influx of workers from elsewhere. I understand that a UK work permit currently costs the employer £200 in comparison with the cost in the United States of just under $2,000. Does the Minister think that there is a case for increasing the cost of work permits, so that a fund can be created to retrain those who might be economically affected by the scale of inward economic immigration?
My hon. Friend the Member for Mid-Sussex (Mr. Soames) should be congratulated not only in the conventional manner on securing the debate, but on the tone in which he addressed the serious issues that he raised. Those few of us who are present agree on the importance of this issue and, I am sure, agree that mainstream politicians need to address it in a tone that is calm, moderate and fact-based. Two extremes too often intrude on this debate—hysteria, bordering on racism, and sentimentality— neither of which gives rise to good policy, so the tone is important, as is content.
My hon. Friend’s remarks were full of interesting content, much of which I completely agreed with, and parts of which I did not. I shall address all those points, but first I shall address the comments by the right hon. Member for Birkenhead (Mr. Field) about the importance of the debate, on which he was half right. Where he was wrong gives rise to an important lesson. He was right to say that the issue is hugely important and that there is a feeling out there that mainstream politicians do not address it enough, but he was wrong to say that for a generation—I think he said 30 or 40 years—it has not been addressed as much as people would have liked. There have been periods in which immigration has been hugely salient as a political issue, of which now is one, and periods when it has not. It was hugely salient in the ’60s and early ’70s, but not in the ’80s and ’90s, because the general public thought that immigration was under control in those years and was therefore a problem at least temporarily parked if not solved. Therefore, people did not have the anxiety about it in the ’80s and ’90s that they had in the ’50s, ’60s and ’70s and have now.
That brings me to my first point—numbers matter. One of the most absurd things that the Minister’s predecessor did was to accuse me, in my early months of shadowing his job, of playing the numbers game. Immigration is essentially a numbers game; numbers absolutely matter in this field as much as they do in welfare and economic policy. That kind of unthinking response to the debate on immigration has given rise to a lack of public confidence. Therefore, Conservatives seek proper control of the numbers as the absolute basis for restoring public confidence in the immigration system. That confidence has been completely lost.
The Minister made a good point earlier this year when he said that immigration makes Britain richer, but that it has also unsettled the country. He went on to say:
“The political risk for any government is that if you fail to solve this paradox you could lose your job.”
My contention is that the Government have failed to solve the paradox, but the Minister is still in post. I am sure that delights him—at least it means that we have somebody sensible tackling this paradox.
I will now turn to the points raised by my hon. Friend the Member for Mid-Sussex. The rate of change matters. Changes in the global economy—or globalisation as we glibly call it—have had some effect, but what is often not addressed is how many of those changes will stay. There is an intellectual current growing that says that most of the people who are coming to the UK, particularly from other parts of the European Union, are coming for a short time. The truth is that we do not know whether that is the case.
The evidence is that an increasing proportion of those people are deciding to stay. In the early months of the arrival of those from the A8 countries, particularly from Poland, about 20 per cent. of them said that they intended to stay permanently. If the same question was asked now, the figure would have gone up to about 25 per cent. That is intuitively plausible; as people live here, they will form relationships, come to like this country and will say, “Perhaps I will spend much of my life here.” We must presume that a smaller proportion will go home than the Government assumed.
We need to look at some of the knock-on effects. The head of the national organisation of Poles in this country has told me that it is now impossible to get a Polish plumber in Warsaw. There are now so many in western Europe that when someone calls for a plumber in Warsaw, they end up with a Romanian, Bulgarian or Ukrainian. Therefore, we must look at our wider obligations.
My hon. Friend the Member for Mid-Sussex did not just talk about the issue—he gave policy suggestions. He talked about benefits. I will leave the Minister to answer that issue in detail. The important point is that the public at large have very little understanding of the difference between contributory and non-contributory benefits. If people think that large numbers are gaining access to benefits that they feel they receive because they have been contributing to them for many years, a sense of unfairness will arise. That in itself would be very damaging for community cohesion, so it is incumbent on the Government to ensure that that sense of unfairness is mitigated in every way possible.
My hon. Friend the Member for Mid-Sussex talked about the European Court of Human Rights. He will be aware, and I am happy to confirm, that my right hon. Friend the Member for Witney (Mr. Cameron) has said that he seeks a reappraisal of human rights legislation. The Conservative party is considering whether a British Bill of Rights might be a more appropriate way to proceed in a world that has changed in the half a century since the ECHR was created. We seek no diminution in what all of us would recognise as human rights. We would like those rights set in a more appropriate context for a vastly different and fast-changing world in the 21st century.
The hon. Member for Sheffield, Hallam (Mr. Clegg) said he thought that that was irrelevant to mass immigration because it affected only a very few people. It may affect only a few people, but some of those people may be very important in the life of this country—they may be serious terrorists. Even if one person whom the British authorities regard as a threat to the safety of life in this country cannot be deported, that would cause a huge lack of confidence in the immigration system more widely and the system that surrounds it. That is why the issue is important, even if the numbers affected are not very large.
My hon. Friend the Member for Mid-Sussex said that he effectively wanted to manage this down to zero net immigration, but I must part company with him as I do not see the magic in that. If the economy benefits from immigration, rationally we should seek a level of immigration that maximises the benefit. At the same time, we should recognise that there will be strains on infrastructure and so on—he mentioned that—and thus we should seek an optimal level. It is not clear that the optimal level will be zero every year. There may be perverse periods—for example, if the economy went into recession for several years—that might increase the amount of emigration. At such a stage, it would seem perverse if that in itself permitted a higher degree of immigration when the labour market would be least able to provide jobs for new immigrants.
Although I do not agree on the zero net figure, I agree with my hon. Friend that we need an explicit limit. He, like other hon. Members, will be aware that the Conservative party advocates an explicit limit. The hon. Member for Sheffield, Hallam said that he does not see how that could work—I can suggest only that he gets out more, because it works in other countries. Many other countries have such a system and it works perfectly well. There is a greater level of public confidence in their immigration systems than exists in this country. Our proposition is that there should be an explicit limit every year, taking into account the social and cohesion factors, the ability of the public infrastructure to cope and the needs of the economy at the time.
We would expect the current limit to be substantially less than the present level of immigration, because we observe all the strains and stresses that have been mentioned today and see that in certain parts of the country the public infrastructure simply cannot cope. We advocate extending the Government’s points-based system so that we are trying to accept only people who are economically beneficial. On top of that there needs to be an explicit limit, because without one the points-based system will be meaningless; it will not increase public confidence or do what is necessary to ensure the radical change that we need.
All the points that colleagues from all parties have made about better enforcement are true. I agree with the hon. Member for Sheffield, Hallam that we need proper border police. As he knows, we have a commission examining that. It is chaired by one of the Government’s own security advisers, so we hope that eventually we shall tease the Government on to our ground on that matter.
In conclusion, I assure my hon. Friend the Member for Mid-Sussex that there is a better way than the current system. It entails more control, better border policing and tighter criteria. It will mean not only a more manageable immigration system, but greater community cohesion, as the capacity to absorb new arrivals in this country is taken seriously for the first time. He will have to wait for its introduction, but I promise him that it will arrive one day.
This may be the first time that I have served under your chairmanship, Mr. Atkinson, and it is a privilege to do so. I echo the congratulations given by hon. Members from all parties to the hon. Member for Mid-Sussex (Mr. Soames) on securing this debate. Its content and tenor illustrate that this House can debate this in an intellectually sensible and important way. I back his call for more of this kind of debate in the House. My right hon. Friend the Member for Birkenhead (Mr. Field) put it well: this is an extremely important matter for our constituents and it needs to be debated more. I understand that immigration is not on Steve Hilton’s prescribed list of topics for general debate by Conservative Members and realise that that has led to a bit of a vacuum, so I am grateful that the hon. Gentleman has sought to step into the breach. I want to sketch out a few points of agreement and a few points where a little more debate may be needed. On a large amount of the policy, there is now a degree of consensus that we have not had before..
I shall start by reflecting on numbers, because that is precisely where the hon. Member for Mid-Sussex started and it is the right place for the debate to begin. It is true that the level of immigration to this country has changed over the past 10 years, and that European economic area nationals have increased—there were around 145,000 in 2005. The number of work permit holders has doubled, rather than tripled, up to 137,000. The point is that underneath that movement of people there is a degree of consensus that is worth sketching out. We agree that we should phase out low-skilled migration from outside Europe. We have introduced controls on Bulgarian and Romanian nationals coming to this country, and for the lifetime of that policy we shall phase out low-skilled migration from outside Europe. That is a matter on which we agree.
There is now a degree of consensus on refugees. In 2005, the Conservative party said:
“We will set an overall annual limit on the numbers coming to Britain, including a fixed quota for the number of asylum seekers we accept.”
That would have involved renegotiation of the Geneva convention, and was an unfortunate policy. The hon. Member for Ashford (Damian Green) was intelligent and wise to reverse it on 29 December when he said in The Guardian:
“We will be looking at that again, and seeing what controls on asylum seekers are needed.”
There is a degree of consensus on the level of EU migration. It does not include my right hon. Friend the Member for Birkenhead, but the position that both sides of the House have settled on is that we should accept free movement of people inside Europe. When the free movement of persons directive was laid on 4 April 2006 and then translated into immigration regulations, no party prayed against it, which signalled a degree of consensus.
The hon. Member for Mid-Sussex referred to work permits. There has been an increase in the number issued, but 25 per cent. were for those in the health and medical services and 17 per cent. for IT workers. There is a sense that the increase in the number of work permits has been driven by changing patterns of economic growth. When we tightened some of the rules on work permits, there was a debate because many people thought that that was wrong. The hon. Member for Ashford wrote to me on 12 June saying that he not only spoke against our changes to the highly skilled migrant programme, but voted against them.
As a courtesy to other hon. Members, I will not give way because of the number of points to which I must respond.
There was one disappointment in what was otherwise an excellent peroration by the hon. Member for Mid-Sussex. He was absolutely right to put the debate in an historical context, but it was not set in the context of changes in the world today. That point was picked up by the hon. Member for Sheffield, Hallam (Mr. Clegg). When there are sharp bursts of increased independence, as during the past 200 years of economic change, there are big movements of people. That was true in the late 19th century and it has been true since the 1980s. The hon. Gentleman was right to point out that global migration has doubled since the 1960s. The annual rate of change began to increase sharply from the late 1980s but, crucially, it was at the beginning of the 1990s that, for the first time, the majority of global migrants moved to developed countries rather than to developing countries. That has affected not just the United Kingdom, but all industrial economies around the world.
Between 1990 and 2005, the United States gained 15 million migrants, and Spain and Germany both gained around 4 million migrants. That is in sharp contrast with the 1.6 migrants who have moved in and out of the UK. Italy’s net immigration rate today is around three times higher than that in the UK. The pattern of the debate has changed over the past decade, but that is because the world is changing.
I am grateful to the hon. Member for Mid-Sussex for making, for the first time, some practical proposals for how an immigration limit could be introduced. That has been talked about on the Opposition Benches for some time and finally we have heard one practical way of doing that. There was a degree of support, and difference of opinion, in the Chamber this morning, but finally we have had a practical solution. I do not think the hon. Gentleman proposes a cap on the number of refugees as part of that limit, which is a change on the Conservative Benches. If the cap does not include EU migration, it may not be the cap that he thinks because around 48 per cent. of the UK’s net migration is from within Europe. However, it was good to hear some practical proposals at last.
Our proposals are obviously different, and we are beginning the countdown to the points system, under which only people whom Britain needs will be able to come to work and study in this country. The system will be introduced in the new year, but with any new points system the important question is, “How many points should someone need to be able to work and study in the UK?” I have said repeatedly that we need a far more open and intelligent debate about what immigration is good for Britain and what is not. I absolutely agree with the hon. Member for Mid-Sussex and my right hon. Friend the Member for Birkenhead that the media must be part of that debate. I am sure that many hon. Members have had debates with colleagues in the media and—dare I say it?—the BBC where there is a sense that the matter is difficult to talk about and that it would be better not to. That attitude must go, and we must debate the matter more openly. It is not racist to talk about immigration, because this is the real world.
When we set the number of points that people need to come to Britain, we should have a debate that includes a much more open discussion of the evidence, which is why we propose to set up the migration advisory committee. It will be in place at the end of the year, and will advise transparently on where immigration is needed in the economy, and where it is not needed. Alongside that, it is not sufficient to set immigration policy simply with an eye on the economy. We must consider what is going on in Britain as a whole, and we are establishing the migration impact forum to take account of the wider evidence of social and other impacts of immigration on British life before setting the points threshold. I am grateful to members of the forum, which met for the first time a few weeks ago and will meet again to begin discussion in earnest after the recess.
When that policy is set, it will be critical that it is enforced effectively. I reject the calls of the hon. Member for Sheffield, Hallam for regularisation, which would be an amnesty in any other name and would put illegal immigrants at the front of the jobs queue when they should leave the country. It would send the wrong signal, and we should reject it.
We have set out measures with which to increase enforcement of the rules. That includes establishing stronger border controls not just in this country, but abroad to keep the problem of illegal immigration as far from our shores as possible. That is why we are introducing systems that will track people in and out. We shall count the majority of passengers in and out by 2009, but the same systems will allow us to increase screening of migrants before they get on a plane, train or boat and before they come anywhere near our shores.
The technology that we have put in place is already beginning to work. We have made progress with biometric visas, and have already found 4,000 people who had applied for a visa to come to Britain but who were misleading us about their identity. Passenger screening systems have found around 1,000 people who were subsequently arrested at airports. That sort of technology will be vital in strengthening future border security. It must be used alongside the new powers in the UK Borders Bill which will be important in strengthening future enforcement.
I want to reflect on Britishness. I completely agree with my right hon. Friend the Member for Birkenhead and the hon. Member for Mid-Sussex that we must have that debate in earnest in the months to come. There must be a stronger relationship between what new citizens get and what they give. Exploring whether English should be required before permanent entry is important, and I hope that when we publish that consultation it will receive wide support.
