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Dermatology Funding

Volume 571: debated on Wednesday 4 December 2013

[Mr Andrew Turner in the Chair]

It is a pleasure to serve under your chairmanship, Mr Turner. I am grateful for this opportunity to debate issues relating to the provision of dermatology in the NHS. This area has received little parliamentary attention over the years, given the considerable morbidity and mortality for which skin disease is responsible. Indeed, I think I am right in saying that this is the first debate in the House of Commons in several years on dermatology and how it is treated in the NHS.

I should declare an interest, because we are always supposed to. I have a skin condition called rosacea. It is not that serious; I take antibiotics every day and it is controllable, but it has, of course, led me to take an interest in this subject.

In preparing for this debate, I consulted widely among the different interests in skin disease, and I am grateful for the insights that I was given. It is noteworthy that the same themes emerged from all quarters. Skin disease is extensive and has a great impact. It results in profound psychological consequences for many, especially for those with severe variants of conditions. It is under-treated in the NHS, and there are commissioning issues that relate partly to dermatology’s continuing to be something of a Cinderella disease. Talking to people, I heard the expression “Cinderella disease” time and again.

Most crucially, there is wholly inadequate training, notably among general practitioners, to enable doctors to handle the dermatology cases that will come their way in day-to-day practice. Why is this? There is a view that dermatology does not matter and that it does not kill. This is both complacent and wrong. Many skin diseases have horrendous effects, even when they are not fatal. Skin cancer is a major killer, and there would be benefits from renewed focus on this disease, both to help people avoid it in the first place and to identify and treat it quickly where it occurs.

The statistics on the burden of skin disease are eye-popping. Some 54% of the United Kingdom population experience a skin condition in any 12-month period. Of those, 14% seek medical advice, usually from a doctor or nurse in the community. Some skin conditions will be trivial, but many are not. Skin conditions are the most frequent reason for people to consult their GP with a new problem. Some 24% of the population visit their GP with a skin problem each year.

I congratulate my hon. Friend on obtaining a debate on a subject that has not been discussed for a long time. I have looked at facts and figures on dermatology services in my constituency. Would it surprise him to hear that, in the first six months of the year, the trust’s dermatology department had 501 day cases, 4,160 new out-patient appointments and 7,951 follow-up out-patient appointments, and undertook more than 3,292 out-patient procedures? Does not that show the demand in the system for dermatological services?

I am not surprised. I found similar figures in Lincolnshire. I should think that the same sort of problem will be found anywhere in the England.

The most common reasons for people visiting their GP are skin infections and eczema. Nearly a fifth of all GP consultations relate to a skin disease. Atopic eczema is the most common form of eczema. All my children have had it, and one of my boys suffered badly. Some children suffer grievously from it. It can affect people of all ages, but is primarily seen in children and affects up to 20% of children by the age of seven. Most people grow out of it, but a number of adults continue to show symptoms at a later age, some having the condition for life.

Eczema is typically characterised by red, sore and itchy patches of skin. For those who have it or those, such as parents, who have to care for a child with it, eczema can be highly debilitating. Sleep deprivation is common in children with eczema and, therefore, of course, in their parents. It causes major disruption to family life, not least because of the application of endless amounts of ointment. I know all about that.

Psoriasis, from which my brother and my mother suffered, has serious effects. It affects only 2% to 3% of the population, but often has devastating consequences for those who have it. Its onset is typically at 15 to 24 years, which is such a crucial stage in a person’s development. It is an immune condition that triggers excess replacement skin cells, which can lead to raised plaques on the skin that can be flaky, sore and itchy. It is a serious problem.

Then there is acne—I know all about that, too—a condition most commonly associated with adolescent teenagers. Although the condition is thought to be linked with hormonal changes during puberty, some 80% of young people above the age of 11 will have a degree of it at some point. It can affect people well into their adult lives, and it can be severe. Acne scarring is permanent. About 5% of women and 1% of men have acne over the age of 25. In a not inconsiderable number of cases, acne is widespread and ever-present, producing feelings of shame, despair and even, I am sorry to say, suicide in some cases. Acne is particularly tricky, psychologically, because it is often at its worst when the young emerging adult is feeling at their most self-conscious.

Other common conditions seen by specialists include vitiligo, urticaria, rosacea, herpes simplex, shingles, vascular lesions, benign skin tumours, benign moles, solar keratosis, viral warts, non-malignant skin cancers—I know all about that, too—and malignant melanomas. The list is almost endless, running as it does to a couple of thousand different conditions, each of which can have profound effects on the lives of those who have them. People who suffer from these diseases often do not want to speak about them. I am attempting, in this small debate, to give these people a voice.

It is worth saying that serious psychological effects are sparked by skin disease. We live in a society where we are subjected daily to images of perfection, selling everything from make-up, fashion and holidays to ice-cream. Skin conditions are sometimes very visible, and some people are highly prejudiced against those who have them, and make little attempt to hide that. That can lead to stress, depression, anxiety, and other related problems.

There is a beautiful picture in the Louvre of a child reaching out to an old man, probably their grandfather. The child is beautiful and the old man, who obviously suffers from rosacea, is deformed and hideous. The point of the painting is that beauty lies inside, not on the skin, but that is not often the view of modern society, so skin conditions lead to psychological stress.

