Nursing and Midwifery: Student Applications
Baroness Hayman Excerpts(8 years, 11 months ago)
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Lord O'Shaughnessy
The Government took the decision to change to a fee-based system precisely because a bursary-based system involves caps and only so many places can be commissioned. A fee-based system allows the cap to be removed, with the intention of increasing the places available by up to 10,000 people a year, which will increase the flow into the profession to address precisely the issue that the noble Lord raises.
Baroness Hayman (CB)
My Lords, can the Minister tell the House whether his department undertook a risk analysis of changing the basis of the funding for nursing education at a time when the age profile was as has been described, and when the security of the EU nurses on whom the NHS depends at the moment—and will do so for the continuing future—is so damaged by the uncertainty of their immigration status? If such risk analysis was not undertaken, might it be done now?
Lord O'Shaughnessy
As the noble Baroness will know, Health Education England is responsible for commissioning medical training places, and I am sure that all necessary impact and risk assessments would have been carried out at the time. As the noble Lord opposite recognised, I was not in post at that point, but I will certainly look at it. I would be surprised if that was not the case.
Drug-Resistant Infections
Baroness Hayman Excerpts(9 years, 4 months ago)
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Baroness Hayman (CB)
My Lords, like others, I congratulate the noble Lord, Lord Lansley, both on securing this debate and on his very cogent introduction today.
My contribution will concentrate on the global health aspects of the report, particularly in relation to malaria and artemisinin resistance. I draw attention to my interests in this area, as set out in the register. Much of what I will say draws on the recent report of the All-Party Group on Malaria and Neglected Tropical Diseases, and the Malaria Consortium, entitled, Racing Against Time: Protecting the Gains Achieved in Malaria Control Against Drug Resistance. It was dedicated to the memory of Dr Sylvia Meek of the Malaria Consortium—its co-author—who died tragically young very soon after completing the report. Sylvia dedicated her life to the fight against malaria with both passion and intellectual rigour. I pay tribute today to the enormous contribution she made, and the example of service she gave in international health.
Malaria control is one of the great global health success stories of this century. Deaths have declined by 60% across the world since 2000, which equates to 6.2 million fewer deaths than would have occurred. The incidence of new cases is down by 37%. The UK has played a major part in this achievement: at government level, through NGOs like Malaria Consortium, and through the enormous scientific contribution of our centres of excellence, particularly the Liverpool School of Tropical Medicine and the London School of Hygiene and Tropical Medicine. Progress has been achieved through collaborative action and the development of new tools—treatments, diagnostics, vector control, prevention strategies—and their effective deployment in endemic countries. The research continues, not least on the development of an effective vaccine against malaria.
But all this progress and all the investments we have made are threatened—and the history of malaria teaches us that progress has been threatened and lost in decades past—by the declining effectiveness of vector control because of the growth in resistance to insecticides and, in particular, to artemisinin combination therapies, which are the most effective treatment we now have for malaria. Resistance to ACTs is already a significant threat to health in south-east Asia and it will be a global threat if it spreads. Drug resistance has been detected in five countries in the Greater Mekong Subregion: Cambodia, Myanmar, Thailand, Vietnam and the Lao People’s Democratic Republic. If it spreads to other parts of south Asia, and worst of all to Africa, a global public health crisis will occur.
Drug-resistant malaria parasites have not yet been detected in Africa, but, following the pattern of the spread of previous resistant strains—as I said, we have been here before—drug-resistant malaria is a distinct and worrying possibility. At the moment, despite ongoing work to develop replacement drugs and a vaccine, no new treatment for malaria is in the pipeline if ACTs were to become ineffective. If resistance were to reach Africa, where the malaria burden is greatest, the impact could be devastating, leading not only to a massive increase in deaths but to massive costs—both medical costs and productivity losses.
I welcome the publication of this report and the opportunities it gives us to tackle the threat and existence of antimicrobial resistance. There are certain areas to which I wish to draw attention. One is recommendation 4, on improving global surveillance of drug resistance. The noble Lord, Lord Lansley, rightly drew attention to this, and I would like to endorse what he said. Strong disease surveillance systems are critical to monitoring and responding to the spread of disease resistance, as well as to the management and elimination of diseases such as pneumonia and malaria. Effective surveillance systems allow resources to be directed to the most affected populations, enabling us to identify gaps in programme coverage, detect outbreaks and assess the impact of interventions. The Ebola crisis provided a stark warning of the need to strengthen surveillance, particularly at community level, as I saw for myself when I visited Sierra Leone 18 months ago at the height of the epidemic. However, countries like Sierra Leone need support to substantially strengthen disease surveillance so that it becomes a core intervention and part of their public health systems. I encourage the Government to prioritise surveillance and would be grateful if the Minister, either in summing up today or separately in writing, told me what plans there are to help countries strengthen their surveillance.
