NHS: Cancer Treatment
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Baroness Pitkeathley
To ask Her Majesty’s Government what action they propose to take to ensure that older people receive equal access to NHS cancer treatment.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
In December, the national clinical director for cancer at NHS England launched a call for action on the treatment for older people. NHS England is now setting up an advisory group to identify where improvements in cancer services for older people can be made. It is also supporting an initiative to ensure that patients are better informed about the options available to them and that they are fully involved in decisions about their treatment.
Baroness Pitkeathley (Lab)
I thank the Minister for that welcome Answer, but is he aware of the recently published Macmillan Cancer Support report, which shows that up to as 10,000 cancer patients die needlessly each year because of blatant ageism among doctors? For example, recommendations for chemotherapy diminish by as much as half if you are over 70. Since we are an ageing population and half of all new cancer diagnoses are in people over 70, does the Minister agree that it is of the utmost importance that we ensure that people are treated as individuals regardless of their age? How will he ensure that this view is held also among GPs and hospital consultants?
Earl Howe
My Lords, I completely agree. The noble Baroness is right that a series of reports has shown that the NHS has too often failed to provide the best possible services to older people. We cannot save lives without tackling inequalities. The NHS has a statutory duty to reduce health inequalities and to improve the health of those with the poorest outcomes. A ban on age discrimination in the NHS services was introduced in 2012, meaning that NHS services need to do everything they can to ensure that they do not discriminate against older people. We will hold the NHS to account for that through the mandate and the NHS outcomes framework.
Lord Turnberg (Lab)
To what extent are these shocking figures due to lack of funding for cancer services? In that light, what is the Government’s plan for the cancer drugs fund?
Earl Howe
My Lords, the noble Lord may recall that the Government pledged an additional £750 million to support the cancer strategy. We are doing that, and a range of actions are proceeding there. On the cancer drugs fund, we initially pledged a total of £600 million for the first three years of the fund and we recently pledged another £400 million, making £1 billion in all. I am pleased to say that the cancer drugs fund has so far helped more than 38,000 patients.
Lord Walton of Detchant (CB)
My Lords, some two weeks ago, the Minister agreed that, when NICE recommends that a particular form of treatment should be given to patients with cancer, rare cancers and other rare diseases, it is incumbent on clinical commissioning groups to see that those drugs are prescribed. Does the Minister agree that clinical criteria must be employed in reaching decisions as to which patients are to receive those drugs and that age alone must never be a barrier to the prescription of drugs in patients with cancers of that type?
Earl Howe
My Lords, I agree. The noble Lord may recall that in December 2012 we worked on a project with Macmillan Cancer Support and Age UK to improve uptake of treatment in older people. That established some key principles for the delivery of age-friendly cancer services. In December 2013, NHS England published an analysis of chemotherapy uptake in older people, and that report reaffirmed those principles and set out some new recommendations around improving the uptake of chemotherapy.
Baroness Gardner of Parkes (Con)
My Lords, in the previous reply the Minister said he had looked at figures for chemotherapy for older people. Has he looked at the figures for radiotherapy for cancer patients of an age, in particular for intensity-modulated radiotherapy, which is not reaching its target but is considered a great improvement on the previous type of radiotherapy being used for cancer cases?
Earl Howe
My Lords, the Government invested £23 million aimed at increasing the capacity of radiotherapy centres in England to deliver intensity-modulated radiotherapy. The latest analysis shows that the median average of IMRT activity in England is at 29%, with the vast majority of centres delivering at 24% or above. That 24% was the magic figure recommended a few years ago by the national radiotherapy implementation group. We continue to monitor progress and local action plans closely.
Baroness Masham of Ilton (CB)
My Lords, I declare an interest as vice-chair of the all-party cancer group. Does the Minister agree that many older people develop cancer and, therefore, to stop treatment would ensure that many Members of your Lordships’ House would not get treatment? Will he therefore take this really very seriously?
Earl Howe
My Lords, I am with the noble Baroness all the way in wishing to see your Lordships live a healthy and long life but, as regards the population generally, I hope that I have made clear the Government’s determination to see that all citizens of this country receive treatment according to their ability to benefit from it.
Lord Hunt of Kings Heath (Lab)
My Lords, I am sure we are all with the noble Baroness in those sentiments. Can I refer the noble Earl back to the research that my noble friend referred to? The report seems to show that survival rates for cancer patients over the age of 75 are very poor in this country compared with other European countries. The noble Earl has said that he will ensure that action is taken through the mandate to NHS England. Should he not give instructions to clinical commissioning groups to start commissioning cancer services with no age discrimination?
Earl Howe
My Lords, commissioning is an important ingredient in this, but there is a range of actions that we can take and have taken. We know that low levels of awareness and late diagnosis are particular problems for older patients, so it is welcome news that Public Health England is to run a national campaign to raise awareness of breast cancer in women over the age of 70. We are also raising the screening age for breast cancer to include women aged 71 to 73, and the extension of the NHS bowel cancer screening programme to men and women aged 74 is now complete.
Health: Confidential Patient Information
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Lord Hunt of Kings Heath (Lab)
My Lords, I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I refer noble Lords to my interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, while we have concerns about the EU proposals, there has been no cause to conduct an assessment of the sort suggested at this stage. The Government do not sell confidential patient information to companies. Drug and insurance companies can receive patient confidential information only where they have a legal gateway, either consent of the patient or some form of statutory authority. In these circumstances the cost of providing information may be recovered, but it is not sold.
Lord Hunt of Kings Heath
My Lords, clearly there is great advantage in using patient research in large-scale research projects. However, can the noble Earl assure the House that patient confidentiality can be assured? Also, is it right that projects such as the UK Biobank could be put in jeopardy were the proposed European legislation to be enacted in its current draft form?
Earl Howe
My Lords, under the 2012 Act, the Health and Social Care Information Centre cannot release data that could be used to identify an individual without a legal basis to do so. As a result, there are strict controls about how such information is released. As regards the UK Biobank, the noble Lord is right to be concerned because the proposed text from the so-called LIBE committee would rule out the work of the UK Biobank, in that it would need explicit and time-limited consent for any research project that it undertook, instead of being able to support a range of research purposes, as it now can, using its existing consenting mechanism. So there is cause for concern if this text is adopted, but that is not yet clear.
Baroness Pitkeathley (Lab)
My Lords, many noble Lords will have received recently a leaflet through their letter box, saying that their records are going to be made available unless they opt out. The means of opting out is to contact your GP. First, has anyone noticed how difficult it is to contact your GP in some circumstances? Secondly, would it have been beyond the wit of the department to include a simple, tick-box form for people to use? Does the absence of such a simple process lead us to conclude that the Government do not actually want people to opt out of making their records available?
Earl Howe
My Lords, everybody in the country has a right to object to their data being shared. Those objections will always be respected. A practical way had to be found to enable that process to happen, and we believe that it is not unreasonable to expect a patient to have a conversation with their GP. I will, however, take the noble Baroness’s suggestions on board and feed them in.
Lord Willis of Knaresborough (LD)
Does my noble friend agree that while patients can object to having their records sent, they cannot, in fact, legally prevent the GP sending those records to the central repository? It is at that point that the discussion as to whether those records should be sold on and used by pharmaceutical companies and others is important. Does he agree that it is important that companies carrying out research into new drugs and compounds can access patient records, because they are an important dataset for making sure that we have better healthcare for our people?
