Ebola

Lord Crisp Excerpts

Thursday 6th November 2014 Lords Chamber

[Lord Crisp (CB)]

My Lords, the noble Baroness, Lady Kinnock, set out very cogently the big picture and the underlying issues. I want to pick up a small but important element in the international response. Let me say how good it is to see the UK leading the way but how disappointing it is to see that some other countries seem to have adopted a fortress mentality, which is short-sighted and contrary to both best practice and international agreements on tackling global epidemics.

I turn to my specific point. I declare an interest as chair of the King’s Centre for Global Health advisory board. King’s has been working in Sierra Leone for two years and is one of the very few organisations that stayed in the country when Ebola broke out. Its team has played a central role in the multiagency effort in the country, and now has very considerable experience. Noble Lords may recall that the King’s programme leader, Dr Oliver Johnson, was previously policy director for the All-Party Parliamentary Group on Global Health, a number of whose members are in the House at the moment.

The King’s team had to work with what was available at the start of the epidemic. Its members created an isolation facility out of the rooms and equipment that they had to hand. As a result, they have developed an approach that engages local people alongside international workers and can be scaled up both quickly and cheaply. They have had 600 people through their unit, of whom 300 have tested positive—that is one-quarter of all those infected in Freetown. There have, however, been no infections of local or international staff in the unit.

Such a scale-up would involve creating small local units for treating people with the minimum of facilities and staff. King’s argues that, while the large, well equipped facilities such as the Kerry Town unit are very welcome, in the short run at least there is also a need for the immediate construction of small facilities that can be operational very quickly and reach into smaller communities. They also have the advantage of maintaining greater local control, rather than just being about international aid. What is Her Majesty’s Government’s view on this? Will they support the further development of these sorts of facilities? Moreover, I have learnt today that seconded NHS staff are going to be allowed to work only in the big units. Is that the case? Will they be allowed to work in these smaller units as well?

I add my praise to the praise that others have already given to the work of so many UK and other volunteers who have shown remarkable courage, as well as skill, in doing the wonderful work that they are doing.

BBC World Service and British Council

Lord Crisp Excerpts

Thursday 10th July 2014 Lords Chamber

[Lord Crisp (CB)]

My Lords, I congratulate my noble friend on securing this debate and on putting values and British interests centre stage, and indeed on linking them. We may not be able adequately to define British values, but I think that all the versions we have seen are pretty compatible with each other. I am also very clear that British values are central to the UK’s reputation and influence in the world. Like others, I see this around me in many different parts of the world.

I agree with my noble friend Lord Alton’s concerns about the resources and support for the World Service and the British Council, and will listen to the Minister’s answer with great interest. The report from the British Academy that has been referred to encouraged the Government to invest in and sustain soft-power institutions such as these over the long term and at arm’s length. That seems to me to be the right formula. That report also pointed out that everything British people do abroad is taken as a representation of the country or a projection of Britain abroad, and it referred to the compartmentalisation of government on this. Those are the points that I want to take up, and I shall ask three questions about them regarding these two great institutions—in other words, how they link with other British activity abroad.

I shall start with what I know about, which is health. You cannot now run the Department of Health or the NHS without having a global perspective on national policy. This means many things, from sharing in the management of global epidemics to, just as importantly, the mutuality of learning and sharing of research in policy development. There is now an established tradition of health as foreign policy and health diplomacy. I am delighted that the Government have set up Healthcare UK to lead this work and to develop these relationships, building largely on the NHS; what could be more emblematic of British values than the NHS? I believe that this is true in other areas and assume that therefore most, if not all, domestic departments need to have some kind of foreign policy, if you like. I wonder how strongly government departments are encouraged to develop relationships with the World Service and the British Council to develop this role.

The comments about activity being a projection of Britain abroad also reflect the importance of civil society and the links of all sorts between hospitals, schools, villages and commercial organisations that exist across countries and continents. Moreover, in today’s atomising society, people-to-people links are more important than ever. People get their news, information and opinions from diverse sources. People are influenced by people like them. National boundaries have become largely meaningless in the way in which people relate to each other around the world. In that context, I also note that today’s Britain is rich in diversity of cultural backgrounds and languages, and in familial and religious links that circle the globe. These, too, are a projection of Britain abroad, a daily, hourly, minute-by-minute and perhaps second-by-second source of interactions globally.

