Alcohol: Impact on Accident and Emergency Services
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Lord Brooke of Alverthorpe
To ask Her Majesty’s Government what discussions they have had with the drinks industry about contributing to National Health Service accident and emergency costs.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the alcohol industry has responsibilities to reduce harm caused by its products. We have challenged the industry to deliver action through the responsibility deal. It is important to recognise that individuals also have responsibility for their behaviour. The Government set the legislative framework, and the United Kingdom has relatively high taxes on alcohol, which are the main way to compensate society for its costs. Our alcohol strategy seeks to prevent and reduce harm from alcohol.
Lord Brooke of Alverthorpe (Lab)
My Lords, I am grateful for the pleasant words from the Minister, but I omitted to pick up on just what action the Government intend to take. Does he share the concern of his new CEO for the NHS, Sir Simon Stevens, that more than 1 million people are now presenting at A&E each year with alcohol problems? Not only that, but they are in the main accompanied by their friends and often family, who swell the numbers and are equally intoxicated. They are creating great difficulties for nurses, doctors and other A&E patients. Many of those people do not come from their home; they come from drinking establishments from which some of them have been ejected. Many of those establishments have personnel there looking after security for the protection of the interests of the drinks industry. If the drinks industry can pay for those people to protect its interests, why cannot it be required to pay to protect the interests of nurses, doctors and other people in A&E who are intimidated by people who are drunk?
Earl Howe
My Lords, alcohol-related attendances at A&E are certainly a matter of concern; we fully recognise that. Having said that, there is no evidence to suggest that current pressures in A&E departments are related to trends in alcohol-related attendances. We are taking a range of actions to prevent and reduce harm both nationally and in many local areas. We are certainly not just treating this as a financial issue. This is an issue to do with people’s health, and it is important. The industry is playing its part through the responsibility deal, which is already yielding some encouraging results.
Baroness Finlay of Llandaff (CB)
Do the Government accept that currently, the cost to the NHS of these attendances is about £120 per taxpayer for England? The arguments for minimum unit pricing are very strong, given that the attendance range peaks between the ages of 35 and 55 and yet, in that age group, you can drink your whole maximum weekly recommended amount of alcohol for less than £10 with the current pricing system. Minimum unit pricing might bring in more money to cover the cost to the NHS.
Earl Howe
My Lords, we are keeping the developing evidence on a minimum unit price under review. It has only ever been part of our alcohol strategy—which, as I said, includes a range of actions. We acknowledge the need to give careful consideration to any possible unintended consequences of MUP, such as its potential to impact on the cost of living, the economic impact of the policy and, importantly, a possible increase in illicit alcohol sales that could ensue.
Lord Avebury (LD)
My Lords, is it necessary to refer to the alcohol industry for measures to alleviate the £21 billion-worth of harm that it causes? Should my noble friend not instead refer to the calculations by the University of Sheffield showing the amount by which alcohol harm can be reduced by increases in taxation?
Earl Howe
My Lords, we have taken a strong policy on taxation in recent years, particularly to reduce the availability of cheap, strong alcohol. Since the 2010 general election, duties on spirits have risen by more than 18%, which is well above RPI, and on wine by more than 21%, again well above RPI. We have also introduced a ban on the sale of below-cost alcohol, which should stop the worst cases of cheap and discounted alcohol sales.
Lord Hunt of Kings Heath (Lab)
My Lords, can I ask the noble Earl about the attitude of the drinks industry? He said that it is responsible but can he confirm that the long delay in the publication of new guidelines from the Chief Medical Officer on safe drinking levels is because she wants to reduce those levels but the drinks industry objects, and the Government have given in to it?
Earl Howe
Not at all, my Lords. As I explained the last time the noble Lord asked that question, the reasons were purely technical and nothing to do with a disagreement. The CMO is overseeing a review of the alcohol guidelines so that we can ensure that people make better-informed choices. That is now under way and in its second phase. During the review we will look at any significant new evidence that relates to pregnancy, in particular, to consider whether our advice needs to be updated. We expect to consult on new guidelines by the middle of this year.
Lord Garel-Jones (Con)
Would my noble friend consider obliging the purveyors of this habit-forming, hallucinatory drug to place a government health warning on their products?
Earl Howe
My Lords, again, there has been a great deal of progress in alcohol labelling. Independent research published in November showed that just under 80% of bottles and cans of alcohol on shelves now have the correct health labelling: a clear unit content, the CMO’s lower-risk drinking guidelines and a warning about drinking when pregnant. That fulfils an industry-wide responsibility deal pledge.
Lord Singh of Wimbledon (CB)
My Lords, does the Minister agree that the drinks industry should bear the cost of treating people with alcohol-related sickness and illness who end up in A&E that is proportionate to their number? For example, it is 80% in some hospitals on a Saturday evening.
NHS: Clinical Negligence
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Lord Sharkey
To ask Her Majesty’s Government what are the causes of the £3.1 billion increase in the National Health Service’s potential liabilities for clinical negligence to £25.7 billion between 31 March 2013 and 31 March 2014.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, there are several factors behind this increase. These include the rise in numbers of patients cared for and the complexity of their care. In addition, there has been a general rise in litigation across a number of sectors, including the NHS, which is driven in part by no-win no-fee agreements. High costs incurred by claimants in bringing civil litigation have also played a role in the increasing clinical negligence cost and associated provisions.
Lord Sharkey (LD)
In the last five years, NHS spending has grown by 12%. In the same period, liabilities for negligence have actually doubled. With the current rate of growth, they will take only six years to reach around £50 billion. The Medical Defence Union thinks that is unsustainable and has suggested reducing liabilities by changing the law. It suggests allowing courts to take account of the fact that the NHS and local authorities can provide some of the treatments required by successful claimants. Does the Minister agree that this is part of the way forward?
Earl Howe
My Lords, moneys paid in settlement of clinical negligence claims cannot be reclaimed or recycled in the way that my noble friend appears to suggest because, in the nature of NHS care, it is free from the patient’s perspective. We are, however, concentrating on various ways to reduce the number of clinical negligence incidents and, indeed, to improve patient safety, which is of course part of the way in which we can reduce the number of claims in the first place.
Lord Hunt of Kings Heath (Lab)
My Lords, what view have the Government taken of the Medical Defence Union recommendation for repeal of the Law Reform (Personal Injuries) Act 1948? In essence, that would mean defendants could buy NHS healthcare packages as opposed to the more expensive private care packages, and, presumably, would reduce some of the cost of the claims that are currently going through.
Lord Willis of Knaresborough (LD)
My Lords, following the passage of the Health and Social Care Act, there are now some 350 other qualified providers. Will my noble friend confirm that they all get support through the Department of Health for any clinical negligence claims? If that is so, how much was paid out in 2013? Further to the point made by the noble Lord, Lord Hunt, if a claim is made within the private sector or third sector, will such providers be prevented from providing that claim within their organisations if negligence was proven?
Earl Howe
My Lords, potentially, independent sector providers may elect to be members of the negligence scheme, although only in respect of their NHS services. Therefore, only NHS-related liabilities would be covered in those circumstances. It is a pay-as-you-go pooled scheme, and I do not therefore have the figure that my noble friend requested. If I can get the figure disaggregated for him, I would be happy to write. In answer to his last question, I take it that he is asking whether the provider would be allowed to continue treatment, having been found to be negligent or having admitted negligence. That decision would be clinically led, with the patient exercising choice in each individual case.
Lord McFall of Alcluith (Lab)
My Lords, may I suggest an examination of the area of clinical governance? I and my family are not alone in having a negative experience of a disjointed, rather than an integrated, clinical governance network, where communication between departments and individuals was virtually non-existent. The admirable Reith lecturer, Dr Atul Gawande, examined the concept regarding why doctors fail, and one of the main reasons he came up with was that policies that fragment a unified system rather than cohere the system were in the interests of neither patients nor the NHS, as can be seen with these claims.
Earl Howe
The noble Lord makes a series of good points. He may be interested to know that part of the series of pledges that form the Sign up to Safety campaign, which hospitals can apply for, can include the principles of being transparent with people—including about any mistakes that have been made and what is being done to tackle safety issues—and collaboration, by taking a leading role in supporting local collaborative learning, so that the system genuinely can work together and learn together.
