NHS: Front-line and Specialised Services

Baroness Masham of Ilton Excerpts

Thursday 13th January 2011 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank the noble Lord, Lord Turnberg, for introducing this important debate. It is important because there are so many concerned people who fear, with the spending cuts, that some of their vital specialised services, which are lifelines, may be severed. I hope that the noble Earl can allay some of those fears.

I must declare an interest, as I am president and founder of the Spinal Injuries Association. There is hardly anything more catastrophic than breaking one’s neck and finding that you are paralysed from that point down. It is bad enough breaking one’s back, but in all cases there can be complications, and specialised treatment is vital, otherwise complications occur, leading to human suffering and unnecessary costs for the NHS.

With this huge reorganisation, perhaps there is a chance to improve some front-line services and the specialised services. The White Paper states that patients should be central to the NHS. Are those just words, or will there be action? Will the Government listen to patients, patients’ groups, and their doctors? There should be shared decision-making—nothing about me without me.

We were once the leading country in the world in the treatment of spinal cord injured patients. All of us with an interest in the subject would like that specialty to be returned to its former glory. Doctors, nurses and physiotherapists would come to our national centre from all over the world to train. We are concerned that, already, some expert consultants have retired, and more are to go. Therefore, I ask the Minister a few questions, which perhaps he can answer by letter.

Are there plans to reinstate spinal cord injury medicine as a speciality or subspecialty? The specialty status was lost in 1995 as a result of the alignment with European regulations. That has resulted in considerable loss of appeal and skills. Are there plans to create a national register, a database, for spinal cord patients? Do the Government know whether current trainees will be able to continue the same services offered by retiring consultants in spinal cord injuries? Is there adequate capacity to meet the readmission needs of spinal cord injured patients to spinal cord injury centres? I do not think so.

Are your Lordships aware that there are more than 9,000 new cases of tuberculosis in the United Kingdom every year? In the UK, the number of deaths from TB is 1.5 times higher than the number of deaths from HIV/AIDS. London has the highest TB rate of any major capital city in western Europe. Prevention is vital. I consider it a front-line service. The Find & Treat team, which runs the mobile x-ray unit, focuses on screening groups in London with social risk factors, especially the homeless with TB. Homelessness is a risk factor for multidrug-resistant tuberculosis. That underlines the importance of ensuring that complex cases are detected early and supported to successfully complete treatment.

The emergence of extensively drug-resistant tuberculosis threatens to make the disease untreatable. The Find & Treat team is excellent, and I hope funding can be found so that it can continue its valuable work.

Childhood cancer and leukaemia are rare conditions that require complex and highly skilled diagnostic and treatment services to achieve the best outcomes. Without specialised, centralised cancer care and excellent front-line local paediatric services, there is a risk that not all children with curable diseases will be cured. These services must be safeguarded, built on and improved.

Blood and Blood Products

Baroness Masham of Ilton Excerpts

Monday 10th January 2011 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lord, who comes to this with considerable knowledge and experience as a former Secretary of State for Health. He is right: it has been a difficult if not an intractable problem for successive Secretaries of State. He is also right to say that the human tragedy has become more obvious as the years have passed. For one thing, it was not so obvious in the early days that there would be so many victims of hepatitis C, because that condition only tends to emerge after a considerable lapse of time. The HIV infection was more immediate and more obvious.

The noble Lord is right that in making this announcement for England, we are creating an immediate disparity with the devolved Administrations. As I indicated, I hope that in our discussions with the devolved Administrations—who are, after all, autonomous—we can arrive at a more equitable package for all victims across the United Kingdom. I am sure, without wishing to appear to interfere in the affairs of the devolved Administrations, that that is something that, as human beings, we would like to see. But I cannot pre-empt the decisions that will be taken in those Administrations.

[Baroness Masham of Ilton]

My Lords, I declare an interest as a vice-president of the Haemophilia Society. I am very pleased that the Government have recognised the plight of so many people and families who have suffered this disaster. But what safeguards are in place to prevent any infections from blood transfusions or blood products happening in the future? Prevention is so important and one never knows what is on the horizon.