These reflections leave me with three questions for the Minister. What can she say about relationships between domestic departments, such as health and education, and the World Service and the British Council? Do these organisations reflect the full range of interactions and possibilities, or is there more that should be done to encourage these departments to engage? Secondly, what contribution can and does the very diversity of the UK population make to the UK’s soft power? That question may go a bit beyond the remit of this debate but it links to my third question. I would be interested to hear the Minister’s reflection on how effective the Government think these two great institutions, the World Service and the British Council, are in using and harnessing the power of electronic communications and social media to project and develop the UK’s reputation globally.

Women: Developing Countries

Lord Crisp Excerpts

Thursday 27th June 2013 Lords Chamber

[Lord Crisp]

My Lords, I congratulate the noble Lord, Lord Loomba, on securing this debate, but congratulate him even more on the topic he has chosen—and indeed on his excellent speech which drew out the issues that we are debating. It is absolutely crucial that these issues are raised here and everywhere; and raised with the force and vigour which the speakers in this debate have shown.

I will concentrate on health and disabilities in developing countries, but I will take in a bit about the bigger picture. At the beginning, I declare two interests. First, my wife is a member of the International Gender Studies Centre at Lady Margaret Hall, Oxford, and, secondly, I chair Sightsavers.

In the wider picture to which noble Lords have already referred, there are so many issues to discuss, as the noble Baroness, Lady Brinton, mentioned, such as violence against women, their lack of representation, issues of access to employment, the fact that so many of the poorest people in the world are women, and access to all kinds of rights such as property and health. All are connected and will be anatomised by others in this debate. Essentially, however, they are all about power, position, mindsets, traditions and, of course, economics.

There is another part of that wider picture which I will draw out. It was mentioned in the House of Lords Library briefing for this debate in the form of a quotation of Kofi Annan, saying that women are the most important actors in development. It also made the point that the empowerment of women, the equality agenda, is right in itself but is also an instrument for progress in the world. We can all think of positive examples; I will mention just two. The first, well cited in health circles, is that if a girl in India has five years of education, her child is 40% more likely to reach the age of five. It is that simple. Education of girls is probably the most effective intervention in healthcare. The second is of course microfinance. The story is well told there as well, of how women have been able to revitalise communities and save their families from difficult situations through the application of microfinance. These issues are not just about women as victims; they are also about releasing the potential of women world wide.

On health more specifically, I start with a wider point about gender and the importance of disaggregating data—which I know is an issue close to the heart of DfID—and knowing the facts. An important paper by Sarah Hawkes and Kent Buse appeared in the Lancet on 18 May entitled Gender and Global Health: evidence, policy, and inconvenient truths. The inconvenient truth that it brings out is that—obviously leaving aside reproductive and sexual health—men have the bigger problems in terms of the global burden of disease and shorter lives. I am not going to talk about men, but the point here is that gender is not just a women’s issue. We need to disaggregate our data much more clearly if we are to have a real impact on health for everyone in the world. We need to think about gender as a key factor in that.

On women and health, all the issues are linked to the wider picture I mentioned earlier. I suspect that we are going to hear lots of numbers on pregnancy-related mortality today. The numbers I have are that 287,000 women died from pregnancy-related issues in 2010—that figure may have halved in 20 years but it is still extraordinarily high—and 99% of those women lived in developing countries. Again, as I suspect we will hear today, it is not just about mortality; it is also about morbidity. I have seen estimates varying from six times to 30 times as many women being affected as result of pregnancy-related complications or injuries.

The issues here are in part about how you get healthcare and proper health provision to people. They are partly about money, and ensuring that there are facilities to which women can get, but they are also fundamentally about society. They are about, as has already been said, unwanted pregnancies. They are about girl brides whose bodies are too small to bear the pregnancy which they have had inflicted upon them. It is about how men handle that. It is interesting to see a number of interesting projects around Africa where male, often traditional, leaders have been encouraged to develop programmes to ensure that their wives and women actually get access to hospitals and facilities when they need them. For example, there is an interesting project in Zambia where traditional leaders in some parts of the country inflict punishment on the men if their wives do not attend antenatal care four times. There is scope within these communities to make serious change.

Linked to that is sexual health. It is not surprising when one thinks of powerlessness and violence that more than half the people affected by HIV/AIDS in the world are women. They are often powerless on contraception. I was staggered to hear that some surveys indicate that men in developing countries understand the importance of contraception and the relevance of using a condom more than women do; that says something about education. Of course, we have already heard about child marriages and the fact that, according to the latest figures, something like a third of girls in developing countries, excluding China, will be married by the time that they are 18. The other aspect of health is that most carers and informal carers are women, a point to which I will come back.