The other recommendation to which I would like to draw attention is promoting new, rapid diagnostics as one of the ways of cutting the unnecessary use of antibiotics. Universal access to accurate diagnosis prior to treatment is a critical element of decreasing the irrational use of drugs, which is one of the causes of their reducing efficacy. The increase in availability of malaria rapid diagnostic tests over recent years has improved the rational use of artemisinin combination therapies. In 2014, for the first time, more RDTs were distributed through the public sector globally than ACT treatments. The availability of RDTs was also crucial in extending the accurate diagnosis and treatment of malaria at community level through trained volunteer community health workers, allowing for the differential diagnosis and treatment of febrile illness and reducing the common blanket prescribing of antibiotics for almost every sick child.
In Uganda, I had the privilege of seeing community health workers, some of whom were barely literate, doing an amazing job of differential diagnosis and effective treatment in the middle of the night with a two year-old with a high temperature. It is extraordinary what can be achieved. Developing new, accurate and easy-to-use diagnostic tools for other diseases, such as neglected tropical diseases like dengue and Zika, would support efforts to eliminate them and deserves priority.
Finally, the announcement of the Ross Fund is much to be welcomed, particularly the £350 million that has been committed to fight antimicrobial resistance. We hope that surveillance will be at the centre of the Ross Fund’s strategy. I would be grateful if the Minister provided an update, either today or in a letter, on the progress of the fund, along with details of how and when funding is likely to be allocated.
The UK Government, through DfID programmes and support for the Global Fund—HIV and TB being other areas, like malaria, threatened by antimicrobial resistance—have made a huge contribution to the fight against those three diseases, particularly in leadership on malaria. I hope the Minister will commit not only to the robust and speedy implementation of the recommendations in this report, but also to continuing the British Government’s commitment to their leadership role in the fight against malaria.
Bread and Flour Regulations (Folic Acid) Bill [HL]
Baroness Hayman Excerpts(9 years, 6 months ago)
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Baroness Hayman (CB)
My Lords, the House owes a debt of gratitude to the noble Lord, Lord Rooker, for his persistence in pursuing this case. I should tell the Minister at the Dispatch Box that I was a colleague of the noble Lord, Lord Rooker, in the days when we were both young MPs in a hurry, and he is a formidable opponent. We are, in our later years, perhaps old Peers in a hurry, but that does not mean that we are any less determined on this issue. Today, the noble Lord has provided the House with irrefutable evidence of the case for supporting his Private Member’s Bill, and in fact I think he has done more than that. A Private Member’s Bill is not the way to implement a measure that is so self-evidently important for public health. He argued for a change in government policy, and I hope that the Minister will not be put in what I know to be the profoundly uncomfortable position on the Front Bench of once more defending the indefensible on this issue.
Last night I was telephoned by my son, who told me of his frustration over the length of time it was taking to get the Government to respond on a completely different, although equally important, issue. It is an issue supported by five Select Committee chairs and committees and over 90% of parents—that of making PSHE a statutory subject in the national curriculum so that all our young people are given the means to protect themselves in today’s world. I fear that, when I explained to him that today I would be talking about an issue on which I had been campaigning for 25 years, that did not add to his optimism or enthusiasm. However, I also told him that one thing I had learned in politics was never to take no for an answer, and that applies to this issue and to his.
As I said, I first became aware of this matter in 1991. I was involved then, as I am now, in the ethics of medical research. The MRC trial, to which the noble Lord, Lord Rooker, referred, was the first trial I had ever known to end early. That was because the results were so clear that it was considered to be unethical to continue to allow one half of the group—the control group—not to receive the folic acid supplement which the other half was getting. The evidence that has had such a profound effect in the rest of the world, but not in the UK, is based on that trial.
A second reason for my concern was that in the preceding years I had helped to found an organisation called the Maternity Alliance. It was particularly involved in pre-conception care—in the health of mothers and babies. It was absolutely clear that the fortification of flour with folic acid was the most effective mechanism for delivering pre-conception and early pregnancy care, as has been demonstrated by the ineffectiveness of the supplement route, as the noble Lord, Lord Rooker, has demonstrated.
However, the main reason for my interest was that I had been having babies myself. I knew the intense anxiety of waiting for antenatal checks and then the birth, worrying about whether the baby was healthy, and thinking through what I would do in the case of an in utero diagnosis of an abnormality and having to face up to the question of whether to undergo a late termination.