I am pleased to have obtained this debate, which is about epilepsy services and the all-party group on epilepsy’s report entitled, “Wasted Money, Wasted Lives”. It is a hard-hitting report about the human and economic costs of epilepsy in England today, and in undertaking it the all-party group was supported by the Joint Epilepsy Council of the United Kingdom and Ireland.
The report found that people with epilepsy are being left behind by society and by a system that has consistently failed them, despite the development of effective treatments in recent years. Some 69,000 people live with unnecessary seizures, while 74,000 people take drugs that they do not need. The regularity of avoidable deaths, at almost 400 a year, is shocking. In addition, the number of people who experience seizures unnecessarily and the number taking anti-epileptic drugs for which they have no need, is an issue that demands recognition as a national scandal.
The money wasted in delivering inadequate services is almost as appalling as the unnecessary deaths and the damage to quality of life that people with epilepsy experience. The all-party group gathered evidence to provide a realistic picture of epilepsy services, and it highlighted problems caused by poor service provision. The written and oral evidence from patients and their families highlights the challenges of life with the condition—and in some cases, death.
During our inquiry, it became increasingly clear that even in today’s world of competing health interests, the case for improving epilepsy services is overwhelming. Government guidelines for major changes to the treatment of epilepsy exist, but without targets or powers they are little more than wish lists, and of little use to patients who face critical failure.
The all-party group calls on the Government to accept responsibility for the shortfall in services, and to ensure that health care providers implement guidelines. It also urges the Government to address work force shortages by increasing as a matter of urgency the number of doctors with a special interest in epilepsy. The group invites the Health Select Committee to drive progress by examining the provision of health services for people with epilepsy in England, and looks to the Government to account for the decades of under-investment in this neglected area.
Epilepsy, which is the most common serious neurological condition, affecting about 382,000 people in England, is defined as a tendency to have recurrent seizures. A seizure is caused by a sudden burst of excess electrical activity in the brain, which causes a temporary disruption in the messages passing between the brain cells. Epilepsy is not a single condition; there are about 30 different epileptic syndromes and more than 38 different types of seizure. A person may have more than one type, and epilepsy can affect anyone at any age from any walk of life. Every year 990 people in England die from epilepsy-related causes, of whom about 365 are young adults and children.
Many people are wrongly diagnosed with epilepsy, and many have been diagnosed with the wrong type of epilepsy. Misdiagnosis rates in England are shocking, standing at between 20 and 30 per cent. An unknown number of people also experience misdiagnosis whereby they have epilepsy, but it is diagnosed as something else. Assuming a misdiagnosis figure of 23 per cent., that means that in England alone, about 74,000 people who do not have the condition are diagnosed with it and receive treatment for it. The Joint Epilepsy Council, in its recently published manifesto for epilepsy, shows how improvements in epilepsy care in England could realise estimated savings of £134 million a year in the annual cost of epilepsy misdiagnosis, based on figures from the National Institute for Health and Clinical Excellence.
The medical cost alone of the unnecessary treatment of people who do not have epilepsy, and of the wrong treatment of people who have been diagnosed with the wrong kind of epilepsy in England, is estimated to be £22.5 million a year. That includes neither the economic cost nor the cost in lost opportunities to people who, because of misdiagnosis or mistreatment, could be in work but are not. When those costs are included, the estimated total cost of misdiagnosis in England rises to £134 million a year.
Some 70 per cent. of the population with epilepsy in the UK could be seizure-free with optimal treatment.
I am most grateful to the hon. Lady, first, for securing the debate, and secondly, for letting me intervene briefly, because as she knows, the National Society for Epilepsy has its headquarters in my constituency. Does she agree that it is important that centres such as the NSE centre in the Chalfonts—and particularly its assessment centre, which is so successful in helping diagnose patients’ underlying problems—continue to operate? Does she also agree that an increase in resources, wherever the financial support comes from, is absolutely essential to reduce the wastage of lives, money and time, which is caused by not having the correct facilities to diagnose and support such patients?
The hon. Lady makes some valid and crucial points, and I agree with her entirely. All her points are reflected strongly in the report. Many such young people find that they have no future—their lives are wasted simply because the initial diagnosis is incorrect, or they are not diagnosed correctly at all. The point about the economic cost—the cost to the health service, and the cost in benefit terms of wasted opportunities and wasted lives—is clear.
As I said, 70 per cent. of the UK population with epilepsy could be seizure-free with optimal treatment. However, only 52 per cent. are, which means that 69,000 people in the UK who experience seizures could in fact be seizure-free. The human cost of those failings, as the hon. Lady has pointed out, is huge—for the individuals concerned, for their families, and indeed for society. Not only do they receive treatment for a condition that they do not have, but their true condition is not treated.
The NICE guidelines on epilepsy recommend that individuals requiring an MRI scan should have the test performed soon. The guideline development group subsequently decided that “soon” meant being seen within four weeks. In a recent survey by Epilepsy Action, only 26 per cent. of the 185 respondents who had undergone an MRI scan within the past two years said that they had undergone it within four weeks.
Surgery should also be made available for all people with epilepsy for whom it is indicated. There is a clear saving when we take into account the alternative of expensive lifetime medication and occasional hospitalisation —and, of course, a health benefit to the individual. Patients who are successfully treated also have better employment prospects. They are less dependent, and the high initial expenditure on epilepsy surgery would result in long-term cost savings.
In recent years there has been an increase in reported epilepsy deaths, the majority of which have involved SUDEP—sudden unexpected death in epilepsy. SUDEP deaths are usually referred to coroners, as they require specialist investigation. I have a particular interest in the draft Coroners Bill, because Harold Shipman practised in my constituency. I have come to realise that the lack of standardisation and quality assurance in post-mortem investigations and certification of SUDEP deaths is a key barrier to the implementation of recognised prevention strategies.
I congratulate my hon. Friend on securing this debate and apologise for not being able to stay for all of it. On identifying and investigating SUDEP deaths, is it not also a problem that coroners are at the mercy of local authorities in terms of the resources at their disposal? A few months ago, the all-party group heard from coroner Mary Hassall about the often grossly inadequate accommodation and staffing with which coroners must contend. It seriously compromises their ability to respond to SUDEP cases and to meet the needs of bereaved families seeking an explanation for a sudden and tragic death.
My hon. Friend is absolutely right—there are important and serious issues concerning the coroner service. I know that he welcomes, as do I, the draft Coroners Bill, which allows for a proper full-time professional service. That will make a great difference to any family dealing with a sudden or suspicious death. My hon. Friend is also right to refer to families, because another issue that needs to be addressed is the non-implementation of NICE guidelines for health professionals on communicating essential information about SUDEP and referring families affected by it to SUDEP support services.
The NICE clinical guidelines note that all adults and children with a recent onset suspected seizure should be seen by a specialist within two weeks. Generally, such specialists are adult or paediatric neurologists, but they also include neuropsychiatrists, learning disability or other specialists, and occasionally even general practitioners. An epilepsy services survey this year by Epilepsy Action suggested that only 14 per cent. of people with a recent onset suspected seizure who were referred to a specialist saw one within two weeks. Access to specialist neurologists is too limited, and a postcode lottery applies to access to neurological services.
England still has one of the lowest numbers of neurologists of any European country. The Royal College of Physicians has called for a target of 909 whole-time equivalents in the UK by 2012. In addition, the Joint Epilepsy Council believes that GPs with a special interest in epilepsy are key in delivering services closer to patients’ homes and are a vital link between primary and secondary care. It is clear that such professionals, who are easier for patients to access and do not have long waiting lists, can play an important role, specifically in making accurate diagnoses and performing effective annual reviews, as recommended in the NICE guidelines.
Epilepsy specialist nurses are also a crucial source of care, support and advice for patients with epilepsy. They enable many to manage their epilepsy effectively and remain independent in the community. Their vital role has often been recognised by the Government, including in recent NICE clinical guidance on the diagnosis and management of epilepsy, which stated:
“Epilepsy specialist nurses should be an integral part of the network of care of individuals with epilepsy.”
However, despite the chronic shortage of ESNs in Britain, recent reports suggest that the current work force is under threat. The JEC feels that it is now being forced to defend the status quo, rather than focusing on expanding the excellent services that ESNs provide. I hope that the Minister will clarify the position.
There are approximately 152 ESNs in England, and epilepsy organisations have long campaigned to increase that number to about 920. Epilepsy Action also recommends that ESNs have a case load of no more than 250 patients with active epilepsy. However, the Government have made it clear that decisions affecting ESN services are made by local health trusts, and that they cannot intervene. The JEC believes that they should do more to prevent local health trusts from seeing ESNs as soft targets when seeking to balance budgets. I welcome the recent dialogue on specialist nursing between voluntary organisations and the then Minister with responsibility for long-term conditions, my hon. Friend the Member for Bury, South (Mr. Lewis). I look forward to the draft guidance on specialist nurses that will be published in early 2008.
Ready access to high-quality, responsive primary and secondary care is crucial for those with epilepsy and would meet the needs of most. However, only 52 per cent. of people with epilepsy have their seizures successfully controlled. The 48 per cent. with seizures not controlled by anti-epileptic drugs should be referred to tertiary care clinics. Unfortunately, there is some indication that it is usually well-educated, assertive and articulate individuals and families who succeed in gaining access to tertiary services. There is concern that many with epilepsy who are less articulate are dissuaded or refused, or give up the struggle with the system, and are therefore denied the opportunity for optimal advice and care.
Between 2002 and 2006, the Government published five reports on the provision of epilepsy care—including the 2002 chief medical officer’s report—along with the 2002 national sentinel audit of epilepsy-related death, the 2003 action plan for epilepsy, the 2004 NICE clinical guidelines on epilepsy, the 2005 national service framework on long-term neurological conditions, and the 2006 White Paper “Our Health, Our Care, Our Say”. All drew much the same conclusions about fragmented and poorly co-ordinated service provision, but provision of services in England for people with epilepsy has not substantially improved over the years. However, the all-party group recognises that the Department of Health has taken initiatives regarding the care of people with epilepsy.
The NICE guidelines were described as groundbreaking in setting standards. However, their effective implementation and that of the action plan remain in question. The all-party group believes that a lack of funding is a significant reason for the serious gaps in service provision for people with epilepsy. Funding for epilepsy is low compared with funding for other conditions affecting similar numbers of people, such as insulin-dependent diabetes. Funding must be urgently rethought to address the gap in service provision.
My hon. Friend mentions the need to improve services for people with epilepsy and the huge problem of misdiagnosis. Is there not also another problem to address—the prejudice that still exists against people with epilepsy, and the misunderstanding of the condition among the general public and employers?
My hon. Friend makes an important point. A great deal of prejudice and a lack of understanding still surround the lives of people with epilepsy. Although we are politely using the word “seizures” in this debate, the general public normally refer to them as fits. It is not a pleasant description, but in people’s minds, somebody having an epileptic fit falls down in the street and jerks about, and lots of people just walk past or turn away, not wanting to face it. We should be talking about education and understanding. One of the most important points about the integration, where possible, of disabled children into mainstream schools is that young people grow up understanding the limitations and strengths of their colleagues.
A group of young epileptics in my constituency—in my home town of Hebden Bridge—now have a social group, and they see part of their role as ensuring that people in the town understand what epilepsy is. Of course, not all epileptics have grand mal seizures; some have small seizures that most ordinary people would not even notice.
Epilepsy organisations have pointed out that primary care trusts often seem powerless or unwilling to implement improvements. The reasons given for non-inclusion in local delivery plans were that national targets took priority and left insufficient funding to put in place the necessary resources to enable the trusts and general practices to implement the NICE guidelines. Yes, serious investment of an estimated £150 million is required. However, in real terms that is only £340 per person with epilepsy, which is a small price to pay for their quality of life.
In conclusion, I quickly remind the Minister of the report’s key recommendations: that the Government should urgently put in place a programme to increase the number of neurologists and other relevant clinicians to levels recommended by the Royal College of General Practitioners; that the Healthcare Commission should carry out as a matter of urgency an improvement review to assess formally the provision of epilepsy services in individual health care organisations; and that an action plan to improve services should be developed.
One issue that concerns me is the Prison Service. Much as I agree with the Government’s reforms, which have taken responsibility for prisoner health from the Prison Service and given it to the NHS, there is now an issue of confidentiality. It is quite likely that a prisoner’s epilepsy would not be known to the prison authorities. That could be worrying, because when someone has a seizure, instant action is important. Will my hon. Friend say something about that? Like me, she will be concerned about how the information is passed over. Those who have to care for such individuals should have prior knowledge of their conditions.
My hon. Friend makes an important point. That balance between confidentiality and ensuring proper care for people with a health problem—be it epilepsy or anything else—is well known to all Members of Parliament, and it is a difficult balance to strike. Obviously, confidentiality is important to those in prison. One of the report’s further recommendations is that the Health Committee should consider an inquiry into the provision of health services for people with epilepsy in England. I would like such an inquiry to include the important issue of the provision of services for prisoners with epilepsy.
The last key recommendation is that the Government should accept that for many decades, there has been considerable under-investment in what is a much-neglected condition, and that it is time for the Department of Health to put right the wrongs of the past.
I am grateful for being allowed to speak briefly in this debate. I had not intended to do so, but I am so pleased with the way that the hon. Member for Calder Valley (Chris McCafferty) has introduced it, and particularly with the report prepared by the all-party epilepsy group, that I should like to speak briefly in the hope that I can contribute to the debate. Sadly, I shall not be able to remain until the end, and I apologise to other Members and the Minister for that; it is due not to impoliteness, but to pressure of timetable.
As I said in my earlier intervention, the National Society for Epilepsy is based in Chalfont St. Peter in my constituency. I immediately issue an invitation—on behalf of Graham Faulkner and everybody else, I am sure—to anybody with an interest in the issues to visit and see the great work carried out by Mr. Faulkner and his dedicated team of professionals.
The society has been called a colony in the past; it has been operating for more than 100 years and is a site dedicated to people suffering from epilepsy. It provides not only the research and assessment facilities that I referred to, but specialist residential care for those who require it.
