Prosthetics for Amputees
(3 weeks, 2 days ago)
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Lord Mackinlay of Richborough
To ask His Majesty’s Government what steps they are taking to ensure that amputees receive appropriate prosthetics at an appropriate time.
Lord Mackinlay of Richborough (Con)
My Lords, I have declarations to make. These are TASKA hands, and they are on long-term loan from Steeper Group. Similar, Steeper Group paid for me to attend a prosthetics conference in France just a couple of weeks ago. As ever, we owe thanks to our library facilities—both the House of Commons Library and, this time, the House of Lords Library, which provided some data for this debate.
Some 55,000 to 60,000 people attending UK clinics have some form of limb loss. We are not entirely sure of the figure. The NHS is a great organisation for collecting a lot of data, but it has not quite managed to collect the data on why people have lost their limbs, which is a little remarkable. There are a number of reasons why people may not be fully limbed or may have suffered limb loss after they were born. There are congenital reasons, obviously: people may not have fully functioning limbs. Indeed, not having limbs at all can be a feature. The examples of limb loss that we are more familiar with, of course, are those caused by trauma, such as car accidents or injuries at work.
I always ask why Leeds seem to be a centre for the whole prosthetic and limb loss industry, if there is such a thing. Leeds hospital is at the forefront of hand transplants. Of course, that is because of the industrial past of that part of the world; we may have a greater population in the south-east, but we do not have those types of industrial accident at quite the same level.
Of course, we see a huge expansion in limb loss during wartime. We saw that during the Afghan and Iraqi wars, with IEDs and mines, which are certainly good at one thing: taking limbs off very effectively. The Ukraine war, though, has come up with some new reasons for limb loss. Some 80,000 soldiers in Ukraine have lost limbs—one can only guess that, in Russia, it is a similar amount—but there is a new dynamic of antimicrobial resistance. If you get a limb injury, it should not kill you; it should just pass. However, because we have an increased amount of resistance, that can lead to limb damage and loss. Then there is the use of field tourniquets, where the urgent decision of saving life, not limbs, is taken; the limbs then die and have to be taken off.
The classic cause is diabetes; it is one of the main reasons for limb loss. When I was in my clinic, the amputee rehabilitation unit just over the river in Kennington, the classic example was that of older men who had lost limbs to diabetes—not living as well as they should, shall we say. You can also lose limbs with cancer.
However, the cause that is of great interest to me is sepsis. The trouble with sepsis is that you often lose limbs in pairs. You do not lose just one: both go at once, whether that is two legs or two arms. If you are really lucky and get the quad, you lose all four, like me. The provision of legs is somewhat easier. I am very lucky in that mine were lost below the knee, so I have knees; that makes life incredibly different. The NHS has been good at bringing forward microprocessor-controlled prosthetic knees, which are known as MPKs. They have been widely provided for some years, and people get on well with them. They have become standard kit.
So NHS provision, particularly on legs, is okay once it is on track. However, it is one of extreme delay. I can tell you the story of the legs that I am on. They are private legs. Thankfully, I have been able to get them. I am 10 months on from a cast and still have not got a leg that fits on the NHS. If I had not been able to get these privately, I would have been in a wheelchair for the last 10 months, with mental health issues, unable to go to work and probably suffering severe muscle wasting.
We have a problem in our clinics. The age profile is poor; it is old. It is not an industry that youngsters feel enthused to enter. The pay is not great, and although it may not be much more, if any more, in the private sector, that sector is growing and there is a feeling there of greater reward, greater ability to do your craft and better morale.
We have university provision for prosthetics. The two primary ones are those in Salford and Strathclyde. Within clinics that I have been to there has often been someone shadowing from their university course. However, the drop-out rates are appalling. We can look even further to the technicians, who make the sockets. It is all very well having a great prosthetist for the mould, but you need a technician. The drop-out rate there is even worse and the pay truly dire—often little better than minimum wage. As a country, we concern ourselves with how NHS provision is, particularly regarding our nurses. We have done a lot to try to improve nurse morale and nurse pay, but we have not had that same focus on the problems facing prosthetists and technicians.