Earl Howe
My noble friend is correct. The UK has a unique advantage in being able to link patients’ data records for the purposes of research and for effective healthcare commissioning. It would be extremely concerning if European law prevented that. I believe and hope that patients will be encouraged that there will be no abuse of identifiable information. The controls around this are very strict and, in the main, only anonymised data are required for research purposes.
Baroness Finlay of Llandaff (CB)
Can the Minister explain if there are circumstances in which personal confidential data might be used and analysed, such as in a public health emergency, and what the safeguards are surrounding that access?
Earl Howe
My Lords, there are circumstances in which potentially identifiable data can be released, but they are very severely circumscribed. A public health emergency is one, but Section 251 of the National Health Service Act 2006 could also allow identifiable information to be shared for specific purposes. However, the controls around that are extremely strict and the only people who can take that decision are the Secretary of State and the Health Research Authority—and then only after expert advice from the Confidentiality Advisory Group.
Baroness Manzoor (LD)
My Lords, some patients do not understand the implications and possible effects of the proposed EU legislation. What steps are being considered to ensure that those patients have full understanding?
Earl Howe
My Lords, until we are clear about the text that is agreed at European level, it is difficult to issue public advice on what the effect of that proposed measure would be. The text is still being argued over. While my noble friend is absolutely right that a public information exercise would be advisable once we are aware, we are not at that point yet.
Health: Dementia
Earl Howe Excerpts(11 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, this has been an excellent short debate. I thank all contributors but, in particular, my noble friend Lady Gardner for having tabled this important subject and for having introduced it with such insight.
As has been said, dementia is one of the biggest challenges society is facing, but it is a challenge that we are determined to get to grips with. That is why dementia is a major priority for the UK Government, and my right honourable friend the Prime Minister launched the dementia challenge last year. We must fight back on an international scale, which is why we hosted the first G8 summit on dementia in December, as the noble Baroness, Lady Greengross, kindly mentioned, and we will continue to provide global leadership.
Five years ago, the national dementia strategy was developed. It has achieved a lot and laid the foundations for real change in how people with dementia and their carers are helped to live well with the condition. However, we recognised the need to build on the strategy and that is why the Prime Minister’s challenge on dementia is the main vehicle driving change and improvement across health and care in the community and for research. The Prime Minister’s challenge runs to 2015, not just outliving the dementia strategy but broadening its vision and providing better accountability. The challenge sets out the Government’s commitment to increase diagnosis rates, raise awareness and understanding, and double funding for research into dementia by 2015.
There are 670,000 people in England with dementia, a number expected to double in the next 30 years. Dementia costs society an estimated £19 billion a year, and currently less than half of all people with dementia have a formal diagnosis. One of the main aims of the Prime Minister’s challenge is to improve awareness of the condition by creating dementia-friendly communities. If we are to help people to live well with dementia, we need all areas of society to become dementia-friendly—not just health and social care but banks, supermarkets, bus stations, post offices and all the different forms of local public services. All those places can become more dementia-aware and supportive of people with dementia and, if they do, people with dementia will benefit enormously, continuing to connect with society in ways we all take for granted.
Last October, Lloyds Bank and the Alzheimer’s Society launched a charter encouraging banks and building societies to join them in becoming dementia-friendly, and we need other companies to follow suit. I was impressed by all that I heard from the noble Lord, Lord Jones, about Airbus. The noble Baroness, Lady Turner, in her moving speech, referred to the importance of local support for people with dementia, and I wholeheartedly agreed with what she said.
The Dementia Friends scheme, which aims to make 1 million people more aware and understanding of dementia, is helping to break down the barriers between people with the condition and their local communities, with funding from the Department of Health and the Cabinet Office. The noble Lord, Lord Jones, was absolutely right in all that he said on this subject. My right honourable friends the Prime Minister and Deputy Prime Minister and Ministers at the Department of Health are all Dementia Friends, as are more than 500 Department of Health staff. I myself am a Dementia Friend. It has helped me to understand the impact that this condition has not just on the individual but on their families who care for them. Dementia Friends is one of several components in creating dementia-friendly communities. Alzheimer’s Society guidance sets out the criteria for becoming a dementia-friendly community, and already 34 communities, from York to Plymouth, have signed up to the scheme, with others having expressed an interest in doing so.
This spring, Public Health England, working with the Alzheimer’s Society, will launch a three-year £12 million social movement to make the nation more aware of dementia and enable people to understand how they can help those with the condition. The “Dementia Movement” will aim to do three main things. The first will be to reduce fear and stigma through activity that improves public attitudes towards dementia and gives more people the confidence to engage with those with dementia. It will also aim to increase social connectedness—for example, by prompting and supporting conversations between people in the early stages of dementia and their families, friends and neighbours. It will aim, too, to improve skills by recruiting people into the Dementia Friends programme so that more people know how to help those with dementia. The movement will target business partners in the private, public and voluntary sectors, and urge them to continue to implement the Dementia Friends programme within their organisations, giving their employees an understanding of the supportive action that they can take to help people with dementia.
The noble Baroness, Lady Greengross, spoke with great authority about the importance of diagnosis, co-ordinated care and support, and I very much agreed with what she said. The noble Lord, Lord Jones, also laid emphasis on timely diagnosis. Raising awareness of the signs and symptoms of dementia is the first step towards getting a formal diagnosis—one that will lead to people being able to access advice, information, care and support. The number of people with a diagnosis is increasing year on year, but the noble Lord, Lord Hunt, was right: still only just under half of all people with dementia have a diagnosis. That is simply not good enough and it is why NHS England has committed to raising the diagnosis rate to two-thirds by 2015.
Clinical commissioning groups are working with their local councils and other partners to better understand how widespread dementia is in their communities, including among people living in local care homes. This will mean that they can identify and support people with dementia in a timely way. GPs are now able to use the new directed enhanced service to improve the diagnosis of dementia by asking people in certain at-risk groups about their memory. This proactive approach should help to identify patients who are showing the early signs of dementia.
The noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt, asked about steps being taken to ensure the identification and treatment of comorbidities in people with dementia. If I may say so, that question is extremely pertinent. NHS England has committed to increasing the dementia diagnosis rate, as I mentioned. A diagnosis of dementia is vital in accessing support and treatment across the board, not just for dementia but for all comorbid conditions.
Once people have a diagnosis. they need to understand the implications of the condition and how they can access advice, information and support to help them and their carers to live as well as they can with the condition. If the condition is advanced, some people will need care and support immediately, but those diagnosed at an earlier stage may need only advice and information. The noble Lord, Lord Hunt, rightly stressed the need to provide information post-diagnosis.
My noble friend Lady Gardner mentioned the important role of charities, as did the noble Lord, Lord Jones, who rightly praised the work of the Alzheimer’s Society. The dementia guide is given to a person with dementia when they receive a diagnosis, and almost 100,000 copies have been distributed since last July. The NHS Choices website has dedicated pages for dementia, highlighting the range of services and support available to people with dementia and their carers. Regional NHS websites, such as myhealthlondon.nhs.uk provide details of healthcare and voluntary services available locally. A free national helpline helps carers to access information about local and national services and individual advice and support.