Lord Phillips of Sudbury (LD)
My Lords, is my noble friend satisfied—I am thinking, for example, of the scandal of whiplash claims—that the legal resources available to the NHS are sufficient for the task?
Baroness Finlay of Llandaff (CB)
My Lords, does the Minister agree that complaints need to be dealt with rapidly, preferably by a phone call or home visit, rather than in the current slow systems that often compound the anger of those who feel that they have been wronged by the NHS and which therefore make the procedure of litigation more likely? There should, rather, be rapid settlement, a very sincere apology and lessons learnt with follow-up.
Earl Howe
I agree with the noble Baroness. We view it as important that NHS organisations manage complaints in a positive manner and use the information obtained to improve service delivery. Saying sorry is important. People who complain often want an apology, an explanation and an assurance that the same thing will not happen to someone else.
Lord Roberts of Llandudno (LD)
My Lords, do the figures we have been given today include Wales, Scotland and Northern Ireland? Are those claims included in the total figure?
Health: Human Papilloma Virus
Earl Howe Excerpts(11 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by congratulating the noble Lord, Lord Patel of Bradford, on securing this debate and on bringing this important subject to your Lordships’ House. I understand the noble Lord’s concerns on this issue. Vaccines provide vital protection from a large number of diseases, including the human papilloma virus. We need to ensure that they are used as effectively as possible and that those who would most benefit from them are included in any vaccination programmes that we implement.
As has been mentioned, the Government are advised on all immunisation matters by the statutory body, the Joint Committee on Vaccination and Immunisation. The JCVI keeps all immunisation matters under review, providing advice and recommendations to Ministers on all current and potential vaccination programmes. It is, therefore, to the JCVI that we look for expert advice when considering issues such as those raised today.
The UK’s current HPV vaccination programme, based on advice from the JCVI, began in 2008, and its aim is to prevent cancers relating to HPV infection, specifically cervical cancer. HPV is a sexually transmitted disease. Our main objective, therefore, is to provide HPV vaccine to young women before they reach an age when exposure to HPV infection increases and vaccination would become less effective because many would have already been infected. For that reason, the vaccine is offered to all girls in school year 8—that is, at ages 12 to 13 years. As HPV is responsible for virtually all cases of cervical cancer, prevention of this disease remains the primary aim of the current programme.
The UK’s HPV vaccination programme has been a considerable success. Almost 8 million doses have been administered across the UK since 2008 and this country has among the highest rates of HPV vaccine coverage achieved in the world. In England, 86.7% of girls eligible for routine vaccination in the 2013-14 academic year completed the three-dose course and 89.8% have received at least two doses of vaccine.
The noble Baroness, Lady Hollins, asked about herd immunity. When recommending introduction of the programme in 2008, the JCVI considered that once 80% coverage among girls was achieved, which we have now attained, the vaccination of boys was likely to provide little additional benefit in preventing cervical cancer in girls. As the noble Lord, Lord Patel, made clear, with high uptake of HPV vaccine among girls, many boys will also be protected against other HPV-related cancers such as anal cancer and head and neck cancers, because transmission of HPV between girls and boys should be substantially lowered.
However, as I mentioned, the JCVI keeps all vaccination programmes under review and has recognised that under the current programme the protection that accrues from reduced HPV transmission from vaccinated girls may not be provided to men who have sex with men, or MSM, because they are less likely to have sexual contact with vaccinated women. Given increasing evidence of the association between HPV infection and oral, throat, anal and penile cancers, and the impact of HPV vaccination on such infections, the JCVI set up an HPV sub-committee in October 2013 to consider a number of key issues around HPV vaccination, including the question of potentially extending the programme to MSM and adolescent boys—that is, to protect those who may go on to become MSM—or to both. The committee has also noted the public, parliamentary and third-sector concern about this issue and agreed that evaluation of potential extensions to the programme to include MSM, adolescent boys, or both, should be a priority.
Your Lordships may be aware that last November, following very careful consideration of the evidence, the JCVI published for consultation provisional advice that a targeted HPV vaccination programme should be introduced for MSM aged between 16 and 40 years attending genitourinary medicine and HIV clinics. The JCVI consultation ended on 7 January 2015 and we await the committee’s final advice on this matter.
The JCVI’s HPV sub-committee is also giving consideration to work modelling the impact and cost-effectiveness of extending HPV vaccination to adolescent boys. I am advised that it is currently anticipated that a model being developed at Warwick University could be presented to the sub-committee in the second half of this year. A separate model being developed by Public Health England may not now be completed until early 2017. I also understand that the JCVI and its HPV sub-committee may need to consider both studies before taking a final view on the impact and cost-effectiveness of extending HPV vaccination to adolescent boys and may therefore not be in a position to do so before early 2017. The JCVI has noted that the cost-effectiveness of an HPV programme for adolescent boys is not certain, because the high coverage rates achieved for adolescent girls are highly likely to interrupt HPV transmission and provide indirect protection for boys to such an extent that there may be little additional benefit to be accrued from extending the programme. However, the committee agreed that a detailed cost-effectiveness analysis was required to fully understand the potential benefits of any proposals.
The noble Baronesses, Lady Gould and Lady Wheeler, asked why there has to be this two-year delay. Work to model the impact and cost-effectiveness of vaccinating adolescent boys with HPV vaccine is dependent on the completion of work by PHE on an individual-based model for HPV screening, as the intention was to use the completed screening model as a basis on which to model adolescent male vaccination. An individual-based model is critical to proper assessment of an adolescent boys’ vaccination programme. Individual-based models are very complex and mathematical; they simulate the impact of an intervention on individuals within a population through time and take a considerable amount of time and resource to develop. The screening model is now not due to be completed until early this year. Although disappointed that modelling work on the cost-effectiveness of HPV vaccination of adolescent boys by PHE will not begin until early 2015, the JCVI agreed that in order to expedite the work it would not be advisable to take any shortcuts, which could undermine the validity of the outputs. As I said, the PHE model may not now be completed until early 2017. The HPV sub-committee will meet during 2015 to review the progress of these studies and will report its findings to the JCVI following consideration of work modelling the impact and cost-effectiveness of extending HPV vaccination to adolescent boys.
Your Lordships will be aware that the NHS budget is a finite resource. New vaccination programmes and extensions to existing programmes will usually represent a significant cost to the health service, in terms of both vaccine purchase and its administration to individuals. It is therefore essential that any advice or recommendations from the JCVI on changes to the national vaccination programme be supported by evidence to show that they would be a cost-effective use of resources.
The noble Lord, Lord Patel, asked about an equalities assessment. An equality impact assessment was completed in 2008 for the introduction of the national HPV vaccination programme for girls. At that time, vaccination for boys for HPV was considered to be not cost-effective for the prevention of cervical cancer.
The noble Countess, Lady Mar, raised the issue of the Japanese experience. HPV vaccines, in fact, remain licensed for use in Japan and continue to be available for girls and women who wish to receive them. The decision of the Japanese authorities temporarily to stop their active recommendation for immunisation due to reports of chronic pain was a precautionary move while they gathered more data. However, EU regulators have reviewed the issue and concluded that there is currently insufficient evidence to indicate that HPV vaccines may be a cause of chronic pain or chronic pain syndrome, which has also been associated with needle injection itself—that is to say, not specific to the vaccine. It remains the case that a causal relationship with HPV vaccines has not been established.
The Countess of Mar
My Lords, I am sorry to interrupt, but even the manufacturers recognise autoimmune dysfunction as a result of their vaccines.
Earl Howe
My Lords, I will take that point away and respond to the noble Countess in writing, as I do not have briefing on it. Suffice it to say, lest there be any doubt, we consider vaccine safety to be of paramount importance. The Medicines and Healthcare products Regulatory Agency has closely evaluated the safety of the HPV vaccine since it was first introduced in this country. The agency takes every report of suspected adverse reactions very seriously and keeps safety under continual review. Again, the view remains that there is currently insufficient evidence to indicate that illnesses are a side-effect of the vaccine.