This country used to have transferrable old skills. I come from north Kent and the Medway towns. I attend the Medway NHS clinic. In days of old, you would have had those transferrable skills from, say, the dockyard, which closed in 1983. In fact, they would have been greater skills of knocking stuff up in fibreglass, wood and whatever else. This would have also been true in parts of the country with car industries that have, perhaps, now gone. Those craft industries were very good at providing technicians for making prosthetics, but those days are gone.
Noble Lords can imagine my frustration that we still use those old ways, which work, of a plaster cast that is prised off and manufactured manually by a skilled artisan, yet we are short of those skilled artisans. Staff are the limitation. I hear all the time, “We’re short of staff”. There are new CAD techniques to direct 3D printing. I talk to various private companies that do NHS provision, such as Steeper Group, which I mentioned, and which is supporting me. Opcare is another. Those companies are still using those old techniques. I am trying to encourage them, if they have a shortage of people, to take people out of the system as far as they can.
If you lose one arm, you might get away with it. However, you could call losing two something of a catastrophe. I am a quadruple amputee. My worry is that we will see more people like me. My sepsis was very severe, and I was lucky to live, but years ago, if you had severe sepsis, you would simply have died. Now, with a greater understanding, greater knowledge and better drugs, you will get survivors, in states such as mine or that are even worse, yet the system is not preparing itself for keeping people alive. If you are going to keep people alive, let us try to get them on a pathway to recovery.
My experience of upper limbs is really poor. In the brief time I have, I will tell the Committee the story. One is that I was given a pair of what I can only call William the Conqueror-designed arms, with a rubber end. If you have one arm, you might get away with it, but being given two of those was the lowest part of my rehabilitation. You are then told, “Within a few months we might think about body-powered hooks”, which are straps around your shoulders—I would not be able to put them on by myself, of course, as I have two limbs missing—and you use your shoulder to open and close them. They are circa 1790. You then progress to a 1950s-style myoelectric. You have to use that for a year before you can be considered for what I have now, which people with two arms missing need at the earliest possible stage.
We have to go through those hoops. Those early hoops are paid for by the local NHS trust; my hands are paid for by NHS England. My experience was to attempt to make a discretionary appeal, as my condition is as bad as it is, to NHS England. It said, “After 10 months of trials, surely we can just get going with NHS-provided multifunctional hands”. The answer from NHS England was no, so I am very pleased to see the end of NHS England because we have to do better.
I have a final few words. If you go into A&E with a wound on your arm, the staff do not reach for a 1920s hot bread poultice; they give you up-to-date drugs, topical solutions and antibiotics. So please stop giving out pre-Victorian prosthetics.
Lord Shinkwin (Con)
My Lords, it is an honour to follow my noble friend Lord Mackinlay of Richborough. I thank him for securing this important debate and draw courage from the example that he sets, as someone who also lives with a disability.
As he may know, non-disabled people often use the term “inspirational” to express their admiration of disabled people. Unwittingly, they thereby place us on a pedestal. The inadvertent implication—subliminal message, even—is that they could never countenance being disabled or, indeed, think of anything worse. Apart from the fact that being placed on a pedestal, however well intentioned, can compound the sense of isolation caused by living with a disability, surely my noble friend’s experience demonstrates that disability—in his case, specifically limb loss as a result of sepsis, as he explained—can affect any of us without warning.
Being placed on a pedestal does not lessen the daily grind of living with a disability, particularly the reliance on prosthetics or, as in my case, orthotics, which I have had to wear on my legs since I was a child. As my noble friend rightly argues, that challenge should not be exacerbated by the system, yet, as he highlighted so graphically, it unfortunately often is.
This seems to be an endemic, even cultural, problem in the NHS, which, to be fair, excels at acute care, as my noble friend and I know from direct experience. The quality of acute care in wonderful NHS hospitals such as St Thomas’, where both of us have been treated, is phenomenal. Yet the failure to follow through with what my noble friend euphemistically termed in his Question “appropriate” care—in his case, prosthetics—at “an appropriate time” perversely undermines the sometimes huge investment made in one individual by inadequate and delayed follow-up care. I hate to think of how much I have cost the NHS over the years. My noble friend is more diplomatic than I am in his use of the term “inappropriate”; what a multitude of sins that word covers.
