Drugs: Prescribed Drug Addiction
Lord Crisp Excerpts(12 years, 11 months ago)
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Earl Howe
I am well aware of the point that the noble Lord appropriately raises. Stigma is an issue and we need to take account of the risk of it. That means that quite often when treatment services are provided to those who are addicted to medicines, they take place in a different setting from those administered to addicts of illegal substances.
Lord Crisp
Will the Minister recommend that, given that withdrawal from legally prescribed drugs is every bit as dangerous as withdrawal from illegal drugs, more should be done, for example, to print warnings in bolder lettering on packaging, to put notices in doctors’ surgeries and to make the public and the patient more aware of this issue as well as making doctors more aware?
Earl Howe
I agree that dependence on prescription medicines can be just as devastating and debilitating as dependence on illegal drugs. The round table on addiction to medicines has agreed actions to improve public and professional awareness of the risk of dependence. They include a review of the updated warnings on prescription painkillers by the Medicines and Healthcare products Regulatory Agency and the development of further materials for GPs and other healthcare practitioners to support patients in understanding the risks.
Health and Social Care Bill
Lord Crisp Excerpts(13 years, 3 months ago)
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Lord Crisp
My Lords, I had not intended to speak on the amendment, but I want to say a word or two in support of what the noble Baroness, Lady Williams, has just said. She and others have referred to the rift that has been created as the Bill has gone through Parliament and been discussed in the country. I am sure the Minister recognises that, but I know that he also recognises that now is the time to move towards healing that rift. Many people have, for whatever reason, been scared by what has been said and many people have also been scarred by what has been said. The noble Baroness is absolutely right to draw attention to the second part of the amendment and the opportunity that it gives to start to bring people together around the practicalities. We talk about the legislation but many people out there have to talk about the practicalities and how you make it happen—something with which many Members of your Lordships’ House, including the noble Lord, Lord Newton, are very familiar.
This has also been about failing communication. I believe there is now more that unites people than divides them. There are many things that people agree on. There are still some very significant differences and, like the noble Baroness, Lady Williams, I am not a fan of the Bill. It has been a damaging process but now is the time for healing. It would be good to see some cross-party approaches to bringing people together in a positive fashion to deal with the practicalities, rather as is laid out in the second part of the amendment.
Earl Howe
My Lords, I think that it is important for me to begin by acknowledging fully the force of the wonderful speech by my noble friend Lady Williams, and indeed acknowledging the powerful points made by other noble Lords regarding the climate of opinion among the medical royal colleges and others in relation to the Bill. I cannot fail to be conscious of the suspicion and doubt expressed by many members of that community, although I have to say that opinions vary as to what the real views of some of the royal colleges are, bearing in mind that only a small percentage of their members were canvassed. However, I cast that aside because I am very aware of the validity of the points made by the noble Lord, Lord Owen. The Government are undoubtedly fighting a battle to convince the medical community of the merits of the Bill, a battle that we have so far not won. I can therefore very readily confirm to my noble friend that the first thing we would wish to do once the Bill reaches the statute book is to build bridges with the royal colleges, the BMA and all those who have an interest in seeing this Bill work, to make sure that its implementation is securely grounded. I completely agree with her that the Government should work with NHS staff, all our stakeholders and, indeed, patient groups during the coming months to make sure that implementation really is a collaborative process. I hope that the undoubted wounds that have been created will be healed, and healed rapidly.
I am grateful to all noble Lords who have spoken in this debate. In particular, I listened carefully to what the noble Baroness, Lady Thornton, had to say, as I always do. The question posed by her amendment is, on the face of it, “How can we improve Part 3?”. The answer that she has given us is, “To postpone it”. However, the subtext of her question is, “Why should we have Part 3 at all?”. I am happy to set out once more exactly why it is essential that we have Part 3 —and not just have it, but have it without delay. We need it for two compelling reasons: to protect patients’ interests, and to help the NHS meet the significant quality and productivity challenges it faces. They are benefits that I am afraid the amendment would stop in their tracks.