As the Minister will appreciate, this is a Cinderella issue. The hon. Member for Calder Valley alluded to that, as did the hon. Member for Romsey (Sandra Gidley) in her intervention—[Interruption.] I apologise; I meant the intervention made by the hon. Member for Bridgend (Mrs. Moon).
I understand that; my eyesight must be worse than I thought.
I understand that there is real ignorance among not only the general public and employers, but the medical profession. That is reflected in the report. Our residential care takes place not only on the NSE site, but in supported units in the community. That is important, as people suffering from severe epilepsy can be rehabilitated and introduced into the community. That is an important part of the work.
Obviously, the research unit is state-of-the-art and works with many distinguished scientists from around the country. One particularly impressive aspect of the NSE is the monitoring suites, which have state-of-the-art facilities for observing people continuously so that if they have an epileptic fit, they are looked at in a real-time situation. That gives those involved in the diagnosis a good chance of getting to the bottom of the problem.
It has always struck me that people come to the NSE’s assessment unit, with their families, from all over the country. Those people are often confused and worried about their condition. They stay for many weeks; the assessment is long-term in some instances. When they know that the medics have got to the bottom of their condition and that they will receive the correct treatment, their relief can be seen.
The hon. Member for Calder Valley laid out the facts and figures well, and they are in the report for the Minister to look at. Is it not a crying shame that nearly 1,000 people a year die from epilepsy? More than 360 are young adults and children—what a waste of our society’s future. Some 400 of the 1,000 deaths are considered to be unavoidable.
The report addresses not only the ignorance of the condition, but the inadequacy of provision and training. It is important that a Government concerned with the health of our whole society should examine the issue of epilepsy and address the concerns raised in the report. With certain adjustments of approach, we could certainly move to better outcomes on epilepsy. Misdiagnosis, work force issues, funding, employment, the stigma and the issues of residential care are all addressed in the report, but, as the hon. Member for Stroud (Mr. Drew) mentioned prisoners, I would particularly like to take up that point. The Minister, with her colleagues in the Ministry of Justice, needs to address the treatment of prisoners who ostensibly have epilepsy. Some 62 per cent. of diagnoses of prisoners with epilepsy were not made by epilepsy specialists and, in addition, 53.8 per cent. of those prisoners diagnosed as having epilepsy had not had a medical review for 12 months.
Does the hon. Lady have any information about the time scale of those figures? Responsibility for prison health passed over from the Home Office to the health service and local primary care trusts two or three years ago, I understand. We might be looking at two different pictures.
I must refer the hon. Lady to the report, if she has read it. I appreciate that responsibility for health passed over to the PCTs. Once again, we are seeing statistics that show that prisoners are not being followed up for a period of 12 months, and that more than 60 per cent. of those who are taking anti-epileptic drugs require a change in those drugs while none of the prisoners who need such a change have had that opportunity or been fully informed about their condition. I urge the Minister to consider that in her Department and with the Ministry of Justice, because it could impact on the access of prisoners to suitable health care, as they cannot readily walk out and consult a doctor or a nurse.
That point highlights another subject that was touched on by the hon. Member for Calder Valley (Chris McCafferty). So often, in the prison population in particular, those who suffer from epilepsy of whatever degree are labelled as having a mental health condition. That is often part of the missed diagnoses, let alone the misdiagnoses. I am anxious, as part of the liaison between the Department of Health and the Ministry of Justice, that there should be a much greater emphasis on considering the condition on its own merits rather than as a part of mental health, which, of course, is one of the main areas of concern within the prison population.
My hon. Friend is absolutely right. We have alluded to the fact that epilepsy is often associated with other complex conditions, and that is no more the case than among some of the individuals who are detained at Her Majesty’s pleasure in some of our prison establishments. I am particularly annoyed because, despite the fact that there are NICE guidelines that cover the subject, I feel from the information that was given to the all-party group that those guidelines are not being strictly implemented. I encourage the Minister to consider that.
If we want successfully to reintegrate former prisoners into our society, adequately treating and informing them, as well as allowing them access to medical services, is even more important. Those circumstances might well be linked to the pattern of offending.
I am delighted that the debate has been brought to the forefront. The area is deserted, but I hope that the Minister, whom I welcome to her role, will take a particular interest in it. If I or any of my hon. Friends can give her any help in the future to ensure that this area of our medical and community life is improved for a large number of people, I would be the first to offer that assistance.
I congratulate the hon. Member for Calder Valley (Chris McCafferty) on securing the debate. The all-party group on epilepsy’s report, which prompted the debate, is welcome because it was apparent while researching for today’s debate that there is a dearth of information about patient experience in epilepsy.
I want to pick up on the point about discrimination made by the hon. Member for Bridgend (Mrs. Moon). Unfortunately, epilepsy is one of those conditions that people often keep to themselves unless they have to tell their workmates. As Members of Parliament we are lobbied about access to all sorts of services, but I cannot recall being lobbied about access to epilepsy services on any occasion. It is clear from the report that there are significant problems. I hope that the groups that might read the debate in Hansard will give some thought not only to how they can provide support for the patients who join them, but to how they can help those patients lobby. One thing that I have learned in this place is that the more people who lobby MPs on a particular subject, the more it is highlighted in Parliament. Sadly, that fact is probably reflected in the attendance here today.
There is a particular problem regarding the families of those who suffer from epilepsy explaining the situation to their friends. I have met the group that meets regularly in Gloucester, and it is difficult to explain what having a family member with epilepsy involves. There is a general view that we must do much more on the education front to allow those people some dignity in their lives. The patient matters, but so does their family.
The hon. Gentleman makes a good point. I used to work with someone with epilepsy and at the outset, she said, “If I fall over, you do not put a spoon in my mouth. This is what you do.” She debunked the myths straight away, and we were not frightened of the condition and learned to cope with it. Sadly, she was the victim of an unexplained death as a result of epilepsy. Such deaths impact on families in all sorts of ways, too. The family found it difficult to cope with the unexplained death and had relatively little support and help afterwards. That was a few years ago, and I believe that more support is available now.
I apologise because I, too, cannot stay for the whole debate. I was lobbied the week before last by a young girl of 17, whom I met at an event in my constituency and who was very distressed because she had just been diagnosed, albeit pro tem, by her GP as having epilepsy and needing to see a specialist and an MRI scan. The waiting time was hell, creating much anxiety and fear in the family. Living with that anxiety and fear and not knowing the long-term consequences often makes it difficult for people to tell others. They do not know what the consequences will be; all they know is that it feels like a huge sentence. It is difficult to articulate their fears alongside what should be done if they have a seizure.
The hon. Lady has admirably highlighted the need for more information, not just once a firm diagnosis has been made but right at the beginning, so that the period of waiting and anxiety can be minimised. We can never get rid of it completely, but the more information, the better, and such information is not always readily available at the right source.
The NICE guidelines issued in October 2004 covered diagnosis, investigation, classification and treatment. Guidelines were also produced specifically for women—because of the issue of their taking medication in pregnancy—for children and young people, and for older people, who have slightly different needs. The guidelines are frequently not fully adopted. There is a problem with NICE guidelines in general, because in many areas of medicine they have no clout. There is no compulsion to adopt them, and although one would hope that PCTs want to optimise best practice, the financial situation often works against service change in the short term. As the hon. Member for Calder Valley highlighted, there are savings to be made by doing things properly, and the money saved can be reinvested in the service, so I do not want to get too hung up on the financial aspects.
As has been mentioned, there have been problems with referrals after diagnosis. The NICE standard states:
“Any person who has had a possible seizure should be seen within two weeks by a specialist medical practitioner with training and expertise in epilepsy.”
It goes on to state that tests such as electroencephalograms, or EEGs, and MRIs should be available within four weeks of a specialist asking for them. The all-party group’s report mentioned referral, and funding panels deciding who is referred. If the guideline is that anybody who has had a possible seizure should be referred within two weeks, presumably the GP, who knows the patient best, makes that decision. As we have heard, GPs frequently miss the first seizures. I fail to see how a GP can suspect something, and somebody else then second-guess their decision and provide a further filter. Will the Minister look into that, so that we can be confident that everything is being done in all PCTs to ensure that the guideline is being met?
The report highlights particular problems with access to diagnostic tests, and the case of someone who had to wait two years. Although when we write such reports we always love to find the worst possible case, so that we can say, “Isn’t that terrible?”, the wider statistics bear some consideration. A recent survey by Epilepsy Action showed that only 26 per cent. of the 185 respondents who needed MRI scans had them within four weeks. Will the Minister outline how this issue will fit into the 18-week patient pathway, which is the centre of attention at the moment?
The survey by Epilepsy Action also pointed out that only 60 per cent. of those affected visited their GPs after their first suspected seizure, which brings us back to the issue of public education and raising awareness of the problem. Only 60 per cent. were referred to a specialist straight away, 29 per cent. were referred after a period of time, and 22 per cent. were not referred at all. That suggests a gap in the knowledge of some GPs. It may just be a lack of awareness of the NICE guidelines, but it may be something more fundamental. Only 27 per cent. were referred to an epilepsy specialist, while 53 per cent. saw a general neurologist and 22 per cent. another consultant. Some 50 per cent. of respondents waited longer than eight weeks for a first appointment with a neurologist or other epilepsy specialist.
The problems of accessing good treatment may have more serious knock-on effects. We have heard that, each year, approximately 990 people die of epilepsy-related causes, of whom 365 are young adults and children. More worryingly, the 2002 national audit of epilepsy-related deaths concluded that 39 per cent. of adult deaths and 59 per cent. of child deaths were considered potentially or probably avoidable. That is about 400 deaths a year that could be avoided. I am not clear about how they could be prevented or reduced, but better information would be helpful. The report cites the case of a family who had not realised the full impact of epilepsy. There is a hint that they hoped that it would go away, or that they wanted to minimise it. Information for parents in particular is vital, so that they can come to terms with their child’s condition and help them to manage it.
On treatment, it was interesting to see that the quality and outcomes framework did not necessarily equate to the Government’s guidelines on best practice. Dr. Smithson stated that it
“measures the basic, not the best care.”
He stressed the need for information, support and empowerment for patients to self-manage their conditions.
One thing in the report caused me a little alarm, and here, I declare an interest as a pharmacist who is still on the register. It states:
“We understand that some pharmacists are now saying they can do an epilepsy medicines review in a chemist’s shop.”
They are called pharmacies nowadays, but I shall leave that point. It continues:
“That proposition would reduce, not improve, the standard of annual reviews.”
That completely misses the point. I am sorry to pick up on a part of the report that I disagree with, but “medicines use” reviews are intended to help patients get the best use out of their medicines. As has been mentioned, polypharmacy is often used, as people often have other long-term conditions. The reviews are about working with the patient to ensure such simple measures as drugs being taken at the right time and in the right combinations, so that they have the optimum effect and benefit. Any changes recommended are automatically referred back to the GP, who, if he is doing his job properly, should be able to use the information in an annual review. The two elements are not mutually exclusive.
By making better use of what is available on the high street—the one thing that we can be certain of is that people have to go to the pharmacy for their medication—a source of help and advice is provided. The passage of the report to which I referred was a disappointing element of it, but I hope that it was just down to a misunderstanding, and that the professions can work together across boundaries to do all that they can for patients.
There are a number of work force issues to consider. England has one of the lowest numbers of neurologists in Europe. France has three times as many by proportion and Italy 14 times as many, which I find staggering. The Royal College of Physicians has estimated that
“to provide comprehensive neurological care, including the care of the acutely ill neurological patient, one whole time equivalent consultant neurologist is required for 40,000 population. This model demands 1,250 NHS neurologists, 175 centre-based neurologists and 78 academic neurologists, which gives a total of approximately 1,400 nationally.”
It conceded that that target is perhaps unrealistic in the short term and called for a target of 909 whole-time equivalents across the UK by 2012. Will the Minister elaborate on what is being done to achieve that target?
Epilepsy nurses are an integral part of the NICE guidelines. Many patients find it particularly helpful to talk to a specialist nurse, because it is not daunting and is often done in an informal setting. They often feel that they can ask the silly questions that they cannot ask a doctor. There are only 152 epilepsy nurses, and we need to reach a target of about 920 before there will be a proper network of nurses who can help deliver the guidelines.
It is clear that an awful lot needs to be done. We are talking about a group of patients who are shy in coming forward, but who deserve help and support. For many, epilepsy is a condition to be frightened of, as was said earlier, but with the right information, support and treatment, many can live with it comfortably. At the moment, we are not helping enough people to achieve that.
I congratulate the hon. Member for Calder Valley (Chris McCafferty) on securing this important and timely debate. I am glad to acknowledge and, indeed, pay tribute to the work of the Joint Epilepsy Council and of the all-party group on epilepsy, particularly its recent report “The human and economic cost of epilepsy in England”, which has underpinned much of our debate today.
The noble Earl Howe, who is a fellow Conservative shadow Health Minister, is a member of that group, and my hon. Friend the Member for Chesham and Amersham (Mrs. Gillan), whom we heard from earlier, is an active vice-chairman. My right hon. Friend, the Leader of the official Opposition, is the secretary. I congratulate my hon. Friend the Member for Ruislip-Northwood (Mr. Hurd) on holding the Government to account over the cuts and postcode lottery in services for epilepsy, and for his part in bringing the report together.
I also pay tribute to all the organisations involved in supporting people with epilepsy and their families. Many of those organisations are members of the Joint Epilepsy Council. One such organisation is the National Centre for Young People with Epilepsy, which is based in Lingfield. It does sterling work under the excellent leadership of Professor Brian Neville. Another is the National Society for Epilepsy. My hon. Friend the Member for Chesham and Amersham ably described its services, which are headquartered in the Chalfonts and are under the leadership of Graham Faulkner and his team. I dare say that we are all tempted to try to visit the society, as she so kindly extended an invitation.
I would like to take this opportunity to welcome the new Minister. This is the first time that we have met in this debating Chamber, although we met briefly on the Floor of the House. She should be congratulated on her new appointment. With her past experience, I am sure that she will be able to help us with many of the issues.