My noble friend referred to the need for good nursing. Services are no good without a skilled workforce. That is why Health Education England is ensuring that staff are dementia-trained. In November, it hit its target to deliver dementia training to 100,000 staff ahead of schedule, and it will continue to roll out training to improve the skills of the workforce. We want people with dementia to receive a better quality of care from informed and trained staff through the CQUIN programme. NHS England has asked all hospitals to identify a senior clinical lead for dementia, to ensure that carers of people with dementia are adequately supported, and that this is reported at board level. Every person joining the social care workforce will undertake common induction standards, which include aspects of dementia awareness. In addition, a number of units and qualifications at vocational levels 2 and 3 have been developed by Skills for Care and Skills for Health to support the development of the social care and health workforce, working with people with dementia.
The noble Lord, Lord Hunt, and my noble friend Lady Gardner asked about research. Doubling funding for research, as I mentioned, is part of the Prime Minister’s challenge, and the quality and quantity of research proposals for dementia are improving. Last year £20 million was awarded to six proposals which will look at areas such as Living Well with Dementia and dementia-associated visual impairment. All the G8 countries signed up to the communiqué at the end of the conference and one of the pledges was significantly to increase the amount spent on dementia research.
As I have outlined, there are a range of services and information sources available to support people with dementia and their carers, but this is only the beginning and we have a long way to go until everyone with dementia is able to live as well as they can with the condition. We are not resting on our laurels. The Government are committed to doing more. We are currently working with our partners in the NHS, social care, local government, public health and the Alzheimer’s Society on a call to action to improve post-diagnosis support for people with dementia and their carers—support on which the noble Lord, Lord Jones, rightly laid emphasis. The work is at an early stage but, over the next couple of months, we will be developing an offer of what should be available to everyone to ensure that we have achieved the Government’s goal of people with dementia and their carers having access to services to help them live well within our society for longer.
Health: Flour Fortification
Earl Howe Excerpts(11 years, 5 months ago)
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Lord Rooker
To ask Her Majesty’s Government what is their assessment of the public health impact of the current programme of fortifying flour; and whether they have plans to extend the programme.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the Government considered the health impact of the current programme of fortifying flour as part of the Red Tape Challenge review of the bread and flour regulations and concluded that it does deliver public health benefits. We are currently considering the case of mandatory fortification of flour with folic acid and will reach a decision when we have considered new data on the folate status of the population due early this year.
Lord Rooker (Lab)
I thank the Minister for his Answer but ask him to speed up that review. Is he aware of the major new peer-reviewed research from the Wolfson Institute, which surveyed half a million women over a 10-year period and found out that folic supplementation is going down? It concluded that the current policy is failing and creating health inequalities. We know that now. Is this not a real worry?
Earl Howe
My Lords, I am not aware of that study but I shall of course make myself familiar with it. I do not doubt that it will feature in the consideration that we give to this issue, which I can assure the noble Lord we will do as speedily as we can. It is important to say that adding to the list of fortificants would be a major step and we need to be absolutely sure that it is the right one.
Baroness Gardner of Parkes (Con)
My Lords, is it not a fact that in the United States bread is already fortified not only with folic acid, which of course prevents spina bifida in newly born children, but also vitamin D? At present there is a great deal of concern here that none of us is getting enough vitamin D due to the lack of sunlight in winter. Would it not be a good thing for us to have that benefit? Can the Minister also assure me that if this applies to wheat it will cover wholemeal as well as ordinary loaves, as we recommend people to eat those?
Earl Howe
On my noble friend’s last question, we are slightly jumping ahead of ourselves because we need to decide on the principle before we decide on which types of wheat might be fortified. However, I recognise my noble friend’s main point. Indeed, the Scientific Advisory Committee on Nutrition, in recommending mandatory fortification of flour with folic acid, sought to highlight the benefits of fortification as well as the risks. It was a balanced recommendation. We value it and we will look at the advice very closely indeed.
Lord Krebs (CB)
My Lords, what has the Minister’s department made of its evaluation of folic acid fortification in the many countries that have implemented it, including the United States, as has already been mentioned, Canada and Australia? What has been the balance of risk and benefit in those countries?
Earl Howe
I am aware that we have looked at the experience of other countries, but, as I am sure the noble Lord will accept, we need to take a decision on this that is right for all of our population rather than another country’s population. That is why we want to make the decision evaluating risks and benefits based on the most up-to-date data of the folate status of our own population.
Lord Turnberg (Lab)
My Lords, the case for fortifying flour with folic acid is now incontrovertible. It is both safe and effective in preventing spina bifida. I should like to follow up the question of the noble Baroness, Lady Gardner, about vitamin D fortification, as there is a rising incidence of rickets in children, particularly Asian children, and we really should take that seriously.
Earl Howe
The noble Lord is absolutely right. I agree with him that the incidence of rickets is a cause for concern. At the same time, he characterises the case for mandatory fortification as incontrovertible. There are risks that SACN pointed out. Its advice to government stated that fortification of flour with folic acid might have adverse effects on neurological function in people aged 65 years and over with vitamin B12 deficiency. Treatment with folic acid can alleviate or mask the anaemia and therefore delay the diagnosis of vitamin B12 deficiency, which can lead to irreversible effects.
Lord Patel (CB)
The noble Earl referred to two things. His immediate answer just now suggested that folic acid levels might interfere with B12 anaemia in older people. That would require a dosage of about 15 milligrams per day; the dosage we are talking about for fortification would hardly reach 1 milligram per day. The risk, therefore, is pretty minimal. Secondly, he suggested in his opening Answer that the folate level of the population might help to devise the policy. How would that help to devise the policy for women in early pregnancy who need the folic acid to reduce the incidence of neural tube defects?
Earl Howe
I am sure the noble Lord would agree that we have to take a decision based on the most up-to-date data. The data that we had prior to this were 10 years old and it is important to take a decision in the context of the nutritional state of health of the population. On his first question, all I can say is that the risk to which I referred was considered as part of SACN’s overall assessment and we will draw on that in reaching our decisions on the fortification of flour and give it the appropriate weight that it deserves.
Lord Hunt of Kings Heath (Lab)
My Lords, on the issue of up-to-date information, as the noble Lord, Lord Rooker, has said, we now have the Wolfson study, which actually leads that organisation to recommend that all countries should introduce folic acid fortification. The Government already have the recommendation of the Scientific Advisory Committee on Nutrition for mandatory fortification. Yes, it says it should be accompanied by actions to restrict voluntary fortification of food with folic acid for the reasons to which noble Lords have already referred. Why on earth are the Government delaying action on this?
Earl Howe
My Lords, I can only repeat what I said before, which was that taking this step would be a major step by any standards. We must base it on a proper assessment of the risks and benefits. We have some excellent advice from SACN and we need to evaluate that advice fully before taking a decision.
Baroness Hollins (CB)
My Lords, does the Minister agree that the public education campaign has failed and that given that most pregnancies are unplanned and that the risk period for low folate levels is in the first 28 days, before a woman is aware that she is pregnant, there is actually some urgency to act?
Baroness Hayman (CB)
My Lords, it is more than 20 years since the MRC study on this issue first had to be abandoned because it was considered inappropriate not to give folic acid supplements to the women who were involved. When the noble Earl reads the latest study, I suggest that he will find it “incontrovertible”, to use the word of the noble Lord, Lord Turnberg. The noble Earl said in December that the Government were looking at this issue urgently. Will they now look to act urgently?
Mesothelioma: Research Funding
Earl Howe Excerpts(11 years, 5 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank the noble Lord, Lord Alton, for having tabled this debate. Mesothelioma is, as we have heard, a terrible and devastating condition. There is no cure and uncertainties remain about the best available approaches to diagnosis, treatment and care. It is therefore completely right and appropriate that mesothelioma research has been discussed a number of times, both here in your Lordships’ House and in the House of Commons.
