Health: Breast Cancer

Lord Alderdice Excerpts

Monday 3rd October 2011 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness, with her expert knowledge in this area, is absolutely right that access to appropriate treatment, delivered to a high standard, is critical to improving outcomes. We have made a commitment to expanding radiotherapy capacity by investing around £150 million more over the next four years. That is intended specifically to increase the utilisation of existing equipment, establish additional services and make sure that all patients who need the therapy can get it. We are investigating a tariff for IMRT; that is part of our work towards the aspiration to ensure that IMRT is available in at least one centre per cancer network by 2012. It is a matter for local decision-making, but an IMRT development programme is now in place.

[Lord Alderdice]

My Lords, would my noble friend agree that progress in this important area of breast cancer is likely to be found in the identification of molecular markers and the design of appropriate targeted medications, as has been the case in breast cancer with HER2 and Herceptin, for example? Would he acknowledge that it is a very expensive treatment? Although it really improves quality of life as well as mortality and outcome, the expense of not only the medication but the tests themselves is considerable. How will the NHS cope with this important but very expensive progress?

[Earl Howe]

My noble friend makes an extremely important point. That is why we need a body such as NICE, the National Institute for Health and Clinical Excellence, to advise the health service on what treatments represent cost-effective value for money. The tendency of drugs to impose considerable cost on the NHS is very great, as he points out. It is important that clinicians focus on those drugs that really do the best for patients. I am aware that a number of drugs are currently being assessed by NICE with regard to breast cancer.

NHS: Future Forum

Lord Alderdice Excerpts

Tuesday 14th June 2011 Lords Chamber

[Lord Alderdice]

My Lords, I am grateful to my noble friend for repeating this important and welcome Statement. It reaffirms the coalition’s commitment to a reformed NHS, which is patient-centred, clinician-led and outcome-focused. Does he accept that the concerns, which are fully addressed in this Statement, were shared not alone on these Benches but by many Conservative colleagues, as well as patients, professionals and other stakeholders, and others in your Lordships’ House, as exemplified in the national debate instituted by the Government? Will he now confirm that, despite the anxieties that there have been, the duties and responsibilities of the Secretary of State will be reaffirmed in the Bill in the language used when our beloved NHS was established? Will he confirm that there will now be a level playing field and that private providers will not be advantaged against public providers, as was the case under the previous Labour Government? Will he further confirm that Monitor will be redesigned to be more than a mere economic utility regulator but will facilitate co-operation and integration, as well as competition on quality rather than on price?

[Earl Howe]

I am most grateful to my noble friend. He is right that the concerns that arose in relation to the Bill stemmed from many quarters—certainly from my own Benches and his but also from the wider public. I think we took on board those concerns almost as soon as the Bill was published. They were reflected in a large volume of correspondence, a high proportion of which I dealt with. I was keenly aware of the issues occupying people’s minds. I believe and hope that in the Future Forum’s report, and in our acceptance of that report, we have the basis for allaying most of those concerns.

My noble friend asked three questions. The first was around the duties of the Secretary of State. The Statement made clear that, as now, the Secretary of State will remain responsible for promoting a comprehensive health service. It has never been our intention to do anything else. Indeed, the Bill did not specify anything else. That will be underpinned by the new duties that the Bill already places on the Secretary of State around promoting quality improvement and reducing inequalities. We shall be setting out other duties on the Secretary of State to strengthen his accountability.

On private providers, the noble Lord is right. We are clear that private providers should not be advantaged over the NHS. Indeed, the amendments that we will make to the Bill will put that concern to rest, I hope, once and for all.

Monitor will have its duties rephrased. As the Statement also made clear, the duty to promote competition, which is now in the Bill, will be replaced by a different set of duties around patients, integration and the promotion of quality. There will be quite a different flavour to Monitor's duties.