As we discussed earlier, this is a health issue. Epilepsy is a condition but it is not even necessarily a long-term condition. It is not a mental health matter, although clearly it involves mental health considerations, and it is important to stress that those who suffer from epilepsy should not be regarded as being part of the disabled and disability agenda.
Above all, as the hon. Member for Calder Valley rightly said, there is a general problem in society in respect of epilepsy. Going back many years, there has always been a lack of understanding in the broad society about it. As the son of a nurse, I certainly remember being taught by my mother not to be frightened of people who have a seizure in the street, but I felt that I was being taught something exceptional and unusual. Also, my wife is a nurse. It is all very well if one understands the condition, but, usually, the fears of others drive the stigma and the lack of understanding that is as much of a battle to overcome as is the need to focus on the best help for those who suffer from the condition.
Behind the widely reported headlines that almost half of the 990 epilepsy-linked deaths in England each year are avoidable, that 70,000 patients do not get the drugs that they need, and that the misdiagnosis of patients is costing £134 million annually, the report is indeed hard-hitting. It is extremely thorough in its assessment of the situation and in its recommendations for action. It makes clear the Government’s failure to make the provision of epilepsy services enough of a priority.
The report notes guidelines, audits and reports published in each year since 2001. In 2001, the chief medical officer highlighted
“the serious and long-standing weakness in the standard of care”
for epilepsy, and in 2002 the national audit of epilepsy-related deaths showed that
“39% of adult deaths and 59% of deaths in children were considered to have been potentially or probably avoidable”.
In 2005, there were 990 deaths from epilepsy, of which 400 may have been avoidable.
The Government’s response was the action plan for epilepsy in 2003. In her winding-up speech, will the Minister tell us how her Department has delivered on it? Has access to neurology services improved, bearing in mind that spending money is not the same as improving services, and that the £1.2 million that was earmarked was delivered through the short-lived NHS Modernisation Agency?
Missed diagnosis and misdiagnosis are all too common for people with epilepsy. What plans do the Government have to improve and broaden the use of diagnostic services such as EEG scanning, particularly during sleep or after a time of being deprived of sleep, where appropriate? Have pathology and post-mortem services been modernised, and have support and information for families bereaved by epilepsy improved? On that particular issue, has the Minister yet looked into the cuts to chaplaincy services in our hospitals? They are key services in the support and counselling of those who are dealing with sickness and death.
Likewise, could the Minister tell us what percentage of general practitioners are GPs with special interests—that is the title that is now bandied about—and, of those, how many are trained in neurology? What progress have the medicines management programmes made? The all-party group said that a review of the action plan is needed urgently. I hope that the Minister will tell us whether she agrees and what she is doing about it.
The all-party group expressed its concern about non-implementation of the National Institute for Health and Clinical Excellence guidelines on epilepsy. The Minister will be aware of her predecessors’ failure—I am sorry to use the word—to avoid boom and bust in our NHS. The Government’s financial mismanagement resulted in cuts to our NHS last year. With a national service framework still eight years away, there is nothing to give epilepsy services the credence that they need at a local level. Until the Government accept the measures set out in our independence and accountability White Paper, the lack of accountability to patients and the public by the ministerial team in particular and by our NHS will continue to render the Government’s cry of local blame farcical and deeply cynical.
The Minister will be aware of the statement that the Department of Health made to the BBC in response to the report:
“In cases where evidence is brought to the department that local NHS is not funding NICE guidance then we will ask Strategic Health Authorities to intervene.”
How many such cases have she and her Department so far been presented with?
The subject of epilepsy specialist nurses is obviously one that is close to the Minister’s heart, as she was formerly a nurse. We are glad that someone in the health ministerial team has that background experience. The first ESN was appointed in 1988. There are now around 152, although epilepsy organisations have been campaigning for the number to increase to 920 in England. The 2004 NICE clinical guidelines stated that
“epilepsy specialist nurses should be an integral part of the network of care of individuals with epilepsy.”
That was reinforced by the Under-Secretary of State for Health, the hon. Member for Bury, South (Mr. Lewis), when he said in answer to a parliamentary question:
“Specialist epilepsy nurses provide an additional clinical resource and have spearheaded the development of nurse led and fast access clinics, monitoring treatment regimes and seizure control, support and information on aspects of medication and side effects and lifestyle precautions.”—[Official Report, 21 November 2006; Vol. 453, c. 77W.]
In spite of that, some 8 per cent. of ESNs across the UK are threatened with redundancy, reduced hours or assignment to non-specialist duties, or are not being replaced.
Furthermore, 72 of the current ESN posts were created because of pump-priming funding through Epilepsy Action. Agreements were made with the NHS trusts concerned that the posts would continue once the pump-priming funding expired. Through the scheme, Epilepsy Action provided £30,000 to £50,000 of financial support to NHS trusts to set up epilepsy specialist nurse services. Since the scheme was set up in 1995, more than £2.5 million has been invested, and 83 nurse posts have been created in the NHS. However, seven NHS trusts have not honoured their agreement to continue funding the posts once the pump-priming funding ceases. Not only is that deeply disturbing—indeed, shameful—in its own right, it jeopardises the provision of future seed-funding by charities that are involved in long-term and special conditions such as epilepsy. Another example would be the funding in 2003 by the Community Fund and the Wolfson Foundation of a new MRI scanner for the National Society for Epilepsy, which is another key member of the Joint Epilepsy Council. What does the Minister have to say to the seven trusts that have cut the funding?
I received an interesting answer to a parliamentary question the other day. In it, the Chief Secretary to the Treasury, who was then a Health Minister, revealed:
“In relation specifically to the treatment of patients with epilepsy, paramedics can supply and administer rectal diazepam, whilst EMTs”—
emergency medical technicians—
“can only administer the drug if it was already in the possession of the patient.”—[Official Report, 25 June 2007; Vol. 462, c. 228W.]
That answer seems to suggest that there is little difference between paramedics and emergency medical technicians, yet when we consider the APPG’s finding that 70,000 patients do not get the drugs that they need, that response becomes much less innocuous. The Chief Secretary to the Treasury, a former Health Minister, also told me that there is no regular collection of data on how often ambulances carry paramedics and that ambulance staffing is up to the local ambulance trust. It seems that those with epilepsy have a postcode lottery in not only elective care, but emergency care.
I come now to a matter that has not yet been mentioned and may even be regarded by some as de minimis. In my increasingly distant past I used to suffer from a severe form of migraine called cluster headache, which has nothing to do with epilepsy. Fluorescent lighting was an immediate trigger of cluster headache and was extremely difficult to deal with. I was intrigued to note that in answer to a parliamentary question asked by my hon. and learned Friend the Member for Torridge and West Devon (Mr. Cox), the Under-Secretary of State for Health, the hon. Member for Bury, South admitted:
“It is known that some people living with lupus and epilepsy, and other long-term conditions, may be affected by energy saving light bulbs. We have made no assessment of the number of such people affected.”—[Official Report, 12 June 2007; Vol. 461, c. 992W.]
That seems somewhat cavalier of the Government, particularly considering that in March this year the last Prime Minister and other EU leaders agreed to phase out old-fashioned bulbs in private homes by 2009—that is quite a short period of time—in order to reduce carbon dioxide emissions. Given concerns about the effect that the show surrounding the presentation of the new London Olympics logo had on those with epileptic conditions, it is vital that we take such potential threats seriously. If the Minister has not made an assessment in relation to that, I hope that she will inform us what steps the Department is prepared to take to ban the sale of tungsten bulbs, either directly through the Government or via the EU directive. I am, of course, fully supportive—as I think we all are—of encouraging the move to energy saving light bulbs. However, we must ensure that we do not condemn thousands of people to an existence that provokes a condition that for them outweighs the unquestionable benefit to the environment, let alone the burden put on health services.
On 24 June the Department told the Daily Mail:
“This is a developing area and we have no further comment”.
I hope that the Minister will take the opportunity to ensure that that is regarded as an historical statement and that she has something further to say on the matter.
Once again, I pay tribute to the APPG and the Joint Epilepsy Council for producing this rigorous report. I know from my work with the all-party group on malaria what an undertaking it is to produce a report of such significance and authority. I hope that the Minister will join me in that sentiment, and will address the concerns raised by the report and those mentioned during this debate.
Thank you for calling me, Miss. Begg.
My hon. Friend may not be looking for special favours, but she is going the right way to get them. I thank other hon. Members who have congratulated me, particularly the hon. Member for Eddisbury (Mr. O'Brien) with whom I look forward to working. I am surprised that although he is surrounded by so many nurses in his home life, he managed to escape to the Conservative party. Perhaps we can look at that in more detail at another time.
I congratulate my hon. Friend on her success in the Speaker’s ballot and on choosing epilepsy services as her subject. Given the number of people who live with epilepsy and the level of stigma that unfortunately still exists in society, it is indeed an important issue. I believe that my hon. Friend the Member for Bridgend (Mrs. Moon), who is no longer present—I understand that hon. Members have had to leave to carry on with their busy day—mentioned the stigma, and my hon. Friend the Member for Stroud (Mr. Drew) mentioned the family stigma.
The hon. Member for Eddisbury was kind enough to mention my former profession. On many occasions when working in an accident and emergency department —or casualty, as it used to be called—I have cared for members of the public who have suffered grand mal attacks. I know how distressing it is to observe an attack, and how distressing it is to phone the family if the person concerned is not with a family member at the time. I also know that caring for anyone suffering from epilepsy, at whatever level, within a family is exceptionally distressing because of the stigma.
I want to mention the importance of the all-party group’s report. I have read it in detail and have been astonished by some of the findings. If I cannot answer all the questions asked in today’s debate, I will give every member of the group—which is chaired by Baroness Gould—and other hon. Members a commitment to seriously consider the recommendations and I accept the invitation to attend the all-party group, with which I look forward to working.
We need to be clear that the findings and conclusions of the report affect us all. The messages are not just for Government, but for NHS managers, front-line practitioners and those who commission health services. Clearly, people with epilepsy need and deserve better services and over the past few years we have sought to address those concerns.
I would like to put on the record some of the areas in which we have made improvements. In 2002, we welcomed the sponsorship by the National Institute for Health and Clinical Excellence of a national clinical audit of epilepsy-related deaths. The audit looked at investigations into those deaths, care provided prior to death, and contact with bereaved families. In 2003, we followed up the audit with the publication of our epilepsy action plan, which drew the attention of clinicians and local health organisations to the need to establish or review policies and practices regarding the management of epilepsy and epilepsy-related deaths. My hon. Friend the Member for Pudsey (Mr. Truswell) raised the issue of the coroner and the hon. Member for Eddisbury discussed what we need to do with coroners’ reports and with pathology. I can assure hon. Members that we will consider all those detailed questions and seek to address them. If I receive an invitation from the all-party group, perhaps I could bring more information on those issues to a meeting.
The Department of Health commissioned NICE to produce a clinical guideline for the diagnosis, management and treatment of epilepsy, which was published in 2004. Additionally, the national service framework for long-term conditions, which was published in March 2005 and about which I will speak in more detail later, focuses on improving services across England for a range of neurological conditions, including epilepsy. Through the quality and outcome framework, we have also taken steps to ensure that GPs provide good quality care for people with epilepsy. Undoubtedly, we will have to look at different levels of training and monitor what happens to patients who present to their GP and how we follow up those cases. It is too early to tell how many practices have been successful in this area, but we will know later in the year when QOF data on the 2006-07 financial year are published.
The diagnosis and the importance of MRI scans and sleep electroencephalograms has also been mentioned. We are making good progress on waiting times for MRI scans, which are crucial for early diagnosis and intervention, as mentioned by the hon. Member for Romsey (Sandra Gidley). Between January 2006 and 2007, over 13 week waits fell by more than 90 per cent. from, I believe, 20,585 to 1,959. Over 26 week waits have fallen by more than 99 per cent., and I believe that now only 23 people, who have a range of conditions, are waiting more than 26 weeks for a MRI scan. We need to do more, but I am sure the hon. Lady will agree that that is a huge improvement. That figure compares with almost 5,000 when we started collecting data. Clearly, we have done much to support NHS organisations in improving epilepsy services. However, I know of the often-voiced concern that without targets or dedicated funding there is neither the power nor the incentive to force through improvements.
National standards will always be necessary to protect people against inequalities in service provision, but in taking forward our improvement and reform agenda we need a decisive shift from top-down to bottom-up as we develop a devolved and self-improving health service, in which the main drivers for change are patients, commissioners and clinicians, rather than national targets and performance management. The all-party epilepsy group’s report and the witnesses that gave evidence very ably will do an awful lot to bring about a patient-centred epilepsy service.
Effective commissioning by primary care trusts is paramount. We expect local commissioners and providers to reprioritise the way in which existing resources are used to better meet the needs and wishes of their population. The changes are being supported by a programme of reforms that include the choice agenda, payment by results and practice-based commissioning. However, all Members present will understand that to deliver positive changes on the ground to health care, we need good leadership on the ground. It is for my Department to encourage and monitor that leadership, because although to devolve responsibility might be a comfortable solution, we cannot walk away. Leadership should come at a national and local level, and I give my assurances that I shall monitor that leadership to ensure that we make that progress.
I agree absolutely with the hon. Gentleman, which is why the review of the NHS in general is being led by clinicians at every level, by people who work in the service and by patients. The review undertaken in London by my colleague the Parliamentary Under-Secretary of State for Health, Professor Sir Ara Darzi, and that for the rest of the NHS managed that very successfully. There is no other way of doing it; users and their families, clinicians, from the top dogs, so to speak, right the way through professions allied to medicine, and all of those who work in our good national health service need to feel involved.
The hon. Gentleman was kind, again, to mention my specialist interest. Specialist nurses must be brought to the forefront. The deployment of specialist nurses is of particular concern to stakeholders, and the all-party epilepsy group’s report requests an immediate commitment to increase the number of epilepsy specialist nurses to 600. Before I respond to that point, however, I take the opportunity to commend the work of Epilepsy Action, which through the Sapphire nurse scheme is doing sterling work to support the appointment of specialist nurses in hospitals throughout the United Kingdom.