Funding is, of course, needed for further research to be carried out. The four largest insurance companies have previously made a donation of £3 million between them, and this is supporting valuable research into the disease. A higher level of funding has come from government—through the Medical Research Council and the National Institute for Health Research. Together, these funders spent more than £2.2 million in 2012-13.
The MRC is supporting ongoing research relating to mesothelioma at the MRC Toxicology Unit and is also funding two current fellowships. The NIHR is funding two projects in mesothelioma through its Research for Patient Benefit programme, and its clinical research network is recruiting patients to a total of eight studies, including industry trials. The NIHR funds 14 experimental cancer medicine centres across England with joint funding from Cancer Research UK, and these centres have four studies focused on mesothelioma.
However, as I have said previously, the issue holding back progress into research into mesothelioma is not—as a number of noble Lords have intimated—a lack of funding but the lack of sufficient research applications. I want to clarify and stress that the work currently being funded is of high quality, and that is consequent upon high-quality applications.
Money is available to fund more research, but measures are needed to stimulate an increase in the level of research activity. That is why the Government have committed to doing four things and I am delighted to have this opportunity to report on progress to the noble Lord, Lord Kakkar, in particular, and other noble Lords who have spoken with considerable insight in today’s debate.
First, we promised to set up a partnership to bring together patients, carers and clinicians to identify what the research priorities are. This is now well under way and a formal launch event took place successfully last month. It is supported and guided by the James Lind Alliance, which is a non-profit initiative overseen by the NIHR Evaluation, Trials and Studies Coordinating Centre. The partnership has a steering group of 16 people, comprising six patient/carer representatives and 10 clinical representatives.
The next stage is a survey asking patients, families and healthcare professionals for their unanswered questions about mesothelioma treatment. The partnership will then prioritise the questions that these groups agree are the most important and the end result will be a top-10 list of mesothelioma questions for researchers to answer. The partnership plans to have the list ready by the end of this year, when it will be disseminated, and work will begin with the NIHR to turn the priorities into fundable research questions.
Secondly, the NIHR will highlight to the research community that it wants to encourage research applications in mesothelioma. The launch of this highlight notice will take place in advance of the identification of research questions by the priority-setting partnership to prepare researchers.
Thirdly, the NIHR Research Design Service will be able to help prospective applicants develop competitive research proposals. This service is well established and has 10 regional bases across England. It supports researchers to develop and design high-quality proposals for submission to the NIHR itself and to other national, peer-reviewed funding competitions for applied health or social care research. The service provides expert advice to researchers on all aspects of preparing grant applications in these fields, including advice on research methodology, clinical trials, patient involvement, and ethics and governance.
Finally, we have made a commitment to convene a meeting of leading researchers to discuss and develop new proposals for studies. Initiatives like this are one reason why it is so valuable to have the National Cancer Research Institute, the NCRI, which enables the major funders of cancer research to work in strategic partnership. I can report that NCRI officials held a meeting with clinical research leads yesterday, 15 January, to develop plans for bringing researchers together, and a representative from the British Lung Foundation also participated. The outcome was encouraging: the NCRI will be organising a mesothelioma workshop in the early summer with the aim of encouraging competitive grant applications in the field of mesothelioma. This will cover the full spectrum of basic, translational and clinical research.
Several noble Lords have—not unnaturally—spoken of a need for an ongoing role for the insurance industry in funding mesothelioma research. While the Government have money available to fund high-quality mesothelioma research proposals, we are also encouraging insurers to provide further funding. My honourable friend the Minister for Disabled People, Mike Penning, has met the Association of British Insurers, and following that meeting I have written to the association’s director general, Otto Thoresen. I am pleased to say that he has confirmed in a reply today that a further £250,000 will be paid directly to the British Lung Foundation. He has also confirmed the industry’s commitment to explore with the Government the range of future funding options. We would welcome another opportunity to meet insurers to discuss this.
Lord Borwick
I thank the Minister for that news. I also have a copy of the letter. The £250,000 is very useful, but it is less than one single claim from a sufferer of this disease. This has to be a short-term solution. If the voluntary agreement mentioned by the noble Earl does not happen for some reason, will the noble Earl push for legislation to make it happen compulsorily?
Earl Howe
My Lords, I note my noble friend’s question. My best answer to him at this stage is “one step at a time”. However, I can assure him that we will use our best endeavours to see a successful outcome from our discussions with the insurance industry. It is perhaps premature for me to go further at this stage.
Lord Alton of Liverpool
My Lords, I am grateful to the Minister, and I promise not to interrupt again, but can he provide further clarity about this £250,000? Is it drawn only from the four companies that have been referred to? How many of the 150 companies are contributing to it? What does it represent in terms of what is currently available from the industry?
Earl Howe
My Lords, as this is a time-limited debate, perhaps the noble Lord would accept my undertaking to write to him with those details. I am not sure, in fact, that I have them, because the letter, although extremely welcome, is quite brief in the detail it gives on the source of the funding.
Lord Wills
I am very grateful to the noble Earl for giving way. I shall be brief. Will he write within the next three months to everyone who has spoken today reporting on the progress of the conversations with the ABI about the range of options he has just referred to?
Earl Howe
I would be happy to do that.
Both the Government and the industry recognise the potential for insurers individually to sponsor specific research infrastructure or projects in mesothelioma, which would provide an excellent way for the industry to remain engaged following the earlier donation. I am pleased to report that the Department of Health is convening a high-level meeting with the association and the British Lung Foundation to explore practical ways to take that forward.
The noble Lord, Lord Alton, spoke powerfully about the need for sustainable funding in this area. I re-emphasise the point that I made a minute ago: research funding is available for good-quality research and what we lack are research applications. What we need, in our view, is to get innovative research ideas that will make a real difference, and that is what the NCRI meeting will hopefully do. The research ideas put forward by the noble Baroness, Lady Finlay, in her intervention are of course very pertinent. She speaks with great authority in this area. They are all questions that the NCRI discussions can address. That meeting will be an opportunity to take a strategic approach, and it requires getting the right people together. The NCRI event will involve researchers from within the mesothelioma community, and from a wider field, and research funders.
It is worth noting that spend on lung cancer research by the NCRI member organisations, including the main public funders of cancer research, has more than quadrupled over the past decade. It has increased from £3.5 million in 2002 to £14.8 million in 2012. That is because of the quality of research proposals that have come forward and the interest shown by the research community.
In conclusion, the Government are strongly committed to ensuring progress is made in research into how best to diagnose and treat this dreadful disease, and care for those affected. A number of very powerful points have been made in this debate. I will pick up those that I have not been able to cover and will write to noble Lords. I have outlined the steps that we are taking, and I hope that noble Lords are assured that these measures will deliver what they, and indeed we in the Government, are seeking.
Public Health Responsibility Deal
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Lord Sharkey
To ask Her Majesty’s Government what progress they have made in persuading further fast food chains to sign up to the Public Health Responsibility Deal pledge on calorie reduction.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
We are working hard to persuade other fast food chains to join the wide range of food businesses which have already signed up to the public health responsibility deal calorie reduction pledge and to sign up to other food network pledges. Eleven fast food partners are signatories of the responsibility deal and are taking action in a range of areas including calorie reduction. These partners cover most of the food sold in the fast food sector.