I should make clear that I do not mean to imply that our highly skilled and dedicated NHS rehabilitation teams, incorporating both prosthetists and orthotists among other relevant healthcare professionals, are at fault—on the contrary. I can speak only as someone who has benefited from the care provided by orthotists, another branch of that rehabilitation family, but I am immensely grateful for the crucial part that they have played in enabling me to keep the show on the road. By that, I mean that, after every fracture—I have had countless fractures—it has only been because of them and the callipers I wear, which they have tailored to support the very broken body in which I live, that I am here today, on my feet, speaking in your Lordships’ Committee.
So I am delighted to have this opportunity to put on the record my sincere thanks to Chris Cody and his brilliant team at the Guy’s and St Thomas’s regional specialist rehabilitation centre for their professionalism, compassion and empathy as I pick myself up, dust myself down and damn well get on with it. I am sure that the same can be said by my noble friend in terms of the pivotal role that NHS prosthetists have played in enabling him to continue both to live a full life and to perform his crucial role as a Member of your Lordships’ House.
In advance of today’s debate, I consulted a few people on the front line of the NHS rehabilitation sector. First, I will give the good news. Technological advancements such as microprocessor knees, which my noble friend mentioned, and the integration of 3D printing are making a difference, although the latter is in its infancy. Such innovations are undoubtedly welcome but—it is a big “but”—they are overshadowed, again, as my noble friend said, by workforce shortages. Indeed, one of the rehabilitation experts said:
“We are a profession at risk”,
such are the workforce constraints. Coupled with funding constraints, which have led to disparities in access to and quality of care, this is a really worrying situation for anyone who cares about value for money in the NHS. As my noble friend explained, demand is outstripping supply. There are not enough prosthetists or orthotists, which has an inevitable effect on waiting times and—quite apart from the low pay for technicians, as has been mentioned, and for prosthetists and orthotists—their morale.
So I would welcome any reassurance the Minister can give that the refreshed NHS long-term workforce plan, which I think is due in the summer, will address the critical shortage of qualified prosthetic and orthotic professionals. In case the Minister assumes that I am asking for the NHS pot as a whole to be increased, let me say that I am not. This is a question not necessarily of increasing the NHS budget as a whole so much as one of reprioritising existing resources to safeguard the cost-effectiveness of the NHS’s investment in people like my noble friend and me, precisely in order to get bigger bangs for bucks.
In conclusion, I go back to the positives and front-line suggestions on improving patient outcomes. As we know, this means greater independence, fewer hospital admissions, better mental health—my noble friend mentioned this—and more disabled people in employment and thus paying into the system. I have three suggestions. First, strengthen workforce development by investing in education and training programmes. Expanding apprenticeship opportunities and providing financial incentives offer exciting potential to attract new talent to the profession.
Secondly, enhance funding and commissioning. For example, a standardised approach to commissioning prosthetic and orthotic services could potentially mitigate regional disparities and promote consistent access to high-quality care. There are lots of amazing products and components out there, but access is limited by financial constraints.
Thirdly, we must embrace technological innovations. This is where investment in research and development and the adoption of emerging technologies are so important. If that means greater collaboration with private sector firms such as the ones that my noble friend mentioned, in the interests of patient outcomes and consistent with NHS values, that is fine.
In closing, I hope that the Minister has found or will find this discussion useful in deepening her appreciation of just how important prosthetic, orthotic and other rehabilitation services are. Neither my noble friend nor I would be here without them; they need to be nurtured, and that requires a shift in priorities. I would love to think that my noble friend might be asked to help effect that change to the culture and priority that the NHS attaches to what are, sadly, Cinderella services.
Lord McColl of Dulwich (Con)
My Lords, I, too, thank the noble Lord, Lord Mackinlay, for securing this debate. I, too, pay tribute to him. What a marvellous man he is, and what an inspiration to us all. He reminds me very much of my friend, the late Duke Hussey—Lord Hussey—who was injured and taken prisoner at the Anzio beachhead in 1943. He lost his leg and the other leg was partly paralysed. He developed osteomyelitis of his spine, and the Germans assessed that he was dying and so repatriated him. He arrived in Oxford and the doctors confirmed that he was, in fact, dying.
