Department of Health: Arm’s-length Bodies
Earl Howe Excerpts(13 years, 10 months ago)
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Lord Knight of Weymouth
To ask Her Majesty’s Government what estimate they have made of the cost of organisational changes required to implement the proposals to reform the Department of Health’s non-departmental public bodies; and whether the cost will be allocated to that department’s budget.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have announced that administration costs will reduce by a third in real terms across the health sector. This will impact on the Department of Health’s arm’s-length bodies. Currently, we cannot determine the exact costs, as they will be affected by how the reduction is distributed across the health sector and how much is met by levels of natural wastage. The department’s spending review settlement will meet these costs.
Lord Knight of Weymouth
I thank the noble Earl for that reply. He will, I am sure, have listened carefully to the debate last week on the Public Bodies Bill. He will have heard half a dozen of your Lordships raise concerns about two health bodies in particular—the Human Tissue Authority and the Human Fertilisation and Embryology Authority. Both have the schedule of Damocles hanging over them; both need independence and sensitivity; and both cost the public purse very little. Will the noble Earl now follow the precedent set by the noble Baroness, Lady Rawlings, when she announced during Questions last Thursday that Ofcom will not be scrapped and was being pulled from Schedule 7. Will he do the same for the Human Tissue Authority and the Human Fertilisation and Embryology Authority?
Earl Howe
My Lords, we will obviously have an opportunity to debate these matters in Committee on the Public Bodies Bill, but I would just make a couple of general points. There are clear synergies between some of the functions performed by the HFEA, the HTA and the Care Quality Commission—they all license treatment. In addition, there is significant read-across to the potential scope of a new research regulator. All political parties at the election were agreed that we have too many of these bodies—too many quangos—and we have to reduce the cost of administration across government as a whole. We can debate at greater length the merits, and perhaps demerits, of the Government’s proposals. I look forward to that debate.
Baroness Hussein-Ece
My Lords, will my noble friend give an assurance that the necessary functions of these bodies will continue and, importantly, will they be more accountable?
Earl Howe
My Lords, the key point to make about our proposals around the HFEA and the HTA is that we are not proposing to change the functions or alter the provisions of the underlying statutes. All we are doing is proposing to transfer various functions in different directions. As for the independence of the advice, I see no reason at all why the current independence should not be maintained under the new arrangements.
Baroness Deech
My Lords, is the Minister aware that a pre-legislative scrutiny committee gave an opinion two or three years ago that there was not a read-across between the HTA and the HFEA and that they had different skill sets? It accepted evidence that there was no money to be saved and that there would be a considerable loss of experience and probably money in bringing the two together. Does the Minister agree that we cannot keep revisiting this issue, which has been so thoroughly looked at?
Earl Howe
They are different skill sets, but I am not aware that Parliament has visited these issues, let alone revisited them. As I said, we will have the opportunity to do that, but the proposals we have outlined will ensure that the teams that are currently involved in inspection activities will be kept together. I see no reason why they should not be.
Lord Turnberg
My Lords, perhaps I may ask the noble Earl about the Health Protection Agency. What advantages does he expect to come out of moving the HPA into the Department of Health?
Earl Howe
The advantages will come from collocating all aspects of public health in one place, including the Health Protection Agency. I emphasise that there will continue to be independent advice on health protection. We will have a clear line of sight in all public health matters from the Secretary of State right down the chain to local authorities and to public health programmes implemented on the ground. We do not have that at the moment.
Baroness Gardner of Parkes
Is the Minister aware that, in health services in general—and I apply this also to these bodies—there is a tendency that if someone leaves a post, it is kept unfilled? Will the Minister assure us that, instead of allowing that to happen on an unspecified basis, the Government will make sure that if a post is essential it is retained and not left simply because a person has given up their job?
Earl Howe
My Lords, my noble friend makes a good point. We need to distinguish between posts that are administrative in nature, where we will see considerable reductions, as I have mentioned, and posts that relate to clinical activities. There is obviously a clear case for the latter posts to be advertised and filled where necessary.
Baroness Thornton
Will the Minister explain to the House why the Human Tissue Authority and the Human Fertilisation and Embryology Authority have been included in the Public Bodies Bill when some 28 other NDPBs—I apologise to the House for that—were listed on 14 October in the announcement made about quangos? Will the Minister also explain whether an impact assessment has been done on any or all of these bodies, and when we might see the results of that? How many people does he expect will be made redundant, and at what cost?
Earl Howe
My Lords, the impact assessment will be published as soon as we know the size and shape of the costs involved. As I mentioned in my original Answer, we do not know that at the moment because we do not know about natural wastage, the grades of the people who will have to leave, and so on. The main reason why those two bodies have been included in the Bill is that our proposals, when we finalise them, will be very simple. As I have outlined, they will involve reparcelling the current functions of the bodies in different directions. That is not a difficult thing to do: it can be done very easily by secondary legislation.
Healthcare: Costs
Earl Howe Excerpts(13 years, 10 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government have guaranteed that health spending will increase in real terms in each year of the Parliament. However, in order to meet rapidly rising demands while improving quality, substantial improvements in economy and efficiency will be required across all areas of health spending. This response is best led by the NHS locally, while the centre will focus on reforming the health service to create a long-term sustainable NHS.
Lord Taylor of Warwick
My Lords, I thank the Minister for his reply. Does he agree with me that putting more funding now into research into terrible conditions such as dementia, in which I include Alzheimer’s disease—for which there is no cure—will ultimately bring down healthcare costs? We must find a cure, and I ask the Minister to commit more research funding to the terrible condition of dementia.
Earl Howe
My Lords, my noble friend is quite right to identify dementia as a particular cost pressure over the next few years. The coalition Government signalled in their programme our intention to prioritise funding for dementia research. The spending review confirmed that and committed to real-terms increases in spending on health research. This investment is indeed essential if we are to increase the quality, productivity and cost-effectiveness of the NHS.
Lord Brooke of Alverthorpe
My Lords, I return to a question which I posed previously to the Minister and which remains unanswered. Does he not agree that if patients in the health service knew what the costs of their treatment, care and drugs were, as they do in the private sector, this would create a downward pressure, which would reduce costs overall?
Earl Howe
My Lords, I know that this is a question to which the noble Lord and other noble Lords regularly return, and it has a superficial attraction. The problem with it, I am advised, is that patients who are informed of the cost of their treatment—some patients, at any rate—take that as a deterrent to accepting the treatment in the first place. That is something we need to avoid. Nevertheless, there is an underlying point here; there is a need to provide better information to patients about their treatment so that they can take ownership of their state of health.
Baroness Finlay of Llandaff
My Lords, what consideration are the Government giving to seven-day working in the NHS, including renegotiating Agenda for Change, to make better use of the NHS’s equipment, promote early diagnosis and decrease morbidity from complications of treatment that is not overseen by senior staff—particularly over weekends and bank holidays?
Earl Howe
My Lords, creating a seven-day service is a particular concern of mine, and the noble Baroness is quite right to raise it, particularly given her long experience in the health service. As for Agenda for Change, any alterations to existing terms and conditions, such as the unsocial hours payment or sick pay, would need to be negotiated in partnership with NHS Employers and trade unions, through the NHS Staff Council.
Lord Alderdice
My Lords, I know it is extremely difficult, but has my noble friend had the opportunity to explore how much of the increase in health service costs in recent years has come about because of the increase in administration and management costs? I refer not simply to the salaries of administrators and managers but to the administration for the administrators, and to the amount of time that clinical and professional staff must spend in servicing the requirements put on them by administrators and management.
Earl Howe
My noble friend is right to pinpoint this area. If my memory serves me correctly, the average annual increase in management and administration costs over the past 10 years has been 6.2 per cent per year, which is by far and away higher than the increase in costs in clinical areas, for example. That is why we are determined to reduce the administrative cost of running the NHS, and we are in the process of planning for exactly that.
Baroness Wall of New Barnet
Does the noble Earl agree that that is an opportunity for us to look at saving costs in the health service by ensuring that we think of methods to persuade people to attend their day clinics? The cost of people not attending—DNA, as it is called in the health service—is huge, particularly in day surgery.
Earl Howe
The noble Baroness is quite right, and I am well aware that she speaks from personal experience. Many hospital trusts, and indeed GPs’ surgeries where applicable, have devised inventive ways of reminding patients of their appointments, either on the day or on the day before, perhaps by text. Good practice in this area is something that we need to focus on.