Let me move on from health to disability. Women have higher rates of disability; perhaps that is connected with longer lives. To take the area of disability in which I am particularly interested through Sightsavers—eyes—some two-thirds of people who are blind are women; the ratio is almost 2:1. Blinding trachoma is caused by dirty water. Women are clearly much more vulnerable to it: they are dealing with the children and dirty water. It is not surprising that this infection carried in dirty water affects women far more than it does men.

Disabled women have a double disadvantage: the disadvantage of disability and the disadvantage of being women. That is borne out through all the statistics, which is another important argument for disaggregating the data. Disabled women are twice as likely to have AIDS as the general population. They have much poorer access to education and jobs. More of them are in poverty.

My final point about the challenges facing women is to recognise that it is often the women who pick up the pieces. In the HIV/AIDS epidemic in Africa, the principal carers of dying people are their female relatives. They are in a difficult position. There is some interesting research on this from the Commonwealth Secretariat which shows that, because of the stigma of HIV/AIDS in many countries and the weakness and poverty of the people involved, they are working in the most desperate conditions. The people bearing that burden are highly disproportionately women relatives.

In other research, I note that in Tanzania, for example, women are literally left holding the baby when their husbands have gone off to be miners elsewhere. They therefore figure among the poorest people in the country. I know that the noble Lord, Lord Loomba, has done his own work to address the disadvantages that widows have faced.

Women face all these challenges. What is the way forward? Some of these are societal and cultural issues, as I have already said, although I was struck by the opening words of the noble Lord, Lord Loomba, who said that when people discriminate on the grounds of race we talk about apartheid, but when they discriminate on the grounds of gender we talk about culture. Culture needs to be handled sensitively; I speak as the husband of an anthropologist, and I understand that. Changes have to happen within societies, and to come from a society’s own leaders. We need the skills of the anthropologist as well as those of the legislator and project manager. However, there is much that we can do as a legislative body, and as part of so many international bodies, as we are.

It is good that the noble Lord, Lord Loomba, has raised this issue here. As my friends in IGS have told me, we must continue to break the silence around violence towards women across all communities and nation states. There can be no well-being and good health without freedom from fear. I urge that the international focus on development, going beyond the millennium development goals, continues to address the silence that perpetuates this violence, whether it is state-sponsored violence towards women in conflict, or within the apparently safer environment of the home.

I am delighted that the millennium development goals and the high-level panel that has recently reported have focused on gender issues. We have fewer than 1,000 days to achieve the millennium development goals, and it is clear that the central role of health and education in empowering women and encouraging greater action to ensure the sexual and reproductive health rights of women and their educational needs needs to be sustained. I encourage the British Government to continue to do so, although they need no encouragement from me.

There is, however, more to say to persuade the Government on disability. I was delighted that the high-level panel on replacing the millennium development goals talked about disability and the disaggregation of data to ensure that disabled people were properly treated. This needs to be maintained. I am much more fearful here, so my only question for the Minister is: will this emphasis on disability be maintained in whatever replaces the millennium development goals, and will there be a continuing emphasis on the double disadvantage faced by disabled women? We need to make sure that we leave no one behind.

Finally, it is easy to talk about large-scale policy in terms of millions, and so on. Ultimately, this is personal; it is about individuals. So I will end on a personal note. I well remember, some years ago, my mother holding my daughter—her granddaughter—when she was just born and saying, “What a different life she is going to have from me”. She said it both with sadness and with confidence. This surprised me, coming from somebody who had more advantages than many of her generation, having graduated from one of our top universities almost 80 years ago; but she spoke with confidence. Are we holding out the same promise for today’s daughters and granddaughters? Can a woman anywhere in the world hold her granddaughter or, even better, her daughter, and see her future getting better equally confidently?

Global Health

Lord Crisp Excerpts

Monday 25th March 2013 Grand Committee

Asked By

[Lord Crisp]

To ask Her Majesty’s Government what action they will take to promote skills mix changes and task sharing in low- and middle-income countries in order to improve quality, access and cost in health services in line with the report of the All Party Parliamentary Group on Global Health All the Talents.

[Lord Crisp]

My Lords, I very much welcome the opportunity for this debate on what action the Government are going to take to promote skills-mix changes and task-sharing in low and middle-income countries to improve quality, access and costs in health services.

I am very grateful to the noble Lords who are taking part in this debate and to the many others who contributed to the report on which this Question is based. I shall explain in a little more detail what I mean by task-sharing and skills-mix changes to make sure that we are all in the same position on that but, first, perhaps I may say a few words on the background.

Health and health services are very much about people and knowledge. The Department for International Development has a good record on both but on people, in particular, I think there is more that DfID could do, and I shall make that point here in relation to this issue.