[Earl Howe]

My Lords, the noble Baroness is, as always, absolutely on the mark. This has been an important issue not just for the current Government but for the previous one.

The measures in place to ensure the safety and quality of human blood, blood components and the blood products manufactured from them have developed significantly since the mid-1980s. We test for viral markers. Donations contribute to a plasma pool which is also tested for viral markers. In 1985, the introduction of heat treatment in the UK removed the risk of both HIV and hepatitis from blood products. Testing of all donations for HIV was also introduced in 1985. Testing for hepatitis C was introduced in 1991 when tests became available. The European directive is now in force. As of 2002, it sets standards of quality and safety for the collection, testing, processing and storage and distribution of human blood and blood components. We have a Community code for medicinal products which affects blood products such as clotting factors. On completion of manufacture, blood products are tested for compliance with specification by the manufacturer. All batches of blood products undergo independent testing by an EU official medicines control laboratory. We are in a different world entirely now from that of the 1970s and 80s.

Health: Parkinson’s Disease

Baroness Masham of Ilton Excerpts

Monday 10th January 2011 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank the noble Baroness, Lady Gale, for bringing this report on Parkinson’s disease to the notice of your Lordships. The noble Baroness is a dedicated chairperson of the All-Party Group for Parkinson’s Disease.

My late husband was diagnosed with Parkinson’s, along with other complicated conditions. He was diagnosed in London but, as we live in North Yorkshire, I found there was a lack of interest in that specialty when I tried to find a consultant in the north. We found one consultant in Leeds, which was a long distance from home, and a very helpful Parkinson’s specialist nurse. That perhaps illustrates from first-hand experience how the specialist care that is needed by people with Parkinson’s is patchy throughout the country, as is stated in the report.

Two years ago, a friend living in the North Yorkshire dales needed the expertise of a consultant with a special interest in Parkinson’s. I was pleased to find such a consultant in Leeds who visited a private hospital in Harrogate. I passed on this information and received a letter from the friend who said that he was very pleased with the consultant, whom he liked and found very helpful. When one has to have complex drugs, it is important that one can have trust and confidence in the consultant who is prescribing the drugs. When I read in the report that there are many people with Parkinson’s who never see a consultant it causes concern, as having expert advice makes all the difference to the patients and their partners or carers.

As I read my Christmas cards this year, I had one which said: “Maureen cannot write this card as she has Parkinson’s”. People with Parkinson’s need the help of expert doctors, nurses, physiotherapists, occupational therapists and speech and language therapists as well as social care. All have a part to play in the patient’s journey while living with Parkinson’s. There is concern among many people involved in patient care and groups of people living with long-term conditions that things may not get better when GP consortia are in charge. Can the Minister say what the terms and conditions of commissioning will be, and what will be the safeguards?

I congratulate Parkinson’s UK on pump-priming nurses for the first two years. I wonder how many trusts take on the services of these specially trained nurses and how many, after two years, do not. The report states that the role played by Parkinson’s disease special nurses in the care of people with Parkinson’s disease was strongly endorsed by submissions from people living with the condition, from carers and from those medical specialists working alongside nurse specialists. Many people with Parkinson’s disease and their carers outlined how Parkinson’s disease nurse specialists provided them with a regular point of contact for advice on all aspects of the condition and for adjusting their complex medication regimes. This service was particularly valued by the group. When individuals did not have access to a nurse specialist, it tended to be identified as the most significant service inadequacy. I should be grateful for the Minister’s views on nurse specialists.

A person with Parkinson’s said in the report:

“The biggest help has been specialist Nurses, bit of a life saver really, could not imagine coping without them”.

There is a great deal to do to make services better for all people living with Parkinson's disease: for those in care homes who are often neglected and for those who find help is not forthcoming or that there is a lack of joined-up working between health and social care. I hope this report will be read and used by many people. I have already sent it to someone in Yorkshire. I hope it will be used by health professionals, many of whom need educating about the needs of people with Parkinson’s disease. I hope that the Minister will help to make services better for these people who really need them.