Lord Kakkar
My Lords, clinical leadership is critical if we are to secure the greatest benefit for patients from NHS spending and the appropriate use of resources. What strategies do Her Majesty's Government have for developing clinical leadership in the NHS? I declare an interest as patron of UCL Partners’ NHS staff college.
Earl Howe
Again, my Lords, the noble Lord is absolutely right to focus on clinical leadership, which will be critical if we are to deliver the improvements in the quality of care that we wish to see, and also to roll out the vision laid out in the Government's White Paper. The department has a number of initiatives under way, as do deaneries in strategic health authority areas around the country, to promote clinical leadership. There are also active programmes in acute trusts. Without good clinical leadership, the programme cannot proceed as we all hope and wish.
Lord Eden of Winton
My Lords, can my noble friend say what proportion of total National Health Service costs is represented by drugs and medicines? Might it not be that if there were tighter control over the dissemination of pills and medicines, particularly in outpatient departments, there could be important savings?
Earl Howe
My Lords, my noble friend is right that drugs and medicines account for a sizeable proportion of the NHS bill. Successive rounds of the pharmaceutical price regulation scheme, combined with what we call the category M scheme for generic drugs, have held down the cost of drugs to the NHS very successfully over the years. However, this is an area to which we are devoting a great deal of attention, not least in our plans for value-based pricing in the longer term.
Mental Health
Earl Howe Excerpts(13 years, 10 months ago)
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Baroness Murphy
To ask Her Majesty’s Government what plans they have to address mental health factors in their public health agenda.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, mental health is recognised as an integral part of public health. The public health White Paper will set out a new approach to public health, giving mental health the same prominence as physical health conditions such as cancer and heart disease. The Government recognise that there is no public health without public mental health.
Baroness Murphy
I thank the Minister for that encouraging reply. Of course, he will recognise that there is a long way to go. Some 50 per cent of all smoking related deaths in this country are attributed to people with mental disorders, and in fact those with mental illnesses account for almost half of all the tobacco consumed. People with schizophrenia and other mental illness have by far the worst outcomes in terms of mortality, losing on average 20 years of their lives. Will there be specific targets in the forthcoming White Paper around the physical health outcomes in terms of mortality and morbidity of those with serious mental disorders?
Earl Howe
My Lords, yes. We know that people with severe mental illness die on average 20 years sooner than others and that the majority of these deaths are smoking related. Improving public health is at the core of the Government’s health policy, as I expect the noble Baroness is aware. We will make clear our priorities in this area when the public health White Paper is published.
Lord Alderdice
My Lords, we know that early years development is absolutely critical to whether adults will be vulnerable to mental illness later. What things do the Government intend to do in terms of early development, not just in health but across departments, to try to ensure less vulnerability not only in young people, although that is important, but also in adults, since these vulnerabilities develop early on?
Earl Howe
My Lords, my noble friend is absolutely right: this is a cross-government effort. It is not simply for the Department of Health to deal with the issue because just about every department has some sort of remit in this area. I would say that, in particular on the attainment of children at school, we will focus very much on children from disadvantaged backgrounds because there is a high correlation between mental ill health and poverty, and mental ill health and deprivation. That will be a major focus.
Lord Turnberg
My Lords, what steps are the Government taking to ensure that GP consortia have access to the expert advice they will need if they are to commission positive mental health messages and the prevention of mental illness?
Earl Howe
My Lords, many GPs understand the issues very well and are keen to get on with the agenda. Our proposed model of GP commissioning means that practices will have flexibility within the new legislative framework to form consortia in ways designed to secure the best healthcare and outcomes for their patients. That will include mental health and could involve, for example, taking commissioning decisions collectively with perhaps a lead consortium for mental health.
Baroness Howarth of Breckland
My Lords, I know that the number of young people being detained in adult mental health hospitals is decreasing steadily, but can the Minister tell us, first, how many remain, and secondly, what policy will be set out in the framework for seriously disturbed young people who will be contained within the community?
Earl Howe
My Lords, the noble Baroness is right to say that there is legislative provision to ensure age-appropriate accommodation for young people in particular suffering from mental health difficulties. A range of products has been produced by the National Mental Health Development Unit to assist hospitals to meet the legal requirement to provide that age-appropriate setting. It does not mean, of course, that no under 18 year-olds may be treated on adult psychiatric wards as there are circumstances where that is appropriate. But my understanding is that this legislation is being observed and is making a difference.
Baroness Corston
My Lords, given that two-thirds of the women in prison have diagnosable mental health disorders and that services are currently commissioned through primary care trusts, how will such services be provided once the trusts are abolished?
Lord Northbourne
My Lords, the noble Earl has already mentioned children with mental health problems. Does he agree that a parent with mental health problems can have a serious and damaging effect on a child’s life chances? Are there any statistics on how many children are today growing up in families with a parent with mental ill health? If not, will the Government consider collecting such statistics in the future?
Earl Howe
My Lords, I do not believe that we collect data on the attainments at school of children with parents who have mental health difficulties. However, we know that severe parental mental health problems are one of a range of risk factors that are statistically associated with poor emotional health. There are some statistics, which I will endeavour to supply to the noble Lord, but my understanding is that long-term outcomes are not particularly clear. Nevertheless, there is evidence that children and young people who are emotionally and mentally healthy and active achieve more and participate more fully with their peers at school.
Lord Patel of Bradford
My Lords, we know that a range of mental health issues disproportionately affect black and minority ethnic communities—for example, the high risk of developing psychosis among the black Caribbean community. What steps are the Government taking to ensure that we have targeted prevention strategies in this area to continue the work of the previous Government?
Earl Howe
My Lords, the previous Government’s Delivering Race Equality in Mental Health Care programme ended in January of this year. That programme was delivered through working in partnership with service users, carers, clinicians and third sector agencies. A tremendous amount of information came out of it and the learning and findings from that programme will inform the work that we are now carrying out on a new mental health strategy, which we plan to publish in a few weeks time.
Lord Wills
My Lords, Professor Marmot’s review of health inequalities found that unemployment has a significant impact on both physical and mental health. In the light of that and indeed of the rest of that excellent report, what are the Government doing to implement its recommendations?
Earl Howe
My Lords, we very much welcome the Marmot review. Fairness and social justice are both key principles of the coalition Government. The Secretary of State for Health has said that he wants to build on the review’s findings and its six main policy objectives, from early years to ill health prevention. The forthcoming public health White Paper will set out our approach to tackling health inequalities and addressing the wider determinants of health.
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Health: Chronic Fatigue Syndrome
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The Countess of Mar
To ask Her Majesty’s Government what event precipitated the Department of Health decision to exclude all people who have or have had myalgic encephalomyelitis/chronic fatigue syndrome from donating blood from 1 November 2010.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this decision by the UK blood services was prompted by a recent independent expert risk assessment of a possible link between a murine retrovirus and CFS/ME. Although the risk assessment found no evidence of a link or of a risk to transfusion recipients, the UK blood services recognised that practice for CFS/ME should be brought in line with other conditions where individuals are permanently excluded from blood donation to protect their own health.
The Countess of Mar
My Lords, I am grateful to the noble Earl for that reply. I offer my congratulations on the precautionary principle being called on in this instance, but ask him why the Department of Health did not say this in its press release. The notice said only that it was for the benefit of patients and no one, but no one, believed it. In the light of the findings on various viruses, not just XMRV, in the blood of patients suffering from ME, what new biological research as opposed to psychological research is being conducted into this terrible illness?
Earl Howe
My Lords, it is important to make clear to the noble Countess that no definite picture has yet emerged from the published literature on whether the virus in question, XMRV, is implicated in CFS/ME. The National Expert Panel on New and Emerging Infections has considered all the available evidence about XMRV and has reported that no public health action is required at this time. The Advisory Committee on the Safety of Blood, Tissues and Organs, on the basis of current evidence,
“does not recommend further measures at present, but wishes to continue to monitor the situation”.
As regards research into CFS/ME, the Medical Research Council is committed to supporting scientific research into all its aspects, including studies into the biological basis of the condition and evaluation of treatments. In 2009-10, the MRC spent £109,000 on research directly related to the condition.
Baroness Gardner of Parkes
My Lords, I am sure that everyone would agree that we would rather be too cautious, but can the Minister explain why anyone over a certain age is automatically excluded from being a blood donor?
Earl Howe
My Lords, this is a pragmatic decision by the advisory committee on donation. In the case of CFS/ME, which we are looking at at the moment, the committee recommended that the donation policy should be brought into line with other relapsing conditions, where the rule is that we do not take blood from people with such conditions.