Being Duke Hussey, he was not going to take this lying down, so he wrote to one of the most eminent professors of orthopaedics at the time and said, “Dear professor, I think you’re the only man in the world who can save me”. This professor was rather impressed with this, and he summoned him and said, “Now look here, Hussey, in this letter you said that you ‘think’ that I am the only man in the world who can save you—but I am the only man in the world who can save you”. He operated on his spine 33 times over a period of years to deal with the osteomyelitis, because the antibiotics were not available, and eventually he was cured. I never heard him complain.
Lord Hussey knew more about disability that most other people, so I got him to sit on my committee to look into the supply of artificial legs and wheelchairs, which Mrs Thatcher set up because she thought that the service was in a bad state—how right she was. I was also helped by the noble Lord, Lord Griffiths of Fforestfach. We found out just how bad the service was in terms of limbs that did not fit. It was not rocket science. With the amputee wearing his artificial limb, you could put your hand in the socket while he still had his stump there—such was the poor fit. The other thing was that they were not aligned properly. Some people got so fed up with this that they decided to have a peg leg, and then you had the alignment much better. Some of the farmers with a peg leg found it quite useful when they were planting potatoes, because they would walk down the field stamping on the ground, making a hole suitable into which to drop the potato—so it had its benefits.
We tried to get them to use modern techniques to make a socket that fitted the amputation stump, and it was not that difficult to do. One of the problems was that the companies had such a secure income that they did not bother to develop too much. I asked them what their export attempts were. They said, “It’s very poor indeed—very difficult to export”. I said, “Guess who exports to Israel?” They said, “We’ve no idea”. I said, “It’s a German firm called Ottobock”. I ask the Minister: what is going on at the moment to ensure that the limbs do fit and are aligned properly?
Baroness Ludford (LD)
My Lords, I am very grateful to the noble Lord, Lord Mackinlay, for introducing this debate. When I first introduced myself to him as someone interested in continuing to be involved in the All-Party Parliamentary Group on Sepsis, because of my late husband’s experience in losing a leg to sepsis, his response was, “Is that all? Only one?” The fact that he could make such a quip to me is a tribute to his wit and humour—by the way, I did check with him before quoting that exchange in this debate. His experience puts my late husband’s in perspective, and his speech was extremely interesting, as were those of other noble Lords. Not only do I not have first-hand experience—that was my husband’s, and I was only an anxious observer and supporter—but it was a decade ago, and I am glad to hear that the development of prosthetics has moved on considerably, although whether they are supplied in the NHS is another issue.
We never knew exactly how and why my husband developed sepsis, which led, after a series of operations—to me they were, and are still, a bit of a haze—to the amputation of his leg above the knee. The surgeons tried to save the knee, but they could not do that if they were going to save his life, which they did by the skin of their teeth. I pay tribute to those excellent surgeons and all the other medical staff. The second bit of slightly dark humour I associate with this topic is that my husband was, at the time, the chairman of the Whittington Health trust at Archway in north London, and we managed to joke—at least once it was clear that he was going to survive—that it would not have been a good advert for them or the hospital to lose the chairman under the knife in their own operating theatre. You sometimes have to find humour in very difficult circumstances and, of course, strength and resilience. My husband was not always the easiest person to live with, and he would say the same about me, I am sure, but learning to use a very heavy prosthetic leg from the hip in his late 60s took every ounce of his considerable grit and determination. The noble Lords, Lord Mackinlay and Lord Shinkwin, have that in spades.
Of course, every person who needs a prosthetic is different—we learned that almost 60,000 are attending clinics—and has specific needs. Steve’s physio and training at the Royal Orthopaedic Hospital in Stanmore took place alongside service personnel who had lost limbs, usually one or both legs and usually to an IED or mine in Iraq or Afghanistan. They were, of course, much younger and fitter than him, though they had gone through a horrible situation. It would have been easy for him to get discouraged, and he tried not to, but—one thing was mentioned about the stump—he had a lot of sores on his stump, I suppose because it was not fitting or just from the situation.
I noted from the briefing that the Library kindly produced for us that there is also a veteran’s prosthetics panel, through which people whose limb loss followed from their military service can access high-quality prosthetics. Of course, service veterans absolutely deserve that, including those 80,000, as the noble Lord said, in Ukraine. But if non-military patients do not also receive the best prosthetics going, they are likely to cost the NHS more as they develop other medical problems—maybe joint, muscular or other problems. This is my first example of where I think the NHS is not doing proper cost-benefit assessments.