Lord Sharkey (LD)
I think the Minister will agree that these public health responsibility deal pledges are very useful. Given the dangers of excessive sugar in our diets, will the Minister consider adding a specific sugar-reduction pledge to the current list—with specific targets, as is already the case for salt—and will he help reduce sugar consumption by following the latest advice of Dr Susan Jebb, chair of the department’s public health responsibility deal food network, and removing fruit juice from the five-a-day recommendations?
Earl Howe
My Lords, I shall take my noble friend’s final question back with me. We will certainly look at it. However, I stress that our current emphasis is on overall calorie reduction, of which sugar can form a part. The scope for a reformulation to reduce sugar levels varies widely depending on the food and a reduction in sugar levels does not always mean that the overall calorie content is reduced—for example, when sugar is replaced by starch or other ingredients. The Scientific Advisory Committee on Nutrition—SACN—is currently undertaking a review of carbo- hydrates and is looking at sugar as part of that. Its report will inform our future thinking.
Lord Palmer (CB)
Is the Minister aware that one supermarket chain has announced today that it is going to remove all sweets from its checkout tills? Would it not be a good idea for the noble Earl to invite other supermarket chains to do exactly the same?
Earl Howe
My Lords, we are talking to the supermarket chains about those very matters, and I welcome the action that has been taken. The noble Lord may like to know that, as part of the responsibility deal calorie reduction pledge, Coca-Cola has reduced calories in some of its soft-drink brands by at least 30%, Mars has reduced its single chocolate portions to no more than 250 calories and Tesco has reduced by more than 1 billion the number of calories sold in its own-brand soft drinks.
Lord Foulkes of Cumnock (Lab)
My Lords, will the Minister help the House by publishing a list of meetings which Ministers, special advisers and senior civil servants have had with fast food companies in the past year?
Lord McColl of Dulwich (Con)
Does the Minister approve of the letter, which will shortly be sent to all Members of this House and of another place, asking them to measure their waist and to ensure that it is less than half their height? That would apply to quite a few Members opposite, who are clearly eating too much of the gross national product.
Lord Hunt of Kings Heath (Lab)
My Lords, I hope that the noble Earl will encourage his own noble colleagues to look at themselves in the mirror in the light of that unwarranted attack on my own Benches. Perhaps I can just refer the noble Earl to the report of the National Obesity Forum yesterday, which suggested that, on one of the worst-case scenarios, more than half of the population of this country will be obese by 2050. Does he not think that the volunteer approach may no longer be appropriate? Do the Government not have to take a greater lead on this?
Earl Howe
My Lords, there are certainly no grounds for complacency on obesity levels throughout the nation. However, the current data do not support the claim by the National Obesity Forum. In 2007, the Foresight team projected that, based on data from 1993-2004, more than half the population could be obese by 2050 if no action is taken. An analysis based on recent data suggests a flatter trend than the one projected by the Foresight team. I do not agree that we should belittle the responsibility deal. It has many worthwhile achievements to its credit and they are being added to month by month.
Lord Elystan-Morgan (CB)
Although appreciating this scurrilous attack on rotundity, does the noble Earl recollect the immortal words of Shakespeare in “Julius Caesar”:
“Let me have men about me that are fat; … Yond Cassius has a lean and hungry look”.
Lord Tebbit (Con)
My Lords, do the Government not accept that people ought to know that if they stuff themselves silly with high-calorie rubbish foods they will get fat? It is their responsibility. All the forums and other nonsense are merely trying to divorce people from the consequences of their own stupid actions.
Lord Brooke of Alverthorpe (Lab)
My Lords, if individuals are required to take responsibility but they do not know what they are consuming because the manufacturers or producers do not let them know, or indeed the Government are complicit in not pressing those manufacturers to let people know what they are consuming, should there not be a responsibility on the Government? For example, no one knows the calories in alcohol. There has been no change since this responsibility deal was introduced and there is no change in prospect.
Earl Howe
My Lords, under the responsibility deal, 92 producers and retailers have committed to having 80% of bottles and cans in the UK displaying unit and health information and a pregnancy warning by the end of last year. That is a worthwhile step forward. As regards the calorie labelling of alcoholic drinks, that, as the noble Lord will know, is an EU competence. It is subject to discussion at this time, but most large retailers include the calorie content of alcohol products on their websites, and that information is also available elsewhere.
NHS: Essential Services
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Baroness Wheeler
To ask Her Majesty’s Government, in the light of the Dr Foster Hospital Guide 2013, how NHS England is monitoring access to essential services and how it intends to address variations in access to and provision of services at clinical commissioning group level.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, to help reduce variations in access to health services, Professor Sir Bruce Keogh, the medical director of NHS England, is working with the medical royal colleges and others to ensure that the NHS is clear about the evidence base for common types of surgical interventions. For example, it will produce guidance for commissioners to help ensure that consistent eligibility criteria are used to access surgical services and so minimise the scope for variation at a local level.
Baroness Wheeler (Lab)
I thank the Minister for his response. Dr Foster’s report shows that the number of knee and hip replacements and cataract removals has fallen to its lowest level in four years, meaning that more than 12 million people now live in areas where the number of these operations has substantially declined. This is despite our elderly population continuing to rise over the same period and these common surgical procedures being vital to ensuring that older people can regain their mobility, keep active and stay living in the community. Does the Minister agree that these are essential treatments? What pressures will be placed on NHS England to ensure that CCGs actually provide them and also that they fulfil their legal obligation to issue guidance to local communities, revealing what their policies are on providing medicines, surgeries and therapeutic interventions?
Earl Howe
My Lords, I should first tell the noble Baroness that we cannot reconcile our own figures with those of Dr Foster. We believe that there has in fact been a significant increase in the number of cataract and knee and hip replacement operations since 2009-10 and not a drop. Regardless of that, I suggest to her that the absolute numbers of operations taking place do not tell us anything about possible rationing or the absence of it. That question can be answered only with the benefit of fuller data. The key to consistent access to these treatments is a common understanding among commissioners of the evidence base in each case. That is exactly what Sir Bruce Keogh is working towards and will provide guidance on in due course.
Baroness Manzoor (LD)
Can the Minister state which local NHS services NHS England has deemed to be essential? If an independent provider of these services gets into financial difficulty, who will provide and pay for those services—NHS England or the clinical commissioning groups?
Earl Howe
My Lords, from April this year, CCGs and NHS England will begin to identify formally those healthcare services that they consider essential to protect in the event of the financial failure of their providers. They will be required to designate such services as commissioner requested services. In doing so, they must have regard to Monitor’s published CRS guidance. Should an independent provider of CRS get into financial difficulty, then Monitor will work with the provider and relevant partners to determine the right solution.
Lord Turnberg (Lab)
My Lords, what safeguards are in place to make sure that CCGs do not have a conflict of interest when they contract for services in which they may have a direct involvement?
Earl Howe
The noble Lord will, I am sure, remember from our debates on the Health and Social Care Bill that NHS England has published guidance for CCGs on managing conflicts. There is also a duty placed on CCGs to have regard to such guidance and CCGs set out in their constitution their proposed arrangements for managing conflicts of interest.
Baroness Finlay of Llandaff (CB)
How are the Government able to monitor how CCGs are commissioning background diagnostic services and imaging services, which are essential for accurate diagnosis in surgical emergencies and will determine whether a patient should be taken to theatre, given that two-thirds of consultants have expressed concern about the level of care of patients at the weekend? I wonder what levers there are for the Government against those clinical commissioning groups which do not ensure that adequate diagnostic facilities are available.