Lord Alderdice
My Lords, given that there is no medical test that is pathognomonic for this disorder or group of disorders, how do the authorities propose to police its exclusion other than simply by hoping that people will come forward with the information themselves?
Earl Howe
My noble friend is right to say that there is no diagnostic test for CFS/ME other than a process of elimination and watching the symptoms. It is largely on a self-reporting basis that the blood transfusion authorities will be alerted to the condition unless, of course, a patient’s GP is involved and can report his or her opinion.
Baroness Finlay of Llandaff
My Lords, do the Government intend to ask NICE to evaluate pathogen inactivation, which is already used on fresh frozen plasma for children, for blood components as well because of new and emerging infections and the increased risk of infections in donors because of the increase in international travel?
Earl Howe
My Lords, I understand why the noble Baroness asked that question. I believe that platelets cannot be stored in refrigerated conditions and are therefore, in theory, open to more infection. I am advised that SaBTO, the expert committee, looked at this and advised that no action was currently necessary.
Baroness Thornton
My Lords, I took a look at the blood transfusion service’s excellent website over the weekend to see what it had to say about who should and who should not donate blood. Basically, it said that you should be in good health. People with CFS/ME often experience a range of symptoms that could be made worse by donating blood. Notwithstanding the problem of diagnosis and that the precautionary principle is exactly right, surely that is the point. There should be a common-sense approach that people with ME should not give blood because they are not well enough.
Earl Howe
My Lords, the noble Baroness has put her finger on it. On a precautionary basis, even though the risk is considered low to those with CFS/ME when they are without symptoms, it was considered appropriate to exclude them permanently from being blood donors in case it affected their own health.
Lord Skelmersdale
My Lords, my noble friend gave us the figure for total research into CFS/ME. How much was for biological research as opposed to psychiatric research?
Lord Turnberg
My Lords, is it not the case that we have not been able to discover the cause of this very unpleasant disease so far and we have no real effective treatments? While we are waiting for both of those, the best form of management seems to be cognitive behavioural therapy. Does he agree?
Earl Howe
My Lords, cognitive behavioural therapy is indeed part of the NICE recommendations, but only a part in so far as it is appropriate for any chronic condition to have such therapy. I am sure that the noble Lord agrees that the NICE guidance recognised a clinical and physical basis to this condition as well. Therefore, a multifactorial approach is appropriate.
Health: Diabetes
Earl Howe Excerpts(13 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Harrison, very much indeed for tabling this Question, and indeed other noble Lords for their contributions on such a very important aspect of care for people with diabetes.
As we have heard, the latest figures suggest that 3 million people—about 7 per cent of the adult population—now live with the disease. Many experience severe complications, most notably heart disease, stroke, kidney failure, loss of sight and limb problems. The growing numbers with the disease are a prelude to many more suffering the worst ravages of the condition. Already the human cost is truly awful. The noble Baroness, Lady Young, whom I warmly congratulate on her appointment, gave us the figures on amputations resulting from complications in diabetes, making it the single most common cause of non-traumatic limb amputation. As she reminded us, this will inevitably have a major impact on a patient’s life. They may lose their job, their income and status, have reduced mobility and suffer from depression. However, as the noble Baroness rightly said, with the right care, it is estimated that four out of five amputations could be prevented. Eighty-four per cent of all major amputations in diabetes are preceded by ulceration, with at least 49,000 people developing foot ulcers every year.
Regular foot reviews with advice on prevention and prompt treatment of ulcers are essential. If identified early enough, foot complications can be treated effectively. Therefore, it is vital that every person with diabetes has access to a multidisciplinary specialist diabetes foot team as soon as they need it. The noble Baroness, Lady Thornton, was right in all she said in that connection. Dr Rowan Hillson, National Clinical Director for Diabetes, considers diabetic foot care services and the prevention of amputations as a major priority.
The Department of Health welcomes the publication of Putting Feet First, produced in partnership between our service improvement team, NHS Diabetes, and Diabetes UK. The report highlights the importance of proper management of diabetic foot disease. The evidence shows that the introduction of multidisciplinary specialist diabetes foot teams has led to a significant reduction in the number of amputations.
In addition to the consequences to a patient’s quality of life, there is a significant financial impact on the NHS. This gets to the heart of the question of the noble Baroness, Lady Thornton, about how we can afford this. Diabetic foot care is part of the QIPP long-term conditions programme, which is the department’s programme to improve the quality of NHS care, while making substantial savings which can be ploughed back into the NHS. By reducing unnecessary amputations, money is saved—the noble Lord, Lord Harrison, was absolutely right—not only on the clinical procedure, but on the longer term rehabilitation and social care costs.
Reducing the amputation rate by half would save the NHS more than £10 million a year. The prevention and good management of foot ulcers could save considerably more. NHS Diabetes is working on the economic case for improving foot care services. It is currently facilitating 10 local projects specifically focused on improving foot care services. In addition and in partnership with several other organisations, NHS Diabetes has published a commissioning guide for diabetic foot care services. This responds to the need for nationally recognised minimum skills for the commissioning of diabetes foot care services. This will stand the GPs in good stead when they come to commission services for diabetes.
A number of Peers spoke about prevention. The NHS is starting to focus on preventing foot complications. In some parts of England, the amputation rate has been drastically reduced by establishing integrated multidisciplinary specialist foot care teams. In particular, Ipswich and the Imperial College Healthcare NHS Trust now have amputation rates among the lowest in Europe. However, the noble Baroness, Lady Young, was right to say that the NHS must do more to embed this approach across the country.
The noble Lord, Lord Harrison, asked about NICE. I am pleased to tell him that NICE is finalising guidelines, to be published in March next year, on the in-patient management of people with diabetic foot ulcers and infection. I can reassure the noble Lord on a more general level about diabetic medication. Prior to the introduction of value-based pricing, which is what we wish to move to, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I assure the House that NICE will continue to play an important role in advising on quality standards of treatment in the NHS—including after the introduction of value-based pricing.
Last year, the National Diabetes Inpatient Audit revealed that one-in-30 patients with diabetes in hospital developed a preventable foot ulcer. NHS Diabetes is making vigorous efforts to ensure that every in-patient with diabetes has a foot check and appropriate preventive care. We will repeat this audit of diabetes care in hospitals next week. More than 90 per cent of acute trusts in England will participate. The audit includes questions on foot checks, the management of complications, prescribing and patient experience. The results will help us to identify the places that need to improve and drive forward change in those areas. NICE clinical guidelines recommend annual foot screening for all people with diabetes and the targeting of prevention and treatment to those at high risk. We will continue to work to ensure that these guidelines are reflected by PCTs when they commission diabetes services.
As many noble Lords pointed out, patients have a role to play. They must learn to manage their condition effectively, and there is strong evidence that a healthy lifestyle—maintaining a healthy weight and so on—along with good treatment can prevent disability and reduce mortality. The noble Lord, Lord Harrison, was right again when he said that education is key to empowering patients to be partners in their own care. NICE has highlighted the importance of structured education in supporting people with diabetes to manage their condition. However, education across the country is patchy, so we are working with NHS Diabetes to see how we can spread these education programmes more widely across the NHS.
The noble Lord also mentioned diabetic retinopathy, which is another serious, preventable complication that can cause blindness. Screening is the responsibility of the national screening committee. Ninety-five per cent of people with diabetes were offered screening in the 12 months to June this year. The department is supporting the minority of primary care trusts that have not offered screening to all people with diabetes, to ensure that they do so as quickly as possible.
I could speak for some time about the importance of early diagnosis. The best way to avoid the complications of diabetes is to prevent people from getting it in the first place. We are committed to doing far more to prevent diabetes wherever possible. Here, I refer to type 2 diabetes, which often is related to obesity and lack of exercise. Around 80 per cent of cases could have been prevented if the person had led a healthier life. Much of that has to do with improving the general health of the population and educating people about good and healthy ways of living.
The noble Baroness, Lady Young, spoke about the need to pick up undiagnosed cases of diabetes. She is of course correct. The NHS health check programme will play a significant role in the early detection of diabetes. As noble Lords will know, the health check is a risk assessment and management programme for everyone between the ages of 40 and 74. It will assess an individual's risk of a variety of conditions, including diabetes, and will support them to reduce their risk. This could prevent more than 4,000 people per year from developing diabetes, and detect at least 20,000 cases of diabetes and kidney disease earlier, in order to allow better management of the condition. Most of the care for people with diabetes is delivered in the community and through primary care. The relationship between primary and specialist services is central to the management of complications and the prevention of admission for amputations.