There are four key points relating to the background. The first is that there is a pressing need in the world for more health workers. The best estimates I have seen are that there are about 1 billion people in the world who do not have access to a health worker. In Africa, it is estimated that there need to be about 1.5 million more health workers in order that 80% of the women who want to can have access to a skilled health worker when they are in labour. That is not even a high standard; it is not what we expect, which is 100%. Therefore, there is a massive shortage of health workers, and people die or are damaged or diseased for lack of access to a health worker who has some knowledge and who can help them.

The second point of background is that if, through the efforts of DfID, national Governments and everybody else, there is to be a real improvement in health in, for example, India’s million villages, then the staffing structure for looking after people in those villages will not be the same as it is in the UK. There will not be a GP in every one of those villages or, indeed, in Africa’s million villages. People will have to do things differently and there will have to be a different range of skills mix. Nurses will perhaps be doing what doctors are doing, and other people will perhaps be doing what nurses are doing, all enabled by technology. That is the real theme that we are talking about.

My third point is that we actually know what to do. The report demonstrates how a skills mix can be changed successfully to reach more people. Finally, the UK has a particular role that it can play in this, and I shall deal first with this final point.

I know that other noble Lords are going to speak about education and training and about the role of British institutions. In this country we have a fantastic track record of educating and training health workers and, indeed, others, and there is a part that we can play in that. However, I also suggest that we have an important role in training and educating more health workers, not least because of our history and links with so many of the countries that we are talking about—the low and middle-income countries—through the Commonwealth and through our history of education. We know that many people from those countries have emigrated to our country and have become health workers here, and we know that emigration is part of the problem faced by other countries. I make it clear that it is not the whole story. The best estimates I have seen are that 135,000 health workers from Africa have moved to other, richer countries over the past 35 years. That is a very big number but it should be compared with the 1.5 million that are needed in Africa. If everyone went home, the problem would not be solved. The bigger issue is getting more people on to the pitch to provide more education and training.

Those are the issues that we set out to address in the report, All the Talents. We undertook a review and were joined by expert witnesses. We had a group of parliamentarians who quizzed those witnesses, and we came up with four or five clear recommendations, which are the ones that I want to put to the Government.

Let me say a little more about what we mean by changed skills mix and better teamwork. We looked at examples from about 20 countries where access was improved because of using staff members to do different things from what would happen traditionally. The example we give in the brief version of the report is in Malawi, where some 135,000 manipulations of bones have been undertaken by technically trained people, not by doctors. As a result there has been improved access. Incidentally, they were trained by British doctors in this particular case in Malawi. So, we have seen improved access by changing the skills mix and allowing different members of staff to do work that others had previously done.

We have seen improvements in quality. The example given in the report is in the UK, where nurse practitioners doing more prescribing has improved quality as perceived by the patient. It is just as safe as it being done by doctors but it has improved quality, as perceived by the patient. Finally, there are examples of improving cost. The example that we use here is that in Mozambique for the past 25 years almost all the caesarean sections outside the capital have been done by nurses with additional training at a third of the cost of using doctors in that country.

These issues of changing skills mix, task-sharing and changing what professionals do can have profound effects on access, quality and costs. We looked at the success factors because we know that many such examples have failed. We identified some very clear success factors that are obviously spelt out in the report. They are about leadership, planning, training, supervision, ability to refer and teamwork. They are about some very obvious ways of doing things. We also identified failure in the absence of those things. It was also interesting for our all-party group to notice that a lot of the most innovative and interesting examples were happening in low and middle-income countries that did not have our resources and, to some extent, our baggage and vested interests. Here, we saw a compelling story.

We also decided that we would want to phrase the report in positive terms, in part thanks to the noble Viscount, Lord Eccles, and call it All the Talents. It is about how to bring all the talents of all the health workforce together to have the biggest impact on the biggest health problems in the world—those in low and middle-income countries. We think that it is a compelling story. If DfID and other organisations are to help national Governments to deliver healthcare in the million villages in India or the million villages in Africa we need this sort of change in how services are delivered to be effective. How can DfID act? We know that it is always difficult for Governments and international development agencies to deal with staffing issues. The argument is: if we train more people, will they not just migrate? How will we handle the professions and the recurring costs? Our four recommendations to DfID are clear. The first is to assist national Governments to develop their human resources and workforce planning. We must help them to make those changes. Secondly, we want to ensure that workforce innovations are mapped and shared. We need to collect and capture the innovation, then share it. Thirdly, together with others, we need to invest more in workforce research and develop better metrics. Fourthly, we should undertake systematic analysis of the effectiveness of role and skills-mix change. Changes can fail as well as succeed.