Many of these facts—I could go on, but I will not—are set out in detail in the recent report on the psychological effects of skin disease published by the all-party group on skin. I pay tribute to my hon. Friend the Member for Mole Valley (Sir Paul Beresford) who chairs that group and does it well.

Despite the fact that skin disorders are both serious and the most likely reason for someone to go to their GP, training and knowledge of dermatology among primary care health professionals is generally very limited. Perhaps “very” is wrong, but it is certainly limited. Astonishingly, there is no compulsory requirement for dermatology training in undergraduate or postgraduate medical programmes of study. Dermatology is still not included in all undergraduate medical school curriculums; it is optional in some, and untested in others. In five to six years of medical training to become a doctor, the average medical school offers—I found this incredible— less than a fortnight of teaching in dermatology. This is often combined with another so-called minor field of medicine. I am told that many miss this teaching altogether, not regarding it as important, and joke about taking a “dermaholiday”. That is like the NHS employing an army of plumbers who are highly knowledgeable about boilers and blocked drains but who do not know how to trace a leak or mend a pipe. By failing to provide adequate education in dermatology, which is an important field of medicine, we are badly failing to meet the needs of patients.

I congratulate the hon. Gentleman on securing this important debate. He is setting out his stall extremely well. According to the consultant dermatologist at Scunthorpe general hospital who contacted me, 15% of patients presenting to GPs have a skin disorder of one kind or another, which underlines the hon. Gentleman’s point on the importance of including dermatology in GP training.

In a moment, I will address the fact that skin diseases can have fatal consequences. As GPs often do not have adequate training, they are not able to spot conditions that can be very dangerous.

Training is important. In a 2008 survey of final-year medical students, only 52% of 449 respondents said that they felt they had the necessary skills to manage skin conditions. A lack of education and training may lead to fatal errors, and I stress that point because skin disease is not only about psychological damage. Skin lesions mistakenly taken to be benign can lead to cancer. Conversely, inappropriate referrals to secondary care can be costly and are blocking up big parts of secondary care. As awareness of litigation increases in the NHS, GPs are, unsurprisingly, less and less willing to take risks, so they refer more and more patients to secondary care. I understand that the general hospital in Lincolnshire—this echoes the point raised by my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan)—has seen a 26% rise in dermatology referrals for secondary care in the past year, and it is not alone.

The exploding incidence of skin cancer, an ageing population and side effects from new potent drugs are all driving referral rates. It has been guesstimated that there are 100,000 cases of skin cancer a year in the UK, but the number is not known for sure because the NHS does not collect figures for cancers that are not melanomas. Work this year suggests that the number may be nearer to 700,000; that is what dermatologists tell me, because they are dealing with such a volume of cases, day by day.

Studies show that the skill of GPs in diagnosing skin lesions needs improvement, and other studies raise concerns about the standard of skin surgery offered in primary care. In 2012, the Royal College of General Practitioners updated its curriculum statement on the care of people with skin problems. The statement goes a long way towards recognising dermatology as a key component of a GP’s training. The statement sets out a number of expected key competences within the field, but crucially, dermatology remains an optional component. For undergraduates, the British Association of Dermatologists recommends a two-week full-time attachment to a dermatology unit, with a realistic assessment at the end of the course. The association thinks that dermatology should also be taught when undergraduates work with general practitioners in the community. When trainee GPs are undertaking their two-year hospital placement, a six-month post in dermatology alone, in a combined post such as dermatology and general medicine, or in a combined minor specialty rotation would go a long way towards helping trainee GPs to take a special interest in dermatology, which is what we need.

The GP training period is likely to be lengthened by 12 months. I urge all interested parties—Health Education England, the royal colleges, the General Medical Council and the ultimate employer, NHS England—to use half or all of that extra time on a proper dermatology rotation, which would ensure that the GPs of the future are properly equipped to address their future work load. If that is to happen, funding must be made available to ensure that there is adequate consultant time to train budding GPs and to pay their salary while they undergo the hospital training.

My hon. Friend is making a powerful argument. Does he agree that there is a worrying lack of provision for the psychosocial aspects of skin conditions? Is he familiar with Changing Faces, which, among other things, provides skin camouflage clinics? It sent me an e-mail when I was preparing for this debate saying that the King’s Fund has stated that there are only 3.7 posts across the country providing support for the psychosocial aspects of skin conditions, and the funding for those posts is under threat. Does he propose that funding should be found to try to support that vital work?

I entirely agree. I talked to a doctor recently who said that one of his patients had not dared to go out for 20 years without wearing enormous amounts of special make-up because she was so worried about her condition. We should take that very seriously, because it affects hundreds of thousands of our fellow citizens and their feeling of self-worth.

The lack of dermatology education applies not only to GPs but to nurses and pharmacists, who also play a key role in the management of patients with skin disease. High and ever increasing sales of over-the-counter skin products suggest that people buy many products from pharmacies, yet training of pharmacists in the management of skin problems is limited, and evidence that they are providing appropriate advice is lacking.

There is considerable potential for improving self-care through the provision of high-quality patient information and the development of the knowledge and skills of community pharmacists in skin diseases. That would save the NHS money, as well as improve patient care, and it is a nettle waiting to be grasped.

