Health: Diabetes

Baroness Manzoor Excerpts

Thursday 2nd July 2015 Lords Chamber

[Baroness Manzoor (LD)]

I congratulate the noble Lord, Lord Harrison, on securing this debate and on his insightful and well-informed views on the issues of diabetes. Like many in your Lordships’ House, I am familiar with the effects of diabetes as, unfortunately, a family member has a history of it. I therefore declare my personal interest in the disease.

Looking at the range of speakers in today’s debate, I am sure that diabetes in the UK will be covered very well. As I have recently taken on the brief of spokesperson on international aid and development, I thought that I would take an international perspective on the disease, which I hope will not throw the Minister off his stride. It is certainly not my intention to do that.

The next big issue in diabetes internationally will be TB-diabetes co-infection. However, before I move on to that area, I want to restate that our NHS spends about £10 billion on diabetes every year, equal to 10% of its entire budget. This is an important disease to research, diagnose and treat effectively in the UK. It should also be a priority to ensure that any variations in treatment—the noble Lord, Lord Harrison, alluded to this—are minimised across the population, particularly as there are currently 3.9 million people living with diabetes in the UK.

The International Diabetes Federation estimates that, worldwide, there are 387 million people living with the disease, equal to 8.3% of the global population. It also estimates that, by 2035, an additional 205 million people will develop diabetes. The World Health Organization estimates that in 2012 diabetes was the direct cause of 1.5 million deaths and projects that diabetes will be the seventh leading cause of death by 2030. The total number of deaths from diabetes is projected to rise by more than 50% in the next 10 years globally. These figures are scary—even more so when you consider that 80% of diabetes deaths occur in low and middle-income countries, many of which may already be ravaged with disadvantage, poverty and conflict.

We in the UK should take a lead in increasing global awareness of this disease through our meetings with the UN and the EU, so that sufficient resources are made available to address this epidemic. As has been seen in the UK, diabetes care is costly and has the potential to cripple any healthcare system. According to the International Diabetes Federation, $1 in every $9 spent on healthcare is currently spent on diabetes.

It is interesting to note that type 2 diabetes used to be seen as a disease of the rich world and that, when it started to affect the better-off in poor countries, it was perceived as a sign of development. Now, three out of four people with diabetes live in low and middle-income countries. This rise in type 2 diabetes is being driven by ageing populations, rapid urbanisation and lifestyle changes. In developed countries, most people with type 2 diabetes are above the age of retirement, whereas in developing countries those most frequently affected are aged between 35 and 64. This means that in low and middle-income countries, type 2 diabetes affects many more people of working age, which has a profound effect on economic productivity.

Of course, type 2 diabetes treatment and care are not yet routinely or widely available in developing countries and, when treatment is available, it is rarely free. For individuals in developing countries, the out-of-pocket costs to treat type 2 diabetes are very high, often leading households to sell their possessions to pay for their treatment. In India, for example, treatment costs for an individual with diabetes make up, on average, 15% to 20% of household earnings and many poor people often cannot afford to get treatment or cannot access it easily.

At a national level, the type 2 diabetes epidemic threatens to overwhelm health systems and, potentially, to reverse development gains made in low-income countries—countries where we are spending a lot of money. Therefore, through DfID, more targeted investment is needed to support fragile health systems and stretched national healthcare budgets and to prevent economic progress from being undermined.

However, there is yet another threat. Low to middle-income countries now face a double burden of disease: rates of non-communicable diseases, such as type 2 diabetes, heart disease and stroke, are on the rise, but at the same time low to middle-income countries are still grappling with high burdens of infectious diseases, such as TB, HIV/AIDS and malaria.