I can totally reassure my hon. Friend the Member for Calder Valley that we support maximising the use of the specialised skills of specialist nurses. Indeed, we are proud that the UK leads the world in the development of specialist nursing roles. We ignore the nurse at our peril!
I thought the hon. Gentleman would be able to relate to that.
Decisions, however, on the skill mix required for patient care are best made at a local level. It is for local health economies to determine how many specialist nurses they require and to prioritise the resources needed for the necessary work force development. Nevertheless, we want to ensure that local health economies are encouraged to utilise fully the skills and experience of specialist nurses. In May, the Under-Secretary of State for Health, my hon. Friend the Member for Bury, South (Mr. Lewis), held a summit with the MS Society, Epilepsy Action, the Parkinson’s Disease Society and the Royal College of Nursing to discuss those very concerns. There was an agreement to produce best practice guidance and to encourage PCTs to advocate the role of specialist nurses across the country.
Having enough staff with the right skills and experience, who are well led and well supported, is of course key to implementing the national service framework for long-term conditions. The national service framework is now our key delivery mechanism for improving services for people with neurological conditions across England. The hon. Member for Romsey asked about the number of neurologists. I believe that the answer is 437. So we have areas to look at concerning the number of neurologists. However, people with neurological conditions will get a faster diagnosis, more rapid treatment and a comprehensive package of care. In addition, all people with long-term conditions will be supported so that they can live as full and independent a life as possible. Those are some ambitious plans. I am very aware of the implications of saying them; implementation is a different matter.
The hon. Member for Chesham and Amersham (Mrs. Gillan) invited me to see work being done in her constituency, and I acknowledge the work that she has done and the spirit in which she made her comments. It is important that the Government and the all-party epilepsy group reflect on that matter and look at how we can work together to bring about the necessary long-term changes.
Successful implementation of the national service framework is of vital importance to us. We are working with a range of key stakeholders to identify and develop practical tools and advice that can help local services and organisations to deliver the NSF. That means that services for people with neurological conditions from diagnosis to the end of life will progressively improve.
My hon. Friend the Member for Calder Valley has been successful not only in securing this debate, but in bringing to it the enthusiasm that she brings to everything that she has done since she has been a Member of the House. I know that in the work that she has done through listening to witnesses for the report, she has not pushed the matter to one side. She has approached it with the commitment that she has brought to everything else since she has been a Member of the House. At this point, it is particularly important that we raise the good practice taking place already. It is easy to place too much emphasis on what is not working rather than reflecting on and celebrating what is working well. Yes, there are problems and yes, the case for improving the quality of services overall is compelling, but that should not overshadow the good work that is currently taking place.
For one example of good practice, I would like to mention King’s College hospital, which is providing a comprehensive service from diagnosis to treatment. High quality care is being provided also through the community-based service in east Kent. That is an example of the direction of travel in which we want to see services going, which would embrace networks of general practitioners, with a special interest, and epilepsy nurses working in collaboration with the local neurology service.
Through the national service framework, NICE guidance and the epilepsy action plan we have set out very clearly what the expectations are for the pattern of services for people with epilepsy. We have mentioned, in this debate, the services to prisoners and those in our prison care service. Much work has to be done, and I give another commitment to work with colleagues in the Ministry of Justice to ensure that that takes place.
I might not have managed to answer other questions, in particular those concerning new light bulbs and the Olympic logo, but they are serious issues. It is important that we really assist those with neurological symptoms and problems, under a diagnosis of epilepsy, and that they are seriously catered for, as they would be if they had any other condition causing alarm to them and their families.
The Minister might want also to bring the Department for Transport into her joint working approach, because often those diagnosed with an epileptic condition find it very difficult, not least because they have to rely on so many others for their transport needs, as often they cannot secure a driving licence. That is another area that could be joined up.
I thank the hon. Gentleman for that intervention. Yes, I would take that forward, because travel is so important to any age group. Someone who has had to lose their driving licence may find it very difficult to explain that to friends and family. Perhaps they will not raise it and family members will not want to say, “This is why we have a difficulty.” That situation is not easy and I relate to it exceptionally well.
We take the findings of the APPG’s report seriously, as I hope my response today has shown. Reforming health care is all about finding out the facts, identifying the problems and facing up to the challenges with strategic solutions. We share the desire of my hon. Friend the Member for Calder Valley for people living with epilepsy to receive the services that they need and deserve. I assure her that the Government will continue to provide support and leadership to the health service to ensure that that happens. Leadership locally, which my hon. Friend has shown, can perhaps encourage us all to deliver leadership throughout the health service.
I am delighted to have the opportunity to introduce a debate on cancer screening, which is a continuation of an interest that I have had ever since I entered the House. I had debates on cervical cancer screening in 2001 and on screening in general in 2003. As the Minister may have guessed if she has had an opportunity to see the record, I want to use this debate to take forward the questions that I was raising at that stage. I have two reasons for wanting to do so. First, I am conscious that this issue is of very great concern to my constituents, particularly women. I discovered in 2001 that there was a major campaign in my constituency and 5,000 women wrote to me, specifically requesting that I raise in Parliament the issue of how to improve cervical cancer screening, as new technology was becoming available that would reduce the risk of omissions from the screening process.
As I explained in the previous debate, I also have a personal motivation: I lost my wife to breast cancer. She was diagnosed aged 43 and I have always been haunted by thoughts of whether, if screening had taken place for women in their 40s as opposed to 50s and 60s, her cancer would have been picked up at an earlier stage and she would have been saved.
In general, cancer screening is one of the great success stories of the NHS. It is more advanced than in almost every other developed country. It has been done on a mass scale, certainly for cervical cancer and breast cancer, for many years and many lives have been saved as a consequence, so it is a positive story, and big advances have been made in the past 10 years in respect of the big three cancers to which screening applies. I want to acknowledge that, while asking questions about the process.
It clearly appeals to elementary common sense to suggest that if we have screening, conditions can be picked up at an earlier stage, avoiding not just premature death but unnecessary surgery. I recognise, of course, that there are limits to that process. There are limits to screening technology, which mean, for example, that it is not applied in the case of some cancers. Prostate cancer is one for which there is not sufficient precision. I also recognise that there has to be a test of cost and benefits. We cannot just have indiscriminate screening of all age groups for all conditions.
Initially, I shall ask a few questions and pursue the issue of cervical cancer screening, in respect of which there have been major advances. There is a long history in Britain, through the smear test, of saving very large numbers of women from that condition. Some of the progress is recognised in the fact that we screen 3.5 million women annually; I understand that there is 80 per cent. coverage. Roughly 4,500 lives a year are saved as a result of the screening process, and I think that deaths have now come down to fewer than 1,000 a year. That is a major success story, with continually falling death rates since about 1990. The big transformation in recent years has been the introduction of the liquid-based cytology tests, which are much more accurate and avoid the 20 per cent. failure rate that occurred under the old testing system.
If the Minister does not have the answers to my questions to hand, I hope that she will write to me. First, since the new LBC system was successfully introduced in Scotland—I think that that was completed by 2004—why has it taken so long to spread it through England? Can she give us some clarity about when the roll-out is expected to be completed? I understand that we are talking about next year, but is it the beginning or end of next year? Is that known?
Secondly, there are substantial disparities between the home countries in respect of the age groups covered by the smear testing arrangements as enhanced by the LBC test. The age group is 20 to 60 in Scotland, 20 to 65 in Wales and 25 to 64 in England. There is nothing wrong with that at all—indeed, there is much to be said for experimentation and trying different approaches—but what lessons have been learned from those different age profiles? Does one work better than another? Can we learn from Wales and Scotland? Are there any proposals to adapt the age profile?
Thirdly, can the Minister confirm the worry that some cancer charities have expressed? One in particular, called Jo’s Trust, has written to me and I met representatives at a reception in the House of Commons. It is particularly concerned with young women and has pointed to the fact that there appears to be a serious tailing off in the number of young women in their late 20s who are going for the screening. Have the Government analysed that? Do they know the reasons for it and do they have any answers to it?
My final set of questions about cervical cancer screening relates to the new technology that is becoming available as a result of the understanding that, unlike other cancers, cervical cancer is caused by a virus—a sexually transmitted virus. I think that the science was developed in the mid-1990s, and out of the understanding of the human papilloma virus come various potentialities. The first is whether the knowledge of HPV is being incorporated in screening: is it being used as part of the new screening process with LBC?
Secondly, the technology now makes it possible to vaccinate against cervical cancer. The Government were right and, indeed, quite courageous to bring in the new programme, which involves vaccinating girls before they leave school. It is hoped that that will greatly reduce the incidence of the disease at an early stage in its transmission. However, the cancer charities that are following this issue have raised various supplementary questions about that and perhaps the Minister will reflect on them. First, it appears that the next school year will be missed. I do not know whether that is correct; perhaps the Minister will confirm it. If it will be missed because of the difficulties of introducing vaccination across the board, what will happen to that age group? Will there be a follow-up, with encouragement and support in getting GP referrals to catch up?
What plans do the Government have to deal with what we might call the missing age group? I am referring to those young women who are too old to have caught the new vaccination programme at school, but who are too young to have the smear test, because they will not get it until they are 25. There is a 10-year group of young women who are missing altogether. What are the plans to deal with that? Is there a system of enhanced GP referral, for example, which would enable them to be captured?
I also have some questions for the Minister about the progress being made in the breast cancer screening programme. That, too, is a major success story for the NHS. It has been going for a very long time, particularly for women aged 50 to 64, and the age group has now been expanded by five years, which is a very welcome step. The analysis shows that about 1,400 lives a year are being saved. As with cervical cancer, there is clinical evidence of a substantial disparity between the survival rate for those who are screened, which is about 95 per cent. over five years, and the survival rate for those who are not screened. The difference, however, is that breast cancer numbers are rising substantially, whereas cervical cancer numbers are falling, and I wonder whether that might have something to do with the difference in the take-up of screening.
One thing that I find difficult to understand is why the take-up of breast cancer screening is significantly lower than the take-up of cervical cancer screening. After all, we are talking not about young women, but about mature women, who are presumably very conscious of their health. We are also talking about the same obstacles in terms of information and literacy. Why, then, should the take-up for breast cancer mammographic screening be significantly lower than for cervical cancer screening? The figure for breast cancer screening is about 75 per cent. on average, as against 80 per cent. for cervical cancer screening. In my area, as the Minister will know because she lives close by and represents a constituency next to mine, breast screening take-up is well below the national average, even though people are generally fairly prosperous and well educated. I have asked the primary care trust to address some of the technical problems, such as the location of the screening site and so on, but the figure is still low, and I wonder how much work has gone into understanding why take-up rates are low and whether they can be improved.
The big issue on breast cancer screening is age, and as I explained to the Minister, I have a personal interest in pursuing this. Everybody welcomes the extension of screening to older women, but the outstanding question is whether there would be value in extending it down the age range to women between 45 and 50 or between 40 and 50. When I last asked that question four years ago, the Government felt that the evidence was not compelling. There have been some pilot studies since then, and I wondered whether there had been any rethink about the desirability of extending the age range to catch younger middle-aged women, substantial numbers of whom get cancer.
My final point on breast cancer screening is that, as with all cancers, screening is only as good as the subsequent cures and treatments. There is no point screening people if they are not promptly dealt with and there is a long-standing issue about the speed of treatment for breast cancer patients. Are the Minister and her officials aware of an article that appeared in the British Medical Journal in recent months, which was based on a case study in Bristol and pointed to the difficulties with the so-called two-week rule? Apparently, GPs are putting a lot of women in the non-urgent category, where cancer diagnosis is growing rapidly, so something is not working with the two-week rule and the other principles designed to get people quickly into treatment.
The third and final category about which I wish to ask the Minister is bowel cancer screening. It is a big step forward and very welcome that the Government have accepted that there is value in screening for bowel cancer, which is of course different from cervical cancer and breast cancer in that it affects men at least as much as—indeed, probably more than—women. There is a large number of fatalities—about 16,000 a year, or about half of those who are diagnosed—and the number is growing rapidly. An estimated 2,500 people a year could be saved if screening were effective, so it is very welcome that the Government have taken a step forward.
I speak on the issue with some local interest because one of the leading charities—Beating Bowel Cancer—is located in St. Margaret’s in my constituency. It is a strong advocate of the screening process, and some of us participate annually in its loud tie day, which is one of its gimmicks to make the subject more attractive. For obvious physical reasons, bowel cancer is not something that people particularly want to talk about, and the charity has done a brilliant job in overcoming some of that psychological resistance.
The screening programme is now being rolled out, which is very welcome, and the primary care trust in my area was one of the first in London to adopt it. However, I have some questions about how the process is working. First, the roll-out has been going on for a year, so do the Government have any preliminary conclusions? If so, when will they publish them? Secondly, some of the feedback from the work that has been done suggests that uptake is quite low and that only half of those who are tested return the kits, as they are required to do. Is anything being done to raise that problem and deal with it? Thirdly, do the Government have the funding to complete the envisaged three-year roll-out? Finally, are interesting conclusions being drawn as a result of different age ranges being applied in Scotland, Wales and England?
My final point about bowel cancer is that, as with other forms of cancer, the success of the Government’s programme depends entirely on whether those who are screened can get treatment. As the Minister will know, difficult and emotive issues have been raised as regards the drugs that are made available to bowel cancer patients once they have been screened and diagnosed. A constituent called Adam Griffin, who is only 30, has run up against the barrier that was created by the National Institute for Health and Clinical Excellence when it ruled that Erbitux and another bowel cancer drug, Avastin, could be made available only in exceptional circumstances, and several young people in their 20s and 30s in London are being denied those drugs because of that new ruling. I know the difficulties involved, and these drugs are expensive, but I wonder whether the Government take account of age in interpreting the phrase “in exceptional circumstances”. Common sense suggests that if people can be saved from premature death in their 20s and 30s, they would, quite apart from any humanitarian consideration, have a much longer life to live, so the value of the treatment would be much greater. How much flexibility is there in that respect? A lot of emotion has, rightly, been generated around Herceptin, but there are some equally dramatic and difficult issues around bowel cancer drugs.