NHS: Reorganisation

Baroness Masham of Ilton Excerpts

Thursday 16th December 2010 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank the noble Lord, Lord Touhig, for securing this debate. I have been involved with the National Health Service for many years and it is without doubt in my mind the most valuable asset we have. It is an insurance policy for anyone who may be hit at any time by accident, illness, infection, disability or an act of violence. Over the years, the National Health Service has been subject to reorganisation after reorganisation. It is a vast and complicated organisation and recently, the training of junior doctors has complicated care of patients. Being restricted to 48 hours has compromised their training to be safe and competent doctors and surgeons.

If the reorganisation is going to work, the best people must be involved in leadership who can take responsibility and work in unity. There should be efficient systems in place; patients should not have to be left for long periods in x-ray waiting for a porter to return them to a ward; hospital food should be edible and nourishing; and nurses should see that patients are not left without food and fluid. The correct drugs should be administered by competent people; there should be responsible leadership to see that patients are always looked after; and nurses and care assistants, when at the nurses’ station, should be working on behalf of patients, not chatting about their next social engagement. There are many dedicated, hard-working staff in many hospitals, but in many more improvements should be made as soon as possible.

“Putting patients and the public first” is the heading of Chapter 2 of the White Paper Liberating the NHS. It states that the principle of shared decision-making is to become the norm—

“no decision about me without me”.

Many patients will tell you that they have difficulty getting an appointment with a GP of their choice—it can take weeks. It is important that at this time of change in the NHS, the patient’s voice is heard and listened to. First we had the community health councils, then the health forums, and now LINks. The general public do not really seem to know much about them. When something happens, such as a disaster like the tragic situation at the Mid Staffordshire hospital, the Patients Association is asked to comment by the press. It is a small, independent, voluntary organisation supporting patients and it has been inundated with work and inquiries. This shows what a need there is for an independent body to help and protect patients of all sorts throughout the country.

In the health White Paper it is suggested that there should be an organisation locally called HealthWatch, and a national body called HealthWatch England. I went to Google to find out what it said about HealthWatch. What came up was:

“HealthWatch is an independent registered charity … since 1991, who try to promote EBM. We are not Andrew Lansley’s HealthWatch”.

Several other HealthWatches came up. Could there not be confusion? With different HealthWatches, it is possible.

I tend to agree with the NHS Confederation when it says:

“We applaud the adoption of the principle of shared decision-making between GPs and their patients and the responsibility that will be given to the NHS Commissioning Board to champion patient and carer involvement but it is far from clear what levers they will have to enable this”.

It would be sad if relationships between the doctors and patients were damaged because GPs did not give patients what they feel they need. At least now they can blame the PCTs. Rather than give responsibility for complaints advocacy to the local HealthWatch, it would make greater sense to build on the existing well established network of local citizens advice bureaux. These already deal with health complaints as well as complaints about other local services and benefits. However, this would require appropriate additional resourcing and requirements to link with the local HealthWatch. HealthWatch is unlikely to have sufficient public profile or the resources or capabilities to deliver these functions.

If this new NHS is going to work, people and organisations, primary and secondary health, should be working together with enhanced communication for the good of patients. There should not be conflict and a silo situation. That would be a total disaster.

There is concern from many groups representing people with specialist conditions about the specialised commissioning. Will the 10 specialising groups still exist? I ask the Minister, but I am used to him not answering my questions. GPs who are generalists cannot be expected to know everything. I hope the Minister will be able to help with the uncertainties and concerns surrounding these issues, which include community care.

Hospices and Palliative Care Services

Baroness Masham of Ilton Excerpts

Wednesday 15th December 2010 Lords Chamber

[Baroness Masham of Ilton]

My Lords, the noble Viscount, Lord Bridgeman, who is chairman of the Hospital of St John and St Elizabeth in London, takes a great interest in everything. I visited the hospice attached to that hospital with the All-Party Parliamentary Group on HIV/AIDS some time ago. The hospice does not discriminate—it takes people who have HIV, cancer or some other condition. People can die in a safe place and receive spiritual support from people who understand their conditions.