Earl Howe
My Lords, the CCG assurance framework sets out how NHS England will ensure that CCGs are operating effectively to commission safe and high-quality sustainable services within their resources. Underpinning assurance are the developing relationships between CCGs and NHS England, which should not be overlooked. One key source of evidence is the national delivery dashboard, which provides a consistent set of national data on CCG performance. In addition, there is the CCG outcomes indicator set, which will be an important wider source of evidence from 2014-15 onwards.
Baroness Pitkeathley (Lab)
My Lords, I know that the noble Earl has disputed the figures but if the volume of operations such as knee and hip replacements and cataract removals is declining, does he accept that this is likely to cause further problems in the social care sector? If older people do not receive timely treatment that will transform, as these operations do, their mobility and ability to manage at home alone, surely they will continue to need more support in the community, which we know is under pressure because of shortages in local authority funding. We may call these operations non-essential—we often do—but they are not non-essential if you are an older person with mobility problems.
Earl Howe
I fully agree with the noble Baroness and her point about mobility is very well made. However, NHS England has stated to me explicitly that the assumption that there should be a rising trend in the number of operations proportionate to the rise in the number of elderly people may not necessarily be right, so we have to be wary of using a statistic in isolation to prove one thing or the other.
Lord Walton of Detchant (CB)
My Lords, can the Minister say whether it is still government policy that clinical commissioning groups should accept the recommendations of the National Institute for Health and Care Excellence in relation to the availability of expensive drugs in the NHS? What sanctions are available for those that do not comply with those recommendations?
Earl Howe
The noble Lord is right that when NICE gives a positive appraisal on a medicine, whether it is for a rare or a common disease, the funding for that medicine must be available through CCGs or NHS England. If a patient is denied the drug, contrary to the instructions or wishes of their clinician, then there is a route of appeal through either the clinical commissioning group or NHS England.
Health: Birth Defects
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Lord Rooker
To ask Her Majesty’s Government what is their current approach to reducing the number of children born with neural tube defects; and whether they will consider fortifying white bread flour with folic acid as an additional measure.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, we encourage women to plan pregnancies, and advise those seeking to become pregnant to take folic acid supplements before conception and for the first 12 weeks of pregnancy, and to increase their intake of folate-rich foods. We are considering our nutrition advisers’ full recommendation to fortify flour with folic acid and will take into account new data on the folate status of the population in reaching our decision.
Lord Rooker (Lab)
My Lords, given that folic supplementation needs to be taken before most women know that they are pregnant, is the Minister concerned that less than 6% of 20 year-olds actually take folic supplements? The follow-up research published earlier this year is now available—on top of the scientific advice that the Government received in 2007 from independent committees and the Food Standards Agency—and shows that putting folic acid in flour causes no side effects for males. Is it not therefore time to change policy and put folic acid in white bread flour, which the BMA says is the most cost-effective way of avoiding the misery of hundreds of affected pregnancies, and to join 50 other countries that are doing the same?
Earl Howe
My Lords, mandatory fortification of food is, by any standards, a big step; it is not a decision to be taken lightly. The issue that we have been facing is that the survey data used by the Scientific Advisory Committee on Nutrition is more than 10 years old. The latest data available on the folate status of the population will be available early next year, and we feel that it is prudent to use that information to assess the risks and benefits of fortifying flour with folic acid before we make our decision.
Baroness Brinton (LD)
My Lords, international academic research since 2005 has shown that including folic acid in bread and cereal products is important and that it reduces neural tube defects by between a quarter and a half, so it undoubtedly helps raise the levels of folic acid in women before and during pregnancy. However, it is not at the level that would remove all possibility of NTDs. Research says that folic acid supplements are recommended, too. What will the Government do to alert women who are thinking about having a baby to take supplements before becoming pregnant?
Earl Howe
My Lords, we recognise that some women do not always access maternity services early or attend regularly for antenatal care, and that poorer outcomes are therefore reported in some cases for mother and baby. Maternity services need to be proactive in engaging all women. To help reduce variation and improve services, NICE has published a comprehensive suite of evidence-based clinical guidelines and quality standards for maternity services. We are also promoting the taking of folic acid supplements through a number of channels including Healthy Start, NHS Choices, Start4Life, and the Information Service for Parents.
Lord Patel (CB)
My Lords, what do the Government think are the contraindications for fortifications of flour with folic acid, knowing that the evidence shows that it would cause a reduction of about 300 in the number of babies born with neural tube defects?
Earl Howe
My Lords, I recognise the opinion that is shared among many members of the medical community on this. However, the advice we received from SACN, our expert adviser, clearly showed that there are risks and benefits associated with this proposal. It is not an open-and-shut case. Among the things that we have had to consider are the practical implications of implementing SACN’s advice, which is no small matter.
Lord Hunt of Kings Heath (Lab)
My Lords, does the noble Earl not recognise that in fact the scientific committee he referred to has looked at the issue that he raised and has upheld its previous recommendation that the Government should go ahead? Some 50 countries have already done that; the scientific advice is clear; why on earth are the Government not getting on with it?
Earl Howe
My Lords, as I said, SACN’s recommendations highlighted both the risks and the benefits of this proposal—and I certainly acknowledge that there would be benefits. However, there are also implications. For example, SACN recommended that mandatory fortification should proceed only if accompanied by:
“Action to restrict voluntary fortification of foods with folic acid; measures for careful monitoring of emerging evidence on any adverse effects of long-term exposure to intakes of folic acid … and guidance on supplement use for particular population groups”.
We have to take those recommendations into account before taking any long-term decision.
Lord Turnberg (Lab)
My Lords, is the Minister aware of a recent publication that suggests that folic acid deficiency in men, too, may lead to birth defects in their offspring? Is this not another good reason for fortifying flour?
Baroness Hayman (CB)
My Lords, the Minister said that this was not a decision to be taken lightly, and that is absolutely right, but we now have the experience of 50 other countries. We have had scientific evidence on this issue for many years. The fortification of white bread flour is a targeted measure that could significantly reduce the number of pregnancies, not just births, that involve neural tube defects, and thus prevent a great deal of unnecessary and painful suffering. Will the Minister undertake to look at this matter again as a matter of urgency?
Earl Howe
My Lords, we are looking at this as a matter of urgency. I recognise what the noble Baroness says about the experience of other countries, but we must make policy in relation to the population of our own country, and that involves weighing up both the potential benefits and the potential downsides of any policy.
G8 Summit on Dementia
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Lord Patel
To ask Her Majesty’s Government what was the outcome of the G8 dementia summit.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, the G8 agreed to work together to tackle and defeat dementia. The declaration announced the G8’s ambition to identify a cure or a disease-modifying therapy by 2025 and to increase collectively and significantly the amount of funding for dementia research. The G8 also welcomed the UK’s decision to appoint a dementia innovation envoy who will work to attract new sources of finance, including examining the potential for a private and philanthropic fund.
Lord Patel (CB)
My Lords, I thank the Minister for his reply. Dementia is the dreaded diagnosis, particularly for the elderly, as it affects more than 5% of people over 65 and between 20% and 40% of those aged over 85. Because of the increasing number of elderly people, an increasing number of people are affected. I commend the Government and congratulate them on taking the initiative at the G8 and particularly on involving the WHO, because now it will become a global initiative. I have two questions. The first is about the funding that the Government announced. There is a great deal of confusion. Is it new money, money that has already been allocated to research or money that the Department of Health is giving for better diagnosis of dementia? Research on dementia must also focus more widely on understanding the biology of the disease, the inflammatory process and the epidemiology. Ring-fencing around a disease will not necessarily get to the point that the Government wish to get to. Secondly, what impact do the Government think the EU regulation on data protection will have on dementia research?