Health: Brittle Bone Society

Lord Alderdice Excerpts

Monday 6th June 2011 Lords Chamber

[Earl Howe]

My Lords, I should be more than happy to see the noble Lord and representatives of the Brittle Bone Society to discuss those matters. I am well aware of the issue he raises. I understand that when an application was made to designate specialised services for children with brittle bone disease as a national specialised service, no similar case was made for adult services. However, if the society or leading clinicians in this field now feel that an application should be made, we would be pleased to refer it to the Advisory Group for National Specialised Services against the normal criteria.

[Lord Alderdice]

My Lords, given that osteogenesis imperfecta is a genetic disorder and that real progress in proactive treatment for sufferers will require progress in genetic medicine, is my noble friend reassured that we retain in this country sufficient researchers, funding and facilities to ensure that sufferers from osteogenesis imperfecta and their families can look to research from this country to see progress in proactive treatment rather than simply to elsewhere, particularly the United States of America?

[Earl Howe]

My noble friend is absolutely right. As he knows, the UK is one of the pioneers of genetic research; it takes a lead role in the international human genome project and its application to medicine. The human genome project has sequenced the 25,000 or so genes that make us human and research is now looking at how groups of genes interact not only with each other but with environmental factors to cause disease. We remain absolutely committed to genetics research and aim to make the UK the best place in the world for that research to continue. If there are proposals relating to this specific condition, my department will be very pleased to receive them.

Health: Cancer

Lord Alderdice Excerpts

Tuesday 10th May 2011 Lords Chamber

[Earl Howe]

My Lords, I pay tribute, first of all, to the James Whale Fund for Kidney Cancer, which is an organisation that I know quite well, as the noble Lord is aware. It is doing tremendous work, not least in the field of specialist cancer nursing but also as regards its care line, on which I congratulate it. The noble Lord asked whether I would agree to meet the fund. For my own part I would be very happy to do so, but it may be more appropriate for my colleague in the department, who deals with cancer services, to do so as well. We recognise that more needs to be done to raise awareness of the signs and symptoms of rarer cancers such as kidney cancer. Our strategy for cancer sets out our commitment to work with a number of cancer-focused charities. Officials have already met such charities and more meetings are planned over the summer.

[Lord Alderdice]

My Lords, the noble Lord, Lord Davies, raised the question of National Institute for Health and Clinical Excellence approval of chemotherapeutic drugs. After a nephrectomy, not much else is available, because radiotherapy is generally not terribly helpful in renal cell carcinoma and other cancers of the kidney. The National Institute for Health and Clinical Excellence has to look, with these often quite expensive drugs, at how much benefit is being achieved for the cost of the drug. It is not an easy decision, which is why the noble Lord, Lord Davies, raised the question of some non-approved drugs. Is the Minister satisfied about the judgments being made by NICE about the benefit as against the cost? They are difficult judgments, but is he satisfied with the judgments being made?

[Earl Howe]

I am grateful to my noble friend. He is absolutely right; these are very difficult decisions to make. NICE issues final guidance on the use of a drug only after very careful consideration of the evidence and wide consultation with stakeholders. The noble Lord, Lord Davies, and, I am sure, my noble friend will be aware that one particular drug has been refused or not recommended by NICE. However, we have established the cancer drugs fund, which will enable individual clinicians on a patient-by-patient basis to apply to access drugs even though they have not been recommended by NICE.

Public Bodies Bill [HL]

Lord Alderdice Excerpts

Monday 9th May 2011 Lords Chamber

[The Lord Bishop of Guildford]

My Lords, I support both this amendment and the two related amendments that follow it. They would guarantee in one way or another that the enormously valuable work of precisely the present ethics committee of the two bodies is continued. I speak in general, so far as a Bishop can ever speak, for the Christian churches and for other faith communities for whom the human embryo and human tissue have moral significance. That is not to say that the present ethics committee is in the pocket, so to speak, of the Bishops or of any faith community leaders. It is not, and the range of views and commitments of its members is and should be wide. However, it would be a serious mistake not to have an ethics committee or expert body specifically to weigh the moral as well as the medico-scientific questions that are involved in this very proper research, not least into the tragedy of infertility.

Also of great significance for me is the serious support of the relevant professional bodies, so I urge the Government to consider these amendments very favourably.