We are not the only people making similar proposals. As the Minister will know, Jeff Sachs, in a recent meeting in Parliament which we both attended, pointed out strongly that if we had a million more community health workers—the lowest trained group of health workers in the world—we would have a much better chance of delivering the millennium development goals. It will be interesting to hear the Government’s response to that as well. We argue in the report that professionals need to lead the changes but Governments, international agencies and DfID, with its very high standing—the highest standing of any development agency in the world—need to lead and to stress the importance of these sorts of issues.

People will be the biggest part of the solution in healthcare. They are not the only one—knowledge, science and technology are important—but caring hands, the knowledgeable helper, the professional and the well-trained non-professional are the biggest need and the biggest deficit in healthcare. That means investing in education and training, setting examples, supporting organisations such as the Global Health Workforce Alliance and promoting the needed solutions. I ask the Minister three questions. How does she respond to those four recommendations? How do she and the Government respond to the million community health workers campaign? Will DfID give people and health workers even higher prominence in policy?

Health: Neglected Tropical Diseases

Lord Crisp Excerpts

Wednesday 30th January 2013 Lords Chamber

[Lord Crisp]

My Lords, I, too, congratulate my noble friend Lady Hayman on securing the debate and her commitment to this whole area. I also congratulate the Government on their championing and funding of this area. It is another great example of UK leadership in development. I agree with my noble friend that Stephen O’Brien provided really knowledgeable leadership and commitment in this area.

I have a non-financial interest as chair of the trustees of Sightsavers, an organisation that treats and provides surgery to more than 20 million people suffering from, or at risk from, neglected tropical diseases every year. I am delighted that we have been supported by DfID to lead a global survey of blinding trachoma, which will take us into 30 of the poorest countries in the world. Noble Lords will not be surprised to learn that with that background my comments are going to be about the two diseases that particularly affect eyes: onchocerciasis and blinding trachoma.

I want to make four simple points. First, while I agree with my noble friend Lord Patel that there is much research to do, when it comes to these two diseases—and others—we know what to do. It is well documented, researched and deliverable. We can rid the world of these diseases and we can do so sustainably.

Secondly, the way in which this whole programme around NTDs is developing is an example to other areas of health and, indeed, development. First, there is wonderful co-operation, which my noble friend Lady Hayman mentioned, but that co-operation is not new; it did not start a year ago. Co-operation has been going on at all levels around these two eye diseases for more than 25 years; indeed, Merck has provided free drugs for these eye diseases for the past 25 years.

In addition, in Africa there has been developed a process called community-directed treatment, which relates directly to what the right reverend Prelate the Bishop of Derby said earlier. We in Sightsavers are in touch with 100,000 community volunteers in villages who deliver these pills. It was developed in Africa; it was not actually developed by western medicine, it was developed by Africans as a way of reaching people in the community. What is interesting is that we can use that network not only to treat people with the eye diseases—indeed, ivermectin happens to treat lymphatic filariasis as well as onchocerciasis—but to deliver other drugs. We as an eye organisation are involved with others in delivering treatments for a whole range of different things. The third way in which this is such a good example is that surgery is often delivered by non-medical staff, and there are examples of how you can do things very effectively by being radical and innovative.

My third point is, as again the noble Baroness said in starting off, that this is smart aid; it works. This should be publicised; it should be communicated. Who can argue with 50p to stop people going blind? That is what we are talking about.

My final point is the sustainability one that has been brought up by a number of people. These are diseases of poverty and indeed, as we have heard, of neglected people. They are linked to things like clean water and weak health systems. So my questions to the Minister are very simple. First, what is DfID doing to integrate its policies around neglected tropical diseases with its policies on water and sanitation? Secondly, how is it going to make sure that the strengthening of health systems will be part of the post-2015 development agenda?

EAC Report: Development Aid

Lord Crisp Excerpts

Monday 22nd October 2012 Lords Chamber

[Lord Crisp]

My Lords, I congratulate the Economic Affairs Committee on producing this report and on provoking this debate. The report is challenging and being challenged in return. Like other noble Lords, I hope that we can have a fuller debate around development at some later date.

The Economic Affairs Committee, not surprisingly, brings a clear economic focus to this issue. That focus brings great strengths but also, I suspect, some weaknesses. I agree with much of the report. There are many interesting discussions here, but there are some omissions which slightly surprise me. For example, in the report’s critique of multilateral donors, it does not make much of the counterpoint that there is great inefficiency in the multiplicity of individual donors and in the multiple requirements that they make of countries. More than one Minister has said to me and many others that managing multiple donors is a real headache and can be very counterproductive. I note that the Government raise that in their reply to the report.

