(10 years ago)
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Lord Kakkar
To ask Her Majesty’s Government what impact the National Health Service innovation and research strategies have had on health improvement.
Lord Kakkar (CB)
My Lords, I declare my interests as Professor of Surgery at University College London, chairman of University College London Partners and UK Business Ambassador for Healthcare and Life Sciences.
It is a great privilege to open a debate on the subject of innovation in the NHS since I believe that at no time in the history of the NHS has innovation been so much at the centre of policy and thinking as it is now—for example, the life sciences strategy announced by the Prime Minister in December 2011, the subsequent Innovation, Health and Wealth report that focused on developing academic health science networks, the creation of academic health science centres, building on the record of the previous Government or, indeed, for the first time in the history of the NHS, including in a Bill the obligation for the Secretary of State, NHS England and clinical commissioning groups to promote research in the NHS.
The environment for research and innovation is at an all-time high. This is particularly important because it is well recognised that from establishing a therapeutic innovation or technical innovation that could improve healthcare, it takes some 17 years for it to be fully embraced and embedded in a healthcare system. This remains a shocking statistic throughout the world given that many of these innovations have the capacity to impact clinical outcomes profoundly, in many cases by reducing mortality and burden for patients.
But beyond the importance with regard to health gain that innovation can provide to the NHS, it is well recognised that many innovations, such as improved ways of delivering the practice of healthcare, can have a profound impact on the utilisation of healthcare resources. We are uniquely positioned in this country to have a life sciences and healthcare ecosystem given our unique National Health Service, our extraordinary universities, some of the leading biomedical research institutions in the world and our small and medium-sized enterprise sector around healthcare and the life sciences. This ecosystem has led to the development of a life sciences industry in this country which is second only to financial services in its importance to the economy, employing some 170,000 people, providing around £52 billion to the economy, and with 5,000 enterprises. This achievement is reflected in the success of our healthcare and life sciences research. A nation with about 1% of the world’s population provides 12% of the annual cited published output in the biomedical sciences globally. We have a huge investment, be it through government and the charitable sectors—and, of course, from industry research and development—in our universities and health service. Every pound of that investment provides a return of 39 pence per annum in perpetuity, which is a quite remarkable contribution to our economy.
There is much that we must do to ensure that this commitment to innovation in the NHS is sustained. At the time of the one-year review following the original publication of the Innovation, Health and Wealth strategy, it was agreed that there would be a sunset review of some 60 organisations involved in innovation and improvement in the NHS. That is a very important commitment to satisfy all involved, particularly the taxpayer, that the commitment to innovation was funded and directed in the most appropriate fashion to deliver tangible results in terms of both health gain and wealth creation for society more broadly. In October, in another place, the noble Earl’s ministerial colleague George Freeman answered a Question where he indicated that that sunset review had been undertaken with regard to what was described as the fragmented landscape for innovation organisations in the NHS, but it was not proposed to publish it. That is a little disappointing because the insights from that important review of the innovation landscape and the many organisations contributing to it could help those organisations that are going to remain in the innovation space in the NHS to better understand the successes and failures of those who have been there previously and organise themselves in the most efficient fashion to deliver the vitally important health gains that innovation can provide to our healthcare system. Can the Minister comment a bit on the sunset review and, in particular, whether there might be some opportunity for those organisations that remain in the innovation landscape to learn from its findings?
Much has been made, quite rightly, of the NHS Five Year Forward View, announced by the chief executive of NHS England on 20 November. It is an exciting document that addresses the question of innovation. One interesting conclusion is that the Government remain committed to innovation in the NHS. It is not entirely clear how that forward view sits with the commitments previously made and, in particular, the work of the Innovation, Health and Wealth Implementation Board in NHS England. This is an important issue, because co-ordination of the different strategies and commitments in the innovation space in the NHS is vitally important. How will that co-ordination be achieved in the future? It was not entirely clear from the NHS Five Year Forward View how that would be achieved. Will be it through an ongoing responsibility for the Innovation, Health and Wealth Implementation Board? What role will the academic health science networks, created as a part of that original review, play in the forward view with regard to innovation in the NHS over the next five years?
There was also the important announcement just last week, again by the noble Earl’s ministerial colleague George Freeman, with regard to the innovative medicines and medical tech review, which proposes to determine how we can better develop medicines that will have a big impact on patient outcome more rapidly in our country and provide additional funding to drive forward a more efficient process for the development and evaluation of innovative medicines and technologies. How will that strategy sit with regard to the already established structures of the academic health science networks, which are there to drive a collaboration between healthcare organisations, universities and the independent commercial sector in terms of the life sciences and biomedical research?