The MHRA recently completed an epidemiological study of myalgic encephalomyelitis and chronic fatigue syndrome following HPV vaccination. This found no evidence to suggest that the vaccine may be a cause of the condition. The results of the study were published in a peer-reviewed scientific journal in 2013, as I am sure the noble Countess is aware. It is estimated that more than 30 million females worldwide have been vaccinated with HPV vaccine. The United States health authorities have also extensively reviewed HPV vaccine safety and the World Health Organization is assured by its safety.
Time is against me, so I will write to noble Lords on those points that I have not been able to cover. Let me just say that this is very much work in progress. Clarity on timelines cannot be achieved until the JCVI HPV sub-committee has met and reviewed the available evidence. We anticipate that sufficient evidence for the JCVI to be able to offer final advice on the vaccination of men who have sex with men will become available during 2015 but that sufficient evidence for the JCVI to be able to offer advice on the vaccination of adolescent boys may not now become available until 2017 at the earliest. I am afraid that I cannot give any comfort on an earlier date. I recognise that 2017 seems a long way off. However, I hope that the noble Lord will agree that it is essential that the JCVI does its work thoroughly and comprehensively before finalising its advice to the Government. He asked whether Ministers will meet the JCVI to discuss this. I will pass that recommendation to my honourable friend Jane Ellison MP, the Minister for Public Health.
The noble Baroness, Lady Hollins, requested that the issue of men with learning difficulties should specifically be brought to the attention of the JCVI. All girls are covered, regardless of disability, so this is an issue that could be brought to the attention of the JCVI and officials will do that.
Finally, I thank the noble Lord once again for initiating today’s debate. I very much hope that the discussion has been helpful in providing reassurance of our commitment.
Meals on Wheels
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Lord Touhig
To ask Her Majesty’s Government what estimate they have made of the number of elderly people who have received meals on wheels in the past year.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Health & Social Care Information Centre does not collect comprehensive data on numbers receiving meals; it only collects a subset of this group: those receiving meals as part of a formal package of care. I understand from the information centre that in 2013-14, 31,950 people received meals from councils with adult social services responsibilities as part of a formal care package. Some 29,605 were older people aged 65 or over.
Lord Touhig (Lab)
My Lords, 220,000 fewer elderly people received meals on wheels last year than in 2010, when this Government came into office. Why?
Earl Howe
My Lords, as I have indicated, there are a variety of reasons for this. The data collected by the information centre include only people who receive meals in their homes as part of a council-arranged formal package. They do not include informal arrangements such as the provision of meals at day centres or via daycare, or indeed those who pay the council for their meals, as many do.
Baroness Greengross (CB)
My Lords, I declare an interest as patron of the National Association of Care Catering. The association recently did some research that showed that, over 10 years, the numbers of people receiving meals on wheels has gone down from 40 million to half that number. That is really very worrying. Can the Government explain whether it would be better to have a statutory requirement for someone to provide these services to the huge numbers of older and vulnerable people within the community?
Earl Howe
My Lords, I do not recognise the figure of 40 million that the noble Baroness mentioned; perhaps she and I could confer after this Question. I think that what matters here is that those with eligible needs receive the service they require. It is up to local authorities to determine eligibility criteria, but the latest available data from ADASS show that all local authorities are setting their eligibility criteria to ensure that they meet at least critical and substantial levels of need.
Baroness Gardner of Parkes (Con)
My Lords, some years ago I was a chairman of social services, and many elderly people did not like the meals that came. I wonder whether that is still the position. I also wonder whether the position in hospitals is similar, as we have found that more people suffered from malnutrition after they had been in hospital than before. That happened because people could not feed themselves adequately and the maid or carer who delivered the food to them would come in and say, “Oh, you didn’t like your lunch, dear”, and take it away. Of course, they have found ways round that, but have they found ways to ensure that people are getting meals that they like, and is someone seeing that they actually eat them?
Earl Howe
My noble friend makes a series of important points. I do not have information on how many people dislike their meals on wheels, but the fact that many purchase them must indicate that the quality of those meals in many areas is of a high standard. There is also charitable provision, which I should have mentioned as well. The context here is surely the new regime that will be ushered in by the advent of the Care Act, which builds support around the individual and their needs and preferences.
Lord Kinnock (Lab)
My Lords, the figures used by my noble friend Lord Touhig were obtained by freedom of information means from local authorities in England. Those figures cover years in which there was a substantial rise in the number of over-65s in the United Kingdom, yet they show a decline of about a quarter of a million in the number of people receiving meals on wheels. I repeat my noble friend’s question: why?
Earl Howe
My Lords, I was not seeking to doubt the figures obtained through a freedom of information request; they just do not happen to be available to my department. However, it is worth noting that the data on the numbers using services also reflect longer-term trends. For example, the proportion of older people in receipt of local authority-supported social care has been declining steadily for the last 10 years. Among those receiving meals on wheels, the numbers have also been declining steadily over 10 years.
Baroness Barker (LD)
My Lords, Age UK County Durham runs an innovative scheme called “Come Eat Together”, which addresses not only the issue of older people having the right food but matters such as loneliness as well. Does the noble Earl consider that that is the sort of innovation that local authorities should bring to social care under the Care Act?
Earl Howe
My noble friend makes an important point—that it is not only the value of the meal that is important to elderly people; it is the relief from isolation and loneliness. Many of the solutions to that lie with local authorities. However, what the Government centrally have been able to do is to raise awareness of the impact of isolation and loneliness and encourage local commissioners to tackle that. To that end we have funded a digital toolkit for local commissioners, which has been supporting them in understanding and mapping commissioning for loneliness and social isolation in their communities.
Lord Foulkes of Cumnock (Lab)
My Lords, I declare an interest as a trustee of Age Scotland. May I try to answer my noble friend’s question for the Minister? The reason why there has been such a dramatic reduction in the number of meals on wheels is the swingeing cuts imposed by the coalition Government—and, indeed, the Government of Scotland—on local authorities and voluntary organisations, and it is about time they were reversed.
Earl Howe
My Lords, local authorities’ funding through central revenue support has indeed reduced, but spending on adult social care has been relatively protected compared with nearly all other local authority services. In cash terms, councils have reported only a small reduction in money spent on adult social care since 2010, despite the tough public funding climate. It is up to the party opposite to explain where the money would come from—if it will increase local authority spending—given that the shadow Chancellor has ruled out increasing local government spending if Labour is elected at the general election.
Lord Touhig
Perhaps I may help the Minister. Could it be due to the fact that the average cost of a single meal has gone up 22% since this Government have been in office? How do the Government justify that?
Earl Howe
My Lords, local councils do not have to charge for meals; they may provide them free of charge or at subsidised rates if they want to. If they charge, they must—as is the case for any non-residential social care service—follow the statutory guidance. That guidance ensures that, where they do charge, the charge is consistent and fair.
HIV
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Lord Fowler
To ask Her Majesty’s Government what estimate they have made of the proportion of people living with HIV who are undiagnosed.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, Public Health England estimates that in 2013 107,800 people were living with HIV in the United Kingdom. Of these, 24%, some 26,100, down from 25% in 2012, were undiagnosed and unaware of their infection. Early diagnosis is important to ensure people can get early treatment and to prevent them infecting others.
Lord Fowler (Con)
My Lords, surely we cannot ever eradicate HIV in Britain, which currently is costing the health service something like £650 million a year, when there are at any one time, as my noble friend has just said, 26,000 people who have contracted HIV but are undiagnosed and untested and can obviously spread the infection further. Will my noble friend consider setting up a working party to report on how testing in this country can be improved, which would be of benefit to those people affected and also to the benefit of the public generally?
Earl Howe
I will gladly take that suggestion from my noble friend away and give it consideration and I am grateful to him for it. The position on testing is, however, quite encouraging. We have seen more than 1 million HIV tests in sexual health clinics in 2013, which is up 5% from the previous year, and that is only in sexual health clinics. As my noble friend knows, there are other routes to testing through GP surgeries, self-sampling kits and so on. Additional testing is vital if we are going to make sufficient inroads into diagnosing this condition.