I have a little time to answer questions. The noble Lord, Lord Harrison, asked about the number of specialist diabetes nurses and diabetologists. We do not collect these data, but we know from the 2009 Diabetes UK survey that 1,278 specialist diabetes nurses were working in the UK in 2007. The noble Lord also pointed to a number of international comparisons. It is often difficult to make international comparisons of prevalence because of the way in which data are collected. The Yorkshire and Humber Public Health Observatory published a recent estimate of the prevalence of diabetes in England that suggests that there are 800,000 people with diabetes who do not yet know it.
The noble Lord spoke about sport in schools and about targeting those who are most at risk from diabetes. The noble Baroness, Lady Hussein-Ece, also spoke in this vein. The key here is for Governments to work with local commissioners to promote the benefits of investing in physical activity and to ensure that local investment in that area is based on an assessment of need. We will set out a strong business case for investment in physical activity, which evidence shows is one of the best buys in public health.
I think that generally decisions taken locally are the way forward. In particular, local commissioners are best placed to target groups that are most at risk from inactivity. The Let’s Get Moving model, which implements brief interventions in primary care, is a good example of that approach.
Similar considerations apply when we reflect on the concerns of the noble Lord, Lord Harrison, about the postcode lottery of services. Healthcare organisations, with their knowledge of the healthcare needs of the population around them, are best placed to determine the services required to deliver safe and effective care.
The noble Baroness, Lady Hussein-Ece, as I mentioned, talked about high-risk groups. We are committed to reducing mortality rates from diabetes. Dr Rowan Hillson, the National Clinical Director for Diabetes, chairs the working group, Good Diabetes Care for All, which has brought together leading stakeholders and providers of diabetes services who are concerned with inequalities. I say to the noble Lord, Lord Rennard, that to support NHS organisations to design services that reflect the whole diabetes community, NHS Diabetes has produced a comprehensive diabetes commissioning toolkit to provide advice and support for commissioners.
Time prevents me from answering all the other questions, to my great regret, as I have copious answers in front of me. However, I shall just say that I believe that the principles that we have set out in the White Paper of pushing power downwards, paying for quality and strengthening the voice of the patient will bring fresh impetus to improving outcomes for diabetes. This is not an issue that the NHS can ignore. We need to strengthen both preventive action and treatment for diabetes. By doing that, we can have a huge impact on the quality of people’s lives.
Health: NICE
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Baroness Sherlock
To ask Her Majesty’s Government which groups were consulted prior to the announcement that the National Institute for Health and Clinical Excellence was to lose the power to decide that some drugs may not be supplied by the National Health Service.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is important to make clear that the National Institute for Health and Clinical Excellence does not have any powers to ban the use of drugs in the NHS, so suggestions that this is a role that will be removed from it are based on a misunderstanding of the position. Our NHS White Paper makes it clear that the role of NICE will continue and, indeed, that it will be extended.
Baroness Sherlock
My Lords, I thank the Minister for that Answer. I am a little confused, but perhaps he can help me to understand the change. In the world that he envisages, is it intended that every single GP consortium will take its own decision about which drugs it is willing to fund? If that is the case, will it be about every single individual drug or treatment? And, if that is the case, can the Minister explain how he will protect patients from the uncertainty and confusion that must arise from a return to a postcode lottery of that magnificence?
Earl Howe
My Lords, currently the NHS is faced with the decision of whether to say in effect yes or no to a new drug at the price that is proposed by a pharmaceutical company. We want to change that so that the price of a drug to the NHS is based on an assessment of its value, rather than pharmaceutical companies being free to set whatever price they choose and expecting the NHS to pay. So value-based pricing, which is the term we have used, will ensure that licensed and effective drugs are available to NHS clinicians and patients at a price to the NHS that reflects the value that they bring. That should get rid of the postcode lottery.
Lord Alderdice
My Lords, of course we already have four NHSs in our United Kingdom. What discussions are there among the authorities of the four NHSs when decisions are being taken about medications of this kind?
Lord Turnberg
Does the Minister agree that to devolve responsibility for prescribing expensive drugs to GPs faces them with a very difficult ethical dilemma? Should they prescribe a very expensive drug, costing thousands of pounds, with only marginal benefit for the heart-rending patient with cancer facing them, knowing that to do so may prevent them from funding 20 or 30 patients requiring eye operations or hip replacements or drugs for schizophrenia, or should they refuse that treatment? Have the Government thought through the implications of devolving the cost-benefit analysis that NICE does so well?
Earl Howe
My Lords, I think the noble Lord has perhaps misunderstood the purpose of the plans that we have set out. Prior to the introduction of value-based pricing, we will continue to ensure that the NHS funds drugs that have been positively appraised by NICE. I hope that that reassures him that clinicians are not going to be placed in an awkward position. We will be consulting on our plans for value-based pricing before the end of the year, but I can assure the House that the point of moving to a new pricing system is to increase patient access to new effective drugs. That is what we aim to do.
Baroness Trumpington
My Lords, my noble friend has already spoken about the time it takes to develop a drug—often many years. This costs money and accounts, in some cases, for the high price of the drug.
Earl Howe
My noble friend, with her experience, is of course quite right. I am told that it costs upwards of $1 billion to develop a new molecule and bring it to the market. It is a very expensive process. That is recognised in the freedom of pricing that currently exists for drug companies at launch and in the patents that they are able to enjoy in subsequent years.
Lord Crisp
My Lords, I declare an interest as I was in the Department of Health at the time that NICE was created. If the Minister accepts that the NHS, which spends upwards of £11 billion a year on drugs, is right to have a clinically-led method of assessing whether they work satisfactorily, will he confirm—there seems to be some confusion—that that will not be replaced by some hundreds of separate ways of doing the same thing? Will he also confirm that, whatever new arrangements he has in mind, the Government will speed up the process? There is sometimes that complaint about the NICE process at the moment.
Earl Howe
My Lords, we have been very clear that NICE, which enjoys international pre-eminence in the evaluation of drugs and health technologies, will continue to have an important expert advisory role, including the assessment of clinical benefits for new medicines. The noble Lord will know, I am sure, that in recent years NICE has done a lot to speed up its evaluations of new medicines and has introduced end-of-life flexibilities, for example, which have meant that patients have had increased and improved access to those new medicines.
Healthcare
Earl Howe Excerpts(13 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been an extremely wide-ranging and well informed debate, and I thank my noble friend Lord Hunt of Wirral for raising these important issues and all noble Lords who have spoken very eloquently. I share the wish that we had more time to debate these matters.
Just three months ago, my right honourable friend the Secretary of State for Health published the White Paper, Equity and Excellence: Liberating the NHS. It is an ambitious plan for reform. It is focused around three key purposes, which are the three themes of today’s debate: first, to put patients first and for patients genuinely to feel that no decision is made about them without them; secondly, to concentrate not on inputs and processes but on outcomes and to build a culture of evidence and evaluation and for innovation and evidence to drive quality care; and thirdly, in aiming to deliver the best care, we must empower the people whose responsibility it is to deliver that care. We will give general practice the power to commission services on behalf of patients, combining clinical decision-making with control of resources.
The Government are determined to improve the quality of the NHS and the outcomes for patients. Our ambition is clear: it is for the health outcomes in this country to be among the best in the world. Today, the NHS has some of the best people and the best facilities in the world, and I do not in the least belittle the improvements made to the NHS by the previous Administration, but the fact of the matter is that when it comes to what is really important—to outcomes—we lag behind. I hope that all noble Lords agree that patients deserve better. The NHS can be better, and with the reforms we have set out in the White Paper, it will be better. I know that there is a wide range of opinion about the White Paper. There always is when you try to do something substantial and challenging, but the Government have been encouraged by the widespread acceptance of the vision that we have set out and the principles of our reforms.
To deliver the best care, we must empower the NHS staff whose responsibility it is to give that care. In essence, GP-led consortia, led by GPs in close partnership with other healthcare professionals, will establish the range of services and contracts needed to give their local population the high-quality services they need and the choices they want.
The success of GP commissioning decisions will be determined by the relationships that they develop with others. Local specialist community nurses will be there to help GPs design the best community services, just as hospital consultants will be essential for designing specialist pathways before, during and after a period in hospital. Local authorities will be crucial for helping to integrate health with other local public services to optimise outcomes.