There is a very important obligation for government to lead on a culture change with regard to innovation. There is no question that mechanisms and organisations have been established to drive forward the NHS innovation agenda. There is also a need to focus on the culture in NHS institutions both in the community and in the hospital sector to ensure that the provision of innovative therapies is at the heart of clinical practice for all healthcare professionals. I wonder what approach Her Majesty’s Government propose to take towards ensuring that there is a cultural transformation in the adoption of innovative strategies in terms of pace and scale both within individual institutions and across health economies. There is also an important question about regulation, because it can impede research and innovation and the adoption of innovative strategies. We saw this, for instance, with regard to the European clinical trials directive, which had a devastating effect on clinical research output. A revised directive is to be adopted but there are concerns that that may not be done by the 2016 proposed deadline. Is the Minister able to provide some further information on that?
Lastly, there is a real concern in the biomedical research community about the proposed European data protection regulation that will replace the current directive. As originally drafted by the Commission it seemed a sensible approach to data protection but, as amended by the European Parliament, it presents a real threat to the conduct of major research programmes that have a profound impact on the delivery of healthcare, particularly the 100,000 Genomes Project, the UK Biobank and the conduct of cancer registries. These are all at the heart not only of the research effort that is a fundamental part of our nation’s strategy, but also of the delivery of healthcare. Can the Minister comment on where the negotiations are to ensure that the detrimental aspects of this data protection regulation will not apply to our country?
Lord Selsdon (Con)
My Lords, I am most grateful to my noble friend for introducing this debate. I suppose that I am the only person here who can declare to be an unqualified amateur, but the word “amateur” means someone who loves his subject. When I was brought up, I was surrounded by four doctors in various parts of the family. I took the view that I could never be ill, because you were not allowed to be ill at that time, and that one should get on with life, but I learnt about the problem of the co-operation between the public sector, as it is called, and the private sector.
I go back to when I was quite a small chap in the 1950s. My father said, “You must learn to play golf. There’s some golf going on at the Liphook golf course”. I went down there, and there was a chap called Douglas Bader, who did not have any legs. Bobby Locke from South Africa was there, and I had never picked up a golf club at all, but Douglas was very kind to me—he showed me his legs. He took one off and waved it at me.
I forgot that partnership is what one looks at, and perhaps the greatest prosthetic partnership between medicine and commerce was Professor John Charnley back in the early 1980s. He was an orthopaedic surgeon who, together with Charles Thackray of Leeds, set up the first artificial hip replacement. In parallel, there was Uncle Archie, as I call him—Archie McIndoe, who had a very attractive wife. He was a New Zealander who came to London in 1930, could not get any work and so worked as a clinical assistant for plastic surgery at Barts. Then he was appointed as consultant to the RAF in plastic surgery, leading to the Blond MacIndoe Research Foundation at East Grinstead. As your Lordships will recall, the patients there were Hurricane and Spitfire pilots who were badly burnt. That was the start, a long time ago, of the co-operation in technology that led to the experience in skin grafts on patients who were known as “guinea pigs”. I believe that there was a smart club you could join if you had suffered, that was called the Guinea Pig Club.
I move forward now to Camp Bastion and the technology that has been developed over that period of time. There have been some very interesting developments. In the research world, we must accept that the Government and the NHS have to co-operate with the private sector. Out there, there is a private sector that is very willing to co-operate on all sorts of developments.
For many years I was a banker. Mainly because I had previously worked in a research company whose office was just above a pump in Broadwick Street that had polluted the whole of London, I got involved in water and sewage projects. In the context of hospital diseases, which were mentioned earlier, there was a company up in the north-east called Henry Cooke, which was on a river belonging to another company—I will not name it—which it did not really want. It made paper that was particularly suitable for the health service. It meant that you could put an instrument in a paper bag and then shove it in to be sterilised at a later date. It was steam-sterilisable paper, which was one form of technology. Over a long period there have been other developments in this field that make me think.
For a while, through an accident of no reason at all with a client, I became a director of Terme di Porretta, the oldest spa company in the world. Ovid wrote of our springs, “From these springs cometh forth life”. We had a problem in Bath: there was an amoeba in the water there, which meant that people could not bathe anymore. Needless to say, one word to the Italians and the whole team decided to come to London, explain that they had created the middle of Bath and put forward new proposals for drilling and things of that sort.
That led me to wonder about the impact of waterborne diseases—C. difficile and the others. I was director of a construction company. We built several hospitals. Suddenly, after having built one hospital and put in all the water systems so that people washed their hands, the NHS decided to change the rules and that you should use some form of chemicals or other things, so the water was not used. The water backed up, and we suddenly had one of the first examples of legionnaires’ disease. These are the sorts of problems that I have had in my life, but with waterborne diseases it becomes quite important. Because of the sewage thing, I ended up in the sewage business, building sewers. I got gippy tummy in Cairo and we then built sewers there, but that is another long story.
The point that I am trying to make is that co-operation with the private sector is very willingly there. In the research field, when you look at the amount of drugs that we are developing, we are a pretty successful nation. I congratulate my noble friend on what he has done.