Baroness Barker (LD)
My Lords, the organisation Halve It reported in a survey last year that one-third of GPs who are in high-prevalence HIV areas were unaware that that is where they worked and consequently were not testing people for HIV routinely. Can the Government work with Public Health England and the RCGP to remedy that?
Earl Howe
My Lords, I pay tribute to the work of the Halve It coalition in raising awareness about the importance of increasing HIV testing. My noble friend is right that apart from ignorance often GPs are reluctant to discuss HIV testing or are unaware of the importance of early diagnosis and possible indicator symptoms. My department was pleased to fund the Medical Foundation for AIDS and Sexual Health’s HIV testing in primary care project that provides a web-based interactive resource for GPs in primary care to help make testing easier in GP surgeries.
Baroness McIntosh of Hudnall (Lab)
My Lords, does the Minister agree that one of the biggest disincentives to testing is the amount of stigma that still remains against those who are known to have HIV? Alongside encouraging people to have tests, can he say what Public Health England is doing to combat that stigma?
Earl Howe
The noble Baroness is absolutely right. If we were to single out three things that are important in this context, they would be prevention, testing and tackling stigma and discrimination. The NHS, local authorities, government, community and faith groups, the media and individuals themselves all have a part to play in eliminating HIV-related stigma. Our framework for sexual health improvement is clear that action needs to continue to eradicate prejudice based on sexual orientation. That depends on building an open and honest culture where everyone can make informed decisions and responsible choices about relationships.
Baroness Gardner of Parkes (Con)
My Lords, is it not a fact that there has been a great change in attitudes about HIV, and not only because of the treatments that are now available? I recall the days when people went into a hospice because it was a terminal condition. I have sat on various inquiries and know that people used to hide—in the fridge, for example —any evidence that they had HIV because they were frightened of other people knowing. Because that no longer applies, there is a great opportunity for people to have testing without any embarrassment at all.
Earl Howe
My noble friend is right. I think that we have come a long way since my noble friend Lord Fowler was Secretary of State, when stigma and discrimination were very apparent in virtually all sections of society. We do not see that so much now, I am glad to say, as evidenced by the fact that we are reporting a continuing reduction in late diagnosis. It was down to 42% last year from 47% in 2012, and that is a key indicator in this context.
Lord Collins of Highbury (Lab)
My Lords, the UK is a leading supporter of research and development into universal prevention methods, including HIV microbiocides and vaccines. With 19 million people globally remaining unaware of their HIV status today, will the noble Earl tell us how the Department of Health is working with the Department for International Development to support this research and development work?
Earl Howe
My Lords, in November 2013 DfID conducted a review of our 2011 HIV position paper. The review paper highlighted three areas of particular focus in the international context. They were to identify the key affected populations—girls and women—and the integration of HIV responses into the wider health system, as well as broader development priorities. That of course includes tackling stigma and the unacceptable things that we see in certain overseas countries, including discriminatory legislation.
Lord Patel (CB)
My Lords, did the Minister refer to 26,000 people being undiagnosed? What is that number based on?
Earl Howe
My Lords, these figures inevitably have to be estimates but they rely on data from three surveys that measure undiagnosed HIV infection among sexual health clinic attendees, pregnant women and people who inject drugs. Comprehensive clinical data from sexual health clinics relating to patients newly diagnosed with HIV are also used to infer the risk of undiagnosed infection.
Lord McConnell of Glenscorrodale (Lab)
My Lords, moving the focus from sub-Saharan Africa, where we have been so focused over recent years, is the Minister aware of the increase in the incidence of HIV/AIDS in south-east Asia? Are the Government looking at advice to British tourists travelling to that area in the light of this increase in the incidence?
London Health Commission: Smoking
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank the noble Lord, Lord Darzi, for securing this important debate. As we have heard, the Mayor of London set up the London Health Commission in September 2013, with the noble Lord, Lord Darzi, as chairman, to review the health of the capital, from the provision of services to what Londoners themselves can do to help make London the healthiest major global city. In October, the London Health Commission published its report, Better Health for London, with a range of recommendations for the Mayor of London to consider. I congratulate the noble Lord, Lord Darzi, and the members of the London Health Commission on their well considered and thought-provoking report.
Local government has responsibility for improving health and well-being in its communities, including reducing rates of tobacco use. Noble Lords will understand that it is not for me as Health Minister to respond to the London Health Commission’s report. That is for the Mayor of London, for whom the London Health Commission prepared its report. I will, however, be very interested to see how the mayor progresses the recommendations that have been made.
Nevertheless, given the Government’s commitment to tobacco control, I particularly welcome this opportunity to tell your Lordships more about the work we are doing to tackle tobacco use. Tobacco remains one of our most significant public health challenges. Smoking is a leading cause of cancer, cardiovascular and respiratory disease; smoking is the primary preventable cause of morbidity and premature death; smoking is a significant driver of health inequalities and remains the biggest cause of inequalities in death rates between the richest and poorest in our communities; and smoking places an enormous strain on the NHS, while the overall economic burden of tobacco use to society is estimated at more than £13 billion a year. We must also remember that tobacco use is harmful not only to individual smokers, but to others around them.
Reducing smoking rates is a public health priority for this Government. In early 2011, we published the Tobacco Control Plan for England, which set out a comprehensive package of evidence-based action to be implemented at national level to support local areas in driving down rates of tobacco use. We also set out in the plan the importance of our efforts to reshape social norms around tobacco use to promote health and well-being. The noble Lord, Lord Faulkner, and the noble Baroness, Lady Finlay, asked what our plans were for refreshing the tobacco control plan. As they said, the plan sets out action until the end of this year. Like both noble Lords, I, too, hope that whoever are in government after the election continue to take comprehensive and effective action on smoking. However, it will be, essentially, for the next Government to take that decision.
From the outset, we ought to reflect the enormous amount of progress that we have made over the past decade. Smoking rates in England are at their lowest since records began. Today, around 18 per cent of adults are smokers, down from around half of adults smoking in the 1970s. Almost 2 million fewer people in England are smokers compared to a decade ago, and London has some of the lowest smoking rates in the country. We know that the majority of smokers take up smoking when they are teenagers. Most smokers were regularly smoking before turning 18 years of age—before they were able to make informed, adult decisions about tobacco use.
The good news is that rates of regular smoking by children in England between the ages of 11 and 15 years have declined by some 70 per cent since 2000. However, I want to be clear that continuing to reduce the uptake of smoking by children is essential. Research published in 2013 shows that every day around 600 children aged between 11 and 15 years start smoking in the United Kingdom.
The Government have taken action to protect young people from tobacco and nicotine addiction and a range of new powers relating to smoking were introduced through the Children and Families Act 2014. We have laid regulations to end smoking in private vehicles carrying children in England, which shortly will be considered in your Lordships’ House and in the other place. New legislation will stop adults buying tobacco on behalf of children.
The Department of Health is currently consulting on proposed regulations to bring the same age-of-sale requirements into place for electronic cigarettes that exist for tobacco. I would just say, on electronic cigarettes—mentioned by the noble Baroness, Lady Finlay—that while there is emerging evidence that e-cigarettes may be helpful to some people wishing to quit smoking, the quality of products on the market remains highly variable. We continue to work towards a regulatory framework that ensures for those smokers who want to use e-cigarettes to cut down or quit that they meet quality standards and are accompanied by sufficient information to enable informed choices. However, e-cigarettes are not risk free. We do not know enough about the long-term health effects of adults, let alone children, using e-cigarettes. Furthermore, as there have been no long-term studies to examine whether e-cigarettes serve as a gateway to tobacco use, we cannot be certain at this stage about whether there is a gateway effect from the use of e-cigarettes into tobacco smoking, so further research is needed to answer that question definitively.
The display of tobacco products in shops can promote smoking by young people and undermine the resolve of adult smokers trying to quit. Legislation to end tobacco displays has already been implemented for large shops such as supermarkets. All other shops selling tobacco, including corner shops, will need to end their displays of tobacco on 6 April.