I come at this issue from a health perspective as opposed to an economic one. From this field, I strongly support the view of the noble Lord, Lord Stern, that the report is too pessimistic about the effectiveness of aid. There may not be conclusive evidence overall, but there are many examples, especially in health, as the noble Lord, Lord Stern, said.

I declare my interests on the register. I chair the trustees of Sightsavers, which receives some match funding from DfID, for which we are very grateful, and is working with DfID on eliminating two blinding neglected tropical diseases. I also co-chair with the Zambian High Commissioner the Zambia-UK health partnerships, which are using UK volunteers, doctors and nurses, to train health workers in Zambia.

I entirely agree with the noble Lord, Lord Boateng, who made the point that we do not yet use the experience and expertise we have in this country in a field such as health—which is the one I know, but I suspect also in other areas—effectively alongside the money to support development and the importance of links, of professionals working with professionals. The Government have done much to support some of those through NGOs but, as the noble Lord said, they could do much more to engage the NHS and the Department of Health as part of the delivery arm of DfID.

Looking at the field from the perspective of health, I understand that underneath the definition of economic development is a much stronger issue, which is why people support the aid given from this country. As the noble Lord, Lord MacGregor, said in his opening remarks, that is about people wanting us to relieve the distress, suffering, illness and poverty around the world and help the millions where we know what to do and can do so cheaply. As my noble friend Lord Stern, said, there are many examples, including GAVI, the organisation that provides immunisation to so many millions of children, the Global Fund to Fight AIDS, Tuberculosis and Malaria and, in my field, Sightsavers. We fund our partners to do cataract surgery at the cost of £17 an eye. That is very much value for money. In our recent research with the London School of Hygiene, the person who has gone blind with cataracts returns to economic activity at the same economic level at which they were within a month. In other words, either they get a job or their carer gets a job.

The point I make with that example is that the links between economic growth and health go two ways. It is not just that economic growth can lead to improvements in health. The Commission on Macroeconomics and Health in 2001, chaired by Professor Jeffrey Sachs, who was one of the witnesses to our report, produced the evidence then that health and education contribute to growth. As we all easily recognise, ill health damages it. There have been many analyses of the impact of HIV/AIDS on economic growth in sub-Saharan Africa—or the lack of growth.

We know that economic growth does not guarantee health. The graphs that show the economic status of the country and the health state of the country do not go in a straight line; there is not a direct correlation. We can see examples such as Kerala in southern India or Sri Lanka where, despite relative low income, they have a health status comparable with many countries with a much higher income. It is also about the policies, approaches and priorities that Governments give to those areas. My point is that we need to be careful not to overemphasise economic development at the expense of some of the other important aspects of development.

I want to go slightly further than that. There is some discussion in the report of how much aid should support the UK’s interests. There is an important point in health and elsewhere about shared interest. The most obvious is that we are vulnerable to diseases created or arising in the poorest, weakest and most vulnerable areas of the world. For example, in the 14th century, the Black Death took three winters to get across Europe; SARS took three days to get around the world at the beginning of this century. We have a shared vital self-interest in health surveillance in the poorest countries of the world.

There is more to that. There is more about the creation of vital global public goods. I suspect that people will not generally be aware how many health treatments have come out of the work between the UK, US and other richer nations working with their partners in low and middle-income countries. Much of the treatment and management of HIV/AIDS has of course been learnt there. The DOT therapy for treating TB, now increasingly important in this country, came from Uganda. The hydration therapy for use with small children with diarrhoea came from Bangladesh. Low-tech treatments for postpartum haemorrhage come from for Sri Lanka, and so on. It is, after all, no surprise that people who do not have our resources or baggage of vested interests are very innovative in health. It is no surprise that I advocate partnerships or that in health, as elsewhere, innovation needs to be sourced globally. Knowledge transfer is two-way. There is much about sharing experience and expertise.

Let me also touch on the fact that history means that the UK has a particular role with many of the countries that are recipients of aid and its former colonies and a particular leverage and ability to get things done because of our shared history. The NHS—I speak as a former chief executive of the NHS—owes a great debt to many of those countries for the staff who have come to support the NHS. In return, we owe them a debt in terms of educating more health workers.

The point I make here is that rather than thinking in terms of totally disinterested aid or narrow self interest, there is scope for thinking in terms of mutual benefits and creating public goods. I imagine that this is much the same in areas other than health, such as agriculture and food, which the noble Lord, Lord Boateng, mentioned. Some of this reflects on some rather old-fashioned definitions of aid. The world has moved on from just charity. We need to think a bit more about co-development as well as about support for development. However, redefining aid is for another debate which I hope we can have in due course.