That rather broader question takes us a bit away from screening, but I wonder whether the Government are responding to the rather critical study by the Swedish Karolinska institute. The study suggested that despite Britain’s screening record, which is second to none in the developed world, we rank among the worst in terms of the availability of cancer drugs. The study partly attributed the relatively low cancer survival rate in the UK to that limited availability.
My final point—I have just exceeded my 15 minutes, so it is my final point—is that some cancer conditions cannot be dealt with through screening because the science is insufficiently precise, and we are always told that prostate cancer is one of those conditions. It is increasing rapidly among men, which is not necessarily as insidious as it seems, because it is a condition of very elderly men, who have many other problems. I was recently invited to an MPs’ health check and I was very struck by the fact that I was offered a prostate cancer test, thereby becoming one of the 6 per cent. of men who are tested. I therefore have one simple question: if such tests are good enough for MPs and for 6 per cent. of the population, why can the other 94 per cent. not enjoy them?
I congratulate the hon. Member for Twickenham (Dr. Cable) on securing the debate. As he recognised, we have neighbouring constituencies and share the same acute trust—the West Middlesex University Hospital NHS Trust. He also mentioned the personal side of the debate, and I acknowledge that.
The earlier detection of cancer is vital to long-term efforts to reduce cancer mortality. Where screening for cancer is possible, it is an essential tool in detecting abnormalities at an early stage. That is why the NHS cancer plan proposed a major expansion of our cancer screening programmes, where it is clear that that can reduce mortality. The efforts of the service to deliver that expansion are now coming to fruition.
The hon. Gentleman mentioned breast cancer screening, and the NHS breast screening programme was the first such programme in the EU. It is regarded as one of the best screening programmes in the world and is estimated to save l,400 lives a year. I wish that our media would portray such things, rather than the negative issues that are usually associated with cancer and cancer screening.
In March 2005 we completed two of the objectives set by the NHS cancer plan. The screening age was extended to include women aged 65 to 70, and the service was fully upgraded so that two X-ray views of each breast are taken at all screening rounds. As a result of those changes, the breast screening programme screened more women and detected more cancers than ever before in 2005-06; 1.63 million women were screened and more than 13,500 cancers were detected, which implies a 62 per cent. increase since 2001; 40 per cent. of the cancers detected were small cancers that could not have been detected by a hand examination.
We cannot, however, be complacent, and we are always looking at ways of improving the service, as long as there is a clear evidence base. For example, the evidence to support inviting women aged over 70, on a population basis, is not clear. That is why research has been commissioned on behalf of the advisory committee on breast cancer screening. Women over 70 can still self-refer for breast screening every three years, and we have collaborated with Age Concern on a leaflet to remind women of that. I am sure that all hon. Members will welcome that, and actively encourage Age Concern’s involvement. In the areas that the hon. Gentleman and I represent it is important to look for ways to approach education in such matters for the ethnic minority communities.
The hon. Gentleman raised the matter of cervical cancer, which is the subject of the NHS’s other longest running screening programme; again, it was the first such programme in the EU. The introduction of cervical screening has prevented an epidemic of cervical cancer and is estimated to be preventing up to 5,000 deaths a year. In 2005-06, 79.5 per cent. of eligible women in England had had a test result in the previous five years, 3.6 million women were screened and laboratories reported 4 million tests. However, again, we are not complacent. Following the National Institute for Health and Clinical Excellence technological appraisal in 2003, we are rolling out the use of liquid-based cytology across the service. That will reduce the number of inadequate tests and speed up the reading of slides. It will mean that 300,000 women a year will not have go through the anxiety of being called back and retested because their slides could not be read.
For women under 25 screening is not a good idea and can do more harm than good, because the cervix is not properly developed. More research on that is taking place. The 2005 Labour party general election manifesto contained a commitment to speeding up cervical screening results. The LBC is a key aspect of that, and the commitment is being taken forward through the cancer reform strategy, which will be published at the end of the year. A more recent development in our battle against cervical cancer has been the advent of human papilloma virus vaccines. HPV is implicated in nearly all cervical cancers. The Joint Committee on Vaccination and Immunisation has recommended that an HPV vaccine should be routinely offered to girls aged around 12 years.
The hon. Gentleman raised a very new area of screening—that for bowel cancer. The NHS bowel cancer screening programme began in April 2006, and full national roll-out is expected by December 2009. It is one of the first national bowel screening programmes in the world, and it is the first cancer screening programme in England to invite men as well as women. Once it is fully operational, each year, around 3 million men and women in their 60s will be sent a self-sampling kit to use in the privacy of their homes. It is an ambitious project and, when fully implemented, will detect around 3,000 bowel cancers every year. I am pleased to say that those of the hon. Gentleman’s constituents who are in their 60s began to be invited to participate in the programme on 8 January.
We are committed to introducing a screening programme for prostate cancer if and when screening and treatment techniques become sufficiently well developed. I note the point that the hon. Gentleman made about what he was offered in the House. The Department of Health is supporting the development of screening technology for prostate cancer by way of a comprehensive research strategy. Prostate cancer is the only cancer with a departmental research funding target, and we continue to fund at least £4.2 million of prostate cancer research each year.
The hon. Gentleman and I both attended an Ovarian Cancer Action charity reception yesterday. The NHS cancer plan committed the Government to introducing ovarian cancer screening as and when research demonstrates that screening is appropriate and cost-effective. The research is well under way, and the UK collaborative trial of ovarian cancer screening began in 2000; results are expected in 2012. The cancer used to be called the silent killer, but we now have evidence to suggest that we can do more. I welcome the research, having taken an active interest in ovarian cancer for some time.
We need, of course, to screen for and monitor other cancers. However, participation is very important, and the hon. Gentleman raised the important issue of increasing participation in our screening programmes. We agree with him, but we must encourage people to attend for screening in a responsible way. People who are invited to participate in our cancer screening programmes need to understand the potential benefits and harms in doing so and to be able to make an informed choice about whether they want to proceed. That is why all people who are eligible to participate in the programmes receive a national information leaflet when they are invited for screening. Those leaflets have been translated into 19 languages; posters and CDs are also available in seven languages.
Cancer screening will form a major part of the cancer reform strategy. As part of the strategy we will be looking at new ways of encouraging people to make the decision to attend screening; that applies particularly to those from more deprived groups, whose uptake of screening has historically been poor. I hope that the leaflets in different languages and the way we approach education in communities where English is not the first language will help to improve constituents’ quality of life.
I pay tribute to all organisations and MPs who keep the issue of breast cancer in the public and Government eye. I hope that the hon. Gentleman will join me in thanking all the staff who have worked so hard in making our cancer screening programmes some of the best in the world, and particularly those in screening programmes in the areas that we represent. I congratulate the hon. Gentleman on bringing the debate to the House.
Cycling Deaths (Abergele)
On 8 January 2006, Thomas Harland, aged 14, Maurice Broadbent, aged 61, Dave Horrocks, aged 55, and Wayne Wilkes, aged 42—all members of the Rhyl cycling club—were killed when a car ploughed into their group after skidding on ice on the A547 near Abergele. Although the tragedy occurred just outside my constituency, three of the four cyclists were my constituents, and the father of Thomas Harland was a close personal friend. It was and remains Britain’s worst traffic accident involving cyclists.
Following the accident, I asked the Secretary of State for Wales, my right hon. Friend the Member for Neath (Mr. Hain), to visit the scene of the crash and to meet the victims’ families and the North Wales police. I raised the matter at Prime Minister’s questions, arranged for two members of the Rhyl cycling club to meet a transport Minister here in the House and have tabled a number of parliamentary written questions. I have also tabled Question 3 for Prime Minister’s questions tomorrow, when I shall raise the issue of the coroner’s report with the Prime Minister.
I pay tribute to the relatives of those killed in the accident. They have conducted themselves with dignity. I also pay tribute to the Daily Post, and to its reporter Roland Hughes for his excellent, sensitive and detailed coverage of the accident and the coroner’s inquest. I have brought some of the Daily Post reports with me and I will be drawing on them heavily—I acknowledge that at the outset. Finally, I pay tribute to coroner John Hughes, whose inquiry has raised a number of issues that must be addressed not just in Denbighshire, Conwy and Wales but throughout the nation.
The first issue is police protocol on two matters. When ice is spotted on the road, what is the protocol for reporting accidents to the control room? The other matter is the protocol governing the control room’s reporting of such incidents to the relevant local authority. There are 43 police forces and 430 local authorities in England and Wales. An absence of protocols, or a protocol that is not strictly adhered to, is a recipe for disaster. Will the Minister seek clarification from his advisers on whether such a protocol exists? I have given them at least 20 minutes to find the answer.
I shall describe the police response to the reporting and actioning of numerous accidents involving ice on or near the A547 on the day of the tragic accident in order to illustrate some shortcomings that have not been addressed. On the day of the accident, police did not tell local councils about four crashes and near misses on icy roads near the site of the Rhyl cycling tragedy. Four drivers—including three on and off-duty police officers—skidded on or near the A547 in the hours leading up to the tragedy, but police did not think it necessary to tell Conwy county council’s highways department that the roads should be gritted, despite the fact that one accident occurred within Conwy’s boundary, just two metres from the county boundary and one mile away from the boundary in Denbighshire. The only time that police rang Conwy’s highways staff was when a car skidded on ice more than two miles away.
At the inquest into the cyclists’ death, police admitted that they had no fixed policy on alerting highways chiefs to icy roads, but said that it was expected of them. That is what I want to flush out. What is expected and what is not? I want a better definition.
A police officer who skidded twice on the Denbighshire side of the Borth crossroads, half a mile away, called the control room at about 3.30 am to say:
“The road is like glass here...I’m not sure if it’s policy to call out the council”.
He stated publicly:
“In our opinion, the road needed gritting immediately and the council needed informing at the least. We had expected those messages to have been acted upon.”
He was unsure of the policy. I am sure that if we were to ask other police officers around the country what the policy is, their responses would be similar. Neither Denbighshire county council nor Conwy, whose boundary is only metres away, were alerted by police to the icy conditions.
At 5.30 am, another accident occurred. An off-duty police officer, a friend of mine, was involved. He lost control on the Borth crossroads, only metres inside the Denbighshire boundary. Neither the Denbighshire nor the Conwy highways department was alerted to the conditions. At about 6.45, another off-duty police officer came off the A525 a mile from the tragedy. Again, the highway authorities were not informed. The only time that highway officials were contacted was at about 8.50 am, after two cars skidded on ice at a bridge in Towyn. A police control room worker mistakenly called Denbighshire—some Members might be unaware of the local geography, as indeed were some of the control staff—saying that the accidents had occurred on the Foryd bridge, which straddles the border between Conwy and Denbighshire. The control room informed Denbighshire that the accident was in its jurisdiction, but it was in fact a mile and a half away on the Towyn bridge in Conwy.
The highways department rectified the mistake shortly afterward, but the incident illustrates the need for local knowledge in order to pinpoint locations. It also illustrates the confusion that can occur if control room staff do not have such information at hand. If they do not know the co-ordinates and cannot report exactly where an accident occurred, they could quite easily end up alerting the wrong authority, as they did in the incident that I described, leading to delay or causing the wrong area to be gritted, with deadly consequences.
I have described a catalogue of errors that contributed to the death of the four cyclists. Is the Minister satisfied that robust procedures are in place for the reporting and actioning of accidents involving ice for every police force in England and Wales? Are they sufficiently understood by police and civilian staff? Confusion can arise if control room staff do not have the exact co-ordinates of an accident, but it can also arise without robust procedures for staff shift changes.
The latter had a bearing on the tragic accident that we are debating. As well as those that I have described, one final accident occurred on exactly the same spot as the fatal crash, just one hour before. The control operator mistakenly told her replacement colleague that both Denbighshire and Conwy gritters were operating, so when the accident was reported, no action was taken. Does the Minister feel that the rules governing shift changes in control rooms need to be reviewed? I spent 25 days with the North Wales police under the police parliamentary scheme, and I am aware that when ordinary bobbies on the beat change shifts, a debriefing session is held. Does that take place in control rooms? Should staff sit down together to debrief each other?
The coroner suggested that a hard copy of all reported incidents involving inclement weather should be left on the desk when staff change over, so that operatives do not have to go back into the computer. They would have no excuse—the information would be before them on the table in black and white. They could not ignore it. That simple suggestion could improve safety dramatically.
In summing up after the inquest, Mr. Hughes said that the way in which information was passed on by the police patrol room left a lot to be desired. I share his concerns and urge the Minister to do all that he can to prevent a repetition of such failings in all police forces in England and Wales. I say “England and Wales” because I know that the Minister has jurisdiction for England and Wales, but I also urge him to contact the Scottish Parliament and the Northern Ireland Assembly, so that they can learn from these mistakes.
Mr. Harland is a personal friend, and I took the family, including young Tom, on a tour of Parliament two or three years ago. They are a lovely, lovely family. When I contacted him to tell him about this debate and to ask whether he wanted me to relay anything to the Minister, he said that
“the main lesson I would like to see learnt is that a single incident suspected of ice should be treated as a road closure situation in every case until it is clarified/dealt with/made safe.
If you can get that written down as a standard practice for Police Forces throughout the UK then you will have achieved something positive from our tragedy.
The situation of suspected ice should be treated (as standard practice) the same as a chemical/oil spillage, which would result in a road closure, as in all these scenarios death can and does result.”
Will the Minister accede to that request from a bereaved father?
The next issue may not be the Minister’s direct responsibility, but I want to apprise him of it so that he has a full picture of exactly what happened, and of the interplay of his Department with local authorities and justice Departments. The issue is the role played by local authorities’ gritting departments.