Some of the children’s hospices now have units for teenagers. This is a very good development because teenagers do not fit in with small children or adults; they need their own space. The hospice at Boston Spa in Yorkshire has such a facility.

I also visited the hospice at Sunderland which is, I am told, the only hospice in the UK that is solely funded by the NHS. I ask the Minister whether, once the GP consortium comes into being, this hospice will still be funded by the NHS. There are dedicated people working in the NHS but, with so many cuts emerging, questions need to be answered to give reassurance to those who feel vulnerable.

Many children with muscular dystrophy need to be able to swim to help their condition. I am told that some of the hospices have swimming pools. Would it not be possible for children with muscular dystrophy to have swimming sessions in these pools when they are not being used? This would benefit both parties in these difficult economic times. It would be good if people could help each other. Would this not be a little bit of the big society?

My husband died in an A&E department after years of complicated medical conditions, including cancer. He developed pneumonia and needed antibiotics through a drip. This was not possible; it was on a Sunday. There is a desperate need for palliative care in the community for those who wish to die at home.

NHS: Prebiotics

Baroness Masham of Ilton Excerpts

Wednesday 17th November 2010 Lords Chamber

Asked By

[Baroness Masham of Ilton]

To ask Her Majesty’s Government what consideration they will give to using prebiotics to prevent Clostridium difficile in a clinical setting, with a view to improving patient experience and saving NHS resources.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

There is currently insufficient evidence to show that prebiotics offer benefits in a clinical setting to be able to make a general recommendation in relation to prevention of Clostridium difficile infection. Of course, we will keep this issue under review. However, it is important for all patients, including those who have contracted Clostridium difficile infection, to have a well-balanced diet.

[Baroness Masham of Ilton]

My Lords, I thank the noble Earl for that answer. Is he aware that C. difficile costs the country about £100 million a year and prebiotics are very cheap? Prebiotics are a food supplement that bypasses the stomach and goes into the gut and helps to keep a person fit, so that they may not get C. difficile. Does he agree that anything is worth trying with such a debilitating and dangerous condition?

[Earl Howe]

The noble Baroness is absolutely right, not for the first time, about the devastating incidence of C. difficile infection. More than 25,000 cases of C. difficile infection are reported annually and there remain significant variations in outcomes among organisations.

In principle, prebiotics should be beneficial, but there is in fact little good evidence to show that they work or that food can provide a prebiotic effect. There is likely to be considerable inter-patient variation in the gut flora response to prebiotics, which could be exacerbated by differences in diet. However, as I have already indicated, we will look closely at the issue.

Healthcare

Baroness Masham of Ilton Excerpts

Thursday 28th October 2010 Lords Chamber

[Baroness Masham of Ilton]

My Lords, in the few minutes that I have, I want to speak on patient safety. I know that all patients, wherever they are treated or looked after, desire safe, good-quality care. Patients and health professionals should come together to achieve good clinical outcomes. There should be co-operation and good communication between all professionals so that patients receive what they need.

I am president of the Spinal Injuries Association and a member of the Patients Association. We have been horrified by the appalling standard of care that left Jamie Merrett, a high lesion tetraplegic who was living at home using a ventilator, severely brain-damaged when an inadequately trained agency nurse turned it off. Jamie, an intelligent man, felt that his care was often inadequate, so he had a camera and video equipment installed in his bedroom to try to safeguard himself in his vulnerable position. I have spoken to his sister and next-of-kin, Karen Reynolds, who told me that they had contacted the PCT several times to alert it to the inadequate care.