In TB-diabetes co-infection, high blood sugar levels suppress the immune system, making individuals with latent TB—someone who does not have symptoms, is not sick and cannot spread the disease to others—more at risk of developing active TB. This is similar to how HIV undermines the immune system and makes individuals living with the virus more susceptible to developing TB. People with type 2 diabetes are three times more likely to develop TB, and type 2 diabetes is responsible for causing an estimated 15% of all TB cases. Brazil, China, Indonesia, Pakistan, India and Nigeria together account for 52% of people living with TB and 50% of all people living with diabetes. This is important for the UK, because of the strong ties that we have with these countries, and we must also not forget the fact that some parts of London have the highest incidence of TB in Europe.

What we are seeing happen now with TB-diabetes is similar to what we saw happen with TB-HIV. When HIV rates rose in the early 1990s, with the immune systems of people with HIV being weakened, that caused TB rates to skyrocket, particularly in Africa. We must make sure that history does not repeat itself by tackling TB-diabetes head on. Failing to act could lead to significant increases in avoidable disability and early death and could have disastrous consequences for health systems. There needs to be more integration between TB and diabetes programmes, similar to how it has been essential to integrate TB and HIV programmes. Perhaps the Minister could reassure us that NHS England in the UK has collaborative frameworks in place to enable this to happen. Could the Minister also reassure me that the Department of Health works collaboratively with DfID to develop policies on TB-diabetes and could he say whether those policies enable more co-ordination between programmes and countries with a high burden of TB and escalating rates of diabetes?

Finally, I know that preventing diabetes and promoting the best possible care for people with diabetes are a key priority for our Government, which is to be welcomed. However, not only does more need to be done to educate our own population about type 1 and type 2 diabetes, but we must also ensure through our aid programme that this epidemic is not forgotten. We are world leaders in providing excellent health services and we have a significant and well-developed research base. That puts us in a strong place to provide a global leadership role and we should embrace that in this key area.

Barts Health NHS Trust

Baroness Manzoor Excerpts

Thursday 19th March 2015 Lords Chamber

[Earl Howe]

The noble Baroness is right. The CQC found that there was a culture of bullying at Whipps Cross. They had concerns about whether enough was being done to encourage a culture of openness and transparency—something on which, as she knows, we place great emphasis in the light of the report on Mid Staffordshire NHS Foundation Trust. I can only say to the noble Baroness that this is one of the issues that will be top of the list for the new improvement director at Whipps Cross.

[Baroness Manzoor (LD)]

My Lords, the culture within the NHS appears to be changing, and not for the better. Is the Department of Health looking at that, as well as at the issue of PFI across the NHS, and is it doing so not in a piecemeal fashion whereby things are identified only when they go wrong?

[Earl Howe]

It is precisely because we have wanted to confront the issue across the NHS that so much has been done following the report of Sir Robert Francis into Mid Staffordshire NHS Foundation Trust. All the recommendations flowing from that report should resonate with every part of the NHS. The recent work done by Sir Robert on whistleblowing can be put into the same category. There are lessons and messages for the NHS as a whole, and I believe that progress is being made, as it needs to be in particular quarters.

Gender-based Violence: Screening

Baroness Manzoor Excerpts

Monday 9th March 2015 Lords Chamber

[Earl Howe]

My Lords, we are concerned about the sometimes patchy provision of mental health services in certain parts of the country, and we have channelled additional money to address that in recent months. One of the main ways in which we have demonstrated our commitment to parity of esteem is by introducing, for the first time, waiting-time standards for mental health treatment. That it is a landmark.

[Baroness Manzoor (LD)]

My Lords, can the Minister please give an assurance that FGM is given a high priority in the health commissioning groups’ plans?

[Earl Howe]

Yes, my Lords. The Government hosted the first ever Girl Summit last year on ending female genital mutilation as well as forced marriage and other issues. We set up a specialist female genital mutilation unit following that summit. We provided money last year for the FGM prevention programme, and as part of this we introduced the first ever data collection in the NHS for all acute trusts, which are now required to record in a patient’s healthcare record whenever FGM is identified. We have also said that front-line professionals will in future have a mandatory duty to report cases of FGM in those under 18.