Let me turn to the 0.7% commitment. I understand the point of the arguments that the committee makes about waste and about targeting inputs not outcomes, but I disagree with its conclusion. I support the Government’s conclusion that they have a budget and manage their programmes against results. They need to review it. There is plenty of competition for that money, as anyone who has bid for DfID money will know. There needs to be plenty of openness and no complacency. There will be a constant challenge from others, such as this committee, about whether the money is being spent well and rightly, and so it should be.

The biggest risk was mentioned by the noble Lord, Lord Tugendhat, and others. It is the pace of growth and whether, even though there is need, there is more need than money, and whether, among other things, DfID has enough staff to be able to go at the pace required. DfID needs to answer that question about pace, not about the overall target.

The 0.7% is, of course, a shared political commitment. It is not about economics but is a commitment alongside others in the world. In some ways, it seems to me that it is not unlike the payment of tithes in churches. It is about who we are. It is about the UK believing that we should support the poorest countries in the world. Very early on in this debate my noble friend Lord Hannay and other noble Lords got this absolutely right, so I shall not repeat it. It would be a terrible signal if we reneged on this. I, too, admired the way that the previous Secretary of State held to the commitment, arguing that the poorest should not pay the highest price for the financial crisis, and I agree with the tributes that were paid to him. I wish the new Secretary of State every success and hope that she will build on the past and on the achievements of the previous Government.

In conclusion, I have talked about what I know, which is health. It is only a part, but it is an important part of this debate about development. It is a plea to think beyond pure economics. Economic and effectiveness arguments are very well made by this report, but we need to bear in mind the ultimate aim. It is not just about growth but about how we think about the world and about the UK’s position in the world. When we look at it in this way we can also recognise that aid can also be about global public goods—not just some of the hard-to-measure ones which many noble Lords have talked about, such as good will, soft power and a leadership role in the world, but also very measurable health therapies and outcomes of benefit to all, which are applicable in other fields as well as in health.

Health: Tropical Diseases

Lord Crisp Excerpts

Thursday 26th January 2012 Lords Chamber

[Baroness Northover]

Yes, the contribution to the Carter Center is based on matched funding, and the conference on Monday will help to take this area forward.

[Lord Crisp]

My Lords, I declare an interest as chairman of Sightsavers, part of the UK Coalition against Neglected Tropical Diseases. I congratulate the Government on this initiative and on continuing the leading role that the UK plays in development. Does the Minister agree that the Government, national Governments in the affected countries, Sightsavers and others can now plan confidently to eradicate blinding trachoma—it is eminently preventable: we know all the ways to do it and we have the drugs—and that we should be able to do that in the next decade?

[Baroness Northover]

I certainly hope that that will be the case, and one of the diseases that this new programme will focus on is indeed trachoma.

EU: Healthcare

Lord Crisp Excerpts

Wednesday 11th January 2012 Lords Chamber

[Lord Crisp]

My Lords, I should like to raise three unrelated issues and ask three simple questions. The first builds on the issues raised by the noble Lord, Lord Kakkar, in his opening remarks and picked up by the noble Lord, Lord Walton, about the working time directive. I understand that the recent attempts to revise the directive have failed but that discussion is under way with what are called the EU “social partners”, which are essentially the trade unions and employers organisations. I ask a simple question: if those discussions raise it in this fashion, will the Government support the opt-out from the EU working time directive proposed by the surgeons, which would allow them to work up to 65 hours a week?

The second unrelated issue is that one of the unintended consequences of opening our doors to Europe in this way—very positive as that is—is that it has tended to exclude those from other parts of the world who have made such an enormous contribution to the UK, particularly those from Commonwealth countries. Will the Minister confirm that the Government will continue to support the international medical training schemes for people from the Commonwealth and beyond? Indeed, will he promote them further? At the moment they are not being picked up in any great numbers.

My third point picks up on the issue raised by the noble Lord, Lord Lexden, concerning the cross-border healthcare initiative. It seems to me from everything that I have read that it is very uncertain what the numbers will be in practice. Can the Minister let us know what the Government’s own assessment is of the likely impact of introducing that directive later this year or next year?

Health: Cancer

Lord Crisp Excerpts

Thursday 11th November 2010 Lords Chamber

[Lord Crisp]

My Lords, I, too, congratulate my noble friend on securing this debate, with its focus on patient experience, and on her forensic presentation of the risks of fragmentation. I am sure that we are all looking forward to hearing the Minister’s response.