In this tragic case, there seem to be unanswered questions. Will the Minister look into this case? Does the Filipina nurse who turned off the respirator and did not know how to resuscitate Jamie have a PIN? Had her qualifications been checked? Was she qualified to work in this country and on a ventilated patient? Jamie and his sister have been let down by many people who had responsibility for his case in Wiltshire. People living with ventilators need to trust those who have responsibility for their care. This case, which has been highlighted in the press, especially by the BBC in “Inside Out West”, might otherwise have been covered up. Many people living with such equipment may also be fearful of this dangerous situation, which must be rectified. When does the Department of Health expect the National Leadership Council to respond to proposals to improve the training quality of NHS managers? Does the Minister agree that healthcare assistants should be registered?

More seriously disabled people are now living in the community. At the moment, it seems that anyone who cannot get a job goes into caring. I know that the Royal College of Nursing is concerned about this. Vulnerable patients need protection. Not only do we want honest, well trained nurses who understand how to use the necessary equipment, but there need to be well trained, honest care assistants who are registered. The Minister has responsibility for primary healthcare. I hope that he will not let down these vulnerable patients and their families, who need a safe NHS—safer than it is now.

Health: Addiction to Prescribed Drugs

Baroness Masham of Ilton Excerpts

Wednesday 6th October 2010 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank my noble friend the Lord Sandwich for this short but important debate. His close association with this difficult problem makes this debate more pertinent. The All-Party Parliamentary Drug Misuse Group undertook an inquiry into physical dependence and addiction to prescription and over-the-counter medication in the parliamentary Session 2007-08. I found the inquiry most interesting but of great concern. I hope that the inquiry will be helpful to the people taking part in the Government’s review and that some of our recommendations will be adhered to.

An estimated 1.5 million people are addicted to benzodiazepine drugs in the UK. Many of these people will have been addicted for long periods. There is a common pattern to their submissions. First, there is a visit to their GP and a prescription for a particular benzodiazepine, followed by years of repeat prescriptions, often without review. For many patients, the drug initially alleviates their symptoms, but for others the symptoms continue and their general health deteriorates.

The British National Formulary states that benzodiazepines are indicted for short-term relief—two to four weeks only—of anxiety that is severe and disabling or which subjects the individual to unacceptable distress. It states that the use of benzodiazepines for short-term “mild” anxiety is inappropriate and unsuitable and advocates that withdrawal from benzodiazepines should be gradual, as abrupt withdrawal may produce confusion, toxic psychosis, convulsions or a condition resembling delirium tremens.

Your Lordships might be interested to hear a case study from the inquiry:

“Ms R was prescribed benzodiazepines following treatment for alcohol addiction. For the next 28 years her doctor allowed her repeat prescriptions of the drug despite the fact that she continued to experience feelings of anxiety and ill health. More recently she has attempted withdrawal but failed on a number of occasions. Her GP told her his medical training did not equip him with the skills to help her withdraw, so she approached her local Drug and Alcohol Action Team (DAAT) who refused to help her as she was ‘only a prescription drugs addict.’ She was told that, as her GP had created the problem, it was up to him to solve it. Her DAAT told her that, if she had become addicted to benzodiazepines through illicit use, they would have been able to help her”.

Clearly, there must be a more joined-up approach to educating all health professionals, from pharmacists to nurses and doctors, to ensure that they are able to help vulnerable patients. Despite the fact that the guidelines have been made quite clear about prescribing benzodiazepines, repeat prescriptions for longer than two-week to four-week periods continue to be allowed. Conversely, some GPs continue to try to reduce the benzodiazepine usage of their patients too fast, which is most dangerous. What can be done about this?

The drugs, which contain codeine and include brand names such as Nurofen Plus and Solpadeine Plus, are sold over the counter and are routinely used to ease headaches, back pain and period pains. Official figures show that tens of thousands of people have become dependent on them, many accidentally, with women at the most risk of developing an addiction. Warning that addiction can begin after just three days, the Medicines and Healthcare Products Regulatory Agency has said that, from this year, all packets of painkillers will carry a prominent warning label that will read, “Can cause addiction after only three days’ use”. Also, the pills will be available at a maximum of 32 per packet instead of 100. That is good news, but has this already happened?