A generation has gone by; I am no longer having babies, but I am having grandchildren and I see my sons, their wives and partners going through exactly the same anxieties. It is no wonder that the British Pregnancy Advisory Service says that this one measure would ensure that some of the saddest cases it sees would not need to come through its doors, and women in the devastating situation of ending a wanted pregnancy because of foetal abnormality would no longer have to do so. Beyond that, many families would not have to deal with the devastating and heart-breaking situation described by the noble Lord, Lord Rooker, of one of our colleagues and of having to support children who endure short and painful lives because of the burden of preventable disease.
In those 25 years, we have had the opportunity in this country to see not just pilot schemes of fortification of flour with folic acid but mass implementation of it. We have had the opportunity to see the effect—an up-to-50% reduction in the incidence of the neural tube defects—and to see that the theoretical risks of the policy have been investigated and not come to fruition.
The question for the Government now is how they can in all conscience continue to ignore the evidence before them and not accept what their own Chief Medical Officer, the Scientific Advisory Committee on Nutrition, the other Administrations of the United Kingdom and the rest of the world accept. I cannot believe that they maintain their position given the conclusions of every piece of research—ending with that which found in December last year:
“Failure to implement folic acid fortification in the UK has caused, and continues to cause, avoidable terminations of pregnancy, stillbirths”—
and permits “serious disability in … children”. That situation should not be allowed to continue. This Bill would not solve every instance of it, but it would do a great deal. Not to do what we can do is a dereliction of duty.
Lord Hughes of Woodside (Lab)
My Lords, I join the noble Baroness, Lady Hayman, in paying tribute to our mutual friend, the noble Lord, Lord Rooker, for bringing forward this Bill and I certainly hope he succeeds. The three of us, the noble Baroness, Lady Hayman, the noble Lord, Lord Rooker and I, were in the other place for some years together. I can testify to the noble Lord’s capacity for identifying a public policy that needs to be taken up and his tenacity in seeing it through. He is perhaps best known, at least among the three of us, for the so-called Rooker-Wise amendment—an unlikely duo—which was successfully introduced to a Finance Bill to make national allowances subject to the rate of inflation. He annoyed the then Chancellor of the Exchequer, Denis Healey, no end. Such tenacity is worth having and it certainly makes us in your Lordships’ House proud.
The issue of adding folic acid to flour has been around for a long time, because we share knowledge of the suffering of families who have had children aborted, who have lost children early or who have had children born with defects that last for years of their lifetime. The question must be asked: why are the Government so reluctant to move in the face of such indisputable evidence about the efficacy of adding folic acid to bread when there are certainly no signs at all of any detrimental effects in doing so? I do not know and I hope the Minister can answer that question.
At Question Time in the House—I say this without malice—the Answers given by the Minister for not doing so have been rather flimsy. He has cited the fact that health problems are improving in women, and there is no doubt about that. But beyond that, there is no reason why the Government cannot move. As my noble friend Lord Rooker said, many countries in the world already do this. The Scottish Government are considering moving on their own and have the power to do so as health is a devolved matter. It would be a great shame if that were to be the case.
Why is there such opposition? I know from personal experience how difficult it is to argue against those who, possibly for genuine reasons, are opposed to vaccination or fluoridisation of the water. I still have the scars on my back from trying to persuade Aberdeen Town Council to adopt that when I was the convener on the welfare committee there. I do not know whether it is a matter of prejudice. It cannot be ignorance because the facts are very well known. But the fact is there is huge opposition to any move to what is called public health medicine. The worst example of that is adding fluoride to the water. I emphasise absolutely what my noble friend said. Adding folic acid is not mass medication. That argument might be made in the case of putting fluoride in the water but this is a different matter altogether. This is a simple and straightforward measure that has been well documented as being successful and safe and for making people’s lives much better.
As my noble friend said, this is not a panacea. It will not eradicate NTDs, but the fact that 50% of women may be beneficially affected by this is a prize that makes it worth doing. The only slight disagreement I might have, although I may have misheard what my noble friend Lady Hayman said, is whether this is the right way to go about getting the legislation. I may have misunderstood what she was saying. But in the face of a Government unwilling to move on their own account through lack of time—and goodness knows what the Government will face in terms of time in the coming months and years—it is absolutely essential that those who have the opportunity to bring forward a Private Member’s Bill should do so.
Baroness Hayman
I would be more than content were the Minister to say today that the Bill in the name of the noble Lord, Lord Rooker, be taken forward with all speed and support by the Government in another place.