GP commissioning will not turn GPs into managers but it will enhance their role as leaders. When it comes to day-to-day managerial and administrative tasks, consortia will have a separate budget with which to buy in the support that they need, be that from a local authority, a charity, an NHS provider, an independent contractor or elsewhere. I say to the noble Baroness, Lady Thornton, that, in effect, there are going to be pilots. We plan to roll out pathfinder consortia over the next few months that will indeed pave the way and learn lessons that others can follow. GP commissioning also opens up the potential for working closely with local authorities.
Baroness Thornton
My Lords, the pilots will be running at the same time as the legislation is going through Parliament. I fail to see how that will influence the legislation.
Earl Howe
My Lords, under current powers introduced by the noble Baroness’s own Government, GP commissioning can take place within certain limitations, but it is possible for GPs to engage now in the kind of joint working that we envisage and indeed that her Government put in place. I see no inconsistency there, and I think that that will helpfully inform our debates on the Bill.
GP commissioning, as I said, opens up the potential for working closely with local authorities to jointly commission services, even for the pooling of budgets to tackle local priorities. For example, by working closely with the local authority and social care providers, far more can be done to help older people or those with a disability to live independently, reducing their reliance on the NHS by avoiding things such as hospital admissions.
GPs will lead but they will not be alone. The NHS commissioning board will be there to support and advise GP commissioners and to share and spread their experiences. There will be no need to reinvent the wheel hundreds of times. One thing that the commissioning board will do as little as possible, though, is tell health professionals how to do their job.
We will also give far more power to patients. Research clearly demonstrates that treatment is better and often cheaper when the patient is an active participant in their care, not simply a passive recipient. In the coming years, we will give patients real control over when, where and by whom they are treated. They will be central to all decisions about their aftercare, often—where appropriate—spending their own budget in a way that suits their needs rather than the needs of the system.
Personal choice will not be the only way that people will be able to shape their care; they will also have a say in how local services develop. Strong local democratic accountability will be an essential part of the new system. Patients will have a strong voice in local decision-making through local authorities and HealthWatch, a new patient champion. For the first time, local people will have real powers of scrutiny over local health services.
We are very good at treating ill health in this country but we are less good at preventing it. We have the highest rates of obesity in Europe, rising levels of drug and alcohol use and, despite recent falls, stubbornly high rates of smoking. As a result, nearly one-quarter of all deaths in England stem at least in part from an unhealthy lifestyle. We have to do far more to stop people from needing treatment in the first place—to keep people healthy. We need a new emphasis on public health. Later this year we will publish a second White Paper on public health. Its aim will be to transform our approach to public health, protecting the public from health emergencies such as swine flu and improving the nation’s overall health and well-being.
I turn to some of the questions that have been asked. As I said earlier, the debate has ranged far and wide, and there have been a great many questions. We are short of time and I apologise to those noble Lords to whom I shall have to write, but I shall endeavour to cover as many topics as I can.
The speech of the noble Lord, Lord Winston, was uncharacteristic of him. I am sorry that he does not buy into the vision that we have set out. I am sorry that he does not think that we published the White Paper in good faith. The noble Lord gave the House to believe that the considerable efficiencies which we have signalled to the NHS it needs to achieve over the next four years were initiated by this Government. He will, I am sure, recall that they were in fact instigated by the previous Government. They are necessary and have nothing whatever to do with the Government’s White Paper. We need to treat more patients for approximately the same money without diminishing quality. That is the challenge.
I could hardly believe what the noble Lord said about the research budget. The announcements that we have made about research, arising out of the spending review, have been widely welcomed by the research community. We were clear that we wanted to protect science and we have done so. In the current economic climate, that is exceedingly good news.
The noble Lord, Lord Turnberg, in particular, should be reassured of our commitment to the promotion and conduct of research as a core NHS role. The White Paper makes that commitment clear. It also commits the department to a culture of evaluation. The reasons are straightforward. Research provides the NHS with the new knowledge needed to improve health outcomes. Research enables the department to know whether our policies are effective, cost effective and acceptable. The Government are committed to maintaining a ring-fence on research funding and will cut the bureaucracy involved in medical research. Work is in hand to achieve that.
The noble Lord, Lord Winston, also expressed scepticism about the whole idea of measuring health outcomes. Again, I was astonished that he, of all people, should pour cold water on our wish to do so. Just because it can sometimes be difficult to measure certain outcomes in a meaningful way does not mean that you should just give up. Great care must, of course, be taken when interpreting outcome indicators. You cannot simply make black-and-white judgments. However, if we focus only on processes, we risk creating a whole system of accountability that has lost sight of the overall purpose: improving the health of patients.
The noble Baroness, Lady Wall, asked me to underline the importance of local decision-making in the NHS. I readily do so. Those in a position to know what services are required to meet the needs of their patients are those closest to those patients—not politicians in Whitehall, but local doctors in general practice, local doctors and managers in hospitals and patient groups with local knowledge. All of this is part of our vision, which we intend to give substance. I was grateful to the noble Lord, Lord Mawson, for all that he said on this.
I welcome the remarks of the noble Lord, Lord Beecham, about health and well-being boards. It is not only they that will be scrutinising their own activities. As part of the public health service, health and well-being boards will be subject to quality and outcome standards set by the Secretary of State, and will be supported in their efforts by the public health service centrally.
The noble Baroness, Lady Masham, spoke in her characteristically impassioned way about patient safety. I agree with her that patient safety is absolutely vital. It is a key domain of our proposed outcomes framework; a key part of the quality agenda. My noble friend Lady Knight will, I am sure, agree that the most important thing that we need to do is bring about an open and transparent safety culture within all NHS organisations, a culture that is open about when mistakes are made and in which the number of serious incidents falls. Most importantly, it must be an NHS that learns from its mistakes.
The noble Baroness, Lady Masham, referred to the case of the tetraplegic man in Wiltshire whose life-support machine was cut off. This is a tragic and deeply distressing case, currently being investigated by the Nursing and Midwifery Council. Under the new registration framework, introduced in April 2010 for NHS trusts, all providers of regulated activities must register with the Care Quality Commission and meet a set of 16 requirements of essential safety and quality. These include a requirement to ensure that all staff have the necessary qualifications, skills and experience, which are necessary for the work to be performed. All agency staff must meet the same professional standards as permanent staff, as set out by the independent regulator, the CQC and each local safeguarding board. The Department of Health expects all NHS trusts to ensure that they employ appropriately qualified and supervised locums and agency staff.
My noble friend Lady Miller set out her view on which outcomes patients want. Her remarks were very helpful. I am pleased that there appears to be much commonality between what she set out and what was included in our proposals for the NHS outcomes framework. At the highest level, the outcomes that we felt mattered were preventing people dying prematurely; enhancing the quality of life of patients with long-term conditions; supporting people to recover from acute episodes of ill health and following injury; ensuring people have a positive experience of care; and, finally, treating people in a safe environment and protecting them from avoidable harm. Those domains get very close to what most of us would regard as a synoptic view of what good outcomes mean.
The noble Lord, Lord Turnberg, spoke about the need to achieve integrated care across primary and secondary sectors. I agree with him. The purchaser and provider split that the White Paper refers to must not be seen as a reason or excuse for GP consortia not to seek the advice, support and collaboration of clinical expertise on the provider side to ensure that the best possible services are commissioned for patients.
The noble Lord, Lord Mawson, asked how we can ensure that GPs will work across the community and public sector generally. Health and well-being boards have a critical role to play in co-ordinating a strategic patient-centred approach at a local level. GPs, local community representatives and democratically elected councillors will be tasked with making sure that they act on behalf of their patients and communities to deliver integrated services. A board will have a formal duty to involve and consult local people.
The noble Lord, Lord Beecham, asked in particular how GP consortia will work with local authorities. We have proposed that local government should have an enhanced responsibility for promoting partnership working and integrated delivery of services across the NHS, social care, public health and other services. It will be important for GP consortia to work in partnership with local authorities—for example, contributing to joint assessments of the health and care needs of local people and neighbourhoods, and ensuring that their commissioning plans reflect these needs.
Lord Beecham
What steps will be taken to ensure coterminosity between consortia and the relevant local authorities?
Earl Howe
This is obviously an issue that is in the minds of those of us in the department as well as those in the health service more widely. It is difficult to give the noble Lord a clear answer at this stage. Coterminosity does help; I agree with him. However, it is too early for me to tell him exactly how consortia will be configured. We can return to that issue.
As part of the consultation exercise, we specifically asked GP practices to begin making stronger links with local authorities and to see how they can best work together. We are currently reviewing the responses that we have received on this.