[Lord Alderdice]

My Lords, I declare an interest because my wife is a pathologist who works in the National Health Service. She does no forensic work. Nevertheless, I declare that interest appropriately.

A number of noble Lords have mentioned the importance of the role of the House of Lords in considering such difficult and complex matters. We had plenty of evidence of that even before the Bill came to your Lordships' House, at least in debate on these two issues. Indeed, we had a very fruitful debate on 1 February this year in the Moses Room on the questions. There is a great deal to commend the amendments, although I have some difficulty with the fact that they link the two bodies. They are quite different in many ways and have a somewhat different track record and set of relationships.

I listened very carefully to what the noble Baroness, Lady Deech, said, and I do not disagree with any of it. She put forward her case clearly, but she focused in particular on the HFEA. A whole set of very important issues are involved there, and I hope that my noble friend the Minister may be able to give some kind of comfort to her and her colleagues, because I have a lot of sympathy for her case, as I do for much of what the noble Lord, Lord Walton, said. However, one of the difficulties has been that although there is clearly a need for legislation and for a body that undertakes these matters—the operation of the HTA in Scotland has been rather better than it has in England—it is important to draw to the attention of your Lordships' House that the impact of the way in which the legislation has been interpreted and conducted by the HTA has not inspired confidence, particularly among pathologists. I heard what my noble friend said about that proving what a good thing it is, but that does not show a very nuanced understanding of what is going on.

NHS Reform

Lord Alderdice Excerpts

Monday 4th April 2011 Lords Chamber

[Lord Alderdice]

My Lords, I am grateful to my noble friend for repeating the Statement made in another place and I will not rehearse our support on these Benches for reform of the health service. Some of those reasons were wonderfully spelt out by the noble Lord, Lord Turnberg, in his debate on the NHS last week. However, it is no secret that Members on these Benches do not regard the Bill as it presently stands as perfect. Despite the fact that it did not receive a great deal of attention in the speculative narrative of the noble Baroness, Lady Thornton, it is known that my colleagues want to see changes and indeed have welcomed some of the changes that we have already seen.

I wonder if I may press my noble friend on two issues. The first was also raised by the noble Baroness—the timescale. My noble friend indicated that he sees the timescale as using the Recess, but the Health Secretary wishes to engage and consult with a substantial number of people. Given that, when the Bill comes back after Report in the other place with amendments, which we would welcome, can we expect it to come to this House before the Summer Recess or will the natural break take us a little further? That may be necessary, and some clarity would be helpful, if my noble friend can provide it.

Secondly, in repeating the Statement my noble friend mentioned increasing accountability,

“locally, through the democratic input to the Health and Wellbeing Boards”.

I and my colleagues welcome this, but can he spell it out a little further? At present, the locally elected democratic input to health and well-being boards is extremely modest, so we would be keen to see an indication that something rather more substantial might be possible.

[Earl Howe]

I am grateful to my noble friend. In answer to his first question, it is likely that the period of listening and engagement will extend through the Easter Recess and beyond. The precise duration of the intermission has not been fixed yet because much will depend on the volume of feedback that we receive. While I have not spoken to the usual channels about this, I am still working on the premise that your Lordships’ House will receive the Bill prior to the Summer Recess. I believe that, if the House agrees, we can thereby reach the Bill’s conclusion within a reasonable space of time. That will enable us to adhere to the current timetable for the implementation of our proposals. But that statement does come with what I might call a health warning because we are clear that we want to listen to the opinions of everybody who counts in this, and it could be that the period of reflection may extend into the late spring. But no doubt I will be able to enlighten him further in due course.

My noble friend mentioned the democratic input at health and well-being board level. This is one of the issues that we will want to receive opinions about because I know there has been disquiet on this front. He knows that his party was instrumental in building into our plans the democratic element of health and well-being boards and the fact that they should be situated at local authority level. That was a very positive contribution made by the Liberal Democrat Party which has, by and large, been widely accepted. If there are ways we can bolster that democratic accountability without cutting through the core principles that we have articulated for decision-making in the health service, then we are willing to look at them.