I will not move on to the worrying business of adult stem cells, except for a brief moment. I found to my surprise that I was involved in this field with a professor from Germany who had looked at the application of stem cells for heart treatment. That was a worry. While he was a German, the Swiss were involved and they needed the support of the Vatican. So after a meeting with the Pope, the Pope shook hands and said that autologous stem cells could effectively be used for the regeneration of hearts. In this area, you look at what happens when people go out to try to buy hearts for regeneration where adult stem cells of different sorts, whether they be autologous or allogeneic, can do an awful lot of work. This is a development area that is very important.
The point is that the private sector can work very closely with government. My favourite exercise of all was when I first met the Da Vinci machine. That is a machine that I brought into the Library and everyone had a look and said, “What does it do?”, and I said, “You’d better find out from Lord Kakkar”.
Baroness Brinton (LD)
My Lords, I congratulate the noble Lord, Lord Kakkar, on securing this important debate on a key issue that is essential if the NHS is to be in the forefront of health improvement in the next few years. The noble Lord focused on the larger strategic picture, but I want to focus more on the impact on the patient and the citizen. The title of the debate refers to both innovation and research. I want first to talk about where innovation and research are providing improvement in treatment and in health, particularly the benefits of the new academic health science networks, which use pure and applied research to create very strong links between hospitals, commercial organisations and universities. These regional bodies are providing a country-wide system to deliver innovation.
I declare an interest as an arthritis patient; I am grateful to Arthritis Research UK for a briefing that it sent me. It has joined with the Medical Research Council to fund the Centre for Musculoskeletal Health and Work. Led by Southampton University, this centre seeks to find ways to reduce the impact of conditions that affect muscles, bones, and joints on the ability of people who work: people like me. At present, musculoskeletal conditions are the biggest cause of workdays lost through illness, with 30.6 million days lost a year. The cost to the economy is significant. For people with rheumatoid arthritis, seven out of 10 are unable to work because of the condition within 10 years of diagnosis. So research that is both scientific and applied can not only make a significant improvement to the individual and their condition, but can also reduce NHS costs and offer the chance of their returning to work and taking an active part in our economy again.
In another example of research innovation, Arthritis Research UK has joined with the Medical Research Council and other medical research charities to invest £230 million in a clinical research infrastructure initiative. This initiative will involve 23 key projects at centres across the country, and will use state-of-the-art technologies to find out how differences in the cellular and molecular make-up of people affect how they respond to disease and to treatment. It will take us forward on personalised treatment as that develops over the next few years.
Innovation does not automatically mean clinical research. The Scottish Health Informatics Programme is a good example, which we in England would do well to emulate. In a report to the APPG on Medical Research, a case study points out that SHIP is a Scotland-wide collaboration between the NHS and Scottish universities which analyses and links patient records. Although currently a developing resource, data linkage has also been used in a number of health studies in Scotland, using anonymous linked clinical diabetes and cancer data to show that patients using synthetic insulin were at no greater risk of developing cancer than those using traditional insulin.
That should be contrasted with some of the very practical problems of not linking data, where each hospital has its own patient number and does not allow data to be transferred between hospitals as a matter of course. A patient who has to have regular blood tests before treatment may have their test carried out at a GP surgery; it is then sent to the local district hospital, which will e-mail the result back to the GP, who often has to sign it off before the patient or the other hospital is allowed to know the result. The patient has to speak to the receptionist, sometimes to the GP as well, and the receptionist again when they go in to collect the blood test result. Because in this example the patient’s treatment is at a regional hospital, not their district hospital, they then have to text their consultant with the result to ensure that the treatment can actually be carried out. If the results are delayed for any reason, when they arrive at their regional hospital treatment may be delayed while a further blood test is carried out, and there is then a backlog of patients seeking treatment. All this is because the NHS cannot allow the transmission by e-mail of formal results. I am told that it is to do with data protection but if the Scottish system can make it work, surely the NHS can as well. Will my noble friend the Minister indicate whether England and Wales will follow the example of the Scottish Health Informatics Programme and solve what seems to me to be a straightforward and simple problem rather than the intractable and expensive problem that it has become?
There is another important area of innovation that provides significant health and well-being improvements, and that is the involvement of the citizen and patient in understanding their own disease and treatment. The National Institute for Health Research launched its “OK to ask” campaign on International Clinical Trials Day in 2013. More than 150 NHS hospital trusts took part and 80% of respondents who were followed up said that it had definitely helped to raise awareness of the importance of clinical research. The National Cancer Patient Experience Surveys of 2012 and 2013 show that only one in three cancer patients is having a conversation with their doctor about research. There is a good body of evidence to show that patients who talk to their clinicians and understand their illness and the treatments that are available—or even not available—are less likely to suffer from depression.