The General Medical Council, working with the Royal College of General Practitioners, the British Association of Dermatologists, the Royal College of Nursing and the Royal Pharmaceutical Society, plus Health Education England and NHS England, has a duty to ensure that urgent priority is given to the provision of proper dermatological training for all GPs, nurses and pharmacists. That training should surely emphasise that most inflammatory skin diseases are long-term conditions and are likely to need ongoing care, often throughout a patient’s life. Similarly, the psychological effects of skin disease should be considered an integral part of any dermatological training course; I echo my right hon. Friend’s important point on that issue. There is good evidence for the effectiveness of general practitioners with a special interest in dermatology working within appropriate accreditation frameworks. More needs to be done to expand that group of clinicians, which is still all too small.

In addition to poor training at primary care level, there is also an issue with the number of consultant dermatologists. I pay tribute to my consultant, Professor Chris Bunker, who is well known in the field and is president of the British Association of Dermatologists. Compared with mainland Europe, the ratio of consultant dermatologists to the general population remains low in the UK, at 1:130,000. It is estimated that there is a 20% shortfall in consultant numbers in the UK.

Furthermore, there are significant issues related to vacancies in dermatology consultant posts—there were some 180 consultant vacancies at the last count. That is due both to an inability to attract people to posts in remote areas and to the widespread problem of funding being available for a post but the relevant deanery refusing to provide a training number that allows the post to be filled by a trainee.

As well as being unpleasant and demoralising for patients, some skin conditions kill; that must be emphasised. Skin conditions are not just a psychological problem. There were nearly 4,000 deaths due to skin disease in 2005, of which 1,817 were due to malignant melanoma, which is now the UK’s most common cancer. That is against a background of 13,000 malignant melanomas each year, a level that has increased 50% in little more than a decade. Those figures continue to rise, driven by the wide availability of cheap holidays in the sun, the continued fashion for using sunbeds and the inadequate resourcing of awareness campaigns. We must do more about that; improved public funding for awareness campaigns, better training and stronger regulation of the use of sunbeds are some of the most obvious answers to the problem, yet very little, if anything, ever happens. Despite skin disease being very common, the direct cost to the NHS of providing skin care is relatively modest. The overall direct cost to the NHS in England and Wales was some £1.82 billion at the last estimate, in 2006.

As of October 2013, there is no policy lead for dermatology in the Department of Health or NHS England; I put that point directly to the Minister. The majority of dermatology services are commissioned by clinical commissioning groups, but national oversight is necessary to co-ordinate care across the country and to drive the agenda. Prior to the April 2013 switchover, primary care trusts were responsible for commissioning dermatology services, but the Department did at least have a policy lead on overseeing service provision. No similar post now exists in NHS England, so no one—I hope the Minister can reassure us on this—champions this area, spots good practice, or drives change.

Earl Howe recently stated in the other place that dermatology would be spread across the five domains of NHS England, and that it would not, as was previously thought, sit primarily under long-term conditions in domain 2. That surely only heightens the need for a director to co-ordinate policy across the five domains. Even if only a junior post were to be created, patients and health professionals would be given a clear line of accountability and a person to whom they could appeal who was above their local CCG lead for commissioning. Given the prevalence of skin disease, a national clinical director for dermatology, which is what I am calling for, would not look out of place among the long list of such posts at NHS England. I urge it to consider such an appointment.

There is a lack of sources of peer-group, independent advice for people with skin conditions. Patient support organisations are mainly charitable institutions that rely, for the most part, on donations from individuals and pharmaceutical companies. People with skin disease place great value on the information and help provided by dermatology patient support groups. Skin disease is not a well-resourced area, and such groups struggle to make ends meet. There is no group at all, for example, to provide support to people with acne, the previous group having run out of funds some years ago. Given that such charities are almost certainly a cost-effective way to provide what might be life-saving support to patients, perhaps the NHS should consider being a little more generous in its funding.

I thank all those who have helped me to prepare this speech, particularly the British Association of Dermatologists. It is clear that a small number of important steps would make the greatest difference in this area of disease, including the appointment of a national clinical director to co-ordinate learning around the NHS and to drive uptake of new ideas and change. More important, however, is persuading the relevant bodies that I have mentioned to ensure that undergraduates emerge from medical school with a reasonable grasp of dermatology and that newly appointed GPs can recognise a malignant melanoma, which is probably the most important point of all. Those changes alone would have far-reaching, positive consequences for dermatology and for those with skin disease, and I urge the Minister to consider what can be done to make them a reality. I hope that this debate will make some difference.

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

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

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

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

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

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

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

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

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

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

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

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

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

I apologise for ducking in and out of the Chamber. I am trying to make arrangements to meet a couple of people, so I apologise to the hon. Member for Gainsborough (Sir Edward Leigh) and to other Members for not being here for the entirety of his speech.

I congratulate the hon. Gentleman on bringing the matter to the House for consideration. He expounded the importance of this matter to him personally. For others in and outside the Chamber, it is something that perhaps members of their families have and that they can relate to.