One of the key lessons to be learned from this tragic accident is the need for a national review of the protocol that governs arrangements for gritting roads that cross county boundaries. This accident occurred 0.9 miles from the Denbighshire border. The A547 runs for approximately five miles between Rhuddlan in Denbighshire and Abergele in Conwy, and the accident occurred almost on the border. On the day of the accident, the Denbighshire side of the A547 was gritted early in the morning, and I congratulate Denbighshire on that. The Conwy side was not gritted, despite the fact that accidents were reported. Had that road been gritted, this accident might not have occurred. A simple agreement between neighbouring authorities could help to share the gritting of principal highways and known danger spots, so that it does not stop arbitrarily at the county border. That would be eminently sensible. If someone is driving and hears rock salt knocking against the bottom of the car, they alter their driving accordingly. If they hit an icy spot after the county boundary, that can and will cause mayhem.
There was no protocol in place for any formal liaison between adjoining authorities before the accident. In fact, the inquest heard that the two neighbouring councils of Denbighshire and Conwy were always haggling over who should grit the road on which the four cyclists died. One control-room worker told the inquest:
“I never knew quite which council was responsible”.
The on-duty highways officer for Conwy county council at the time of the accident was informed of an earlier accident by the police. He told the police that the road had already been gritted that morning, but that he that he would get someone to the scene of the accident immediately. That did not happen. He had decided to take no action, and to delay his decision to send someone out until he had received more reports of crashes. The coroner also asked why notes were scribbled in the margin next to the entry of the Towyn crash, when the rest of the operative’s records were immaculate and pristine. He even went so far as to suggest that they had been altered.
Over the past five days, I have been trying to find out whether any protocol is up and running between Denbighshire and Conwy, 18 months and one winter after the accident. I have been informed that, in the great tradition of Wales, a committee has been formed, and that Denbighshire, my own local authority, is taking the lead role. When I asked to meet chief constable of North Wales, Richard Brunstrom, the chief executive of Denbighshire, Ian Millar, and the chief executive of Conwy, Derek Barker, I received positive, professional responses from the chief constable and the chief executive of Conwy. However, the chief executive of Denbighshire said:
“It is not clear to me what the locus of the Home Secretary is in matters to do with roads in Wales. Indeed the UK Government has very limited functions in this area: highways are a devolved matter with only limited exceptions such as signage design, national speed limits etc.”
One would not have thought that we were discussing the deaths of four innocent people. I trust that my hon. Friend the Minister is as appalled as I am at that response. Mr. Millar has missed the big picture. Death is not a devolved matter. Wherever it occurs, we must look at the reasons, learn from mistakes and spread best practice around the UK and beyond.
Cross-border issues are of concern in the four nations of the UK. They are of particular concern in Wales, because we have 22 small local authorities with thousands of miles of borders and thousands of miles of roads crossing those boundaries. The matter should be considered seriously.
I now turn to the remaining issues that I want to raise, and again, the Minister may have only tangential, indirect responsibility, but I hope that he will take these issues back to his colleagues. The driver of the car involved in the crash, Mr. Robert Alan Harris, admitted that he was driving too fast for the weather conditions. His car had three defective tyres. A collision expert, PC George Skinner, blamed Mr. Harris for failing to drive at an appropriate speed for the road conditions. The ice on the road was patchy and there were enough dry patches for Mr. Harris to regain control of his vehicle. PC Skinner said that if Mr. Harris had paid attention to the freezing conditions and not driven at 55mph, which was his estimated speed before the crash, it might not have happened. He said:
“It would have to be accepted that he failed to observe the ambient temperature display in his vehicle. He set off on his journey having scraped ice off the window of his car, and subsequently drove through countryside where visible frost lay.”
He also said:
“He drove in an inappropriate manner for the prevailing conditions”
“In my opinion, there was sufficient grip available to the driver to control the vehicle. Had he driven according to the prevailing road conditions, as had the vast majority of motorists before this collision, then I am of the opinion this collision could have been avoided.”
Despite all that evidence, the Crown Prosecution Service refused to prosecute Mr. Harris. The family have said that they were badly let down by the CPS. The coroner said that, and I say that. The family said:
“Our lawyers, on our behalf, made clear to the Chief Crown Prosecutor our disbelief at the decision not to prosecute Mr Harris for driving offences. We remain unhappy with that decision. In fact we feel badly let down by this decision, and that justice has not been done”.
I want to apprise the Minister of the time taken by the inquest to reach its conclusion, and of the added burden on, and torment of, the families affected. The whole process could have been speeded up if the police, Conwy county council and their legal and insurance advisers had co-operated more fully with the coroner, John Hughes.
I do not expect the Minister to respond to the last two points, but I shall take them up with the Ministry of Justice and with the Prime Minister at Question Time tomorrow. I hope that the Minister will be able to meet me and the families when the police and the local authority have concluded their inquiry into the coroner’s report.
I congratulate my hon. Friend the Member for Vale of Clwyd (Chris Ruane) not only on obtaining this debate and raising the important issue of safety on our roads, but on the dignity with which he has campaigned and the gravitas with which he conducted himself during a difficult debate. That is a credit to him and his constituents.
I was sad to hear of the tragic death of the four cyclists, Thomas Harland, Maurice Broadbent, David Horrocks and Wayne Wilkes, on a practice ride on the A547 near Abergele in north Wales on 8 January 2006. I express my deepest sympathies to their families, and pay tribute, as my hon. Friend did, to the dignity with which the families have conducted themselves following this terrible event.
I am perfectly happy to meet my hon. Friend and the families to discuss with them the matters that he raised and his ideas so that, as Mr. Harland said, something positive comes out of this terrible tragedy. I am perfectly happy to meet my hon. Friend to discuss the whole issue of reporting to the police, what action the local authority should take and what protocols are in place. As far as I am aware, protocols do not exist, and the issue is an operational matter for each force, which will have systems by which officers report to the control room as they think appropriate, and the control room contacts agencies as it thinks appropriate. Following the accident and the coroner’s report, it will be necessary for North Wales police to consider the situation, and one would hope and expect that following what happened, other police forces will also consider it. Again, we may discuss it at a meeting to understand the way in which we can take the process forward.
My hon. Friend appreciates that I cannot comment in detail about the police handling of individual cases, particularly as I understand that that incident is still the subject of a continuing inquiry by the Independent Police Complaints Commission, which North Wales police voluntarily requested. I shall turn in a while to the inquest into those tragic events, and to what has emerged from it, but first I shall briefly outline the general situation regarding police investigations of fatal road collisions, and the Government’s position with respect to it.
The investigation of road traffic collisions and the enforcement of road traffic law are entirely operational matters for individual chief police officers. However, the police service is duty bound to investigate all serious incidents, particularly those involving death or serious injury, professionally and thoroughly. They will of course be expected to gather all the evidence from the scene, so that follow-up action can be taken as appropriate. In undertaking that work, all police forces now use the Association of Chief Police Officers road death investigation manual.
The manual brings out the need to investigate road deaths and serious injuries in order to serve justice. It recommends best practice for such investigations, and its overall aim is to standardise and improve the criteria observed during an investigation, and to promote a consistent approach. Of course, the manual’s guidance and police best practice are relevant only after the event, when the tragedy has already occurred. What concerns us more is trying to prevent such tragedies in the first place. Indeed, my hon. Friend said that we should learn from what has happened in the incident under discussion, and that, although we cannot rewind the clock, as much as we would all like to, we should work out whether any lessons can be learned from it to prevent such a tragedy occurring again.
Roads policing and police motoring law enforcement have a vital role to play. That is reflected in the roads policing strategy statement, which was agreed by the Home Office, the Department for Transport and ACPO, and published in January 2005. It cites reducing road casualties as one of the five key actions on which roads policing will focus. It may be that during my next conversation with the ACPO lead on road policing, I can mention some of the general issues about the investigation of road traffic accidents, and the way in which the manual is applied, to work out whether lessons can be learned from the tragedy that my hon. Friend has described.
I now turn to the outcome of the inquest, and to any lessons that there might be for the police, especially the North Wales police. The inquest jury ruled out accidental death and returned a narrative verdict, delivering factual statements on events leading to the fatalities. They decided that the deaths were a direct result of an out-of-control vehicle crossing the carriageway and colliding with the oncoming cyclists. From the evidence, the jury deemed the following points to be contributing factors: the vehicle was being driven inappropriately for the adverse weather conditions; there was a serious lack of communications and guidance in the following areas, with critical information not being passed on to key personnel by all parties involved within the North Wales police area control room, between Conwy borough council and Denbighshire county council and between Conwy borough council’s duty officer and his field staff. Conwy borough council lacked a proactive approach to its legal responsibilities, particularly with reference to its out-of-hours service.
The coroner subsequently publicly made his own critical comments about the North Wales police control room, communications between the councils and the failure to prosecute the driver of the vehicle involved—a point that my hon. Friend made. He knows that the last point is a matter for the Crown Prosecution Service, and I cannot comment on it. However, following the inquest, the coroner also wrote highlighting his concerns to the chief constable of North Wales police.
At the inquest, there emerged one issue that I know is of particular interest to my hon. Friend: road gritting. As the inquest jury were informed, North Wales police had earlier that day, following a motorist’s report of skidding, advised Conwy council that roads needed treatment. It was then a matter for the council to review the state of local roads and take action accordingly. I understand that the council has reviewed its procedures, and that it has measures under way to improve communications.
As I said in my speech, one incident was reported, which was actioned by the police control centre. There were, however, another three incidents involving police officers during that morning, and the information was given to the police control centre but not to the local authorities. That is a Home Office responsibility, so may I ask my hon. Friend to comment on it? There was a lack of action on behalf of the police.
As I have said to my hon. Friend, I shall review all his remarks today to work out whether there is anything that we must do in response to them. The point that I was also trying to make is that the lack of communication, as the coroner pointed out, is one of the key aspects that the local authorities have analysed in order to ensure that they do not happen again. It will clearly be something that the police themselves must analyse to ensure that they, too, have listened to the coroner to work out whether they need to change their practices and procedures. In trying to reassure my hon. Friend, I shall of course review his remarks to work out whether there is anything that we must do in respect not only of north Wales, but, as he has made it clear, of the rest of the country in order to prevent any such occurrence, due perhaps to a lack of communication, anywhere else.
More generally, I know that the North Wales police roads policing unit works in collaboration with local authorities and the Mid Wales Trunk Road Agency to identify routes with collision cluster sites. A multi-agency site meeting follows every fatal collision to identify opportunities for remedial engineering work, which is exactly the sort of co-operative working that we need, and I welcome it.
From the comments that my hon. Friend, the families and the north Wales public have made following the accident, the key issue is about people working together and communicating with one another. Whenever something as terrible and awful as that event takes place, it is incumbent on all of us with responsibility to reflect on it, work out whether there are lessons to be learned and put in place, as far as we possibly can, procedures and practices to stop it happening again.
In addition to those actions, the police consider education and enforcement and tailor their activities to address the relevant features of any emerging trend. Where appropriate, “red routes” will be established, enabling local authorities and the Mid Wales Trunk Road Agency to prioritise engineering work, and the North Wales police to deploy roads policing officers to key locations for visibility and enforcement. Again, it is recognised that road safety involves a number of different agencies.
The police will fulfil their role of patrol and enforcement, and I am sure that the local authorities and others will play their part in ensuring a co-ordinated approach. North Wales police also recognises the particular vulnerability of road users who are cyclists, and in partnership with its local authorities, it is seeking to adopt the updated cycling proficiency training and test, Bikeability, which has been introduced in England with the aim of giving cyclists—children and adults—the skills and confidence they need to ride their bikes safely. North Wales police is also involved in implementing the “Safer Routes to Schools” programme.
I have been in touch with North Wales police, and I assure my hon. Friend that it will consider the coroner’s observations very seriously. As I have mentioned, it has already voluntarily referred the handling of the incident to the IPCC, and the investigation is not yet concluded. When it is, the police will have to consider what it says.
I am very happy to meet my hon. Friend to discuss in more detail the points that he has raised. The key issue is for everyone with responsibility for safety on our roads to work together and communicate effectively. Although we cannot bring back those who unfortunately have gone from us, all of us, as Mr. Harland and no doubt the other families would wish, can as far as possible try to learn from that tragedy, to ensure that not only in north Wales but elsewhere, any such event does not occur again where it could reasonably have been prevented.
NHS Emergency Care
It is a delight to speak under your chairmanship, Miss Begg. I am pleased to have obtained a debate on this issue as it is one of the most important things facing patients and staff in the national health service. I am delighted to welcome the new Minister, especially as this is a one-to-one debate. The huge advantage of such debates is that one gets the undivided attention of a Minister for half an hour. I am pleased that the Minister could come and I thank him very much.
Miss Begg, you and the Minister will have noticed that I am sitting bang in the middle of the Chamber. My regret about the main Chamber is that there are no seats bang in the middle so I have to sit on the Opposition side. I am sure that the Minister will have noticed that I not infrequently vote with the Government on NHS issues. I regard my job as voicing the concerns of patients and staff, both of whom I am in close touch with, to help the Government to get things right. In so many ways, they have got things right in the NHS, and I am the first to acknowledge that, but we must address the problems with emergency care.
The recent Opposition day debate on access to NHS care showed that both sides of the House recognised the problems with access to emergency care. I shall divide my contribution into two parts. First, I shall address access to emergency care. Secondly, I shall suggest a long-overdue classification of hospital emergency departments so that people will know what they will get at the end of their journey.
Access to emergency care is confusing and poorly understood, especially in areas that have lost their accident and emergency department. There are at least eight options for people who are worried about a sick child, who are sick themselves or who have a wife in the late stage of pregnancy. They can do the following: dial 999; go to an accident and emergency department—if there is one; go to a minor injuries unit; go to a walk-in centre; contact their GP, but that is only possible a third of the time because GPs are only there for a third of the hours of the week; and out of hours they can call the GP out-of-hours service or NHS Direct, or drop in to a primary care out-of-hours centre.