I have one anecdote from 10 years ago—I apologise for the aged anecdote. When I was the deputy chair of the East of England Development Agency, we did some work with the Williams Formula 1 team. As its social responsibility action, the team that changed tyres in the pits was working closely with the Great Ormond Street Hospital operating theatre teams to work out how they might be able to improve their performance to speed up operations. Both Great Ormond Street and Williams have found it extremely useful because Williams learnt something from it as well. That is an unusual form of innovation—actually, I think it is good lateral thinking—but it works very well in other ways. I know that many people involved in the Williams thing now sell that expertise for management teams to work better as teams in the future.
We have had some good cases this evening to show that the benefit of innovation is much wider than we imagine. Not only do Parliament and government have a key role to play but so does the citizen and patient. We need to ensure that innovation and research is at the heart of the NHS as it faces the challenges of the 21st century.
Lord Mawson (CB)
My Lords, I thank the noble Lord, Lord Kakkar, for introducing this important debate. I will focus my remarks on innovation in the primary care setting.
The report Creating Change: Innovation, Health and Wealth One Year On, published in December 2012, makes two references to community. The first was the procurement community and the second was the research community, and therein, I suggest, is the fundamental problem.
If you look at how primary care is being run in developing countries, you will find a clue to what works and what is cost-effective. They do not send in professional teams at great expense to change the behaviour of patients. They invest in informal networks, particularly among women, because that is how you get the key programmes running at the front edge. In this country we seem determined to professionalise everything. Instead of creating relationships, networks and local gossip, we churn out papers and reports.
I have made these opening remarks because my conversations with the senior consultant at Barts and the London, who is responsible for working on our national diabetes crisis, tells me that his department is already overwhelmed by the scale of the health problem and that the only real solution to it lies in the community.
An impending epidemic of diabetes faces this country. It has already arrived in east London. It is not because people are ill but because they have unhealthy lifestyles. To address this challenge we genuinely need everyone working together in the local community: the school, the health centre, the pharmacy, businesses, the voluntary sector and local parents. This is where innovation is needed, yet we turn to the procurement community and research community. The message for patients is, “Health is not something I own; it is something that professionals do to me”.
At the moment there are lots of projects that try to join up service delivery and connect with the community, but the delivery of actual programmes affected does not change very much because often the professionals say that they cannot afford the overhead of the meetings needed to discuss the programmes, so people revert to type. Thus innovation and change become stifled. We need people collaborating on practical projects—“learning by doing”—but doing things in a significantly different way.
Let me share a practical example of what I mean. I declare an interest as the director of the St Paul’s Way Transformation Project. Seven years ago I was asked to intervene in a group of deprived housing estates in Tower Hamlets by the then CEO of Tower Hamlets council, Christine Gilbert, and the CEO of the local health service. A young man had been murdered and another set on fire, and there was serious concern across the public sector and beyond. Despite the many years of successive Governments talking about joined-up thinking and the need for integration, I found a failing secondary school with 1,000 pupils, the GP practice next door injecting 11,000 patients with dead vaccines stored in a cheap domestic fridge, and the excellent pharmacist across the road, a respected member of the community, being ignored by public bodies. Everybody was operating in silos and basic human relationships between the key leaders in health and education were not in place. No one was investing in any joined-up thinking, let alone action, and little innovation was taking place.
Six years later, by bringing the key leaders together and building relationships between them, we have a rather different situation. The new, recently opened £40 million school, to which only 35 families applied five years ago and which was one of the bottom 10 schools in the country, had 1,200 families apply this year. Six months ago Ofsted rated the school outstanding in every regard. Across the road from the school, the local social housing company has built a new £16 million health centre, with the agreement of the then PCT, in a campus development. The plan is that this will open shortly with a team of new GPs, working alongside a diabetes DNA research laboratory run by the school and Queen Mary University of London. The students at the school will be researching the causes of diabetes in the 11,000 patients, many of whom are extended family members.
The first phase of 500 new mixed-tenure homes has been built, alongside a new community services centre. Support from JPMorgan Chase, just a few hundred metres to the south, is now enabling pupils at the school to start their own businesses. Our patron Professor Brian Cox and I have just run a very successful third science summer school, addressing the issue, “You are what you eat”. This year the science summer school brought together 30 schools in east London.
How did we do it in six years? At its core, it was about establishing relationships between the key leaders responsible for the local health service, education and housing and getting them to communicate with resident leaders and to be entrepreneurial. The result is a piece of innovation that is now generating further innovations in health, education and housing. We are all learning by doing things together. This is where innovation and integration start. None of these individual activities alone will solve the diabetes crisis in east London but, by combining our shared efforts and resources over a period of time, we will change behaviour patterns and patients will start to see themselves as responsible for their own health.