Jimmy Savile: NHS Investigations

Baroness Manzoor Excerpts

Thursday 26th February 2015 Lords Chamber

[Earl Howe]

The noble Baroness has our admiration for the way in which she has coped with her spinal injury over these many years. She is, of course, absolutely right about the way in which Jimmy Savile duped so many people. He was a forceful character as well as somebody with a superficial charm, and he got away with what he did. She is, of course, correct that the protection of patients lies at the centre of all this and we must ensure that we have proper systems in place to make them feel confident that they can come forward.

I take the noble Baroness’s point about patients perhaps not feeling able to complain to the ward staff. The answer to her question is that the patient, or someone on their behalf, can complain to the chairman of the organisation or trust or to a member of the board, and thus bypass the clinical staff. There should always be a member of the board at the hospital whose responsibility is the protection of patients above all. In the end, it is for that organisation to investigate its own supposed failings. If somebody is not satisfied with the result of that investigation, it is then open to them to go to the ombudsman. We believe that complaints should be investigated at a local level, either with the provider of the service or, if that is not thought appropriate for any reason, with the commissioner of the service.

[Baroness Manzoor (LD)]

My Lords, in relation to the protection of patients, I ask the Minister whether it would it be possible, each time a patient is seen by anyone—whether it is an external visitor or, indeed, a doctor—to ensure that there is another person present, such as a nurse. Just recently, a colleague went for a breast examination. She was seen by only one person, a male doctor; no safeguarding was available there. As part of that consultation, I would welcome this assurance.

[Earl Howe]

I take my noble friend’s point. However, I would hesitate before committing to a situation where, in every instance that a doctor or nurse examined a patient, they had to have somebody with them. In the real world, I do not think that is going to be practical. What one should have, however, is an assurance that whoever examines the patient, or performs some intimate caring service with the patient, should have been checked for both a criminal record and a previous employment history. I will take my noble friend’s point away, but I think that what I have said would be accepted by those in the National Health Service as the only practical way forward.

NHS: Maternity Care

Baroness Manzoor Excerpts

Thursday 5th February 2015 Lords Chamber

[Baroness Manzoor (LD)]

My Lords, I also congratulate the noble Lord, Lord Harrison, on securing the debate. Today is Time to Talk Day, a national day where everyone across the country is encouraged to take five minutes to talk about mental health. That is what I intend to do today.

Women in around half of the UK have no access to specialist prenatal mental health services. Up to 20% of women develop a mental health problem during pregnancy or within a year of giving birth. Suicide is also a leading cause of death for women during pregnancy and within the first year of giving birth. More than one in four women have c-sections. Evidence suggests this rate is well in excess of the number of c-sections necessary to create health benefits for women and babies, as has already been alluded to by the noble Lord, Lord Harrison. Perhaps the Minister can see whether this financial tariff is to be re-evaluated and reviewed again.

The Centre for Mental Health and the LSE examined the economic and social costs of perinatal mental health programmes and problems, and the cost of effective interventions to manage them. They looked at three of the most common mental health problems—depression, anxiety and psychosis—which affect women during both pregnancy and the first year after they have given birth. Those organisations found that these perinatal mental health problems carry a total cost to society of about £8.1 billion across the UK each year. This is equivalent to a cost of just under £10,000 for every single birth in the country. Some £1.7 billion of this cost is borne by the public sector, of which the greatest costs of around £1.2 billion accrue to health and social care services. They also found that nearly three-quarters of the costs of perinatal mental ill health relate to the poorer health and prospects of the mother’s child. This is based on growing evidence that mental health problems during and after pregnancy have a significant impact on children’s health, many of which can last a lifetime.