NHS: Standards of Care and Commissioning

Lord Alderdice Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Alderdice]

My Lords, we are all indebted to the noble Lord, Lord Turnberg, for obtaining this debate. The only unfortunate thing is that he did not obtain more than two hours as that leaves us with relatively little time to discuss an issue about which many of us are extremely passionate. However, as an additional service to your Lordships' House, he introduced the debate with understanding, passion and compassion and identified some very real and long-standing problems in the NHS. I wish to pick up on those as they are of enormous importance.

As the noble Lord pointed out, over a considerable time there has been a deterioration in what I might describe as the culture of care. I say “care” rather than “treatment” because, as he rightly pointed out, specialist, high-quality, acute treatment is often of a very high standard indeed; but in areas such as the one closest to my heart—care of the mentally ill, whether in the community or in in-patient care of various kinds—or care of the elderly, as he rightly pointed out, that long-term care has often deteriorated because of cultural changes in the NHS itself. I shall explain what I mean by that.

As the service expanded and became more complex, there was an increasing and necessary focus on management. It became increasingly the case that those who progressed would move into management. The noble Lord referred to this. In most professions, such as social work, psychology and particularly nursing, if someone wanted to make progress, inevitably they moved out of direct clinical care. For the ambitious and capable young nurse, for example—although this state of affairs was not confined to nursing—to make progress in the profession meant focusing on training and development, to move out of direct clinical care and into management, rather than making clinical care a long-term career commitment.

For obvious reasons, this disadvantaged the concern and commitment of the ambitious and capable young nurse for clinical care; the culture was to move into management. Doctors moved in the other direction. They continued to focus on clinical care—even when they got into management, they rarely gave up care completely—but that meant that they were disadvantaged when they were good managers. They tended to let go not of the care side but of the management side, which increasingly became detached from medicine, so doctors became disenchanted with the whole process of management.

In their different ways, our different professions found that the domination of management in the service took us away to a management culture rather than to a professional culture of devotion and care, which is what our NHS ought to be about. It is that change that we need to find a way to reverse. This is the idea of the reforms that are proposed. They are not necessarily the same as the proposals that will come forward, and it will be your Lordships' responsibility to try to change things in such a way that the principles are best expounded in the legislation and ultimately in its implementation. The challenge is how we move to less management focus in care and to more clinical focus, and focus on the patient.

We must move to greater local accountability; greater clarity of governance; competition in quality of care and not in the price of care, because that will be set down in tariffs; and to ensuring that there is a greater integration and collaboration of the various groups involved—public, private, and charitable and non-governmental, which often produce good-quality niche care in various ways. If we can ensure that progress and do it together—I hope that the exercise will be collaborative rather than partisan in your Lordships' House—we will have something to look forward to despite the difficulties that the noble Lord pointed out.

Health: Polymyalgia Rheumatica and Giant Cell Arteritis

Lord Alderdice Excerpts

Wednesday 30th March 2011 Grand Committee

[Lord Alderdice]

My Lords, as the noble Lord, Lord Black of Brentwood, said, we are all grateful to the noble Lord, Lord Wills, for attaining this debate. The two noble Lords who have preceded me in the debate have pointed out a number of the problems of dealing with these disorders. The terms of the debate are polymyalgia rheumatica and giant cell arteritis. Although they are related disorders, there are important differences as well as overlapping and connections.

In the case of the condition that the noble Lord, Lord Wills, was particularly exercised about, he was talking really about temporal arteritis, as giant cell arteritis can happen in other places, the aorta, and so on. The question of early, rapid and irreversible blindness is really a function of temporal arteritis. Indeed, many people who have temporal arteritis also have polymyalgia rheumatica and probably about 15 per cent of those with polymyalgia rheumatica have temporal arteritis. They are overlapping and we do not really know why they come about but the management is very different.