Innovative, integrated programmes like this are the exception rather than the rule. Why is this? Negotiations on securing the integrated health centre that I mentioned have dragged on for seven years, through one NHS structure after another. Jeremy Hunt helpfully assured me in the summer that we were nearly there, yet minutes before I came into this Committee I was unexpectedly phoned by the chairman of the housing company that is bearing all of the costs and was told that she, a very experienced businesswoman, had had enough—today, yet again, another group of civil servants asked to renegotiate the lease.
Bernadette Conroy is a former colleague of the noble Lord, Lord Green, and a senior person who used to work at HSBC. She has now given the NHS 24 hours to come up with a decision rather than prevarication, or she will walk away and this opportunity at the frontier of health innovation will fall. I ask if the Minister can help. We have been on the case for seven years and we are all becoming exasperated.
Innovation in the health service is a very challenging business. When you are operating at a new frontier, you need friends and leadership that grasps the opportunity when it arrives. The opportunity for innovation in health has now arrived at St Paul’s Way in Tower Hamlets. I ask for a helping hand from the NHS.
Lord Saatchi (Con)
My Lords, every year my respect and affection for your Lordships’ House grows. That is largely because of occasions such as this, expertly secured for us tonight by the noble Lord, Lord Kakkar, when your Lordships can hear the voices of great leaders and pioneers in medical science.
I should like to pay a tribute to my noble friend the Minister and his team at the Department of Health for the work that he has undertaken with the Chief Medical Officer and the NHS medical director to take forward an agenda of innovation and to try to advance in the NHS a culture of innovation, as the noble Lord, Lord Kakkar, described it. I also thank the noble Baroness, Lady Wheeler, for the interest that she has taken in the innovation agenda and her scholarship, which I appreciate enormously.
Perhaps your Lordships share with me and many others in the medical world a sense of anticipation at the appointment of George Freeman as the Minister for Innovation in another place. It is often said of politicians that they will say anything to be elected. In the case of George Freeman, it really is the case that here is a man for whom the pursuit of genomics, the Cancer Drugs Fund, early access to medicine, more transparency and more disclosure have been his life’s work. It is rather a marvellous moment now that he has become a Minister, as I hope noble Lords agree.
I am a late arrival in the world of medical innovation. I will borrow the family credo of the former Leader of your Lordships’ House, Lord Salisbury—“late but in earnest”. I am certainly late and I am certainly in earnest. I will tell you why. Perhaps I am reflecting something that was said by my noble friend Lord Selsdon early in his remarks. To me, the medical innovators are true heroes. Isaiah Berlin addressed his considerable mind to the question of whether such persons as heroes can ever really be said to exist. He defined a hero as an individual who, acting alone or almost single-handed, makes what seems highly improbable in fact happen. It means a flat refusal to accept the status quo—a determined conviction that an individual can change the world by an act of will.
By Berlin’s definition, we have before us two examples of such people. The first is the noble Lord, Lord Kakkar, himself, whose Thrombosis Research Institute is dedicated to the study of a disease which is responsible for 95% of fatal heart attacks and 92% of fatal strokes. His institute, of which Prince Philip is the royal patron, aims to develop novel therapies to prevent long-term disablement and early death. Secondly, we have the noble Lord, Lord Turnberg. The noble Lord recently brought together at his alma mater, the Royal College of Physicians, two of the great medical innovation institutions in the world. He hosted the launch, by the Memorial Sloan Kettering hospital in New York and the Weizmann Institute in Tel Aviv, of a visionary collaboration, combining the long-standing track records of both institutions for breakthrough science. This new partnership unites Weizmann’s basis scientists with MSK’s clinical practitioners—a combination long considered impossible between two completely opposite cultures—to try to speed up the process “from bench to bedside”.
These noble Lords inspired me, so here is a question: what inspired them? Perhaps it was the night of Saturday 25 May 1940 when something took place, at the Dunn School at Oxford, which the New York Times called,
“perhaps the most exciting tale of science since the apple dropped on Newton’s head”.
Until then, there had apparently been many ways to measure a human body in distress: pulse rate, blood pressure, blood sugar, body weight, white cell count, red cell count and so on. Then one man decided to concentrate on only one measure: body temperature. I have here the lab notes of Dr Florey that night, and I thank one of today’s other great innovators, Professor Alistair Buchan, the Dean of Medical Sciences at Oxford, for letting me see them.
At 11 am, Florey injected eight white mice with virulent streptococci, known to be fatal to a mouse of average weight. At noon, mice 1 and 2 were given an injection of 5 millilitres of penicillin solution. Mice 3 and 4 received injections of 10 millilitres. The other four were controls and received none. Further injections of penicillin followed through the day. As this great event unfolded, just before midnight Florey wrote in the lab notebook that all four mice with penicillin were apparently well, but the controls were certainly not. He wrote that one mouse got up and staggered about for a few seconds, then fell down, twitched once or twice and was dead. Others were “seedy”. His colleague, Heatley, made a cross sign in red ink to mark the death. By 1.30 am on 26 May, the four protected mice had napped and awoken, but two more controls had died, noted by two more red crosses. At 3.28 am, Heatley noticed that the last control moved about drunkenly. With each respiration it lifted its head and opened its mouth widely. Respiration became slower, the animal twitched and died.