As the hon. Gentleman outlined, there is a need for sufficient funding. When we look at what this involves, we can quickly appreciate the importance of the subject. He referred to the 75% increase in skin cancer in the past year. As an elected representative with a particular interest in health issues—I am my party’s health spokesperson in this place—I have a close relationship with my counterpart and colleague in Northern Ireland, the Health Minister, Edwin Poots. He furnished me with figures that indicate that the increase in Northern Ireland is equal to the figures given earlier, if not just above in many cases. I find that as worrying as the hon. Gentleman did.

I have read the report and it is helpful to read some of the background information. A team from East Anglia recorded data. Some people will say that there are lies, damned lies and statistics. Perhaps that is not entirely fair, as they can provide helpful information. The team referred to an 11-year study that showed that basal cell carcinoma increased by 81%. They extrapolated their figures across the whole of the United Kingdom to come up with figures. Whether they are entirely accurate, I do not know, but I think that they do give a feel for the subject and an indication of the number of people who may be affected. The report said that

“around 200,000 patients had 247,000 cases of BCC treated surgically.”

That is just one type of skin cancer, which gives an idea of the magnitude of the problem.

I want briefly to give some details of what we are doing in Northern Ireland. Again, I do that from a positive frame of mind, because I believe that, if we are doing something, that can be helpful. The hon. Member for Mole Valley (Sir Paul Beresford) may not have known about the programme that is taking place in the area of the right hon. Member for Chesham and Amersham (Mrs Gillan), but if something good is happening, we should exchange those ideas to help each other. That is something that we initiated in relation to dermatology overall as well as skin cancer. In the past year, the Health and Social Care Board invested some £1 million recurrently and another £3 million non-recurrently in dermatology services, including psoriasis drugs. That is for a population in Northern Ireland, as the Minister will know, of 1.8 million, which puts the amount invested into some perspective.

My second son, like the hon. Member for Gainsborough, was born with what I would refer to as scaly skin, or eczema. I have to say that I did not wash him very often, but my wife would always wash him morning and evening up to about the age of six or seven, as well as creaming him twice a day. What was interesting was that eventually the eczema left him, but, as that left him, something else took its place: asthma. That was an unusual reaction, but as the eczema left, the asthma increased, so there is obviously, as the doctor at the time made us aware, a medical connection between the two conditions. The interaction was close and clear.

The Northern Ireland Department of Health has an additional £240,000 of recurrent funding confirmed for dermatology services in the Northern Health and Social Care Trust. That is only one of four trusts in Northern Ireland. The board is working with the others to finalise their recurrent funding requirements, which are estimated to be about £500,000. I mention that strategy of working together with the trusts because trusts and councils on the mainland could come together to do something similar to spread the cost.

The debate is about the funding of dermatology in the NHS. We are in difficult times, and everybody acknowledges that finance is not always available in the way it was in the past. We have to make better use of the money we have, and we have to try to do that in a way that delivers services and address all the issues. We have tried to do that in Northern Ireland, and I know the House and the Minister are also trying to make better use of the money that is available.

The Health and Social Care Board has also been working with local GPs to redesign the traditional patient pathway for dermatology assessments. Again, early diagnosis is important, and the figures in the background information for the debate indicate that. Some of the survivors of skin cancer I have spoken to would say the same. Some of those cancers are usually completely curable. One cancer, if caught in the early stages, might need surgery, chemotherapy and/or radiotherapy, but there is hope when the dreaded “big C”, as many people call it, comes upon us.

Initiatives have also included the funding of a photo-triage pilot. It will, I hope, help the Minister to hear what we have been doing. The pilot scheme will deliver its results in March next year, and it would be helpful if they were made available so the Minister can see what has happened. As part of the pilot, GP practices can refer patients with suspected malignant melanoma or—forgive my Northern Ireland accent—squamous cell carcinoma to a dedicated photographic clinic, which is used to triage the patient, thus reducing unnecessary out-patient attendances. That pilot can shorten the process and focus resources on the issue in hand. If the pilot is successful, as I hope it will be, the figures it produces will be helpful.

I want quickly to comment on sunbeds. Some Members have spoken about them, and others will speak about them as well, including perhaps the hon. Member for Romsey and Southampton North (Caroline Nokes).

Maybe not—I thought that might be one of the issues she would touch on.

In my previous job as a Northern Ireland Assembly Member and a member of Ards borough council, in my constituency, I had some influence on this issue. The council was concerned about the effects of sunbeds, and it was aware of the importance of controlling, monitoring and regulating them. It took decisions to do that, and other councils took similar initiatives. Again, that shows we have done things in the way they should have been done.

Again, I congratulate the hon. Member for Gainsborough on bringing this important matter to Westminster Hall for consideration. I very much look forward to the Minister’s response. I hope that my comments about what we do in Northern Ireland have been helpful, and that is particularly true of my comments about the pilot scheme and the way in which triage can work with GPs, hospitals and, more importantly, the patient.

I assure you I will keep my comments brief, Mr Turner. I congratulate my hon. Friend the Member for Gainsborough (Sir Edward Leigh) on securing this important debate on the funding of dermatology in the NHS and on giving Members the ability to raise specific issues that may have been put to them by dermatologists, expert groups and patients.