I shall come back to sepsis, but I want to say something about diabetes. My husband had been a type 1 diabetic since he was 21, and because type 1 damages organs and the immune system, all this was no doubt a contributory factor in his acquiring sepsis. His blood sugar control was pretty good by 2015, but it was a big fight for him to get access to the then latest technology, which would make keeping his blood sugar as level as possible a bit easier and less hit and miss than the old reliance on pinprick tests. The point is not just about the personal welfare of diabetics—though a severe hypo is horrible for the person suffering it and as a spouse, it can be pretty terrifying to deal with—but for these purposes I want to highlight the long-term costs for the NHS of not investing in the latest technology for patients. Because poor sugar control contributes to long-term complications of diabetes, and many diabetics face limb amputation as well as other devastating conditions, such as kidney failure, I have always found it puzzling that the NHS does not pursue a policy of up-front investment to stop even higher costs down the line. It may be something to do with the siloing of budgets between the GP, the hospital and specialist diabetes services.
The same applies to sepsis, from which a shocking 48,000 people die every year. The NHS ombudsman issued major reports on sepsis care in 2013 and 2023, but last September, the current one, Rebecca Hilsenrath, said she not seen the health service do enough to improve staff’s awareness of the condition and the imperative to diagnose it quickly. The noble Lord, Lord Mackinlay, rightly mentioned the threat of antimicrobial resistance, which is putting another challenge on the fight against sepsis. Dr Ron Daniels, an NHS doctor and the founder and joint chief executive of the UK Sepsis Trust, was quoted in the Guardian as saying
“Ministers need to ensure that the NHS starts giving sepsis the same priority as other big killers such as heart attacks and strokes”.
Obviously the biggest tragedy is those who die, but for those who survive—and we hope that more may do so as care improves—the care and provision of prosthetics is vital. I should say that in a Guardian article I read, the noble Lord, Lord Mackinlay, was referenced, as bionic man, as helping to raise the profile of both sepsis and prosthetics. I pay tribute to him not only for coping with his personal circumstances but making it a campaign issue for the benefit of all.
All noble Lords who spoke before me highlighted that the biggest challenge is staff. I am glad to read that bionic prosthetics, or whatever they are called nowadays, which respond to the body’s electrical signals, have been available from the NHS since 2022; that is what we learn from the briefing. I do not know whether that is general and everyone is getting what they need, and I have no idea whether that could have helped my husband’s mobility, but the more that people who have lost a limb can do, including possibly work, the less help and expense they will need, so here too the NHS needs to invest upfront. Time and again, the NHS does not join up the dots in this respect.
The last thing I want to say is about people with poor mobility trying to get around safely in the public sphere. For my husband, even the consistent provision of railings on steps could have helped. In many places, there are, quite rightly, ramps for wheelchairs, and he was in a wheelchair for a few months before he had his prosthetic fitted, but those ramps made life more difficult for him because, without an ankle joint—the leg was rigid—he could not go up or down a slope. Every person with disabilities has different needs, but just having a rail in public spaces would have helped enormously.
I conclude with what is, I am afraid, a constant preoccupation of mine with e-bikes, e-scooters, bikes and scooters. Steve found that even then, a decade ago, it was scary trying to dodge the proliferation of bikes and scooters on pavements because, if he fell, without a knee, he could not get up on his own. To me, this is another reason to stop this menace on pavements. Of course, he did not like asking for help; it could be humiliating and he was a very self-sufficient sort of chap. If noble Lords will allow me that personal anecdote, it was a reminder to me of the huge difficulties that people needing prosthetics face.
I am hugely grateful to the noble Lord, Lord Mackinlay, and the other contributors to what I think is a very important if relatively short debate.
Lord Kamall (Con)
My Lords, I congratulate my noble friend Lord Mackinlay of Richborough for securing this debate. I also pay tribute to him for his courage in the various battles he has faced in recent years, and for his determination to come back and return to public life. I have to say that I am simply in awe of him, but I hope that does not come across as patronising or putting him on a pedestal either. Based on his own experience, he is fighting for the causes dear to him, and he can talk about it in a meaningful way based on his own experience.