The issue of standardised packaging for tobacco has been raised by almost every Peer who has spoken. I want to be clear that the Government have not made a final decision on whether to introduce legislation for standardised packaging. We held a final, short consultation that closed in August and the results are informing decision-making. It is important that the Government have time to carefully consider all issues relevant to the policy. I assure noble Lords that a decision will be made in due course. However, in saying that, I reassure your Lordships that we in the Department of Health are, as I speak, very actively working towards a decision. The draft regulations for standardised packaging were notified to the European Commission under the technical standards directive on 29 August. We have received detailed opinions from 11 member states, which extends the “standstill” period to six months. This will expire on 2 March 2015 and until then we are unable to make regulations, although I hear what the noble Baroness, Lady Finlay, says about laying regulations.
As regards evidence from Australia—
Lord Faulkner of Worcester
Before the noble Earl moves on, will he confirm that Sir Cyril Chantler’s report, which he commissioned, is helpful to him in coming to a view as to whether or not standardised packaging should be introduced? Does he accept the report and its conclusions?
Lord Naseby
Can my noble friend assure those of us who take a detailed interest in this that the decision will be based on the independent evidence from Australia after two years of implementation against the yardsticks that that Government set?
Earl Howe
I am grateful to my noble friend. I was about to answer the question posed by the noble Lord, Lord Faulkner, on exactly that point. Evidence and experience continue to emerge from Australia, as my noble friend rightly said. I can reassure noble Lords that my department is looking very carefully at the evidence as it emerges. We will introduce standardised tobacco packaging if, having considered the evidence both here and around the world and other relevant information, we are satisfied—I emphasise “satisfied”—that there are sufficient grounds to do so.
The UK leads the world in supporting smokers to quit, and local authorities are now responsible for providing “stop smoking” services in their communities. The Government have continued to invest in tobacco marketing campaigns to encourage smokers to quit. Your Lordships may have seen Public Health England’s latest campaign that is currently running. Our “Stoptober” campaign has become hugely successful, encouraging smokers to quit for a whole month, giving them a significantly better chance of remaining smoke-free for good. Today, we offer smokers information and support through a range of media, including through the internet and mobile telephone applications.
A new European tobacco products directive has been agreed and will come into force in 2016. The new measures cover labelling, ingredients, tracking and tracing, e-cigarettes, cross-border distance sales and herbal products for smoking.
Making tobacco less affordable is proven to be an effective way of reducing smoking prevalence. The Government continue to follow a policy of using tax to maintain the high price of tobacco at levels that have an impact on smoking prevalence. In the Autumn Statement, my right honourable friend the Chancellor of the Exchequer announced that the Government will consult on whether to introduce a levy on tobacco manufacturers and importers. That consultation is now under way.
The Government have taken sustained action to reduce levels of illicit tobacco, and over the past decade, the illicit market has declined significantly. In the past two years, nearly 3.6 billion illicit cigarettes and 1,050 tonnes of rolling tobacco have been seized. Local authorities continue to take their own action against illicit tobacco, which is to be welcomed.
Smoke-free legislation, implemented in 2007, has had beneficial impacts on health. I would say to my noble friend Lord Naseby, who mentioned this, that the legislation has been highly successful in terms of public health and it continues to be popular and well complied-with, on the whole. The Government have no intention of amending this important legislation along the lines suggested by my noble friend. As I said, levels of compliance and public support for the law are high. While smoke-free legislation covers enclosed work and public places, local authorities may wish to take action to limit smoking in open-area environments. That is a recommendation in the London Health Commission’s report. However, I do not believe that changes to smoke-free legislation would be needed to achieve this. I commend local authorities across England for the commitment they have shown to reducing tobacco use; for example, more than 80 councils have signed the Smokefree Action Coalition’s Local Government Declaration on Tobacco Control.
My time is up. I will finish by saying that the Department of Health has worked actively to support the implementation of the World Health Organization’s Framework Convention on Tobacco Control, including protecting tobacco control from vested interests, and is today regarded as a global leader in the implementation of effective tobacco control policies. The UK deserves that reputation and I am proud to be able to share with your Lordships the news that the Department of Health has just been named as the winner of the American Cancer Society’s prestigious Luther L Terry Award for exemplary leadership by a government ministry in the field of tobacco control.
NHS: Accident and Emergency Services
Earl Howe Excerpts(11 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I very much welcome the opportunity to debate this important issue and I pay tribute to the right reverend Prelate the Bishop of St Albans for introducing it so admirably. The NHS is facing unprecedented demand with record numbers of people attending A&E and the ambulance services providing record numbers of emergency journeys. Despite this, the NHS is still providing high-quality care, and alongside the right reverend Prelate the Bishop of St Albans and other noble Lords, I place on the record my thanks to all NHS staff for their hard work in responding to this challenging time.
Winter is always challenging and this year it comes on top of a general increase in A&E attendances. In 2013-14 these were up one-third on 2003-04. So far this year, A&E attendances have been higher than in any year since 2010 with, on average, almost 3,500 more people a day attending. This has led to an increase in emergency admissions of nearly 6% on last year. The noble Lord, Lord Hunt, said that this was nothing new. I have to tell him that it is. It is about double the trend of increase that we have seen in recent years.
There is no single cause of the increase in A&E attendances. Healthcare is a system and problems that arise in one part of the system will impact elsewhere. Commissioners and providers need to look at what is happening not just in hospitals but more widely, and address the issues that are most salient in the particular area. That is what they have done in drawing up local plans to spend the £700 million of additional support mentioned by my noble friend Lord McColl that the Government have made available to the NHS so it can ensure urgent and emergency care services are sustainable year round and ready for the pressures of winter. In addition to providing more staff and beds, the money has funded local initiatives including: local information campaigns so people are better informed on where and how to access the services they need; seven-day pharmacy services; enhanced NHS 111 and GP out-of-hours services; and schemes to help people recover in the comfort of their own home after surgery. Some £50 million of the winter money was specifically to support ambulance trusts.
I have set out what the Government have done in response to the immediate winter pressures. However, we recognise fully that we require system-level change to ensure that services can be delivered on a long-term sustainable basis. I will now set out our longer-term plans to achieve this goal. The right reverend Prelate the Bishop of St Albans called for a systematic review and that is already under way. NHS England’s urgent and emergency care review should improve access to, and the availability of, services outside hospitals. This will involve providing consistent and same-day access to primary and community services.
The vision for the review is simple. For people with urgent but non-life-threatening needs, the NHS must provide highly responsive, effective and personalised services outside hospital and deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families. For people with more serious or life-threatening emergency needs, the NHS should ensure that they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery. If the NHS gets the first part right, it will relieve pressure on hospital-based emergency services, so that the focus can be on delivering excellent care.
NHS 111 plays an important role in ensuring that people get access to the right care when they need it. Only around 8% of calls handled by NHS 111 result in advice to attend A&E. In November the figure was in fact 6%. Moreover, 30% of callers say that they would have attended A&E if NHS 111 had not been available. That indicates that NHS 111 is instrumental in diverting people from A&E rather than adding to those attending. It is a myth that NHS 111 makes matters worse.
Implementation of the urgent and emergency care review will include enhancing NHS 111 so that it becomes the smart call to make, offering a 24-hour, personalised priority contact service. The service will have access to people’s medical history and allow them to speak directly to a nurse, doctor or other healthcare professional if that is the help and advice that they need. NHS 111 will also be able to directly book a telephone call-back service.
Another key aspect of improving services outside hospitals is providing seven-day access as a matter of course. Currently, not all services are delivered at weekends, and sometimes staff cannot get the advice and decisions that they need from more senior colleagues on Saturdays or Sundays. Delivering the vision of seven-day services could improve the clinical outcome for patients. NHS England is therefore working with NHS employers and staff to develop plans on how seven-day services can be delivered. This should improve outcomes and experiences for patients as well.
I should like to move on to the better care fund. For the first time, this Government will join up health and social care services through the £5.3 billion better care fund. I can say to the noble Baroness, Lady Gale, in particular, and to the right reverend Prelate the Bishop of Ely that the vast majority of this money is being spent on social care and out-of-hospital community health services. These aim to keep people—especially the frail elderly—out of hospital and, if they have to be admitted to hospital, support them to leave safely as soon as they are well enough to do so.
Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that over two years, the number of older people supported to remain at home at least three months after discharge from hospital will increase by 33.7%. That will be good for those patients but it will also save a great deal of money. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.
I now turn to our plans for access to primary care. We are offering 7.5 million more people extra evening and weekend appointments, as well as e-mail and Skype consultations, through the Prime Minister’s Challenge Fund, and by 2020 we will offer seven-day GP services to everyone in England. We have announced a £1 billion primary and community care infrastructure fund, which will improve access for millions more people through introducing new models of care and improving estates and infrastructure—including, I am sure, GPs’ surgeries. There are now more than 1,000 more GPs working and training in the NHS compared with the position in September 2010, and there are 40 million more appointments every year than there were in 2008-09.
I turn to some of the questions that were asked during the debate and, as usual, I shall write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Hunt, made me prick up my ears when he said that the problem is that no one is actually in charge of the system. I contend that the system is now more co-ordinated than it has ever been with the system resilience groups that we see in every single area of the health service. These groups comprise commissioners, acute providers, social care and all the players in the system so that they can genuinely co-ordinate their actions and assess the risks and priorities that they need to address.
The right reverend Prelate the Bishop of St Albans said that people are turning up at A&E when they could go elsewhere, and he is absolutely right about that. The urgent and emergency care review that I referred to noted that it had been estimated that about one-quarter of A&E attendees could have been treated elsewhere. A number of local areas are taking action to make people aware of the range of different urgent and emergency care services that are available and the circumstances in which they should be used, as well as the alternatives, such as pharmacies, that are open to people.
The right reverend Prelate also asked about staffing, especially doctors—a point also raised by the noble Lord, Lord Hunt. Compared with last year, more than 260 more new doctors will be available in A&E. That is good news. It includes British trainees but also senior staff from other countries, including India, the UAE, Egypt and Malaysia.
A number of noble Lords, including the right reverend Prelate the Bishop of St Albans, called for more collocation of services. I fully agree with the wisdom of that suggestion. As part of the urgent and emergency care review, NHS England is supporting the collocation of community-based urgent care services in co-ordinated urgent care centres. He may like to know that 112 out of 143 NHS hospitals already have GPs working in, or collocated with, A&E departments.
My time is nearly up but I want to touch briefly on ambulances. The department is working closely with NHS England, Monitor and the NHS Trust Development Authority to improve performance, and the Government have provided an extra £50 million of funding to ambulance services. However, these services are facing unprecedented levels of demand, with an additional 2,000 emergency journeys a day. Despite that, they are still providing high-quality care. We have introduced the ability to fine providers where handover delays at hospitals are unacceptable. Since then, those delays have gone down markedly.
I will respond to my noble friend Lord Greaves about the North West Ambulance Service, and I will also respond on the incident of the dead body, which the noble Lord, Lord Hunt, mentioned in relation to the East of England Ambulance Service.
My time is up but I hope that noble Lords have been able to glean from what I have said that there is a great deal going on. We are gripping the issue. There is no one cause of the increasing pressure on A&E, but we have comprehensive plans, which I have just covered in some detail, to relieve the pressure that we are currently seeing on our A&E services.
Health: Neurofibromatosis Type 1
Earl Howe Excerpts(11 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I congratulate the noble Lord, Lord Hunt, on securing this debate and thank him for his obviously heartfelt interest and commitment in this area. I also greatly appreciated the contribution from the noble Lord, Lord Bassam, which was very moving.
The noble Lord, Lord Hunt, described these conditions very clearly. Like so many uncommon disorders, those affected by neurofibromatosis can face a regime of constant condition management, hospital visits and treatments for them to have the quality of life that the rest of us take for granted. However, like the vast majority of people who have to deal with all the problems that such conditions can bring, those with neurofibromatosis respond with bravery and resilience that can only be admired.
At this point, I want to pay tribute to the vital role played by the Neuro Foundation and the excellent work it undertakes to help improve the lives of those affected by neurofibromatosis through the information, advisory, advocacy and other services that it provides. As well as this support and guidance, clearly there is a need for professional help for people with neurofibromatosis, who require the best services the NHS can provide. That is why we continue to invest in and improve our services.
As we have already heard, neurofibromatosis, or NF, is a genetic condition mainly affecting the nervous system and skin and causing the formation of tumours, which in some cases can be malignant. Neurofibromatosis type 1, NF1, is the most common form, with a birth incidence of one in 3,000. The number of people with the condition in England is estimated, as the noble Lord, Lord Hunt, told us, at 11,267. That is a significant number. Furthermore, around 10% of people with NF1 will be affected at some time in their life by a cancer known as malignant peripheral nerve sheath tumours. This is one of the most serious problems that can affect a person with NF1 and requires specialist care and treatment. Government-funded research has included a study to improve the diagnosis of this type of tumour using positron emission tomography—computerised tomography. Both the National Institute for Health Research and the Medical Research Council welcome funding applications for research into any aspect of human health, including neurofibromatosis.
In terms of diagnosis and the care pathway, NF1 is a condition which people are born with. Usually a diagnosis can be confirmed or excluded in early childhood, with most cases of NF1 confirmed through clinical examination and the identification of characteristic symptoms. If, at a young age, there are few or no signs, clinical diagnosis may take longer, but generally clinicians can be confident clinically whether or not a child has NF1 by the age of five years. The suggestion that there may be a way to use the red book in monitoring NF1 or other rare diseases should be considered further.
Undoubtedly, as I am sure noble Lords would agree, all those with the condition, particularly those with a complex form, need and deserve access to high-quality, multidisciplinary care. Since 1 April 2013, NHS England has been responsible for specialised commissioning. Last year, it created a task force which aims to improve ways of working and to ensure that specialised commissioning is undertaken in the most efficient and effective way possible. This work is being carried out with input from key stakeholders. I am sure that we can all agree that it is only right that NHS England keeps all its services under review to ensure that they are fit for purpose. We will need to await the outcome of any review before we can comment on any changes to services. NHS England remains responsible for securing high-quality care for all patients with complex NF1. NHS England’s service specification clearly sets out what needs to be in place for providers to offer evidence-based, safe and effective care, ensuring equity of access to a nationally consistent, high-quality service. As mentioned, we should applaud the excellent work carried out at Central Manchester University Hospitals NHS Foundation Trust and at Guy’s and St Thomas’. The complex NF1 service is accessible by all patients with a suspected or confirmed diagnosis of NF1, subject to an appropriate referral. Patients identified by the service as having non-complex NF1 will have their care transferred to the appropriate local team, as required.
It is worth noting where there have been positive developments in services in recent years. These include: a noticeable increase in the awareness of NF1 through better training of doctors and nurses, particularly through community paediatricians; the development of links between expert centres and local hospitals, and improved transfer of complex patients to centres; and a greater understanding of the disease and the targeting of treatments towards particular clinical problems. The commissioning and consequent funding of these services is relevant at all levels of care, including specialised, secondary and primary care, and there are generally good support systems in place, so we have made recent progress. Clearly, however, more needs to be done, and we all want to see continued improvements in healthcare services for all types of patients.
As part of the implementation of the UK strategy for rare diseases, the Government committed to raising awareness about rare diseases and empowering patients. The Department of Health is currently working with its partners to produce two videos about rare diseases, one focusing on healthcare professionals, particularly GPs, as the first point of NHS contact, and the other providing information for patients and parents about rare diseases.
The noble Lord, Lord Hunt, raised the issue of support for the young in education and finding a job. Obviously, we must support all people to attain their full potential, irrespective of what illnesses or conditions they may have. However, as he will appreciate, assessments of what type and level of support is needed must be made on a case-by-case basis and at a local level. For example, there are clear guidelines for the application of special educational need that take account of many factors. All children with a recognised need are assessed for SEN support, taking into account additional factors such as physical and mental health.
Clearly, there is much work ahead, and debates like this remind us that there are patients out there who rightly demand—and deserve—the best from their NHS. We all support the need to help those who might struggle to build a social life due to the difficulties which their condition presents. We would be interested to hear more about the kind of initiatives which the noble Lord, Lord Hunt, mentioned and would suggest that all avenues of possible funding should be explored by charities and others to put in place programmes that can respond to this need.