One of the mice that received a single shot of penicillin lived two days, the other six. Of those that received five shots, one lived 13 days, the other indefinitely. What no one realised at the time is how little penicillin it actually took to save the mice that received it. However late the hour, the result was clear and its implications so breathtaking that Heatley was overcome with “relief, joy, happiness”. He got on his bicycle and began his ride home, the first light of day already in the sky. He had, as he later wrote,
“just witnessed the world change”.
At 11 am on Sunday 26 May, Florey, Chain and Heatley returned to the lab for a pre-arranged meeting. “It looks quite promising”, Florey said, although even he could not maintain that sober view for long. In the end he said, “It looks like a miracle”.
Here is a real miracle. At exactly the same time that morning—26 May 1940—a miracle of another sort took place, to rescue hundreds of thousands of British, French and Belgian soldiers, trapped in northern France along the coast by Dunkirk. Dr Florey became Sir Howard Florey and the winner of the Nobel Prize for Medicine. We conclude from this that God works in mysterious ways.
Lord Turnberg (Lab)
My Lords, it is about two years since I last stood in for the Opposition Front Bench, so I reckon that I have been forgiven for my previous appearance. It is a pleasure to speak after what has been a fascinating debate, and of course I am grateful to the noble Lord, Lord Kakkar, for introducing it in his usual erudite manner. If anyone is an expert in innovation, he is. I declare my interest as a scientific adviser to the Association of Medical Research Charities.
The noble Lord, Lord Kakkar, is surely correct in asking the question in the title of this debate about what impact innovation has had on the NHS. Of course, we need to know much more about how helpful all the innovations that we are introducing into medical practice really are, but it is easier said than done. It is rather like trying to measure the productivity of services like nursing or medicine. Economists tell me that it is easy to measure the productivity of material goods, but what do you measure in services? Is it the number of patients seen, the number cured, patient satisfaction or other intangibles? It is not straightforward. Furthermore, we may know that something works under the carefully controlled conditions of a clinical trial, but we do not know how effective it might be in the hurly-burly of clinical practice. It may take many years before an innovative treatment is widely taken up. Even when it is, it may take a long time before we see its impact on a reasonably representative number of patients. So, although it is essential that we try our best to trace the relationship between innovation and improved care, it is not straightforward. Despite those difficulties, it is clear that the UK is really pretty good at innovation and we are doing well from advances in medicine. We are all living longer than ever before, gaining about two years of life expectancy for every 10 years that go by, and at least half of that improvement has been shown to be due to advances in medical treatment. So we must be doing something right.
When I look back—if noble Lords will forgive me for looking back—at what medical practice was like when I started as a young doctor more than 50 years ago, the transformations have been remarkable. In 1957, there were few effective treatments for cardiovascular disease. Heart attacks had a high mortality rate. There was no angioplasty or bypass surgery. There was nothing for childhood leukaemia—uniformly fatal then, but now mostly cured. Hip replacement surgery was hazardous and rarely successful; that was before John Charnley, who the noble Lord, Lord Selsdon, mentioned. There were no knee replacements or cochlear implants and there was no organ transplantation. I remember going round the wards and seeing rows of polio victims lying immobile in iron lungs. Thankfully, all that has gone.
Medical innovation has been a constant during my lifetime, and patients are infinitely better off, even in the absence of a good system for monitoring its impact. Now we are on the cusp of an even more dramatic change in medical care, with remarkable advances in genomics, digital health and regenerative medicine, and the UK is at the forefront in most of these fields. As the noble Lord, Lord Kakkar, said, the Government, to their credit, are supportive in a number of ways. They set the scene with their Innovation, Health and Wealth report a couple of years ago. The NIHR, under Dame Sally Davies’s direction, is producing results, not least through its very successful academic health science networks and centres, as the noble Baroness, Lady Brinton, emphasised. The various innovation initiatives are also very helpful. The recent rationalisation of ethical approval processes and regulation by the HRA is bearing fruit, and the moves now afoot to reduce the time taken for regulatory approval by the MHRA and the EMA are very welcome. They should help bring much needed drugs to market more quickly for patients and, at the same time, encourage the pharmaceutical industry to invest.