I also thank my noble friend Lord Shinkwin for warning us about placing disabled people on a pedestal, something that I think we ought to be aware of, and for adding the issue of orthotics to this debate, which is very important. I thank my noble friend Lord McColl for explaining his experience. I think in those days the official term was artificial limbs, when he worked on that group, when asked by the Prime Minister at the time, Margaret Thatcher. I thank the noble Baroness, Lady Ludford, for sharing her experience based on diabetes and living with someone with diabetes.
I have two early experiences of prosthetics or artificial limbs—whatever language it was, given that I was born in the late 1960s—and one is storybooks and Long John Silver. In some ways, from what my noble friend Lord Mackinlay said, the service has not really moved on from that. We talk about Captain Hook and people are still being asked to have hooks. The second experience was a friend of my brother who was deaf and had type 1 diabetes. During the time we knew her she went blind, lost limbs and sadly died far too early. I really relate to the point the noble Baroness made. One of the issues for all type 1 diabetics—I say that, having a type 1 diabetic in my family—is to look after your limbs and the extremities of your body and get regular check-ups, as well as controlling and monitoring sugar.
Having heard the speakers, I think this is a matter of both policy and principle. Ensuring that amputees receive timely and appropriate prosthetics is more than simply a healthcare issue; it is a matter of dignity, independence and fairness. Those who require access to these services are those who have faced illness, trauma and those who may have suffered injuries while serving their country in many ways. My noble friend rightly raised the issues with current NHS provision of prosthetics. In this speech, I will look at two main challenges.
First, there is the issue of the workforce, which seems ironic; I see a smile from the Minister. As my noble friend said, skilled prosthetists are not being replaced quickly enough. The provision of high-quality prosthetic care is heavily reliant on a skilled workforce. I thank my noble friend for going into the details and making us all understand the importance of that. My noble friend highlighted training deficits in the field of prosthetics and orthotics. Noble Lords will know that Health Education England has acknowledged these challenges and is working to improve the education and training of prosthetists and orthotists.
I remember, when I was a Minister, the noble Baroness who is now the Minister and others rightly raised issues about the workforce and workforce planning. After pressure from noble Lords at the time, including from the noble Baroness who is now the Minister, the previous Government eventually published the NHS Long Term Plan to address some of these workforce challenges. But in this area, if we look at the numbers, the baseline training intake for 2022 was 57. The workforce plan looked to increase that to 89 per intake. It identified that between 25% and 50% of prosthetists could be trained via the apprenticeship route as part of an expansion of apprenticeships for allied health professionals. This is, as anyone can see, only part of the solution, and there is always more that needs to be done.
Can I ask the Minister to inform noble Lords how the Government will build on some of that work? Going from 57 to 89 clearly, for many, is not enough. What work is being done and what thought is being given to increasing that capacity and to making it an attractive career? One hears about the latest technology being used, such as computer aided design, so maybe there is a way of attracting the best engineering students who may never have thought about going into that career. They may have thought about designing cars or aeroplanes, but they might realise that they could put their skills to good use in improving the health, well-being and mobility of many of our citizens.
I know that the 10-year plan is going to be published at some stage. I am not necessarily asking the Minister to tell us what is in the plan, but does she know what consideration is being given to this specific area in the plan? If so, can she share that with the Committee at the moment?
The second issue to highlight, clearly, is inequality of care. Concerns have been raised. Some noble Lords have raised their concerns around a postcode lottery of care for amputees; others have raised other issues. As noble Lords have said, there have been innovations in the technology and expansions in access. Other noble Lords have referred to the NHS providing multi-grip bionic arms since 2022, using electrical impulses from the brain to control movement and representing what is considered the cutting edge of that technology.
However, we have to confront a painful irony: we can have the best technology out there but it is not much good if people cannot get it in the first place or have to jump through a number of hoops to do so. My noble friend Lord Mackinlay spoke about the stages that one has to go through before qualifying for the very latest technology; I wonder whether we can look at those. Is there a cost involved in patients going through all those stages? Could getting them to that final stage be more cost effective? Hopefully, the technology is always evolving anyway, but could we get them to the last stage quicker, rather than them having to jump through all those stages? Is there a way of making it more efficient?