I am a member of the all-party group on skin, although I am obviously not as exalted a member as my hon. Friend the Member for Mole Valley (Sir Paul Beresford), and I do not share the same expertise, but I have benefited over the years from personal experience of dermatological services. I am also the chair of the all-party group on body image, which has given me the privilege of working with organisations such as Changing Faces, which has brought to my attention some of the work that it does with patients with severe skin conditions. Changing Faces provides what it refers to as skin-camouflage clinics, and the word “camouflage” is interesting in this context. Many people who suffer from serious skin conditions will attempt to camouflage themselves—to hide away—because they are so self-conscious about their conditions.

I was present in this Chamber yesterday afternoon for a debate on the effects of the drug Roaccutane—a very effective, serious drug used to treat severe acne. I have a different Minister to address my comments to today, and I do not intend to rehearse the whole of yesterday’s debate, but there are some pertinent issues that I would like to draw to her attention.

Many sufferers of skin conditions will have depression and anxiety long before they ever get to see a dermatologist, and yesterday we heard in detail how important it is for dermatologists to have the time and the knowledge to be able to go through in detail the possible side effects of any medication that may be prescribed. Even dermatology drugs—drugs for the skin—can have severe side effects, including depression, and I am sure Members will agree that psychological illnesses need careful handling and treatment. Medical professionals need time to address concerns properly, but more than one consultant dermatologist contacted me before the debate to say that the specialism is under pressure and that time is at a premium.

Yesterday, the hon. Member for North Devon (Sir Nick Harvey) raised the issue of Roaccutane and the need for rigorous up-to-date research to ascertain why some groups of patients are more vulnerable to its severe side effects than others. When I say there are severe side effects, I should point out that there have been some incredibly tragic cases, in which young people who have been prescribed the drug have suffered terrible depression, and that has sometimes gone on for many months or even years after treatment has concluded. A number of young people have also committed suicide, and that is thought to be as a result of having taken this drug. Sadly, we lack up-to-date research and scientific evidence that proves a causal link between Roaccutane and suicide. The hon. Gentleman’s contention yesterday—I support him in this—was that only a public authority will be in a position to undertake the level of research required.

I would like to take the opportunity of today’s debate to highlight some points to the Minister. About 13 million people will present at their GP with a skin condition, and family doctors spend a significant proportion of their time treating patients with a skin problem, so dermatology is a significant part of the work of primary care. Dermatologists are concerned that the time they are spending on these conditions is not matched by the investment in research and that dermatology is something of a Cinderella service, as we have heard.

The overall burden of skin disease is large and growing, and to that mix we can add a lack of consultants and the drugs that can have a seriously negative impact on mental well-being, so it is not surprising that there are real concerns. With the specific case of Roaccutane in mind, I suggest that there needs to be better investigation of the causal link between the use of Isotretinoin and depression, self-harm and even suicide. That research is long overdue, and I have no doubt that it will fall to the Department of Health to make sure it is funded. I urge the Minister carefully to consider the case, which I wholeheartedly support, for better science, more evidence and independent study.

I know from work with organisations such as Changing Faces that those suffering serious skin conditions are far more likely than the general population also to suffer depression. Skin conditions can be extremely debilitating, especially for the young; they can cause a lack of confidence and an unwillingness to engage in social activities. At that particularly difficult and hormonal time, they can also have a disproportionate impact on mental well-being.

It is very careless to dismiss skin complaints as nothing more than a few spots or a bit of dryness or redness, especially if the face is affected. To the sufferer, such things can be a huge emotional and psychological burden. My hon. Friend the Member for Gainsborough spoke of the endless images in the media of physical perfection and perfect, flawless skin, and that all adds to the psychological stress.

I wish to focus briefly on training and the importance of making sure there are trained professionals to step into the 180 unfilled consultant posts the British Association of Dermatologists estimates currently exist. In some places, those posts are filled by long-term locums, who might be without the training and credentials required of a permanent appointee.

I would like to take the Minister back to the subject of Roaccutane. It is a highly toxic drug, intended for use in only the most severe cases and requiring very close supervision. It can be prescribed only by a dermatologist, the very specialism in which as I have explained there is a shortage; so patient waiting times increase, and the time the consultant has to spend with each patient reduces, along with the opportunity to discuss changes in their mood or mental well-being. The time for follow-up care is inevitably limited. That all comes together to give patients the impression of long waits and rushed appointments and results in a greater temptation to find a private consultant and pay for a private prescription. Among the families of people who suffered negative effects from Roaccutane, several have emphasised to me how many young people who had self-harmed were in receipt of private prescriptions because the families were too desperate to wait the six months for an NHS consultation.

My experience of consultant dermatologists working in the NHS has been nothing short of fantastic. The professionals with whom I have been in contact are dedicated and determined to get the best outcomes for their patients; and they have cut no corners. However, the growing dermatology case load puts them in an increasingly difficult position—perhaps particularly on the south coast. In places such as my constituency there are longer hours of sunshine and high life expectancy, and the incidence of cases of skin cancer is increasing. That all adds up to a stretched service. A local consultant dermatologist wrote to me outlining what he called a work force crisis, with a national shortage of consultants and considerable variation in the quality of dermatology provision across the country, as services are increasingly provided by those without appropriate training. That cannot go on. The service is demoralised and under pressure, and is struggling to identify where the next generation of skin experts will come from.