The noble Lord, Lord Hunt, referred to the difficulty, in many cases, of achieving a diagnosis. A diagnostic odyssey is not something that any of us would wish on any patient. We are aware of this issue. We are starting to address it and have commissioned early research to get a better idea of the scale of the problem. Part of the answer is raising awareness among healthcare professionals. We are working on this and it will be bolstered, undoubtedly, by the establishment of genomic medicine centres as part of the 100,000 whole genome project.
The noble Lord, Lord Bassam, referred to the difficulty of familial diagnosis of these conditions. It is true that it is a difficult issue, especially as NF1 can be a mutation in the individual, so seeing a family history is often not possible. I mentioned the research that was currently being funded by the NIHR. The chief investigator for the study is Professor Rosalie Ferner, who is also lead for the national NF1 service. Professor Ferner aims to include data from the study in a paper, which is a work in progress at the moment, on long-term follow-up in people with NF1; we await that with interest. Other studies are going on, including an evaluation of the clinical phenotype of malignant peripheral nerve sheath tumours; international prospective clinical evaluation of optic pathway gliomas in NF1, including reasons for commencing treatment and visual and radiology outcomes; the evaluation of migraine in NF1; the development of a disease-focused patient quality-of-life outcome measure for NF1 adults; and other work besides.
We have delivered and will continue to deliver improvements in services for all patients, including those with a rare condition such as neurofibromatosis. I believe that steps are being taken that will lead to a measurable difference to the lives of all those with a rare disease. However, as I have said, we cannot rest on our laurels; more needs to be done. I have no doubt that this debate will continue in one form or another outside this Room. The debate that we have had today has undoubtedly been helpful in promoting a wider discussion on these issues. In the mean time, I thank the noble Lords, Lord Hunt and Lord Bassam, for all that they have said in support of those with this devastating condition and for their invaluable contributions.
Elderly People: Powers of Attorney and Living Wills
Earl Howe Excerpts(11 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I am very grateful to the noble Baroness, Lady Bakewell, for bringing this important issue to the House. At a time traditionally associated with making resolutions it feels like a particularly appropriate moment to be considering how we plan for later life together with our families and loved ones. I hope she will agree with me that the contributions from all speakers this evening have combined to make for an excellent debate.
I am sure all noble Lords would agree with the basic premise that all citizens should be cared for and treated in a manner that they themselves would choose, at a time in their life when they may no longer be able to make decisions themselves. The Mental Capacity Act 2005—the MCA—provides the legislative framework for how caregivers should support individuals who may lack the mental capacity to make decisions themselves. The Act and its associated code of practice emphasise the importance of treating each person as an individual and of seeking out their particular wishes and preferences, to ensure that any decision made is in the best interests of that person.
Noble Lords will, I am sure, be aware of the excellent work of the Select Committee of this House which scrutinised the implementation of the MCA last year. Its report, published in March 2014, highlighted that awareness of the Act was poor and that as a result many individuals were not aware of or taking up their legal rights. The Government embraced this finding and set out a programme of work in our response, which was entitled Valuing every voice, respecting every right. The response sets out the great challenge we face—essentially that of bringing about a change in culture whereby individuals are comfortable talking openly with friends and families about their wishes for later life and where wider society treats those who lack capacity with the same respect as those who have capacity.
The noble Baroness asked specifically about lasting powers of attorney—LPAs, to use the abbreviation—and living wills. An LPA allows someone with mental capacity to appoint an attorney to look after their affairs in the event that they lose capacity at some point in the future. As well as the traditional property and finance LPAs, the MCA legislated for health and welfare LPAs, which, I believe, are the focus of the noble Baroness’s question. There are currently more than 1.3 million LPAs registered, and applications are increasing at a rate of 20% year on year. This is good news, but we do not intend to rest on our laurels, especially when we look into the statistics and see that for every three finance and property LPAs registered, only one health and welfare LPA is recorded. The Office of the Public Guardian, which has responsibility in Government for registering LPAs, is using all available opportunities to raise awareness of LPAs through conference events, media engagements and work with multiple partners across finance, legal, health and care settings.
A number of noble Lords voiced concerns that executing an LPA is difficult and complicated. A good example of recent success is the LPA digital tool. This tool allows applicants to enter all the required information step by step on a personal computer and then simply print it out, add the relevant signatures, and send it to the OPG. This online service was the first so-called “government digital exemplar” to pass the Government Digital Service’s stringent new 26-point test. We believe and hope that this user-friendly service will help drive further increases in LPA registrations.
In 2015, the Department of Health and the OPG will continue to work closely to raise awareness of health and welfare LPAs. The department is in the final stages of production of a statement of rights which will inform the public about their rights under the MCA, including their right to make an LPA. In addition, the OPG is looking at how LPAs are used and will look to include use within the NHS as part of this project. This should lead to potential new guidance for the health system on LPAs.
Noble Lords will I am sure be aware that overall policy responsibility for the Mental Capacity Act lies with the Ministry of Justice. This was referred to by the noble Baroness, Lady Bakewell. I can inform the House today that the Ministry of Justice plans to run a campaign to raise public awareness of the options for planning for the future and encourage members of the public to think about what would happen in the event of their death or if they lost their mental capacity and needed someone to make decisions for them.
As for living wills, an issue which was mentioned by a number of noble Lords, the House will be aware that this term has no strict legal meaning but in common usage can be taken to describe an individual’s wishes and views about any future medical treatment or indeed any other care, support or lifestyle preferences. An advance decision to refuse treatment however does have a specific legal meaning under the Mental Capacity Act. End-of-life decisions are intensely personal matters. As individuals, our views on how we would like to be cared for can change over time, even when we still have full mental capacity. The Government’s policy is to seek to ensure that individuals are aware of their rights under the law—to make them aware that they have the choice to make a living will or advance decision to refuse treatment—but fundamentally to allow the individual to decide if they want to exercise this right. Our awareness raising efforts here are tied closely to our work to raise understanding of the wider provisions of the MCA. This work is multi-faceted: professional training, which I will mention again in a moment; revising our national governance structures; and ensuring that the MCA is a key line of inquiry in the Care Quality Commission’s new inspection model for care homes and hospitals.
The noble Baroness, Lady Bakewell, cited various obstacles which she felt can deter people from registering an LPA. One of these was the cost factor, which was also mentioned by the noble Baroness, Lady Wheeler. The OPG appreciates that the cost of making an LPA may be an important factor for those who wish to plan ahead. The cost of an LPA is £110. LPA forms, however, have been designed so that they can be completed without a solicitor. However, if a person chooses to seek advice from a solicitor they will have to pay the solicitor’s fees, which may vary and, of course, are a consideration. Another obstacle cited by the noble Baronesses, Lady Bakewell and Lady Flather, was that of complexity. We need to look at the balance of the arguments here. On the one hand, as I have mentioned, there are more than 1.3 million current instruments registered and LPA applications are increasing at quite a rate. Nevertheless, the OPG recognises that it is important to ensure that the LPA process is as straightforward as possible and acknowledges that some people find the existing LPA forms too complex to complete without legal assistance. It continually reviews its forms to make sure that they are easily understood. The OPG is also rewriting and restructuring its guidance and correspondence on LPAs so that it is clear, consistent and accessible to all.
The noble Baroness, Lady Bakewell, asked whether Scottish powers of attorney were recognised in England and Wales. We are aware of the important question of cross-border recognition of powers of attorney, and are considering how best to address it. We are in frequent communication with our colleagues in the devolved Administrations—for example, in Northern Ireland, where that Administration is consulting on new mental capacity legislation based on our Mental Capacity Act. Clearly, raising awareness of issues surrounding mental capacity is a UK-wide concern. My officials intend to share learning with colleagues in the devolved Administrations as part of our upcoming work programme. I will be happy to write to the noble Baroness with the precise legal response in terms of the validity of Scottish lasting powers of attorney in England.