My noble friends Lord Alderdice and Lady Hussein-Ece spoke well about having informed and engaged patients. This goes back to what I was talking about a moment ago—“no decision about me without me”. That principle is a critical plank of our policy. Shared decision-making means patients jointly working with clinicians to ensure better outcomes and higher satisfaction. As my noble friend Lady Fookes said, the idea is to make the NHS genuinely patient-centred.
My noble friend Lady Hussein-Ece made the vital point that our need to focus on outcomes must reach well beyond simply measuring clinical outcomes. We need to measure patient-reported outcomes as well as patient experiences. Our proposed outcomes framework, as I have just outlined, seeks to do this. However, it is not all about measurement. It is critically important that all parts of the system, whether providers or commissioners, listen to and engage with patients, patient groups and the public more widely about their concerns and ambitions. That is exactly why we have set out proposals to strengthen the patient voice in the new system. The design of HealthWatch draws on the best of previous models of patient and public engagement.
With great respect to the noble Lord, Lord Rea, I fundamentally take issue with his point that all the major health think tanks disagree with our reform proposals. Most, if not all, agree with the vision of a health service judged against outcomes with the patient at the centre of commissioning and provision. The questions they have asked—they are natural ones—are mainly around the implementation. We have consulted on the implementation and will publish our response to these consultations. I look forward to debating the details of our proposals with him and the noble Baroness, Lady Armstrong, when the Health Bill reaches the House. I say to the noble Baroness, Lady Thornton, that that is likely to be in the spring of next year, although I hope that she will not hold me to a precise date.
The noble Lord, Lord Rea, asked us to rethink the whole idea of GP commissioning. I say to him that reform is not an option but a necessity if we are to sustain and improve our NHS. The fundamental problem is that PCT commissioning is remote from patients and does not have sufficient involvement of GPs and clinicians, who are those closest to patients and whose referrals and decisions incur the expenditure of the NHS budget. They are the people who can do much to improve the quality of care, but it needs to be clearly understood that our proposed model does not mean that all GPs have to be actively involved in every aspect of commissioning. A smaller group of primary care practitioners is likely to lead consortia.
I could address many other matters and I am sorry that I do not have time to do so. As I say, I will write to noble Lords. I apologise to them in that the clock is against us. I hope that we can come back to these matters. Suffice to say now that we are living in a financially constrained environment. An extra penny spent on new cancer drugs is excellent. We have the luxury of being able to spend those extra pennies within the confines of a protected budget and of being able to plan on the basis of stable finance over the next three years, unlike colleagues in some other departments. We also have the luxury of being able to plan for higher quality, integrated, patient-centred, outcome-focused health services led by clinicians and patients. I look forward to doing that. Leadership is about making hard choices in difficult times. The choice we have made is to put health first, and the way to do that can be put very briefly—we need to trust the NHS.
Health: Spending Review 2010
Earl Howe Excerpts(13 years, 11 months ago)
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Baroness Thornton
To ask Her Majesty’s Government whether, in the light of Spending Review 2010, they will meet the commitment to free prescriptions for people with long-term conditions, the right to one-to-one nursing for cancer patients and the target of a one-week wait for cancer diagnostics.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, following the spending review, some of the programmes announced but not implemented by the previous Government will not be taken forward. We will, however, explore options for creating a fairer system of prescription charges and exemptions, taking into account the financial context. We are committed to improving early diagnosis of cancer and to ensuring that cancer patients have the care and support they need. Our updated cancer strategy, published later this winter, will set out the future direction for cancer care.
Baroness Thornton
I thank the noble Earl for that Answer, which goes some part, but not definitively, towards answering my Question. According to the Conservative Government’s own figures, waiting lists to detect cancer and other serious conditions have almost doubled since Andrew Lansley scrapped the 18-week target and other targets. We know that the quicker cancer can be detected, the better the likely outcomes. How does the Minister justify this growth in waiting lists, made worse by the CSR, and what do the Government intend to do to get back to a situation of reduced and reducing waiting lists that previously existed during the Labour Government? How long does the Minister think that that will take?
Earl Howe
My Lords, the noble Baroness is completely misinformed and wrong. The Government have not scrapped the cancer waiting time standards. Therefore, the figures that she referred to can have no bearing on the scrapping of the 18-week target, which is quite separate. People with suspected cancer will still benefit from the two-week waiting time target. That is clinically underpinned and we are keeping it. The statistics for those waiting for diagnosis on cancer are down very sharply over the longer term. There are, of course, fluctuations from quarter to quarter. The median waiting time at the moment is just under two weeks, and 95.5 per cent of people are seen within two weeks. That is an acceptable figure, although we of course maintain a close watch on the trends.
Lord Walton of Detchant
My Lords, part of the Question refers to the exemption of prescription charges for people suffering from long-term conditions. In my professional capacity as a neurologist, I looked after many such patients. Is the noble Earl aware that, as a result of recent research in molecular biology and genetics, many people with previously incurable conditions which are genetically determined are facing the prospect of drugs becoming available to treat their condition—so-called orphan or ultra-orphan drugs? Because these drugs need to be taken on a long-term basis, can we have an assurance that, as they come on stream, they will be made available to patients who will then be exempted from prescription charges when receiving this kind of treatment?
Earl Howe
The noble Lord raises two issues: access to new medicines for sufferers from cancers, particularly rarer cancers; and prescription charges. On the first, he will know that we have already created a cancer drugs fund to enable those people who cannot access cancer drugs to apply for funding for those drugs. That was part of the spending review announcement made last week. On the issue of prescription charges, we are looking for ways to make the system fairer than it is at the moment. We have not implemented the previous Government's plan to exempt all people with chronic conditions. Frankly, it was not affordable in the current context. However, we are looking at other means of creating fairness in the system.
Lord Naseby
Is my noble friend aware how important it was that he re-emphasised that there had been absolutely no change in the targets for dealing with cancer patients? Is it not surprising to him that the opposition spokesman was not aware of that fact? If we are to have a further report before the end of the year, will it include a review of NICE’s attitude to all cancer drugs, and of their availability to NHS patients?
Earl Howe
My Lords, we believe that there is a long-term role for NICE, not least in the area of assessing the clinical effectiveness of drugs. In the longer term, we believe that the problem that my noble friend identifies can be addressed more satisfactorily by a system of value-based pricing for medicines, which will mean that the price of a medicine will reflect its value to the patient, as assessed. That is a longer-term exercise that we cannot bring in in a hurry, but we are extremely conscious of the problem that my noble friend alludes to. Having said that, I stress that NICE will remain at the centre of our plans to roll out quality in the NHS.
Lord Wills
My Lords, the Minister has just accepted that early diagnosis is key to the survival rates for cancer. Can he confirm that his Government is indeed scrapping the Labour Government's commitment to reduce to one week the wait time for test results for cancer? If he can confirm that, does he seriously believe that extending the prescribed time for diagnosis results is going to help the health outcomes of those living with cancer?
Earl Howe
My Lords, there is no question but that timely diagnosis of cancer is extremely important. I do not think that anyone would argue with that. However, we believe that there may be more cost-effective ways of improving access to diagnosis than just imposing a blanket prescription—which, incidentally, has a very high price tag attached. The spending review settlement includes funding for improving early diagnosis in the context of the cancer reform strategy that we are reviewing, and we will set out our plans on that in more detail later in the year.
Contaminated Blood (Support for Infected and Bereaved Persons) Bill [HL]
Earl Howe Excerpts(13 years, 11 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I congratulate the noble Lord, Lord Morris of Manchester, on the reintroduction of the Bill and echo the noble Baroness, Lady Wheeler, in paying tribute to the noble Lord. On a personal level, I am sorry that I was unable to be present at the Second Reading of his Bill in the previous Session, but I am pleased to be able to rectify that situation today, albeit on a different side of the House.
Since this debate was scheduled, an important development occurred in another place, which is of direct relevance to the debate today. My honourable friend the Under-Secretary of State for Public Health laid a Written Ministerial Statement on 18 October which stated that the Government are reviewing a number of aspects of the support available to those affected by contaminated blood. This includes ex gratia payments for hepatitis C, access to insurance, access to nursing and care services, and prescription charges.
I can confirm to my noble friend Lady Hussein-Ece that the review will look at a number of aspects of the hepatitis C payments scheme, including the size of payments, whether annual payments should be made, payments to spouses or dependants of those who died before the scheme was set up, and additional payments in respect of spouses or dependants of those who are still alive. The terms of reference of the review have been placed in the House Library, and I can confirm to the noble Baroness, Lady Wheeler, that the issue of free prescriptions for this group will indeed form part of the Government’s review. I believe that my honourable friend sent copies of the Statement to the noble Lord Morris of Manchester, and the noble and learned Lord, Lord Archer of Sandwell.