Lord Hughes of Woodside
Hear, hear to that. But in the event of that not being the case, it is the duty of this House to pass this legislation through all its stages and send it to the other place to deal with. That is imperative and essential and I am pleased to give my support to my noble friend Lord Rooker.
Health: Neural Tube Defects
Baroness Hayman Excerpts(9 years, 10 months ago)
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Lord Prior of Brampton
My Lords, speakers in this House have by and large very much supported the views of the noble Lord, Lord Rooker—I entirely accept that. But I do not think that the case has been made outside this House perhaps as strongly as it has in other areas. If we are going to change the way we produce white bread in this country, a much stronger and broader case has to be made.
Baroness Hayman (CB)
But, my Lords, it is not just in this House, is it? It is in the Scottish Government, who I understand are now laying out plans to introduce fortification. They are supported by the Administrations in Northern Ireland and in Wales. Why is England taking this isolationist view when across the world it has not been taken? Is it correct that Sir Nicholas Wald, the leading scientific expert in this field, was granted an audience with the Minister for Health in Scotland, but not in England?
Lord Prior of Brampton
My Lords, I cannot answer the latter question, but I will try to find out and write to the noble Baroness. She is right that Scotland is considering this and looking at the practical issues around implementation. She is right that other countries in the world—I think 50—have done this, but many others have not, including all European Union countries.
Health: Red Cell Folate
Baroness Hayman Excerpts(10 years ago)
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Lord Prior of Brampton
My Lords, the danger of overmedication with folic acid is small, I accept that. It is not non-existent but it is small. Just so that the House knows the numbers, the number of babies aborted because of neural tube defects is about 400 a year; the number who are born with neural tube defects, alive or not alive, is about 60 a year. It is a very serious issue and one that the Government are taking extremely seriously, but we have to weigh that against the other issues of medicating the entire population.
Baroness Hayman (CB)
My Lords, some of us have long memories that go back to 1991, when the MRC study into this issue had to be stopped early because the results were so overwhelmingly in favour of folic supplementation. The lead researcher on that study was Sir Nicholas Wald. More than 80 countries have taken very seriously those results and have taken on board fortification of white flour. In 2015 Sir Nicholas published a paper about the lost opportunity in the UK. Is it not a matter of profound regret, verging on shame, that in this country, where the initial research was done, we are now being told that there will be a decision “in due course”? If I remember correctly, the last time the Minister spoke about this, he said that it would be very early in the new year.
Lord Prior of Brampton
My Lords, I think we are still quite early in the new year. I do not go back to 1991 but the noble Baroness is right: for many years now there has been a large body of scientific opinion in favour of increasing the uptake of folic acid. There is no dispute about that—I do not think there is much science to dispute. The issue is one of balancing the scientific and medical arguments with issues around choice and whether or not it is right to medicate the entire population for the benefit of a fairly small part of it.
Pregnancy: Neural Tube Defects
Baroness Hayman Excerpts(10 years, 1 month ago)
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Lord Prior of Brampton
The noble Baroness is absolutely right. When you know you are pregnant, it is too late to start taking folic acid, and that is the fundamental reason why the noble Lord, Lord Rooker, is pushing for fortifying flour with folic acid. However, she is absolutely right that education is fundamental to this as well.
Baroness Hayman (CB)
My Lords, is the Minister aware that the best tribute that he could pay to the noble Lord, Lord Rooker, and his campaign would be to make an early and positive decision on the fortification of white flour in this country? How long are the Government going to go on not taking any notice of either the scientific evidence or the evidence in practice from 78 other countries? I remember the definitive trial proving the benefit of folic acid in pregnancy in 1991. We have seen that advice alone does not work. When will the Government take action?
Lord Prior of Brampton
My Lords, as I said in my response to the noble Lord, Lord Rooker, this matter is being actively considered by the Minister for Public Health, and she expects to come to a decision very early in the new year.
Health: Flour Fortification
Baroness Hayman Excerpts(12 years ago)
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Baroness Hayman (CB)
My Lords, it is more than 20 years since the MRC study on this issue first had to be abandoned because it was considered inappropriate not to give folic acid supplements to the women who were involved. When the noble Earl reads the latest study, I suggest that he will find it “incontrovertible”, to use the word of the noble Lord, Lord Turnberg. The noble Earl said in December that the Government were looking at this issue urgently. Will they now look to act urgently?