There are many confusing ways of accessing the service. That has been brought to light dramatically by the sad case of Penny Campbell who died of septicaemia. This week’s British Medical Journal contained a comment on that, the last paragraph of which stated:
“No one should underestimate how stressful it is to be left, as Penny Campbell was, to steer your own patient journey. Doctors can’t guarantee a good outcome but they can, and should, help patients navigate their way as safely as possible through our complex and fragmented health systems.”
I can also illustrate the point with a sad case in my own area. The parents of a seven-and-a-half-year-old boy were concerned about his intermittent, but very severe, attacks of breathlessness. They took him to the minor injuries unit because they were used to having an accident and emergency department; although we lost that department six-and-a-half years ago, people still access services inappropriately. It was 3 pm and, appropriately, they were referred from the minor injuries unit to the GP. By the time that the boy got to the GP he was much better because his problems were intermittent. The same situation occurred the next day, but out of hours. Again the family went to the minor injuries unit, which was quite wrong. They were pointed to the out-of-hours primary care centre and as there was no one there they had to phone up to make an appointment. The triage was arguably incorrect—I cannot say any more because this is under investigation by the Healthcare Commission, save that the little boy died three days later.
Where blue light accident and emergency departments have been lost, it is crucial that people understand what is in their place and how to access that. This is likely soon to be of more widespread interest, given the threats to accident and emergency departments across the country. Every potential patient, worried parent, worried husband and so on should have only two choices. If they have an accident and emergency department, they should go to it. If they do not have one, they should ring a telephone number—it should be the same number for the whole country—that will access a standardised telephone triage system.
I have recently learned that the NHS possesses exactly such a standardised, well-proven telephone triage system under the heading of NHS pathways. I tested it out in respect of that little boy who was so sadly lost. The fourth or fifth question would have said straight away that he needed to go to hospital immediately, and that would have given him his only chance.
I am sure that the Minister is aware that the system is being piloted with the North East Ambulance Service and an out-of-hours service in Croydon. Both of the trials are about to report, and the news is looking extremely good. He will be aware of the dramatic technicolour poster that NHS pathways did about the North East Ambulance Service pilot, and the extremely encouraging results that have already emerged.
The other advantage of NHS pathways is that it not only advises the patient what to do, but transmits the information to the right provider and makes the transition to the provider appropriate and rapid. My plea to the Minister is to examine NHS pathways, to consider a roll-out of the system across the country, to try to get NHS Direct to use it—we must certainly get out-of-hours triage systems to use it—and to ensure that there is one phone number, widely known across the country, that everybody uses in these circumstances.
The spin-off is that the NHS pathways triage system is designed to be used by lay people. No longer do we lock up the nurses in their triage stations; we get them out doing nursing. I guess that they would prefer to be doing that, and they should be doing so. That is the first part of my argument, and I turn to the classification of hospital emergency departments.
Everybody, including the ambulance people and the GPs, should know what their local emergency department can do and can cope with. To know that, a definite classification must exist. The first such classification that I have come across was in Northern Ireland, whose acute hospital review group reported in June 2001. Three grades were involved. There are no arguments about the top two, although there is a difficulty in that some of the schemes call them level 1 and level 2 whereas others call them level 5 and level 4.
Let us consider the top two grades of hospital emergency department for the breadth of things with which they can cope. The first one is the major trauma unit, which is currently available in major centres. There can never be more than limited numbers of those. They will cope with everything—including, specifically, major trauma, burns, chest injuries and head injuries. That is the top level—no argument about that. Nor is there any argument about the second level, which is what we know as the standard accident and emergency department. It copes with all medical and surgical emergencies except burns, head injuries, chest injuries and cardiac injuries, which have to go to the major units. Those top two levels are well agreed.
The second level is probably under threat, largely because of specialisation and medical staffing problems. That makes level 3, the middle level, very important; that is why a tremendous amount of discussion is needed. I should like to read out the description of level 3 in Northern Ireland:
“a centre serving a smaller catchment population, operating in a managed clinical network with a level two service. The range of services available in each centre will vary according to local circumstances. They would have physicians, surgeons and anaesthetists available during the day and a full A&E service.”
So far, we have gone down a slightly different route in England. What in this country are now called urgent care centres—such as those in Bishop Auckland and Hexham—have lost emergency surgery in their hospitals. Not only can they not take any surgical emergencies; they cannot take all unselected medical emergencies, although they can take a number of medical emergencies. The Royal College of Surgeons has reservations about the situation. It believes that if there are to be any medical admissions at all, there must also be full acute surgical back-up; if there is an attempt to specify the medical admissions, things may sometimes go wrong.
People wish to have as much as possible locally, and as medical emergencies are far more common than surgical emergencies, people desperately want facilities for medical emergencies near to home. Just yesterday, I was speaking to Don MacKechnie, president of the British Association for Emergency Medicine. The association too, has five tiers of emergency department. Its middle tier would be the ideal. That would keep medical admissions because there would be a 24-hour A and E service, CT scanning, critical care and adequate surgical back-up. My fear is that that may not be affordable or possible, but it is what people would like.
Recently, a lot has been said about cardiac care and stroke care. We are not yet in the ideal world of being able to offer emergency angioplasty and reboring of the arteries to everybody who has a heart attack. Until we are in that situation, it will surely be far better for paramedics to give clot-busting drugs rapidly to patients with acute heart attacks. In that way, they will get the drugs within minutes, and then go to the local hospital rather than travelling miles and miles to the nearest unit that could do the revascularisation. If reorganisation is seen as a quick fix for financial or staffing purposes, the danger is that it could go ahead before replacement facilities are ready. Such facilities must be ready before changes are made.
I have covered the top three levels. The lowest level is the minor injuries unit, led by nurses. Having lost our A and E department and got a nurse-led minor injuries unit, my area has discovered that although that unit is good for minor injuries, that is absolutely all it can cope with. That is not enough. The name is wrong; the unit has to cope with minor illnesses as well as minor injuries. The president of the British Association for Emergency Medicine agreed with that. He also agreed that the presence of a doctor in such a minor injuries unit would increase the range of patients who could be seen. That is why I am delighted that at home the primary care trust and acute hospital trust have agreed to trial a doctor at our minor injuries unit to study whether such an arrangement can be self-supporting and cut down on the people who go to the A and E department by avoiding unnecessary journeys and unnecessary admissions. That is crucial.
To conclude, there should be clear pathways for accessing emergency care and we should beware of drastic reconfigurations before replacement facilities are in place. In all reconfigurations, we should remember the needs and wishes of patients. I finish with two quotes. In 2004, Andy Black, a well known health service management consultant, wrote in the British Medical Journal:
“If the price of moving the complex emergency to an appropriate centre of expertise is that it is accompanied by another 9 or 10 patients who are not complex acute cases, another set of problems is launched.”
I commend to the Minister the Department of Health document “Keeping the NHS local”, published in 2003 and added to in 2004. At last, the document recognised that big is not always best and that patients want more, not fewer, local services. In describing the pilot sites, the document stated:
“The objective is to provide as a minimum a ‘first port of call’ (a service able to receive and provide assessment, initial treatment and transfer where necessary).”
That is indeed the minimum. Anybody requires a pathway; we talk about the patient journey. For a patient journey, a route map and a destination are required. At the moment, I contend that patients in areas that have lost A and E departments have neither a route map nor a firm idea of their destination.
I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this debate. I also thank him for all his work on health, which is done in a bipartisan spirit, and for his contribution to policy formation and furthering debate. Before I move on to the hon. Gentleman’s specific points, I should like to spend a moment on the national context and reflect on the transformation, in recent years, in access to both urgent and emergency care delivered by the NHS.
More and more patients in A and E departments are receiving timely access to quality care. In 2003, almost a quarter of such patients waited for more than four hours; in contrast, in the year 2006-07, more than 98 per cent. of patients were seen, diagnosed and treated within four hours of their arrival at A and E. The ambulance service and its staff also provide an excellent service day in, day out—saving lives and caring for patients.
In 2006-07, 1.3 million category A patients—those with potentially life-threatening emergencies—received a response within eight minutes. That compares with a figure of 710,000 for 2001-02. A recent patient survey showed that 98 per cent. of patients were satisfied with the ambulance service—one of the highest ratings for any NHS service. The 2006 National Audit Office report on out-of-hours care also confirmed that we are making progress towards providing good round-the-clock GP out-of-hours services. The report found that patients’ experiences of such services are generally positive: eight out of 10 patients are satisfied with the service, and six out of 10 rate the service as excellent or good.
We have also put in place national quality requirements for out-of-hours providers, setting standards for the delivery of care so that patients can be assured that their clinical needs should be consistently met. Services are being provided closer to home by GP practices, pharmacies, ambulance clinicians, community hospitals, NHS walk-in centres and minor injury units, rapid response teams and new technologies. NHS Direct provides a 24-hour information service to patients. In May of this year, it recorded its best ever performance scores for access to the phone line—how quickly a call is answered—and for clinical triage.
As the hon. Gentleman said, we should ensure that when patients need to go to hospital they should go to a facility that is best equipped to meet their needs. For some patients with particular care needs, the equipment, facilities and expertise required to deliver their care safely may be provided in a more specialist centre. As Roger Boyle, the national director of heart disease and stroke, said in his recent report:
“Going via a local A and E can add a delay that can mean it is too late for the patient to benefit from the newest drugs and procedures.”
I wholeheartedly agree with the hon. Gentleman about how important it is for people to have straightforward information, clearly communicated, about what to do in an urgent or emergency situation and to be aware of the options available. That is all the more important given the wide range of urgent and emergency care services that are now available. People have consistently told us that they want more convenient local health and social care services. In particular, they want different services more closely integrated to meet their needs.
The NHS has made progress in that respect. When people have an urgent or emergency care need, they now have a number of access routes: they can call 999 or visit an accident and emergency department, a minor injuries unit or a walk-in centre. Alternatively, they can make a same-day appointment with their GP or call NHS Direct or their local out-of-hours primary care service. The configuration of those services will vary from place to place so that they are responsive to people’s needs and take account of local circumstances. It is important that those services work closely together everywhere to provide an integrated service for the public, for example using technology to patch telephone calls through to a single assessment team.
It is important, too, that people who need to contact services by telephone need to make only one call, as far as possible. That was the hon. Gentleman’s point. They should not have to repeat basic information to different providers, and nor should they be uncertain about what number to ring. NHS Direct provides a national number that people can ring around the clock to get an assessment of the urgency of need, and works closely with other providers. Similarly, 999 is available to assess and prioritise calls and respond to emergencies.
Whichever route the patient or carer chooses to take in accessing care, they should have the urgency of their need assessed consistently and rigorously at their first point of contact with the service, and should then receive an appropriate response. I am desperately sorry about the case that the hon. Gentleman outlined that affected one of his constituents. He rightly said that it was subject to an investigation by the Healthcare Commission, so I will not make any more of that. The patient should receive an appropriate response, whether that is advice on self-care, referral for a GP appointment or an immediate emergency response, such as an ambulance being dispatched.
The hon. Gentleman is right to point to some of the promising evidence that is emerging from the piloting of the NHS pathways project in three areas. We will and must wait until we have properly evaluated those pilots, which we hope to do later this year. It would be inappropriate for me to comment further on the potential for wider use of NHS pathways, but I agree with the hon. Gentleman that the evidence so far is promising. We will keep him informed of the progress that we make as time progresses.
The hon. Gentleman also raised the need for clarity about the range of services that are provided for people to address their urgent and emergency care needs. In each local health care community, patients, staff and the public need to understand clearly what they can expect from urgent and emergency care services. Local services should be planned and delivered safely and effectively in a way that is responsive to people’s urgent and emergency care needs, but the local NHS is in the best position to understand the needs of local health care communities and can work with them and other stakeholders to plan, develop and provide services that best meet the needs of the local population. I congratulate the hon. Gentleman on the role that he has played in initiating the doctor-led unit in his local hospital. We will be watching its impact and progress with great interest.
The national review announced by the Secretary of State for Health on 4 July will seek to build on recent improvements in access to services, including emergency care. I hope that under Professor Sir Ara Darzi’s leadership a major focus of the review will be discussing and working with NHS staff to determine how the safest and best quality care can be provided. He has already made a promising start with the publication of his review of services in London, which was already in progress. The national review will seek to put the patient first and the public’s views will be very important.
As the hon. Gentleman knows from his experience, access to emergency care is an emotive issue and it will be vital to discuss with people how the NHS can provide the best possible care and what that will mean for local services. He also mentioned another sad case, that of Penny Campbell. He will know that we have issued directions to PCTs in response to that case, instructing them to review arrangements for transferring information between clinicians, which was a contributing factor in Camidoc’s failure to respond effectively to her needs. As I have said, he has a point when he says that the access to emergency and urgent care can be confusing. There will always be a slight tension between offering people choice, depending on the severity of their condition and clarity of access. We need to be clearer with people about what they should do when they have an urgent need. My officials are working on some ideas to make that simpler. He mentioned a number of such ideas, including the experience in Northern Ireland and NHS pathways.
As the hon. Gentleman says, the NHS needs to take advantage of developments in technology and medical practice. We believe that the local NHS is best placed to understand the needs of local health care communities and to work with other stakeholders to plan, develop and provide services that best meet the needs of their local population, ensuring appropriate, timely and safe access to care and ensuring that the different services that are available are clearly communicated and understood. We do not believe that there is a one-size-fits-all approach that we can impose from above.
I thank the hon. Gentleman for securing the debate. I hope that we agree that people need timely access to appropriate care when they have an urgent or emergency care need. Progress has been made, but we need to make more progress on some of the issues about clarity of access and proper diagnosis that lead on from the sad cases that he has highlighted. We are determined to do so. When patients contact an urgent or emergency care service, they need the most appropriate response from the most appropriate professional at the right time, in the right place. Of course, the way in which that happens will not be the same in every area, and those planning care will have to take into account their local populations and health needs to provide the most responsive service to meet local requirements. Making the most of opportunities and medical and technological advances is also crucial. What is important is that the NHS continues to ensure that patients receive the highest standards of patient care.
Question put and agreed to.
Adjourned accordingly at three minutes to Two o’clock.