I urge the Minister to consider the situation closely. The specialism is crying out for the sort of TLC that the specialists are so good at giving their patients, which gives those patients the confidence to go out and face the world. I commend to the Minister the remarks of my hon. Friend the Member for Gainsborough about training, the threat of fatal mistakes in diagnosis and the need for a national clinical director in dermatology.

It is a pleasure to serve under your chairmanship for this afternoon’s debate, Mr Turner. I congratulate the hon. Member for Gainsborough (Sir Edward Leigh) on securing this important debate, which will be relevant to the 13 million people who present each year with skin problems, and their families.

I want to focus on psoriasis, on the often under-appreciated burdens that its sufferers bear, which go beyond the effect on their skin, and on the barriers to their getting the best care. On 1 November, I chaired a summit in west Lancashire, where seven of my constituents with psoriasis met the award-winning dermatology team at Ormskirk hospital, as well as some local GPs and the west Lancashire clinical commissioning group. I learned how psoriasis affects people, beyond the plaques on their skin, and the changes that we need to make to secure the high-quality care that my constituents and other psoriasis sufferers deserve.

Psoriasis is a terrible and lifelong condition. I have observed it through a personal connection, because after my mum died my father, who was 62, developed psoriasis. The Psoriasis Association tells me that the average member has been living with psoriasis for 32 years. The personal toll of living with the disease and its cumulative impact, which commits people to lifelong skin care, is enormous. The effects are felt beyond the individual and reach to people’s families, employment prospects and participation in society. The painful plaques are highly visible, which leads to rejection and stigma on top of everything else. Worse, 40% of people with severe psoriasis will develop psoriatic arthritis, which can lead to more pain as well as joint damage.

Psoriasis is also associated with mental health problems. It affects the skin and the joints, as well as people’s psychological well-being and life expectancy. Research has shown that the cumulative impact of psoriasis on people’s quality of life can be as significant as that of type 2 diabetes. One person in 10 with psoriasis considers suicide. I met such a person at the summit and it was heartbreaking to hear how the condition had affected her life. That is the most extreme end of the condition, but it shows the devastating impact that psoriasis can have on people’s lives.

Many positive things are happening for people with psoriasis, including the recent publication of the National Institute for Health and Care Excellence quality standard on psoriasis, which gives guidelines on treatment. The national standard constitutes progress, but the Psoriasis Association called it a

“minimum standard, not a gold standard”.

Psoriasis care is not always up to that standard. In some areas, even achieving the minimum standard is, sadly, an aspiration.

To an extent, the degree of understanding and appreciation of the full effects of psoriasis has a direct consequence on the funding of services. Despite the fact that 13 million people present with skin problems each year and that 15% of GPs’ time is spent managing patients with skin conditions, there is still a lack of understanding, even within the medical profession, about dermatology. I have been contacted by a consultant dermatologist who believes that dermatology has been neglected in medical schools and in GP training, so that GPs are often ill-equipped to deal with the variety, complexity and volume of cases. We need more specialist education for people such as GPs who look after patients when they are not in the care of the dermatology team.

Sitting suspended for a Division in the House.

On resuming—

Figures provided to me show that 180 dermatology consultant posts in the UK are unfilled, out of a total of 830. In Ormskirk, the dermatology service struggles to attract doctors to fill full-time roles. It has a work load roughly equivalent to that of nearby St Helens, but whereas St Helens has seven consultants, Ormskirk has two. We also need specialist nursing capacity and more space in the department. Nearby services have several light-therapy machines, but Ormskirk has only one, so my constituents have to wait six or eight weeks for treatment—once they have had their referral, and on average there is an eight to 12-week wait just to be seen by a specialist. Ormskirk is an award-winning service, yet the team there do not have the resources they need.

A 2008 audit showed wide variations in treatment. Access to specialist treatments such as biologic drugs, specialist nurse support and psychological services is sporadic throughout the country. Access to psychological support is a major theme of the new quality standard for people with psoriasis, yet 80% of the 170 dermatology departments that responded to the 2013 BAD audit of services reported having no access whatever to psychological support for patients.

We know from research that early intervention and appropriate treatment for psoriasis will contribute to a person’s psychological well-being and ability to continue in the working environment. It really is not enough simply to treat the skin. I have seen pioneering dermatology services where patients have access to a resident psychologist as a routine part of their treatment. I want and need that level of support for my constituents. I hope that the Minister will encourage commissioners and dermatology services across the country to look at the evidence base and adopt that model.

That does not mean that we need to find a magical pot of new money; it means using existing tools to incentivise what works best. That could even save money in some cases. Commissioning groups are held to account through the outcomes indicator set; will the Minister encourage the National Institute for Health and Care Excellence to develop indicators covering dermatology? As in other areas, in dermatology we need better co-ordination between primary and secondary care; will the Minister encourage NICE to create a quality and outcomes framework indicator on dermatology, to incentivise that? Eventually, it would be great to see a best practice tariff or a national CQUIN—commissioning for quality and innovation—payment framework for psoriasis. At the moment, dermatology is such a Cinderella service that that seems ambitious, but we must aim for it. We need central clinical leadership to push dermatology up the agenda, to promote quality improvement and to reduce local variation.