As the noble Lord, Lord Black of Brentwood, pointed out, there are significant problems with the treatment with Prednisolone, although there is not much in the way of an alternative. Very early diagnosis is difficult because there are other disorders that are similar in their symptoms. Indeed, a noble colleague remarked earlier that, listening to the list of symptoms, she began to become concerned about herself. There are many different disorders that can cause some of the symptoms of polymyalgia rheumatica—some even in my professional background in mental disorders. Rushing into treatment may not actually be the best thing and there is not a pathognomonic diagnostic tool. For temporal arteritis it is quite different because, as the noble Lord, Lord Wills, said, it is crucial to get on with the treatment very quickly. If you do not, the blindness supervenes. You might get a good diagnosis but it is all too late. There is a clear diagnostic tool, temporal artery biopsy. It can be done by a physician, surgeon, or whomever, and very quickly the dose of Prednisolone can be instituted. If at all possible, it is better if the biopsy can be done first, and then, even before the biopsy has been looked at carefully, you can start with the treatment. If you start with the treatment immediately it tends the make the diagnostic problems of a biopsy a little more difficult, but the key thing is stopping the blindness.

One of the problems with the difference, overlapping and so on, is how one gets the message across to medical practitioners on how to deal with things, which was the burden of what the noble Lord, Lord Wills, was bringing to your Lordships’ and the Minister’s attention. It is very important to focus on the fact that we are talking about temporal arteritis leading to the blindness. Even the very term itself tends to focus the general practitioner’s mind on when he should become alerted to the range of symptoms, but focusing particularly on those things that might indicate temporal arteritis. In that case, he or she should quickly get a biopsy and start the treatment even before the results come back from the pathologist.

If you mix giant cell arteritis in general with polymyalgia rheumatica, you have a range of difficulties, disorders and treatment approaches that are complicated and cannot be diagnosed very clearly. There are lots of different tests that you might do, by which time the person is blind. That is exactly the kind of problem that the noble Lord has pointed out.

The noble Lord suggested raising the profile and having the Minister make a speech—I wholly agree with his sentiments about the standing of the noble Earl and the beneficent way in which he deals with these matters. He made a number of valuable suggestions about reference to NICE, getting matters across, a “Dear colleague” letter from the CMO, and so on. But, if the main concern is early, rapid treatment to prevent blindness, we need to focus specifically on temporal arteritis and move on quickly to treatment. If the burden of our concern is polymyalgia rheumatica, we ought to go a little more slowly and conservatively because there are other possible diagnoses. There are not obvious diagnostic tools and moving too quickly to treatment and not holding back can be, as the noble Lord, Lord Black of Brentwood, pointed out, more of a tragedy than the disorder itself.

Health: Cancer

Lord Alderdice Excerpts

Wednesday 2nd March 2011 Lords Chamber

[Lord Mawhinney]

My Lords—

[Lord Alderdice]

My noble friend introduced the question of diagnosis, which is increasingly a multi-professional matter, involving pathologists, surgeons, radiologists and so on. This seems self-evidently a good thing. However, is the department accumulating evidence to show that it is actually improving the outcomes? It is of course an expensive procedure to involve so many senior professionals together.

[Earl Howe]

My noble friend is quite right. It does involve often a number of senior clinicians. The key to diagnosis, however, is to get in early, as I am sure he would recognise. The outcomes strategy commits us to saving the additional 5,000 lives very largely through additional identification of early cancer. In fact, 3,000 of the 5,000 lives that we are hoping to save will be saved, we hope, by earlier diagnosis. A good example of that is that over 90 per cent of bowel cancer patients diagnosed with the earliest stage of the disease survive five years from diagnosis, compared to only 6.6 per cent of those diagnosed with the advanced disease.

Health: Mental Health Strategy

Lord Alderdice Excerpts

Monday 14th February 2011 Lords Chamber

[Lord Alderdice]

My Lords, like other noble Lords, I am grateful to my colleague, the noble Baroness, Lady Murphy, for obtaining this debate, albeit, as the noble Lord, Lord Newton of Braintree, said, a brief debate in which it is not possible to deal with such a complex subject as mental well-being and a complex system for dealing with it.