It is important that the House understands that this review is under way and that Ministers of this Government are not impervious to representations made to them to reconsider these matters. The noble Lord, Lord Morris, is I hope already aware of my sympathy for the group of people affected by this tragedy and the fact that I recognise and respect what he is trying to achieve with this Bill. Nevertheless, I have to be candid in expressing some reservations as to the need for legislation on this issue. We all acknowledge the plight of those affected, but in debating the Bill we should consider whether it delivers tangible benefits for those affected by this tragedy. In this respect, there are three main themes in the Bill that we need to consider: first, improving treatment and services for those affected by this tragedy; secondly, preventing a similar tragedy occurring in future; and thirdly, financial support for those affected.
I will start with the issue of improving treatment and services for those affected. This Government are firmly committed to the principle of ensuring that NHS services for all patients are of the highest possible standard, and that standards continue to improve. That principle is at the centre of our approach to the NHS. It applies as much to those infected by contaminated blood as to any other patient group. Where services are failing or inadequate, there are established procedures in place to address this. Clause 1, the main clause in the Bill, aims to establish a statutory committee,
“to advise on the treatment of haemophilia”.
The purpose of the committee would be to provide advice on the selection, procurement and delivery of therapies, as well as access to those therapies, for haemophilia patients. But what additional benefit would be gained by placing the proposed committee on a statutory footing? The only clinicians that the Bill stipulates should be members of the proposed committee are the haemophilia centre doctors themselves. I take this to be implicit acknowledgement of the effectiveness of haemophilia doctors in using their clinical expertise to secure the best treatments for their patients. We have to ask: what more is to be gained from their forming a committee?
I recognise that there is a wider issue here of patients being involved in decisions about their care and that, historically, haemophilia patients feel that they were subjected to treatment without sufficient knowledge of the risks. However, it is exactly for those reasons that the Government’s White Paper, Equity and Excellence: Liberating the NHS, published in the summer, sets out a vision to place patients at the heart of the NHS, giving them greater choice and control over their treatment, with the objective of making shared decision-making the norm. Progress is already being made in achieving this objective for this patient group through the Haemophilia Alliance, a network of patients, doctors and others involved in caring, which was established in 1999. The Department of Health now formally meets the alliance twice a year. Two such meetings have already been held and the group has unanimously agreed that it would be helpful for all parties to better understand how specialised services for haemophilia patients are commissioned, and to identify how the Haemophilia Alliance can influence service provision countrywide. The alliance is working well, and I have not yet heard a convincing rationale for replicating its role in a statutory committee.
Lord Archer of Sandwell
I am most grateful to the Minister. Does he appreciate that one matter that concerned us was the establishment of a permanent secretariat to the committee, so that one would not have to wait for a meeting of the committee before responding to something that had happened? It would monitor events as they arrived and respond to them quickly.
Earl Howe
I am grateful to the noble and learned Lord. My understanding is that there are established routes of communication to enable the alliance to contact officials in the department if such a contingency were to arise. I am not sure that the fact that the meetings are at intervals makes any appreciable difference in this context.
Clause 3 also focuses on treatment. It provides for a scheme of NHS cards for those infected through treatment with contaminated blood and blood products. These would enable access to NHS services, including prescriptions, free of charge. In fact, the majority of services specified in the Bill, such as counselling and physiotherapy, are already available in England under the NHS, where needed, free of charge. Perhaps I may venture that the real issue for this patient group is not that of cost, but whether they receive high-quality, adequate levels of treatment and care. I recognise, however, that prescription charges are a particular grievance for this patient group, and that some have experienced difficulties in accessing nursing and care services, including specialised counselling. That is why these issues are included in the current Department of Health review.
I was concerned to see that the clause also provides cardholders with priority access to NHS treatment. This could have significant implications. At one level, it would give priority access for everyday treatments such as chiropody services. At another, it could provide for jumping the organ donation queue, which, when organs are at a premium for everyone, cannot be justified. Those decisions must be based on clinical need and nothing else.
Lord Morris of Manchester
My Lords, perhaps I should explain why I made that provision. Other people know all the statistics about the disaster, but I personally knew hundreds of its victims—and now, day by day, I hear of the deaths of valued friends. That is why I approached this in the way that I did. As honorary parliamentary adviser to the Royal British Legion for many years, since 1985, I know that the priority that their members are given under the National Health Service is never abused. No one has ever said that disabled ex-servicemen abuse that privilege. I am certain that the Haemophilia Society will act just as honourably as those who so readily give their lives in the service of this country.
Earl Howe
My Lords, I respect greatly the points that the noble Lord, Lord Morris, has made. Nevertheless, it is difficult to enshrine in legislation priority access to NHS services for an individual group of patients. That is the real issue, but of course I shall reflect the point that he has made.
As I have indicated, the issue is whether patients infected with contaminated blood receive prompt access to the necessary treatment, based on clinical need. I have heard no reports that anyone in this patient group faces difficulties in this regard. I therefore argue that nothing in the Bill would improve treatment or services for those affected by contaminated blood beyond what is already on offer from the NHS or the Department of Health, or is being considered by Ministers.
I turn now to the critical issue of making sure that no similar tragedies occur in future. The Government are firmly committed to ensuring that the blood supply is as safe as possible, and we continue to work to provide ever safer blood and blood products. Clause 2 provides for haemophilia patients to be offered testing for a number of specified infectious agents, and for blood donations to be screened for those agents; yet testing for all but one of the agents is already available to haemophilia patients, and all blood donations are screened for those same agents. The sole exception is variant CJD, for which there is currently no validated test available. We cannot legislate on something that it is currently not possible to implement. The Bill rightly acknowledges that the list of agents for which the blood supply is screened needs to be kept under constant review. There are effective systems in place to ensure that this is done, both within the UK blood services and also through the Advisory Committee on the Safety of Blood, Tissues and Organs, SaBTO—which I can assure the noble Baroness, Lady Finlay, will continue to exist. Therefore, there is no need to replicate this function on a statutory basis.
The Bill also provides for the introduction of prion filtration. The Government are currently undertaking an evaluation of the costs, benefits and implications of prion filtration to inform our decision on whether to implement this recommendation. We do not need primary legislation to do this.
Finally, blood safety is regulated by European directives that set standards of quality and safety for the collection, testing, processing, storage and distribution of human blood and blood components. Blood products such as clotting factors are regulated in accordance with the Community code for medicinal products. Therefore, there is nothing in the Bill that would improve the safety of the blood supply. I fully support the principle of making the blood supply as safe as practically possible, but it is not appropriate to use legislation to require the blood services to adopt a specific technology such as prion filtration. Such legislation cannot properly take account of emerging scientific advances, and it is important for the blood services to retain the flexibility to introduce the most appropriate measures on the basis of expert advice.
I now turn to the subject of Clause 4, the issue of compensation. In recognition of the plight of those affected, the Department of Health has already set up ex gratia payment schemes for those infected with HIV and hepatitis C. It is worth pausing to lay out the level of financial support currently available to people in this group. Those infected with HIV receive a flat-rate payment of £12,800 a year. They may also be eligible for additional discretionary payments. In the year ending April 2010, the average total payment to an individual infected with HIV was £17,400. Those infected with hepatitis C are eligible to receive an initial one-off lump sum of £20,000 when they develop chronic infection. Despite contracting the virus, some people will make a full recovery. However, others may go on to develop serious liver disease. For this group, there is a second one-off lump sum payment of £25,000. All these payments are tax-free and are not counted when calculating individuals’ eligibility for state benefits. Therefore, if they are unable to work for health reasons, they will receive state benefits in addition to these payments.
One of the key elements of this clause is subsection (4), which states that,
“the Secretary of State shall have regard to any comparable compensation schemes offered in other countries”.
I should like to inform the House that previous Governments did indeed have regard to comparable schemes when the Macfarlane and Eileen Trusts for HIV were first set up, and we are taking account now of schemes elsewhere. The current payments for those with HIV generally compare very favourably with payments in other countries, and I direct that remark particularly to the noble Lord, Lord Low of Dalston.
I acknowledge that there are anomalies between the current payments for HIV and those for hepatitis C, whose payments are less favourable. That is why the Department of Health’s current review includes payments for hepatitis C, as well as looking into whether there are any alternative payment mechanisms. In the light of that, the House needs to consider what purpose there is in trying to legislate on this issue.