There is clear guidance from NICE about what services need to be in place for women. This includes: training midwives and GPs to spot the early signs of distress; speedy access to talking therapies; specialist community services for women needing more intensive support; and mother and baby hospital beds for women who need in-patient care once their baby is born. However, the NHS offers just a fraction of the treatment and support required to meet this level of need. It is estimated that only 40% of women with perinatal depression have their needs identified. Of those recognised, just 60% receive any treatment, of whom only 40% get effective care—that is, care according to national guidelines. This means that just one woman in 10 is getting good quality care for prenatal or postnatal depression.

The Centre for Mental Health and the LSE calculated that the cost of improving perinatal mental health support to include all the interventions recommended by NICE would be about £300 million nationally. This would imply an additional spend of £1.3 million for an average CCG—about a third of the cost to the same CCG of not providing the right care. In other words, investing in better care could actually save the NHS money, as well as bringing about both immediate and longer-term benefits in communities.

The Government have recognised a major deficit in support for women with postnatal depression. The most significant area of progress so far is investment in greater numbers of midwives and health visitors. It is crucial that these are trained adequately in recognising and responding well to distress in women they see. However, there has been no “big push” relating to maternal mental health; little reliable data about outcomes and coverage; and no one is accountable for achieving improvements. Hence, NICE guidance on perinatal mental health is not being adhered to in most areas seven years after its publication.

What needs to be done? First and foremost, we need government to make it clear to the NHS that improving mental health in maternity services is a top priority for reinvestment, and that progress will be monitored actively to improve identification of needs and speed of access to psychological support. Identification of mental illness is key. This could be improved by better training of GPs, midwives and health visitors in perinatal mental health. It is not the quickest of wins, but could be achieved within a reasonable timescale if given priority. The other major change would be to prioritise women in the perinatal period for access to psychological therapy, so that there is a clear process for getting women in to these services quickly. It is estimated that it would be possible to develop a fully functioning service at all levels—including specialist mother and baby units—within five years. It would be helpful to hear the Minister’s views on this.

To conclude, the cost to the public sector of perinatal mental health problems is five times the cost of improving these services. That is why we, as Liberal Democrats, have committed to invest at least £500 million extra in mental health each year in the next Parliament, building on the waiting time standards that we have already introduced and improving support for new mothers, children and adolescents.

NHS: Financial Tariff for 2015-16

Baroness Manzoor Excerpts

Wednesday 4th February 2015 Lords Chamber

[Earl Howe]

My Lords, yes of course the bureaucratic nature of commissioning needs to be minimised and we do all we can to achieve that. However, the need to ensure that we make a careful distinction between commissioners and providers does, I am afraid, mean that rather a lot of numerical work has to go along with that and, as is right, discussion between commissioners and providers to ensure that the system works smoothly.

[Baroness Manzoor (LD)]

My Lords, Choose and Book has been a success story for the Government. It is a hidden gem. Will this be affected by the level of tariffs that are to be offered and will patients have a real choice?

[Earl Howe]

My Lords, no, Choose and Book will not be affected, although NHS England has plans to update it to make it a much richer and more informative system.

HIV: Late Diagnosis

Baroness Manzoor Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

My Lords, local authorities have an important part to play in the battle against HIV and AIDS. They are mandated to commission open access sexual health services, and that means that people can self-refer to the service of their choice, regardless of its location. However, as the noble Baroness will know, this is an issue that goes beyond local authorities. The key message from National HIV Testing Week, which was last week, was that we should all take responsibility for reducing HIV transmission, and that those who feel they may be at risk should take an HIV test.

The testing taking place in sexual health clinics in 2013 was up on the year before. We are seeing very good work with, for example, African faith leaders, and we have also piloted national HIV self-sampling services, which undoubtedly have a great utility for those who are too embarrassed to go to a clinic.

[Baroness Manzoor (LD)]

My Lords, geographically the highest rates of late diagnosis of HIV were in the Midlands and the east of England with 52%, followed by the north of England with 42%, the south of England with 41% and London with 35%. In light of the announcement that was expected later in the week but which was made at the weekend by the Chancellor of the Exchequer—that there will be an additional £2 billion for the NHS—can my noble friend say whether community testing for HIV will be part of the money being spent?