Perhaps the Minister will tell us why, when other specialists are getting going with their strategic clinical networks and have plenty of clinical leadership from the centre, dermatology does not even have a national clinical director. From a response to a written question back in May, I learned that NHS England does not have a single person responsible for dermatology. Will she tell us whether that is still the case? We must recognise the burden that psoriasis places on people’s lives and ensure that dermatology services are properly joined up and properly funded. I hope that the Minister will task NHS England with making that happen.

Finally, will the Minister join me in congratulating the Psoriasis Association on a very successful psoriasis awareness week last month? The members have created a booklet, “I wish someone had told me…”, which is full of practical advice, and I recommend it to anyone suffering from the condition. We must all work together to provide a quality service for all patients with skin conditions, particularly psoriasis.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It is a pleasure to speak under your chairmanship, Mr Turner. I pay tribute to the hon. Members who have spoken today and particularly to my hon. Friend the Member for Gainsborough (Sir Edward Leigh) for securing the debate. As has been illustrated throughout, this is an under-discussed area and it seems to be neglected in other ways, too. The debate has been valuable, and I have certainly learnt a lot during its course and in my preparation for it. Inevitably, there will be some points on which I cannot give a full answer today, but I shall endeavour to follow up with hon. Members if I cannot. I also pay tribute to the all-party parliamentary group on skin. I have looked at the recommendations in its recent report, and I pay tribute to the members of the group who have spoken today.

We have heard from several Members how many people are affected by skin disease and I shall not go over those numbers, which are very large indeed. There is a huge range of skin diseases; some are manageable and others are life-threatening, as we have heard. All have an impact on people’s lives and, in particular, can affect their personal appearance, as Members have highlighted in moving terms. In that way, skin problems perhaps represent more of a day-to-day challenge than many other conditions. They impact on all aspects of life, such as employment and personal relationships. It is, therefore, important to ensure that people with skin disease receive both the treatment and support that they need. As today’s debate has highlighted, considerable challenges remain, many of which we have not necessarily bottomed out during the debate, but we have begun to highlight some.

Let me first plug the national framework. Skin disease is a long-term condition, and through the NHS mandate we have made it clear to NHS England that we want to see the NHS among the best in Europe at supporting people with long-term conditions. We want them to live healthily and independently, with better control over the care that they receive. Those improvements are monitored through the NHS outcomes framework, for which ambitious expectations have been set out. In turn, the NHS will monitor the performance of clinical commissioning groups through the clinical commissioning group outcomes indicator set, on the quality of the services and health outcomes achieved through that commissioning.

As my hon. Friend the Member for Gainsborough highlighted, commissioning for most dermatology services is a matter for CCGs. They are better placed to use their clinical insight, local knowledge and local relationships to do excellent commissioning at a local level than Ministers in Whitehall, but I take on board the challenge about the more specialist areas. We are not leaving CCGs to commission without support. NHS England is working closely with them to ensure high-quality commissioning, and it has established commissioning support units and quality surveillance groups across the country. However, as my hon. Friend the Member for Mole Valley (Sir Paul Beresford) said, it is certainly something that I can raise on appropriate visits when the opportunity arises. As the Public Health Minister, given that so much of my portfolio is localised, I am very keen to draw attention to good practice where we see it.

There is an example in the area of my hon. Friend the Member for Gainsborough, where his local CCG has introduced a teledermatology pathway, which allows patients to be reviewed at their own practice. We also heard of an excellent example from Buckinghamshire, which I was speaking about with my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan) during the break for the Division. The pathway in the area of my hon. Friend the Member for Gainsborough is being implemented across 10 practices from September. If it is successful, it will be rolled out across all the practices in the Lincolnshire West CCG. I am always interested to hear about good practice. A number of kind invitations for visits have been made during the debate and I look forward to following those up with Members so we can highlight people who are being innovative in a way that will help other commissioners.

As has been mentioned, with some highly specialist dermatology services for conditions that cannot be treated locally, it is appropriate for NHS England to commission them directly. NHS England has set out detailed service specifications for the services that it directly commissions. I realise that a number of Members have made points about the national clinical director, and that issue has been raised in other contexts, too. It is a matter for NHS England whether it appoints a national clinical director. I understand, from asking it the question, that there are no current plans to introduce an NCD for dermatology, but it is continuing to discuss with the British Association of Dermatologists the best ways to improve outcomes for patients.

As has been said, aspects of treatment of people with skin conditions can be considered under any of the five domains. That change in the new NHS focuses on people as individuals rather than on their conditions, which is why the patient pathway and not the organisations that treat them is given the closest attention. Many of the national clinical directors have cross-cutting roles—I have come across that in other areas of my portfolio—rather than roles that are related to individual medical conditions, so it is not the case that dermatology is being singled out. Clinical directors often cut across.

There is interest in the research—points have made about it—that is going on to get better results in dermatology and to come up with new treatment, so I shall touch on that. I reassure the Chamber that investment by the National Institute for Health Research in skin research increased from £4.7 million in 2010-11 to £8.7 million in 2012-13. That includes the NIHR investing £2.6 million over five years in the biomedical research centre at Guy’s and St Thomas’s and the King’s College London centre, which is leading the way in research on cutaneous medicine. The NIHR is dedicated to translating these scientific discoveries into improvements in treatment, which we hope will benefit patients at the earliest opportunity.