Health: Birth Defects
Baroness Hayman Excerpts(12 years, 1 month ago)
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Baroness Hayman (CB)
My Lords, the Minister said that this was not a decision to be taken lightly, and that is absolutely right, but we now have the experience of 50 other countries. We have had scientific evidence on this issue for many years. The fortification of white bread flour is a targeted measure that could significantly reduce the number of pregnancies, not just births, that involve neural tube defects, and thus prevent a great deal of unnecessary and painful suffering. Will the Minister undertake to look at this matter again as a matter of urgency?
Earl Howe
My Lords, we are looking at this as a matter of urgency. I recognise what the noble Baroness says about the experience of other countries, but we must make policy in relation to the population of our own country, and that involves weighing up both the potential benefits and the potential downsides of any policy.
NHS: Mid Staffordshire NHS Foundation Trust
Baroness Hayman Excerpts(12 years, 2 months ago)
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Earl Howe
My Lords, my noble friend should be listened to with great care. Of course, I remember those cases. I was not the Minister in charge at the time she submitted those cases to the Department of Health, but she shared them with me, and I share her concerns, which are, of course, directly relevant to the matters we are discussing today. We have the new duty of candour and in April the Enterprise and Regulatory Reform Act strengthened the main whistleblowing legislation introduced by the Public Interest Disclosure Act so that an individual who suffers harm from a co-worker as a result of blowing the whistle now has the right to expect their employer to take reasonable steps to stop this. The idea is to ensure that people do not feel intimidated from speaking up. The Care Quality Commission is using staff surveys and the whistleblowing concerns it receives as part of the data in its new intelligent monitoring system. That data will guide the CQC about which hospitals to inspect. Since September, the commission’s new inspection system includes discussions with hospitals about how they deal with whistleblowers and handle them.
Baroness Hayman (CB)
My Lords, I declare an interest as a member of the General Medical Council. In no way do I speak on its behalf today, but it is obvious from the remarks that the Minister has made that the GMC has been working with the Government and other regulators and is committed to underlining professional responsibilities, particularly in relation to the duty of candour. That work will, of course, continue. On a personal level, I welcome the return to naming the consultant and the nurse responsible for an individual patient. It is emblematic of that personal sense of responsibility and accountability for patient welfare.
In respect of the new complaints procedure, as the Minister said, the care of patients and their safety are the responsibility of not only the named consultant and nurse but everybody in that institution. Does he agree that there is also a particular responsibility on the trust’s non-executive directors in that respect and that the new system should ensure that they are taking their responsibilities seriously? I know from decades ago, when I chaired the complaints panel at a London teaching hospital, that that resource, in terms not only of the ability to protect patients but of improving efficiency and the quality of care by understanding complaints, was a treasure trove that should not be abandoned.
Earl Howe
I entirely agree with the noble Baroness, who of course has immense experience in these fields. I agree with her in particular about the role of the non-executive director. If an organisation has what may look like quite a high number of complaints, it should be regarded as a sign of openness, transparency and the right kind of culture in that organisation. It is only where suspiciously low numbers of complaints have been recorded that alarm bells should start ringing. I agree that boards of directors, led and encouraged in this area by the non-executives, should make it a central part of their business to analyse complaints and make sure that they have been followed through, not just that the matters have individually been remedied but that any systemic issue has been properly addressed.
NHS: Out-of-Hours Services
Baroness Hayman Excerpts(12 years, 6 months ago)
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Earl Howe
The last thing I would ever wish to be is complacent, and I certainly am not. Whenever problems and concerns arise, we take them extremely seriously. I do not think anyone takes issue with the concept of 111. Unfortunately, however, we have seen problems arising in a few isolated cases. I emphasise that the vast majority of the country is receiving a good service. Incidentally, there is no evidence that attendances at A&E have been affected by the rollout of 111; in fact, attendances have not increased since 111 was introduced—the figures have actually gone down.
Baroness Hayman
I wonder whether the noble Earl could help me, because I am genuinely puzzled about the current status of NHS Direct, its funding and governance, who makes decisions about contracts and whether they are viable or not. NHS Direct was set up as a national service, paid for and provided by the NHS. What exactly is it now?
Earl Howe
The NHS is a provider, in certain parts of the country, of the 111 service, and other services more generally. But there is a very distinct difference between NHS Direct’s old service and the 111 service being provided now, in that 111 is a much more comprehensive service. That was an area of agreement between the Government and the noble Baroness’s own party before the last election. I sense that I have not answered the noble Baroness’s question; perhaps she would like to ask it again.
Baroness Hayman
Since I can quibble about my own party as I am now a Cross-Bencher, I take this opportunity to say that I am not puzzled about the 111 service—but who is NHS Direct now? Who is responsible for its governance, its funding and decisions about whether it goes for contracts?