[Earl Howe]

It is far too early for me to say how the new money will be spent. In any case, that has to be a decision for commissioners weighing up the healthcare priorities that face them. But the new money is excellent news for the NHS, and there will be a Statement later today about that.

NHS: Funding

Baroness Manzoor Excerpts

Monday 17th November 2014 Lords Chamber

[Earl Howe]

My Lords, I cannot speak for a party other than my own, but I can tell the noble Lord firmly that we are averse to any system of charging and wish to keep the NHS free at the point of use, regardless of ability to pay.

[Baroness Manzoor (LD)]

My Lords, the NHS five-year review clearly highlighted that there was a need to upgrade preventive and public health services. Can my noble friend the Minister say how this will be done, particularly when you go back to the 2011 WHO agreement on 25 goals, under which 25% of deaths have to be reduced by 2025?

[Earl Howe]

My noble friend is right to highlight the role of public health. That is why many people are encouraged that health and well-being boards, which now oversee the planning and prioritisation of healthcare in their local areas, are taking those public health goals into account and building them into the strategic health assessments. So the co-ordination of healthcare and public health is in a much better position than it was before the reforms.

Mental Health: Beds

Baroness Manzoor Excerpts

Tuesday 29th July 2014 Lords Chamber

[Earl Howe]

My Lords, if people with a learning disability are detained under the Act, this must be for assessment or treatment of mental illness. The person must satisfy the strict criteria laid down in the 1983 Act. When a learning disability is identified as well as a need for assessment or treatment of a mental disorder, the important thing is that alternatives to the use of the Mental Health Act are considered—for example, use of the provisions of the Mental Capacity Act and whether reasonable adjustments would assist the person with learning disabilities fully to access the assessment and treatment. This is an area we have explicitly covered in the draft code of practice, which is currently out for consultation.

[Baroness Manzoor (LD)]

My Lords, more black and ethnic minority people continue to be detained under the Mental Health Act. Can my noble friend the Minister say what is being done to address that issue?

[Earl Howe]

Yes, my Lords, we know that BME groups are overrepresented in the detained patient population. The reasons for that are quite complex. Research studies indicate that rates of detention reflect the needs of patients at the time of detention. We know that the rates of psychosis, for example, are higher in some BME communities, and they often access mental health services in a crisis. The reasons for that are not entirely clear. We recognise that more work needs to be done to establish the causes of higher rates of mental illness in some communities.

Health: Midwives

Baroness Manzoor Excerpts

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My Lords, we attach great importance to choice in maternity care and, in particular, to each mother having a named midwife throughout the care pathway. That is what we are aiming at and what NHS England and Health Education England are charged with delivering. As regards the age profile of midwives, my advice is that there is not a particular age bulge, although we are keen to ensure that we do not lose qualified midwives who, clearly, we can ill afford to lose. However, we have made a commitment to ensure that the number of midwives in training is matched to the birth rate and, so far at least, we have been successful in that.

[Baroness Manzoor (LD)]

My Lords, continuity in care is very important, particularly when you consider that one in 10 women suffers from postnatal depression, and that number increases to four in 10 for teenage mothers. Can my noble friend reassure the House that, first, there is good identification of health needs for mothers during the prenatal stage; and, secondly, that there is one-to-one care during labour and postnatal so that these women are helped and supported?

[Earl Howe]

My noble friend makes two important points. As I said, we attach great importance to each mother being able to have throughout the care pathway a named midwife. Improving diagnosis and services for women with pregnancy-related mental health problems is one of our objectives for maternity care. The mandate from the Government to NHS England includes an objective for NHS England to work with partner organisations to reduce the incidence and impact of postnatal depression through earlier diagnosis and better intervention and support. We are clear that midwives have a key role to play in that.