Finally, Clause 5 requires the review of a number of issues which were covered in the previous Government’s response to the report of the noble and learned Lord, Lord Archer. Again, the question is whether any benefit is to be gained from putting this work on a statutory footing.
The one issue in Clause 5 on which I should like to comment specifically concerns medical insurance. I am aware that patients infected with HIV and/or hepatitis C by contaminated blood either cannot obtain health insurance or are subject to a significant premium loading. However, one of the underlying rationales of the welfare system here in the UK is to provide services for those who cannot obtain insurance, for whatever reason. The whole point of the NHS is that people should not need private medical insurance. For the state to assist a particular uninsurable patient group to obtain private medical insurance would, I believe, set a dangerous precedent that could undermine the core principles of our welfare system.
In conclusion, I should like to address a few of the questions raised in this debate, dealing first with some of those raised by the noble Lord, Lord Morris. He asked what the Government have done in relation to the recent case of variant CJD having been found in a haemophilia patient. My advice is that, although these concerns are of course very understandable, no haemophilia patient has ever developed clinical variant CJD.
The noble Lord, Lord Morris, asked about the calculation of the £3.5 billion—a point mentioned by a number of other noble Lords. A note of how much the department estimated it would cost to replicate the compensation scheme of the Republic of Ireland in the UK has been placed in the Library, and I refer noble Lords to that document.
The question of comparability with Ireland was raised not only by the noble Lord, Lord Morris, but by the noble and learned Lord and the noble Lord, Lord Corbett of Castle Vale, among others. I have taken the opportunity of looking carefully at this comparison. From what I have seen, I am satisfied that the Irish scheme was set up in response to a very specific set of circumstances which are unique to the Republic of Ireland, and I say that not least for the following reason. In an article in the Irish Times dated 5 August 1997, Brian Cowen, then Minister for Health and Children in the Republic of Ireland, and currently Taoiseach, confirmed that the Irish Government knew in 1995 that the Blood Transfusion Service Board had been negligent and had attempted to conceal this fact. I do not believe that I have ever heard the noble Lord, Lord Morris, or others acknowledge the contents of this article.
The noble Lord, Lord Morris, raised the question of Crown immunity in respect of Bio Products Laboratory. I understand that the activities of BPL were covered by Crown immunity and therefore fell outside the requirements of the Medicines Act until 1991. Therefore, it could not be prosecuted under the Act. This immunity did not protect from civil suit but only from prosecution under the Medicines Act. Indeed, some affected persons brought an action in 1988, which was settled out of court. Affected persons did and do therefore have rights of redress in civil law. Our legal advice is that permitting prosecutions under the Medicines Act after all this time would be seen as unfair and oppressive by the courts for various reasons, not least the breach of the European Convention on Human Rights.
The noble Lord, Lord Low, called into question the use of commercial blood products. Most countries experienced similar tragedies as a result of contaminated blood and blood products—even countries that were totally self-sufficient. The fact that the UK domestic blood supply was also contaminated with these viruses does not therefore mean that the tragedy could have been avoided if the UK had been self-sufficient in blood and blood products.
The noble Baroness, Lady Kennedy, asked about the future of benefits in this context. My honourable friend the Parliamentary Under-Secretary of State for Public Health said during the Back-Bench debate in the other place last week that she would be raising the issue of benefit payments with the Minister responsible, and at this point I have nothing to add to that assurance.
I urge the House to consider the Bill very carefully. The contaminated blood issue is enormously emotive, but we should not be passing legislation simply because we have compassion for those affected. All legislation passed by your Lordships’ House must deliver meaningful benefits. I have argued that any changes that this Bill would introduce are limited. Some are impossible to deliver, some are inappropriate, and the tangible benefits that might arise from others are unclear at best. The Bill will not of itself improve patient safety; it will not of itself improve treatment or services; and it will not of itself influence Ministers to agree to more generous ex gratia payments for this patient group. I refer again to the review currently under way. For these reasons, I respectfully suggest to the noble Lord that there is no need for recourse to legislation on the issues that he has brought before us.
Health: Osteoporosis
Earl Howe Excerpts(13 years, 11 months ago)
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Baroness Cumberlege
To ask Her Majesty’s Government what steps they are taking to reduce the number of fractures which result from osteoporosis.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the steps we are taking in this area include guidance via a commissioning toolkit to support organisations on effective falls and fracture prevention and management, NICE’s published guidance on osteoporosis, falls and fractures—NICE is also working on clinical guidelines for hip fractures for publication in spring 2011—and a best-practice tariff which offers financial incentives to hospitals meeting quality standards for hip fracture patients, including a fracture prevention assessment.
Baroness Cumberlege
My Lords, I thank my noble friend for his comprehensive reply and welcome the progress that has been made. We must bear in mind that last year alone, some 65,000 people were admitted to hospitals for hip fractures, which represents an increase of 17 per cent on the previous decade and is one of the highest figures in Europe. Will my noble friend ensure that the outcomes framework currently under review, which concentrates mostly on hip fractures, also includes indicators to reduce all fragility fractures? That would ensure that the NHS puts a comprehensive fracture preventive service in place.
Earl Howe
My Lords, my noble friend is right to say that the outcomes framework will be central to assessing the performance of the NHS and driving up quality generally. The framework is still in development, and my department is currently looking at the responses to the recent consultation and carrying out the necessary analysis to ensure that it is as balanced and robust as possible. Having said that, the consultation document contained a number of proposed indicators that relate to falls and fragility fractures which are candidates for inclusion in the framework, although the department cannot take any final decisions until we have digested all the consultation responses.
Lord Walton of Detchant
My Lords, is the Minister aware that drugs are now available that can halt the progression of osteoporosis? Is he satisfied that there are sufficient facilities in hospitals across the country to carry out bone density measurements, from which the position can be assessed at an early stage to allow those at risk to be given appropriate treatment?
Earl Howe
My Lords, the NHS in England has invested in additional diagnostic capacity over recent years, including the provision of more DEXA scanners, which are bone density scanners. The most recent data I have show that only 145 people in England waited for more than six weeks for a bone scan, and of those only seven had been waiting for over 13 weeks. That does not suggest that there is undercapacity. However, the noble Lord is right to say that several treatments are available, along with many messages put out by the department to promote a healthy lifestyle in order to prevent fractures.
Baroness Massey of Darwen
My Lords, is the Minister aware that a number of excellent leaflets containing information about the prevention of osteoporosis are available? What initiatives are in place to encourage the distribution of these leaflets in libraries, supermarkets, gyms and so on to enable women and men to get the information they need?
Earl Howe
My Lords, information is produced by the National Health Service on the risk of fragility fracture and, indeed, on how to prevent it. A number of good and authoritative sources of information exist on this topic, not simply from the NHS, but I would just say that information on osteoporosis is available on the NHS Choices website, which of course is accessible on computers, including those in libraries.
Lord Alderdice
My Lords, if the normal communal incidence of osteoporosis were to be applied to your Lordships House, it is likely that half or even more than half of its membership would be suffering from it, even if they were not aware of any symptoms. That tells us what a common disorder we are dealing with. Does my noble friend agree that it is important to raise public awareness not just of diagnosis and treatment, but of how lifestyle changes to diet, smoking behaviour and alcohol consumption are extremely important in making sure that these adverse consequences do not arise?
Earl Howe
My noble friend is right. The job of the NHS in its public health role is to provide information about healthy lifestyle choices. NHS Direct does this at the moment, and in the future we will be looking to the new national public health service to maintain the provision of high quality and authoritative health advice. Moreover, as my noble friend says, that advice includes information about the value of a diet rich in vitamin D from oily fish, liver, cereals, eggs and so forth, as well as from safe exposure—I emphasise the word “safe”—to natural daylight.
Baroness Greengross
My Lords, it is well known that if an elderly or frail person living at home has a fall which results in a hip fracture is monitored, a great deal of future pain, distress and huge expense to the NHS can be avoided. Does the Minister agree that installing a fracture liaison service in every health area would reduce this serious situation and that the Government ought to make public that aim?
Earl Howe
The noble Baroness is correct: fracture services have produced some positive results where they have been used in various parts of the country. I can best answer her question in two brief ways. While decisions about the provision of particular services are best taken locally, it will be the outcomes framework, which I have mentioned, and the incentives that go with it, that will determine the extent to which the NHS locally responds to needs related to this area. Funding for the NHS is protected and will increase above inflation every year of this Parliament. In this difficult climate, that demonstrates the Government’s determination to provide the best outcomes from services, including falls and fractures services.