Earl Howe
The noble Lord asked a number of questions. The Government have stated an ambition to double research funding in dementia. That will depend on the quality of the proposals that come forward and on the rate of scientific progress. We very much hope that arising out of the summit, momentum will be gained, not only in this country but internationally. As regards the noble Lord’s second question, we recognise how important this is for future dementia research and I can tell him that the Government, through the Ministry of Justice, are negotiating with member states in Europe and are aware of the impact that the proposal would have on research. It is likely to be some months before there is an agreed approach between member states and the Commission, and the Parliament is unlikely to vote on the proposal before 2015.
Lord Warner (Lab)
The Minister will no doubt be aware that there is growing interest in this country in assessing whether drugs used for conditions other than dementia might be useful in tackling dementia. Will the Minister say what efforts the Government are going to put into this area as a result of the G8 summit?
Earl Howe
My Lords, we certainly hope that the private and charitable sectors will respond to the call, but at the same time the Government are not dictating to the research funding bodies which projects they should support. The Haldane principle is very important. The noble Lord makes an extremely powerful point, and we would hope that the pharmaceutical companies will wish to step up to the plate.
Baroness Hanham (Con)
My Lords, will the Minister be kind enough to explain exactly what is going to be achieved by training public servants such as bus drivers in dementia, what is the purpose behind it and what we hope those public servants will be able to do?
Earl Howe
My noble friend raises an important issue, because it is going to be increasingly necessary for not only health and care professionals but members of the public to be properly attuned to dementia and the needs of those who have the condition. We want to see all those who deal with the public trained in dementia, at least to a basic level, in a way that is appropriate to their level of engagement with those who suffer from dementia. Dementia training is now a key part of Health Education England’s mandate.
Baroness Greengross (CB)
My Lords, I would like to add my congratulations to the Government, and in particular to the Prime Minister on his personal commitment and on securing the summit focusing on dementia. I ask the Minister whether there are any commitments from other G8 countries, both for research and for the other side of this, which is care and how we help the growing number of people—it will be one in three of us in the near future—who are going to experience dementia, in all the G8 countries and beyond.
Earl Howe
My Lords, it is perhaps too soon to expect concrete proposals from other G8 countries, but I can tell the noble Baroness that the summit was not the end of the story. The G8 countries will be meeting throughout 2014 to build on and develop further agreements. We have agreed to host the first legacy event on social-impact investment in March next year. That will be followed by an event in Japan on what new care and prevention models could look like, and by an event hosted by Canada and France on how industry can harness academic research. There will then be a meeting in the United States in February 2015. We hope that the momentum generated by the summit will elicit the kind of commitments that the noble Baroness rightly seeks.
Lord Foulkes of Cumnock (Lab)
Is the Minister aware that after the very brief exchange about dementia yesterday, I heard it suggested that dementia should not be grouped in any way with mental illness because of the stigma involved? Surely the solution to that is that we must all work to remove any stigma from all kinds of mental illness.
Earl Howe
The noble Lord is absolutely right, but he will recall that the question yesterday dealt with the WISH summit, which was focused specifically on mental health and not on dementia. I did not mean to imply that there should be any less emphasis on tackling stigma in both areas.
Baroness Brinton (LD)
My Lords, I, too, welcome the result of the G8 dementia summit, but what progress is being made in appointing nurses who specialise in dementia in the same way that there are nurse specialists for cancer, rheumatology and epilepsy? Dementia UK’s admiral nurses are wonderful and provide real help to patients and families, but there are a mere 103 for an estimated population of 800,000 dementia patients.
Earl Howe
My noble friend raises a very important point. I come back to the point that I made a short while ago: people with dementia in practice access all parts of the health and care system. We want all staff who care for people with dementia to be trained to the level of their engagement so as to deliver high-quality care for people with dementia. I mentioned that dementia training was a key part of Health Education England’s mandate. Already, 100,000 NHS staff have received dementia training. As my noble friend will know, decisions on the commissioning of admiral nurses are made locally, but I recognise the work that they do.
Lord Walton of Detchant
Does the Minister accept that much of the increased incidence of dementia is a result of the fact that many of us are living much longer than was the case in the past? Does he further agree that there is clear research evidence to suggest that continuing intellectual and physical activity, care and attention to diet, and control of blood pressure can delay the onset of dementia in many individuals, and that, as a consequence, once early dementia appears, programmes to promote such physical and intellectual activity are very valuable? In such programmes, volunteers play a very important part across the country. What are the Government doing to promote these projects?
Earl Howe
The noble Lord, as ever, makes some extremely good points. My department is looking at the role of volunteers in a number of areas. He is right that increased age is the greatest predictor of dementia. It has been estimated that delaying the onset of dementia by two years could decrease the global disease burden by 22.8 million cases by 2050. The point that the noble Lord makes is therefore well made, and I have no doubt that there will be an increasing focus on this over the coming years.
Smoking: E-cigarettes
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank my noble friend Lord Astor for securing this important and highly topical debate.
As we have heard, e-cigarettes are nicotine-containing devices that work by atomising a nicotine solution which is then breathed in as a vapour by the user. E-cigarettes claim to deliver nicotine to the user without the toxins and carcinogens found in tobacco smoke. They do not involve any combustion and do not produce smoke. E-cigarettes are a very recent innovation. They are available in various shapes and sizes, as we have heard, and many are designed to both look and feel like conventional cigarettes. Some even incorporate a light at the end of the device that glows when the product is being used, to replicate a cigarette. Today, they are marketed as a cheaper and healthier alternative to smoking tobacco. However, e-cigarette manufacturers have avoided directly suggesting that their products are smoking cessation aids, as making such claims would subject their products to regulation as medicines.
I turn to whether e-cigarettes are safe to use. When we compare the use of e-cigarettes to smoking of tobacco, the Department of Health is confidently able to say that e-cigarettes are likely to be much safer to use. That does not mean that e-cigarettes are safe to use; it probably says more about how enormously unsafe it is to smoke tobacco. Nevertheless, the safety of e-cigarettes is yet to be fully established. Given how novel these products are, we need to see much more evidence about their safety, especially regarding the use of e-cigarettes over a long period.
At present, e-cigarettes are sold without any product-specific controls relating to quality and safety in use, or specific provisions on advertising and promotion. There are general product safety provisions that apply to these products, but they are not designed for these sorts of product and are not fit for this purpose. We also must keep in mind that nicotine itself is not only highly addictive but can be highly toxic. Electronic cigarettes are not risk-free. Known and reported health risks include acute effects on lung function, possible pneumonia and other risks related to poor product quality.
My noble friend Lord Astor made reference to Action on Smoking and Health. ASH says that there is significant variation in device effectiveness, nicotine delivery and cartridge nicotine content, both between and sometimes within product brands. ASH cites research that suggests the presence of toxins, released in low concentrations, from the vaporisation process involving certain e-cigarette cartridges. It cites other research that concluded that e-cigarettes have a low toxicity profile, are well tolerated and are associated only with mild adverse effects.