Of course, not everything in the garden is rosy. For example, there are still things to be done by NHS England to speed up its approval of drugs for rare diseases. The recent report from Genetic Alliance UK found that there are no fewer than eight committees involved in assessing these innovative drugs and no fewer than 11 stages to be gone through before approval. Clearly that cannot be right. Perhaps most important is the thorny problem of the woefully slow dissemination into clinical practice of all the fruits of our excellence in innovation. This resonates very much with the remarks of the noble Lord, Lord Mawson. It is here that the Government need to focus much more effort. The barriers to spread and to practice are multiple and well known. They include not simply a medical profession that is not always eager to accept change—although there is some of that, particularly in general practice, where pressures to provide the service are high and distracting—and a lack of tools and expertise to be able to take up innovation. Even more importantly, there is a lack of continuity at trust chief executive level, where few stay in post longer than two years. Introducing change and innovation in a hospital takes years of planning and the winning of hearts and minds not only in the hospital but in the community, but managers are too often taken up with immediate fire-fighting pressures and only just begin to think about the longer term before they are moved on.
Then there are the funding issues that bedevil the introduction of new treatments. CCGs and trusts are too often reluctant to fund new drugs because of costs. This is especially true of the high-cost so-called personalised medicines that are being developed to treat smaller and smaller subgroups of patients. None of this is helped, of course, by the uncertainty surrounding the future of the Cancer Drugs Fund or the continuation of funding for the academic health science networks. Some clarity there would be helpful.
The UK does extraordinarily well at innovation and has a health service in which a million patients are seen every 36 hours, and they are patients that we have in our care for the whole of their lives. What a marvellous opportunity that provides to innovate for the good of everyone. However, if we are to take full advantage of these wonderful resources, we must place much more emphasis on overcoming the multiple barriers to dissemination that are getting in the way. I hope that the noble Earl will comment on how the Government will address them and the many other issues raised by other noble Lords.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by thanking the noble Lord, Lord Kakkar, for having tabled this debate, and all noble Lords who have spoken with passion and insight on these very important matters, and from a rich variety of perspectives.
Our ambition is for the people of this nation to live as well as possible for as long as possible. However, trends show that we can expect ill health in many of our later years, health inequalities persist, and the cost of ill health is increasing. The Government are clear that the National Health Service innovation and research are critical for addressing these challenges and I welcome this opportunity to discuss the impact of our strategies.
In the Five Year Forward View, NHS England and its partners commit to driving improvements in health through developing, testing and spreading innovation across the health system. This encompasses a wide range of activity and is part of the response to NHS commitments in the mandate to support research and innovation. The NHS has a unique position as a population-focused comprehensive health service, so we are building on this to facilitate more cost-effective randomised control trials as well as observational studies to support initial research.
We are setting up real-world innovation test bed sites linked to academic health science networks and centres. In these test beds, combinatorial approaches can bring together innovations where the benefit of combinations could be greater than the sum of their parts. That principle of integrated working in health was well illustrated by the noble Lord, Lord Mawson, in the context of which he spoke. I will be happy to look into the latest developments in Tower Hamlets and write to him.
A core plank of the health service’s approach to innovation will be improving the connectedness of information and data, providing whole data sets that enable the effect of new innovations to be tracked and assessed across all parts of the health system. I listened with great attention to my noble friend Lady Brinton. I agree that unlocking the value of data is a key challenge in improving health outcomes. As she will know, it is a thorny issue but there are exciting developments; for example, Manchester AHSN is exploring how to connect the NHS data across its whole region.
As a result, we anticipate broader adoption of innovations such as the Airedale telecare service, which I visited last week. This has transformed care provision for care home residents where it has been deployed, reducing the number of disruptive visits to hospital by more than half, and cutting the need for hospital admission by 35%.
The Five Year Forward View builds on the progress made under Innovation Health and Wealth, published in 2011. As a result of this work, innovation has a much higher profile within the NHS than it did, relationships with industry are stronger, and we are starting to see very encouraging signs of improvement in the uptake and utility of innovation. Since the publication of Innovation Health and Wealth, the NICE Implementation Collaborative has been established to provide practical solutions to overcome barriers to adoption of NICE-approved innovations. NHS England has launched Innovation Exchange and Innovation Connect, two key platforms to enhance the development and spread of innovation. Medical technology briefings have been introduced to provide the NHS with guidance on emerging medical technologies, and Innovation Challenge Prizes are now celebrating the groundbreaking innovations developed in the NHS and delivering better health outcomes for patients.
Not only that but in 2013 England became the first country in the world to implement a universal system of academic health science networks, AHSNs. These act as system integrators, linking all parts of the health landscape, including every commissioner and provider of health services in their geography, with industry and academia. Through their work to build a culture of partnership and collaboration and to drive adoption of innovation into practice, AHSNs help to improve the health of their local populations. As the noble Lord, Lord Kakkar, is no doubt aware, University College London Partners AHSN has taken major strides forward in the fight to prevent strokes. A preventive strategy is being introduced across the whole UCL Partners region, which could prevent 700 strokes each year and save more than 200 lives. This project is supporting primary care to improve the management and detection of people with atrial fibrillation and increase the number of people on appropriate anticoagulation medicines. Early work over a six-month period in one borough, Camden, has resulted in 131 more people with atrial fibrillation now taking appropriate anticoagulation drugs. Using the learning from this work, they have an opportunity to roll out similar interventions across a further 19 boroughs in the partnership.