I come to this debate with feelings very different from those of previous speakers. For the whole of my professional life, I spent half my time on Northern Ireland politics and the other half on developing mental health services, particularly psychological services, in Northern Ireland. As a young psychiatrist, I discovered that there were very limited services for alcoholism and drug dependence. There was no proper training for psychological treatments within psychiatry, so I devoted myself to working at that for the next 25 or more years. When I retired at the end of March last year, part of the reason for doing so was because I felt increasingly depressed about the way that mental health services were going. For the first 10 or 15 years, every year I could look at services, not just the one I was working in, but more generally, and see improvement and development, but for the past 10 or 15 years, everything seemed to get worse every year in a number of different ways. In devoting myself more to working in Parliament to try to make changes, this document is the first time in the past 10 or 15 years that I have felt seriously encouraged that people are beginning to address mental health and well-being problems in a proper and serious way.

I shall describe the document from two or three perspectives. First, it is the first document I have seen issuing from government that recognises that mental health and well-being go across all government departments. We talk about stigma. One of the key elements of stigma in mental health is that everybody in the community and right across government is very happy to deposit mental health in psychiatric departments and not recognise that education, maternity services and well-being in employment practices all contribute to mental health. We had a Government who demanded that people reconstruct the management of their businesses in such a way that bullying became good management to get the best out of things. It was neither good management nor good for people’s well-being. The point about this document is that it makes it clear that in business and management—which includes management within government—we have at our disposal the mental well-being of those who work in the services. We need to take that into account.

We can get into the details. I see that one Royal College of Psychiatrists document—No Health without Public Mental Health—is well represented but Self-Harm, Suicide and Risk, which I was involved in, is relatively little represented. In particular, there is not much recognition that self-harm is a different phenomenon from suicide; it is not just uncompleted suicide. In the details there are things that one could point out. At a high level this document seems to be an attempt to get recognition right across government and the healthcare services that not only in what people sometimes dismiss as the walking wounded but in serious, enduring mental illness—the schizophrenic disorders, manic depressive psychosis and the more organic disorders—there is a psychological component.

One of the difficulties in my own college is that for some years—it is not true more recently—there was such a focus on the biological side of things that the psycho-social became much less important. Many professionals, including some from my own profession, fell into the trap of thinking that the way to deal with things was to retreat into a biological approach. This document says, “No, I’m sorry, that’s not sufficient. We have to see the person as a whole”. Four hundred million pounds may not be a lot of money in terms of developing psychological services but at the moment it would not be easy to find all the trained therapists within the National Health Service who could go on to do the work. You cannot produce therapists at the drop of a hat, particularly in the psychological services. It will take some years to train them. One of my anxieties is that to spend the money quickly there will be a temptation to employ all sorts of people who might not necessarily be good therapists. The previous Government never got around to the statutory registration of psychological therapists, despite considerable pressure over the past 10 years from some of us.

As I look at this document, it is wholly possible to point out all the flaws and difficulties. We are starting from very difficult circumstances. However, it seems possible to understand from this that the Government are trying to point to a whole new direction in this document. I am not much enamoured of the term “big society”, which is used in this document and pretty much everywhere else. However, I do like the notion of active citizenship. When people come along with difficulties in their lives, it is not about what we do to them in healthcare services, but about how we engage with them and help them to engage with their lives.

I pick up on one comment in closing. The noble Baroness, Lady Murphy, whom I regard as my noble friend, talked about the danger that serious, enduring mental illness might not be dealt with because lots of other things might be espoused first, particularly in psychological therapies. It was not this Government who produced the notion of recovery models. However, the Government pointed out, albeit in a footnote, that recovery does not necessarily mean that you recover. It means, as it says in the footnote on page 16,

“living a satisfying, hopeful and contributing life even with the limitations caused by the illness”.

The noble Baroness is totally right. It would be Utopian to have the notion that mental illness can be done away with completely. It is part of the human condition for more of us, including some in this House, than we would like to believe. In the face of the enormity of that problem, we should not be dismayed by this report but encouraged by it.