The NIHR has also awarded nearly £2 million to Salford Royal NHS Foundation Trust to undertake a programme of research on psoriasis. The studies will look at crucial issues, including individual patient experience, difficulties faced by service providers and identifying levels of risk in populations. I hope that the hon. Member for West Lancashire (Rosie Cooper) will take particular comfort from that, and I am sure that she will be interested in the outcome of that programme. The NIHR is also investing nearly £1 million in a trial of silk therapeutic clothing for the long-term management of eczema in children.

My hon. Friend the Member for Gainsborough will know that NICE has also published guidance on a range of dermatological conditions, including atopic eczema in children and psoriasis, and it has issued quality standards on those topics. NHS England is statutorily required to have regard to NICE quality standards, and we expect health and care professionals to take NICE guidance on the treatment of relevant conditions fully into account when deciding how to treat a patient.

NICE has also recommended a number of drugs for the treatment of dermatological conditions such as eczema and psoriasis. Patients have a right in the NHS constitution to access drugs and treatments recommended by NICE technology appraisal guidance that their clinicians want to prescribe.

As I acknowledged earlier, and as has been very much illustrated during the debate, skin disease can have adverse psychological effects on patients. The NICE quality standard on psoriasis recognises that and sets out that people with psoriasis should be offered an assessment of how their physical, psychological and social well-being is affected when they are diagnosed and when they undergo treatment. It is the responsibility of all commissioners, providers and clinicians to ensure that patients receive the psychological and emotional support that they need. Hon. Members may be aware of the IAPT—improving access to psychological therapies —programme, which is an NHS programme rolling out services across England offering interventions for people with depression and anxiety disorders. I understand that as part of that programme, NHS England is looking at how best to support people with psychological problems arising from their physical problems. That issue was raised a number of times during the debate.

I listened carefully to the comments of my hon. Friend the Member for Romsey and Southampton North (Caroline Nokes), who highlighted that the issue of Roaccutane was discussed only yesterday in the Chamber. It is associated with rare, serious side effects and can only be prescribed by or under the supervision of a consultant dermatologist. The BAD has published guidelines for its members about when to prescribe it and how best to monitor patients for adverse effects during treatment. I will certainly make a point of catching up with my hon. Friend the Minister of State, who responded to that debate. I will ensure that we touch base with regard to the important subject that my hon. Friend the Member for Romsey and Southampton North has raised today.

The issue of GPs’ and other health workers’ education and training has come up a lot. My hon. Friend the Member for Mole Valley made it the focus of his speech. It is important that health professionals have the right training. Training and education of health professionals is a matter for Health Education England and the royal colleges. NHS England is statutorily required to have regard to the NICE guidelines, and we expect health professionals to have regard to them, too. I am aware that the BAD has produced toolkits and guidance. They are valuable resources for health professionals and should be promoted widely. NHS England has responsibility to support CCGs, as I said, with commissioning guidance and tools and it can flag up the relevant dermatology guidance and standards.

I understand that NHS England’s domain director for long-term conditions regularly meets the president of the BAD, who is also an adviser to the all-party group on skin. I am sure that the issues about the education of GPs are raised at those meetings.

The current framework for accreditation and re-accreditation of GPs with a special interest remains under review, following the transition to the new arrangements for the NHS in England. NHS England is working with the Royal College of General Practitioners and with dermatologists to produce an improved and consistent accreditation system. It is expected that there will be a report early next year, and I am sure that there will be interest from hon. Members in that.

I am concerned about the point that has been made about the shortcuts being taken on some of the training courses. I thought that what was highlighted today was quite alarming. I have heard that before. It is certainly something that I will put on the agenda for my forthcoming meeting with the Royal College of General Practitioners. I will report back to my hon. Friend the Member for Gainsborough, who raised the matter and said that there was considerable interest in it in the House.

Since 2002, there has been a 40% increase in consultant dermatologists, but I accept that that is from a modest base. It is clear that, although there was an increase of 28% between 2002 and 2012 in the total number of staff, we still have more to do, but things are improving. Health Education England needs to ensure that we have the right dermatological work force. I will ensure that it is aware of the issues that have been raised today and highlight the concerns of hon. Members.

Many of the problems highlighted in the debate have not really been funding issues, which I suppose makes a change in an NHS debate. They have actually come out of a lack of engagement that hon. Members have highlighted. I think that some hon. Members have even alluded to there being a sense of complacency sometimes with regard to skin conditions and they asked whether such conditions are taken sufficiently seriously. I am not sure that in this debate we have quite got to the bottom of why clinicians perhaps do not choose to specialise in or pursue this line of work, but today’s debate is useful in highlighting that.

Will the Minister take away to her fellow Ministers the point that the psychology of all this is very important and, in particular, read the report from the group chaired by my hon. Friend the Member for Mole Valley (Sir Paul Beresford)? A lot of people, when they poke fun at others because of their appearance —their skin colour or something else—do not realise that they are causing them psychological damage. That is the particularly the case with children. It is an important point that we want to be taken away from the debate.

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

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

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

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

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

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

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

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

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

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

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

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