I have referred to some of the things addressing the concerns that the noble Lord, Lord Turnberg, raised about the dissemination of innovation. There is also another innovation. The Department of Health is working very closely with NHS England and other key stakeholders to develop the innovation scorecard in order to make it a more useful tool in helping the NHS to understand and address unjustified variation in the spread and adoption of innovative new treatments. It is designed to help users—clinicians, patients, commissioning groups, government and other stakeholders—to understand and monitor the uptake of innovations in the NHS. In doing so, the innovation scorecard should ultimately be used to promote an equitable spread of clinically effective, cost-effective innovations at an appropriately rapid pace, and to encourage the decommissioning of outmoded practice where appropriate. This will help to ensure that innovations have the greatest impact in driving better health outcomes.
In NHS research, our achievements over the past five years are also extensive. Recruitment to trials and studies through the NIHR clinical research network has increased by over 30%. There were more than 600,000 participants in 2013-14; more than 99% of trusts were involved. Recruitment to commercial studies has increased by 26% in just one year, including 35 first global patients.
Following the landmark report by the Academy of Medical Sciences in 2011, we have established the Health Research Authority and awarded £4.5 million for delivery of a unified approval process and we are driving forward financial consequences for poor performance against the 70-day benchmark for recruiting the first patient to a trial. In five years, NIHR revenue spend has increased from £851 million to £987 million which demonstrates our commitment to NHS research even in the prevailing economic climate. In addition, the Health and Social Care Act is a milestone, creating unprecedented powers and duties at all levels to promote research. By the end of this year, NHS England will share a plan with the Department of Health for delivery of its research objective.
In the past, public health research has been neglected, and I particularly want to mention how the NIHR has brought about a step change in building the evidence base to drive health improvement. Fulfilling a commitment in our public health White Paper, we have established the NIHR School for Public Health Research. The NIHR public health research programme is looking at issues as diverse as air pollution, traffic accidents and binge drinking. To help to increase research capability in this field, the NIHR is funding a wide range of fellowships.
The noble Lord, Lord Kakkar, expressed concern about amendments to the proposed EU general data protection regulation, which could prevent health research involving personal data from taking place. Many of these concerns centre on amendments to the proposed regulation that have been agreed by the Civil Liberties, Justice and Home Affairs Committee of the European Parliament. The Government’s view is that the ability of researchers to process personal data in the way that they are legitimately able to do at present must be preserved. We remain attentive to the concerns raised and will continue to engage with representatives of the research community about the processing of personal data for medical research purposes under the proposed regulation.
As noble Lords know, work on the Medical Innovation Bill is ongoing. This Bill, introduced to your Lordships’ House by my noble friend Lord Saatchi, sets out a series of steps that doctors can choose to take when innovating. This is to give them confidence they have acted responsibly, with the intention of reducing doctors’ fears about claims in clinical negligence. The Government are pleased that the amendments that my noble friend tabled to help ensure patient safety were accepted by your Lordships’ House in Committee on 24 October. The Bill will now proceed to Report.
I cannot in the time available do justice to all the questions that have been asked; I shall, of course, write in relation to those questions that I have not had time to answer. I will, however, address as many as I can. The noble Lord, Lord Kakkar, asked about the follow-on from Innovation Health and Wealth and my honourable friend George Freeman’s review. NHS England has stated its intention to increase alignment between different supporting organisations for innovation, which will take account of the work and governance of Innovation Health and Wealth as well as the issue of the innovation culture in the NHS. As regards the Five Year Forward View and the medtech review, the review announced by George Freeman will look at the whole pathway for new treatments from bench to bedside, and these two must closely dovetail, as I am sure is clear to all. Of course, the AHSNs have a key role to play in that connection.
My noble friend Lady Brinton spoke about arthritis research and, in particular, patient participation in research. NIHR investment in musculoskeletal disease research has increased from £15.5 million in 2009-10 to £25.6 million in 2013-14. In May this year, the NIHR published Promoting a ‘Research Active’ Nation. It set out a new programme of work to encourage greater public engagement and participation in research.
I will have to write to the noble Lord, Lord Kakkar, on the sunset review to which he referred. My noble friend Lord Selsdon spoke about the potential of stem cells. He will, I am sure, be interested to know that the Government have an extensive agenda to seize the potential of stem cells for new groundbreaking treatments, and are working in close partnership with industry in this field. I am afraid that time is against me, and while I would like to respond to further questions from the noble Lord, Lord Turnberg, I hope he will forgive me if I pen him a letter about those.
In conclusion, I have outlined some of the major steps that we are taking through our strategies for NHS innovation and research. These are already impacting positively on the health of the population and, I am convinced, hold the promise of health outcomes as good as any in the world.