As my noble friend Lord McColl said, it is about looking at the best technology in the world. Rather oddly, I remember a very interesting man I met. He used to be the rabbi of Richmond Synagogue, and he and I got on very well. As a sideline, he started a business based on the latest Israeli technology on prosthetics. In the end, the rabbi gave up, and he and his company developed to sell prosthetics based on Israeli technology to countries in central Asia. I noticed that he is still doing that; it just shows that there is really good technology around the world. It is great that Britain could be at the leading edge, I hope, but it is important that, when you need these devices—limbs or prosthetics—you get the latest ones. It is all very well us being proud of them being built in Britain or whatever, but surely it is better to get the latest technology.
We also understand—this is one of the challenges that we faced in government—the issues of funding for a trained workforce and the extra, increasing demands on health and social care. How do we challenge those? We know that, for example, veterans have in many cases been able to receive care due to dedicated funding streams—we pay tribute to those programmes and support both their continuation and their strengthening—but we have to ask: what can be done for civilians? What can be done for children and the elderly, who face longer-term waits or limited options? In one region, an amputee may receive a personalised limb with integrated sensors; in another, in certain circumstances, they might wait months for a basic replacement. Do the Government know about or understand the reasons for some of these disparities? Have they looked into disparities and understood them, or is it simply about having the workforce in the right area? Is it about the way in which resources are allocated? What steps are the Government taking to reduce some of this unequal geographic access to prosthetics? One of the challenges when I was a Health Minister was that there were always health variances. In some cases, they were the same for all types of health, but, in other cases, it was specific to a particular health or care issue.
This is not just about prosthetics and orthotics; it is also about opportunity. It is about having the ability to walk your child to school or to return to work. It is about having the ability not just to live but to survive—indeed, to thrive—having gone through a very traumatic experience. It is important, whatever our politics, that we think about how we can empower individuals to live their fullest lives. For amputees, that power begins with access to the right limb or limbs at the right time and with the right support. Our amputees deserve no less.
I look forward to the response from the Minister.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)
My Lords, I thank the noble Lord, Lord Mackinlay, for securing this debate and for giving your Lordships a tremendous opportunity for a very informed and meaningful debate. Having listened as the Minister, which I did very closely—I assure noble Lords that I will also review the points that were raised—my summary is that the case is well made. The current service is not where it needs to be and we have some way to go. That has been the theme throughout.
I associate myself with the comments of the noble Lord, Lord Kamall. The noble Lord, Lord Shinkwin, also spoke about those who rely on prosthetics as well as orthotics. The fact is that they cannot play a full part, reach their potential and lead a reasonable live without the right services and support. I wanted to set out those general points.
We have heard a lot of powerful and personal testimonies today. I particularly thank the noble Baroness, Lady Ludford, who spoke of her dear late husband, and the noble Lords, Lord Mackinlay and Lord Shinkwin, for bringing colour to this very important debate. I absolutely agree that all those living with limb loss deserve the right care, as do those with disabilities, because everybody should lead independent fulfilled lives.
I was interested when the noble Lord, Lord Mackinlay, started by outlining the various reasons for limb loss—running from war to diabetes to cancer to, of course, sepsis. I have heard and understand the call, particularly from the noble Baroness, Lady Ludford, for greater attention to be given to sepsis, as it is a killer of so many.
I will make some general points, which I hope will be helpful. First, we are committed to improving access for patients to the right prosthetics at the right time. That is why the Secretary of State for Health and Social Care, Wes Streeting, was delighted to meet with the noble Lord, Lord Mackinlay, and those affected by limb loss a few months ago to hear their first-hand experiences of the services that are and are not being provided. During the meeting, the Secretary of State also heard about variation in practice across the country and the need to improve personalised care. I will come back to this point later, but the noble Lord, Lord McColl, spoke about the importance of fit, which is so obvious, but this is about getting the right thing for people’s needs. People are individuals and it is important to recall that.
The noble Lord, Lord Shinkwin, talked about the isolation for those with disability and I absolutely take that on board. The NHS in England cares for around 60,000 patients with amputation or limb difference, around 25,000 of whom are seen annually. I highlight that care is delivered in 35 centres that provide specialist prosthetic services across England with multidisciplinary teams. On the point about isolation and practicality, a multidisciplinary approach is absolutely right.