As many Members of your Lordships’ House will know, I was the chief executive of the NHS for some years. However, I want to use these few moments to talk about the experiences of people with private health insurance who are seeking treatment for cancer. It is clear that the NHS is the priority, and it is important to get it as good as possible for everyone. Where drugs are proven as effective, they should be available to everyone, and I absolutely take the point about early diagnosis. However, this is not the whole story. I understand, too, that private medicine or insurance have their place for some patients, and any debate about cancer care needs to take account of this.

I have learnt about some of the practices of some insurers thanks to the sad experiences of a friend who has cancer. In a nutshell, people who thought they had bought complete cancer care funding find out, sometimes in the worst of all possible circumstances, that they have bought partial cover at best. I was shocked when my friend told me that his insurer was setting limits on his treatment options which were not referred to in his policy documents and, even worse, proposing to change the terms of their agreement after he had started to claim. My friend is a lawyer, who has great determination and a very loving and supportive family. He decided to fight, and got his MP and me involved. We met the insurers and won some concessions which have prolonged his treatment. It should not be like that.

Having made some inquiries, I find that my friend is not alone. I have spoken to a number of consultants who have told me of patients faced with similar problems who are now paying their own way or have given up. I know of one woman who has to make that decision this week.

These would be sad stories but understandable if it had been clear at the outset what their policies covered. It was not. The fundamental problem is a lack of transparency. Insurance policies are all too often vague and confusing. They do not tell people precisely what they have bought or give them the certainty they need at the time they need it most. Patients find themselves in a negotiation where the insurers hold all the cards. The vagueness of the policies allows the insurers to make decisions entirely on their own terms. I have heard some say that this allows them to exercise compassion and to cover treatments that are not really covered. I am sure that they are compassionate people but they also have a financial bottom line, and such vagueness also allows them to be less compassionate.

The Association of British Insurers has a mandatory code of conduct which sets out the information patients should be given. However, even on its publication it was subject to criticism in the industry, with one source saying that it is very difficult to get any clarity over what is and is not covered. It is not just a question of picking up the policy document; we have to consult the medical advisers and heads of claims in each insurer, and even then it is not clear.

Private health insurance is a financial product, and individuals can complain to the Financial Ombudsman Service. By all accounts, this service works well although of course it can be very difficult for patients to pursue lengthy complaints when they are ill. Nobody, however, appears to be looking at complaints or problems which affect groups of patients or the whole industry. The Financial Services Authority has the power to do that, but has not looked into this in any depth, and I believe that the regulatory system is not working.

Cancer research is developing rapidly, with many new diagnostics and therapies. They offer hope but often bring extra costs. I can see that this makes it difficult to provide cover, but it also makes it all the more important that NHS and insurers’ policies develop equally rapidly.

When I was NHS chief executive, I was very familiar with the criticisms that we did not pay for new and expensive cancer drugs and that patients were subject to a postcode lottery, with access to treatment depending on where they lived. We tried to deal with these problems by setting up the clinically led National Institute for Clinical Excellence to assess scientifically how effective the drugs were. Decisions were made in public; NICE is accountable to the public.

More recently, I have campaigned with others for patients to be able to pay for additional drugs which did not meet NICE’s criteria on the understanding that this field is developing very fast and new treatments are being introduced. In 2008 I was delighted and honoured to co-author a piece to this effect in the Lancet, along with the noble Baroness. I am delighted that the previous Government agreed to do this, and I congratulate the current Government on increasing funding for cancer drugs.

The NHS continues to develop its policies and to improve. It could go further, but what about the private insurers? Let me be clear that not all insurers are as bad as those of my friend; when I talk to consultants, they name the same two or three which they believe are very good and the same two or three which they believe are very poor. But the reputation of all of them is damaged. The industry needs to get its act together. The Financial Services Authority needs to act and the Government need to ensure that they review this whole area.

In the mean time, I would advise any patients in this situation to do the same as my friend—to get their MP involved and to fight. I know that this is not the Minister’s responsibility and that he will refer this matter to his colleagues. However, the Department of Health has a responsibility for looking across this whole territory—we have been given wonderful voluntary sector examples of hospices—and at the impact on the NHS of private insurance and private healthcare. My complaints about clarity also apply to the NHS. It is very important that the NHS spells out what treatment people can expect and therefore, by implication, what space may be available for private insurance.

My experience is that people want clarity and certainty. Whether they are NHS or private patients, they do not want to wait around for decisions. The private insurance industry is failing on this, and I believe that the Government and the NHS could do more.