With so many problems in the training of junior doctors and student nurses, it is important that the British Medical Association, the General Medical Council and the Royal College of Nursing should ensure that all medical students and nurses are trained to recognise the symptoms of physical dependence and addiction to drugs, including over-the-counter and prescription medications, and that voluntary groups working in this field should be supported. There is the added problem of people ordering drugs such as anabolic steroids over the internet, despite the potential health risks. Does not the Minister agree that the safety of all drugs should be made a priority?

NHS: Pain Management Services

Baroness Masham of Ilton Excerpts

Wednesday 7th July 2010 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I thank my noble friend Lord Luce for this important short debate on chronic pain and congratulate him on his ongoing campaign to make conditions better for people with continuing chronic pain. Some years ago, when I was sitting next to my noble friend at lunch, he had such excruciating pain in his back that he had to go out and lie on a bench, and an ambulance was called. I have always had the greatest admiration for his tenacity in holding down an important position while enduring such chronic pain. It is good to see him still bringing this matter up. Who knows better what pain means? He is an expert and I hope that the Government will listen.

I know excruciating pain. I broke my back and fractured many ribs in an accident many years ago. When I arrived at the spinal unit at Stoke Mandeville Hospital I was not given any painkillers for fear of addiction. In those days, that was the policy because we were turned only three-hourly to prevent pressure sores. Cramp used to set in and I understand the expression “blood, sweat and tears”.

When a doctor told me that the pain should ease off in three weeks, that was the light at the end of a very dark tunnel. It is important that the psychological implications of chronic pain are understood—for example, how it can cause depression, break up partnerships or loss of jobs. Pain can eat into people’s lives. In 2008, there was hope in the Chief Medical Officer’s annual report, which wanted,

“to widen access to high-quality pain services”.

What action has been taken in the past two years by the National Quality Board on clinical priorities for the NHS? What are the Government’s views on this subject?

The public need education in what to expect from analgesics and in how they can help themselves to cope with chronic pain. Postgraduate training is needed for the safe and appropriate prescribing of analgesics and the use of other therapies. Often, GPs prescribe pain-killing drugs to patients who are not reviewed and end up becoming dependent and addicted. About 8 million people of all ages suffer from chronic pain. Only about 14 per cent of them have access to any pain specialists. Long-term pain can have a devastating effect on the lives of sufferers and families. Forty nine per cent suffer from depression; 25 per cent lose their jobs; and 16 per cent feel suicidal.

Pain can be very complex. I am president of the Spinal Injuries Association. Some of our members have root pain or phantom pain, which is not well understood. Some people turn to alcohol, which may help but can damage their kidneys. Something has to be done to improve the situation. There is much need for research into pain and for multidisciplinary pain management services across the NHS which encompass doctors, physios, nurses, occupational therapists, psychologists and expert patients who are all trained in pain care. There needs to be co-operation and co-ordination, and not fragmentation. I wait in anticipation for the Minister’s reply.

NHS: Budget

Baroness Masham of Ilton Excerpts

Wednesday 23rd June 2010 Lords Chamber

[Earl Howe]

The noble Baroness is quite right that patients who do not attend their appointments cost the NHS a great deal. How do we deal with the issue—I am sure that the previous Government wrestled with it, too—if we are to avoid charging patients for failing to turn up? I would resist the idea of charging because I do not think that it is a road down which we should be going in secondary or primary care. However, the ways in which we can encourage patients to turn up on time should attract greater focus in our efforts towards achieving efficiency.

[Baroness Masham of Ilton]

My Lords, will the Minister assure us that trained nurses, physiotherapists and occupational therapists will not be replaced by cheaper care assistants?

[Earl Howe]

My Lords, to ensure that the quality of NHS services continues to improve in a climate of constrained growth, we must achieve greater productivity, but that means designing services for better quality and value for money. It does not mean downgrading the quality of the services. It is for local NHS bodies to decide how services can best be delivered most efficiently. I would be very surprised if that kind of dilution of expertise formed a part of any such plans.