I agree with the noble Baroness that raising awareness is important. We recognise that awareness among the general public of what an LPA is and the benefits of having one is low. We are working to increase this level of awareness, as I described. Having said that, we would not seek to tell adults that they should have an LPA; ultimately we believe that this is a matter of personal choice. My noble friend Lord Hodgson asked whether someone could use a power of attorney to make decisions about legacies. There are exceptions to the decisions that an attorney may make. I would be happy to write setting out these exceptions in more detail.
I take the point made by the noble Baroness, Lady Flather, that it is important for people to know if someone has an LPA in place. Good practice is always changing, but we should not forget that lasting powers of attorney are registered by the Office of the Public Guardian, which maintains a register. Those who wish to know whether an LPA is in place may apply to the OPG to search the register. The noble Baroness, Lady Greengross, stressed the importance of carers. I absolutely agree that carers do a fantastic job supporting those who lack capacity. I am pleased to say that my department has worked closely with the Standing Commission on Carers—
Baroness Flather
Yes, I will be quick. The Office of the Public Guardian charges a lot of money to give the information.
Earl Howe
I will write to the noble Baroness about that. The Standing Commission on Carers, which represents the needs of carers to the government policy-making process, is a body we are working closely with. It will help us channel our new statement of rights directly to carers, providing them with an understanding of the rights of the person they care for under the law.
The noble Baroness, Lady Wheeler, spoke about the need for professional training. I agree that that is vital. Health and social care professionals need to learn the basics of the MCA through their initial training and to keep updated on this through continuing professional development. Health Education England provides national leadership for planning and developing the whole healthcare workforce. The mandate set for it by the Department of Health specifically states that Health Education England should,
“work with … partners … to improve skills and capability to respond … to the needs of people who may lack capacity as well as maximise the opportunities for people to be involved in decisions about their care”.
The noble Lord, Lord Joffe, indicated that he felt that there was a lack of government leadership in this area. I would defend, in fact, our leadership record. We do not want to shy away in the least from our responsibilities when it comes to supporting better implementation of the Act. The legislation underpinning the MCA has been widely praised. Indeed, only a few months ago, we were visited by a delegation from the Swedish Government, who are looking to learn from our legislation as they draft their own. The problem is not the framework. The problem is a lack of understanding at the local level on the ground. It is the Government’s belief that the primary drivers of better implementation of the MCA are local organisations—hospitals, care homes, local banks and solicitors. That is why we intend to make the new national mental capacity forum, which we are setting up, predominantly outward looking. Its emphasis will be on forging collaborations, but then taking these out into the country and putting actions in place at the local level. I would be happy to write further on that, when I do write, as I shall, after this debate.
I have overshot my time but, in conclusion, I emphasise that planning for a time in later life where we are unable to make our own decisions is something that we are all likely to benefit from and which can ease the burden on our loved ones. Unfortunately, as the noble Baroness, Lady Flather, reminded us, I know many people find this type of conversation uncomfortable—even morbid, perhaps. That is to an extent understandable: no one wants to dwell on the possibility of a serious debilitating disease or, indeed, on death itself.
Ultimately, however, planning for the future can be greatly empowering. It can provide a degree of comfort as we approach a vulnerable period in our lives, it can allow us to determine how we are treated—which itself can improve our well-being and health outcomes—and it can provide comfort to our friends and family. The Government are determined to support our citizens in this regard, and the thoughts and expert advice of noble Lords are, as always, most welcome.
Alcohol: Addiction
Earl Howe Excerpts(11 years, 9 months ago)
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Lord Avebury
To ask Her Majesty’s Government what are Public Health England’s plans for combatting alcohol addiction.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, Public Health England recognises that the harmful use of alcohol is a major health risk. The harm from alcohol is preventable; alcohol is one of seven key priorities that PHE is focusing on. It is implementing a programme to support national and local government, the NHS and partners to implement evidence-based policies and interventions. Included in this work is the reduction of alcohol addiction.
Lord Avebury (LD)
Considering that three years ago, there were 1.1 million alcohol addicts in England and that abuse of alcohol was costing the nation £21 billion—and probably much more than that today—how can the Minister reconcile the fact that we spend only one-tenth as much on treating alcohol addiction as we do on patients suffering from drug addiction? Why is it taking until 2016 to update the guidance on access to mutual aid fellowships such as Alcoholics Anonymous, when the ACMD has shown that there are effective ways of combatting the addiction?
Earl Howe
My Lords, my noble friend was kind enough to give me advance warning of those questions. I have to say to him that we do not recognise the figures he quotes; nor do we think that the comparison he makes is like for like. In 2007, an estimated 1.6 million people had some degree of alcohol dependence, including those with a slight dependence. Of those, some 250,000 were believed to be moderately or severely dependent. The specialist treatment centre system continues to work well for many people. Many of the trends in terms of treatment are positive. As regards supportive relationships, I fully agree with what he said; they are a vital element in helping individuals build their own recovery. In October 2013, Public Health England produced a strategic action plan for supporting the treatment sector to strengthen its links with mutual aid organisations to ensure that everyone in treatment can benefit from that support.
Lord Hunt of Kings Heath (Lab)
My Lords, how many meetings have been held between Ministers and representatives of the alcohol industry since the last election? Why are the Government delaying the publication of the Chief Medical Officer’s review of safe drinking levels until after the election? Are the two connected?
Earl Howe
No, my Lords, they are not. The Government have regular dialogue with the industry, but the industry does not formulate policy and never will do. There has been a delay on the new guidelines; the consultation on them had been planned for December last year but will not now happen until shortly after the general election. That is simply due to problems with Public Health England commissioning expert advice on guideline methodologies, which took longer than intended. The academic body that PHE wanted to do the work decided that it did not have the capacity to do so. A tender exercise was therefore necessary and the work is being carried out by a team from Sheffield University.
Baroness Howarth of Breckland (CB)
My Lords, the Minister is well aware of the effect of alcohol on unborn children. What are the Government doing for young mothers who are either addicted to drink or unaware of the difficulties that alcohol creates for their children in terms of education both through the health service and the education system?
Lord McColl of Dulwich (Con)
My Lords, does the Minister accept that although alcohol was until recently the commonest cause of liver disease, the commonest cause is now the obesity epidemic, which is killing millions of people? Some 13 million people in this country are suffering from obesity—far more than are suffering from alcohol problems.
Lord Brooke of Alverthorpe (Lab)
Will the Minister explain to the House why, when his Government came to power, they tore up the draft strategy on liver disease that had been prepared by the previous Government? What are they going to do to put one in place and, given the complaints we have heard, make sure that the growth in the number of deaths is reversed?
Earl Howe
My Lords, Public Health England has a programme of work to ensure that all the bases are covered. It is producing a report for government that will be published later this year. Over the next 18 months, there will be a longer programme of work on such things as a framework for liver disease, setting out the evidence base for the introduction of a minimum unit price for alcohol and using alcohol as the trail-blazer for a new whole-system approach that establishes what works and is clear on the return on investment, to enable government to take action based on evidence.
Baroness Hollins (CB)
My Lords, the Board of Science at the BMA, which I chair, believes that the availability of cheap alcohol, such as white cider, is one of the main causes of the rise in addiction. We believe that the sale of cheap alcohol needs to be tackled through the introduction of a minimum unit price and that prevention really is better—and cheaper—than cure. What does the Minister think about that?
Earl Howe
Minimum unit pricing remains under consideration while additional evidence becomes available. We are not taking it forward at the moment. We need to give careful consideration to any possible unintended consequences of minimum unit pricing, such as the potential impact on the cost of living, the economic impact of the policy and increases in illicit alcohol sales. It is, and has only ever been, part of the Government’s alcohol strategy—although, as I mentioned a moment ago, Public Health England will be assembling the evidence base for the introduction of a minimum unit price for alcohol to advise the next Government.
Lord Garel-Jones (Con)
Does the Minister agree with me that alcohol is properly defined as a habit-forming, hallucinatory drug, and is it not about time that Governments began to treat the use and abuse of this particular drug with the same seriousness as they do the abuse of other drugs?
Earl Howe
My noble friend makes a very good point. Alcohol in moderation is something that we can all enjoy, but people who binge drink or drink drive cause problems for accident and emergency departments. They are the people we have to bear down upon. I believe that we do now have effective systems of regulation and enforcement, which are proving their worth.