As we have heard during this debate, the e-cigarette market is growing rapidly. More than 300 companies are estimated to be importing or supplying e-cigarettes in the United Kingdom. The e-cigarette market in the UK is estimated to be worth in excess of £100 million, and we know that across the world the tobacco industry is becoming increasingly involved. There is little doubt that awareness of e-cigarettes has increased quickly through advertising and promotion of these products. It has been said that e-cigarettes are being promoted in similar ways to how cigarettes were promoted before we introduced a comprehensive ban on tobacco advertising in this country. I am sure that I am not alone in noticing the vast amount of promotion for e-cigarettes in my local convenience store, or the representatives of e-cigarette companies in shopping malls or outside train stations promoting their products.
The University College London smoking toolkit study is a national study of smoking and smoking cessation in England. The most recent data from the survey suggest that electronic cigarette use by tobacco smokers has increased from around 2% in 2011 to around 14% in August 2013. If this trend were reflected across the UK, it would translate to around 1.4 million smokers who have used electronic cigarettes. There is little evidence to suggest that non-smokers are becoming attracted to using e-cigarettes.
My noble friend Lord Borwick asked about the behaviour of children and young people. ASH commissioned research into the use of e-cigarettes by young people and found that, in Great Britain in 2013, 95% of 11 to 14 year-olds and 90% of 16 to 18 year-olds have never used e-cigarettes. Among young people, e-cigarette use appears to be confined to those who have already tried smoking. Nevertheless, we remain concerned that e-cigarettes could quickly become popular with young people, particularly if they continue to be vigorously advertised and promoted. We are also very aware of concerns expressed that e-cigarettes could act as gateway products for young people into smoking, and will continue to watch the evidence closely.
The Government recognised in the tobacco control plan for England that smokers are harmed by the tar and toxins in tobacco smoke, not necessarily by the nicotine to which they are addicted. There is no way of avoiding these deadly toxins if you inhale smoke from burning tobacco.
Earlier this year, the National Institute for Health and Care Excellence published public health guidance on harm-reduction approaches to smoking. The noble Lord, Lord Hunt, asked about this. NICE recommends the use of licensed medicines only. The guidance suggests that while the best way to reduce smoking illness and death is to encourage smokers to quit completely, there are other ways of reducing the harm from smoking, even though this may involve the continued use of nicotine. If someone does not want to, is not ready to or is unable to stop smoking in one step, the guidance suggests that licensed nicotine replacement therapies could be of use.
My noble friend Lord Borwick asked about the possibility of sponsoring research in this area. We already know quite a lot about the safety profile of nicotine and its use in cutting down and quitting. The evidence we have is that these products are used mainly to cut down and quit.
My noble friend Lord Ridley called for clearer evidence of effectiveness. The problem is that there is not good evidence of effectiveness. These products are not magic bullets, in other words, but even at this stage we feel that we want to exploit the potential that we see in them. He referred to aubergines as potential medicines. I think he would agree with me that people do not eat aubergines in the expectation that that will help them to quit smoking. Clearly, whatever remedy we encourage has to be effective in its ability to cut down and quit the habit of smoking.
There is potentially a place for e-cigarettes within a harm-reduction approach to public health, but only if they meet the requirements set out in the public health guidance; that is, if they are licensed medicines. I would expect that the NHS and health professionals would also only recommend the use of e-cigarettes that are licensed as medicines. My noble friend Lord Astor asked whether we envisaged e-cigarettes being sold on prescription. We want effective products to be widely available, not just on prescription but in general sale outlets such as supermarkets and corner shops.
The noble Lord, Lord Hunt, asked how much it would cost an e-cigarette manufacturer to get a medicines licence. The impact assessment that we published estimated that the annualised cost to a single UK e-cigarette importer for complying with medicines regulation ranged from £87,000 to £266,000.
I am particularly grateful to my noble friend Lord Astor for securing this debate because it provides me with the opportunity to explain to your Lordships the action that is under way to regulate e-cigarettes. As the Chief Medical Officer for England has said, since more and more people are using e-cigarettes, it is only right that these products are properly regulated to be safe and work effectively.
A European tobacco products directive was proposed late last year and is now in its final stages of negotiation in Brussels. I can tell noble Lords that no deal has yet been reached in the discussions but the Government hope that agreement might be reached shortly. I reassure your Lordships that the United Kingdom has been active during these negotiations, as we believe that the proposed tobacco products directive will benefit public health and help to reduce the number of young people who take up smoking in the UK.
From the outset, it was envisaged that e-cigarettes would be regulated within the proposed directive. Protecting and promoting public health has always been our starting point, and we want safe and effective nicotine-containing products that can help smokers cut down and quit. The Government took the view that proportionate medicines regulation was the best way to deliver that objective.
Viscount Astor
Does my noble friend consider that e-cigarettes that contain no nicotine at all but contain other flavours will or should come under the tobacco directive?
Earl Howe
My Lords, that is probably the hardest question that my noble friend has asked me during this debate. My answer is that we certainly need to give careful consideration to that issue, which is about products that have the appearance of e-cigarettes but contain no nicotine. We would need to look at how common those products are or are becoming. Frankly, that work has yet to be done, but I am grateful to him for raising the issue.
I was speaking about our approach to the regulation of e-cigarettes, saying that we felt that proportionate medicines regulation was the best way forward. Nevertheless, we must consider carefully the views that have been forthcoming, including from the European Parliament, that there are alternative approaches to the regulation of e-cigarettes. Moving forward, the Government will want to be satisfied that the directive can deliver the right checks and balances on e-cigarettes. It is important to underscore the fact that there is a wide consensus across the European Commission, the European Parliament and European member states that additional regulatory safeguards are needed for this relatively new category of product. We are listening carefully to the genuine debate about how best to take this forward in the directive.
There is also emerging consensus that the advertising of e-cigarettes needs to be controlled. Options for doing so as part of the proposed European directive are under negotiation. In addition, the Committee of Advertising Practice, which writes and maintains the UK advertising codes that are then administered by the Advertising Standards Authority, announced in October that it intends to develop new rules to give clarity to advertisers and to ensure that e-cigarettes are promoted responsibly. It is considering running a public consultation on this issue early in the new year.
The Government’s priority during negotiations is to secure a directive that will reduce as far as possible how attractive e-cigarettes are to young people and closely to monitor the development of this market. When the directive has been settled, we will undertake an analysis to consider whether further action could be taken on a domestic basis, in particular to protect young people from e-cigarettes that contain nicotine. We also need to give further consideration to my noble friend’s question about non-nicotine-containing products, as I mentioned.
Regardless of how e-cigarettes are regulated within the proposed directive, we will still encourage the manufacturers of these products voluntarily to seek medicines licences for their e-cigarettes, so that they can be made available to support smokers to quit in the same way as other forms of nicotine replacement therapy, such as gum and patches. These e-cigarettes could be recommended for use in reducing harm, in accordance with the recently published public health guidelines.
Viscount Ridley
Has my noble friend taken on board the point that both I and the noble Lord, Lord Hunt, raised about the risk of regulation stifling innovation? By stifling innovation and slowing down the rate of take-up of these things, regulation could kill more people by preventing their coming off tobacco cigarettes.
Earl Howe
I most certainly have taken that point on board. I am grateful to my noble friend, who I hope will take some encouragement from what I said about our wish to see take-up of effective products. However, we need to be cautious about allowing products to flood the market that purport to contain certain quantities of nicotine and to deliver them safely but in fact do not. The safety and efficacy of these products are particularly important and we need to look at that.