We need to consistently and fairly account for varied clinical circumstances and patient preferences. To state the obvious—I think it is worth doing so—the needs of an adult who has lost a limb caused by diabetes will be very different from the needs of a child with sudden limb loss caused by a traumatic and tragic event. It is hard, and the literal point from the noble Lord, Lord McColl, was that one size does not fit all. We need the engagement of those with lived experience so that healthcare services can meet those varying needs.
On the matter of taking action—because I think we can see that we are not where we want to be, and I freely acknowledge that—we have committed to reforming elective care equitably and inclusively for all adults, children and young people. I know that noble Lords appreciate and have identified that prosthetics are complex and intricate devices, and they have also rightly spoken about cost—and, might I add, value for money. For example, a multi-grip device can cost more than £20,000, while at the same time some 70% of patients may decide—and by that I do not mean that they decide freely but that they may be in a position whereby they have to decide—to abandon their upper limb prosthesis. Our health service has to ensure that the right prosthesis is available for the patient, not just because of value for money but because of the trauma associated with being offered a solution that just does not work. The noble Lord, Lord Mackinlay, spoke powerfully about that.
Currently, patients often wait 12 months or more to access advanced prosthetics. On the practical side, that is to ensure that they have recovered from surgery and are able to use them. However, I have to acknowledge that there are a number of cases where earlier access to advanced prosthetics is clinically suitable yet is not happening.
When it comes to action, I am therefore pleased to say that, because of the Secretary of State’s meeting with the noble Lord, Lord Mackinlay, in November, there is a review of the clinical commissioning policy relating to multi-grip hand and upper limb prosthesis. The aim of the review is to reduce timelines as far as possible and shift to a much-improved patient-focused service. NHS England is starting that work with an audit of the latest clinical data on uptake and patient outcomes. We can expect to see the result of that this summer. To the noble Lord, Lord McColl, that will of course include the matter of literal fit, which he rightly spoke of.
Furthermore, this month NHS England will issue updated standards and expectations for prosthesis care across the 35 regional rehabilitation centres. There will be a greater emphasis on services for children and young people and prenatal consultations for congenital limb loss as well.
The point about workforce came up; I think all noble Lords spoke of it, and rightly so. I smiled at the noble Lord, Lord Kamall, only because he is more than aware as a former Health Minister of the challenge that we have and the absolute need to address that issue. To improve access times to prosthetic services and get the right services in place, it is clear that we have to increase the capacity and retention of the prosthesis workforce.
I was very interested that the noble Lord, Lord Mackinlay, referred to craft industries and the fact that they are reducing and have done over many years—because of course they provided the possibility of skills and no longer do so in great numbers. But I thought that it was a very important reflection, as is the fact that prosthetists and orthotists are the smallest group, I am afraid to say, among the 14 allied health professionals in the NHS, and there are very significant staff retention issues. A report by the Health and Care Professions Council found that 12.8% leave within four years of registration.
We are faced with a small number of people entering the profession and limited places that offer the relevant degree. To put that in context, only 43 students graduate each year from a joint prosthetics and orthotics degree, of which approximately 25% follow a career in prosthetics and 75% in orthotics. I think that lays out the reality.
To address this capacity challenge, a new degree course in prosthetics and orthotics has been established at Keele University, complementing the three existing courses at Derby, Strathclyde and Salford universities. As I hope noble Lords are aware, we are working at pace to publish a refreshed long-term workforce plan to deliver the health service fit for the future on which the 10-year plan is focused. As part of that, we have a national retention programme. I say none of these things because everything is all right; I say all these things to show the direction we are taking.
The question was raised by the noble Lord, Lord Kamall, about how we attract the best engineering students to input into this field, and I thought that that was a very strong point. In addition to expanding routes and apprenticeships, and the new workforce plan, those who are eligible students can get a non-repayable grant of a minimum of £5,000 a year, and prosthetists and orthotists can get a grant of an extra £1,000 a year.
Noble Lords have spoken much about the need to harness modern-day technology and how the current techniques that are used may be out of date. I very much share the need to continue to embrace technology, including by making research grants available, and I hope we will see more activity in that.
I thank noble Lords not just for their time today but their insight and experiences. It has been a very moving and very practical debate, in my view, and one that I look forward to taking forward to get the right steps in place.