Part 3 sets out a clear, overriding purpose for regulating NHS services—to protect and promote patients’ interests. That contrasts with Monitor’s duty under the National Health Service Act 2006, which is merely,
“to exercise its functions in a manner consistent with the performance by the Secretary of State of his”
functions. That 2006 duty is not adequate as it stands. It does not mention patients’ interests and it is unclear. However, that duty is what would apply if Amendment 300A were accepted. The amendment would also discard the recommendations of the NHS Future Forum that Monitor should have additional duties: first, to involve patients and the public in carrying out its functions, as my noble friend Lady Cumberlege and the noble Lords, Lord Patel and Lord Warner, rightly emphasised; and, secondly, to enable integration.
It needs to be made clear that the provisions in the Bill interlock and are interdependent. Deferring Part 3 would not achieve the continuation of the status quo, but it would leave an NHS without strategic health authorities and primary care trusts and without a comprehensive and effective framework for sector regulation. There would be no organisation with the powers needed to support commissioners in developing more integrated services. That is something that the noble Baroness, Lady Finlay, and others have rightly demanded. There would be no organisation capable of enforcing requirements on providers regarding integration and co-operation. Neither would there be sector-specific regulation to address anticompetitive conduct that harmed patients’ interests. The powers that currently exist to enforce advice of the Co-operation and Competition Panel would no longer be available. Instead, it would be reserved to the OFT to consider complaints under the Competition Act, rather than by a sector-specific healthcare regulator with a duty to protect patients’ interests.
I mentioned protecting patients for a good reason.
Health and Social Care Bill
Lord Crisp Excerpts(13 years, 4 months ago)
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Lord Crisp
My Lords, like, I suspect, every other Member of your Lordships’ House, I very much respect the way in which the Minister has handled the Bill and his willingness to engage in debate. I sit here as a Cross-Bencher listening to what seems to be the healing of a rift between the coalition parties, if I may put it like that, but I also see—my postbag is full of this, as I am sure everyone else’s is—a rift with the medical profession, the nursing profession, midwives and others. Even though this approach may deal with some of the issues that they have wished to raise, I do not see that it will deal with the much more fundamental issue of the loss of trust and unity that seems to have been created as part of the passage of the Bill. Can the Minister say something about how he believes that that will be handled? These issues go far beyond your Lordships’ House, as we all understand.
Earl Howe
The noble Lord is right. The stance taken by a number of medical bodies and members of the medical profession is of course a matter of great regret to me and my ministerial colleagues. I say to them and to the noble Lord that once the Bill has been approved by Parliament, as I sincerely hope it will be, that will be the time to re-engage with the medial profession and work with it to ensure that the Bill delivers on the promise that we have held out for it and that we still believe in. The principles that the Bill embodies, which the medical profession has always said that it supports, can then be given substance in the form of the improvements that we would like to see delivered to patients. From all the comments that I have heard from doctors and others who are in doubt about the Bill, most of their concerns revolve around its implementation and what it will mean in practice, rather than the principles that it enshrines. We need to look forward collectively and work together to make the NHS work better.
Health: Non-communicable Diseases
Lord Crisp Excerpts(13 years, 8 months ago)
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Lord Crisp
To call attention to the worldwide incidence of non-communicable diseases; and to move for papers.
Lord Crisp
My Lords, it is a privilege to open this debate on such an important issue, which sadly affects, or will affect, the lives of all Members of your Lordships' House, either directly or indirectly through family members. In talking about non-communicable diseases, I am talking about diabetes, cancer, cardiovascular disease, respiratory diseases and mental health. You may ask why I am drawing attention to this at this time, because these diseases have been with us for a long time. The reason is that this is a growing problem. It is now the biggest set of health issues globally and the fastest growing set of health issues in every continent, including those afflicted by HIV/AIDS. We are ill equipped to deal with them, and we need a new and concerted effort to confront them.
When I put forward this proposal for a debate, I actually wrote, “To draw attention to the worldwide epidemic of non-communicable diseases”. Somebody in the Table Office, quite rightly I guess, chose to change that to “incidence of non-communicable diseases”, reasoning that an epidemic is something that is spread and communicated. In the ordinary sense of the word, however, we are dealing with an epidemic. As far as we know, these diseases are spread not by infection or biological process but they certainly are spread by social processes. Diet, the availability of food—healthy and unhealthy—smoking, alcohol, lack of exercise, stress and social pressures, which may in turn lead to overeating, alcohol, smoking and so on, are all key factors in the major spread of these diseases. They are sometimes called the diseases of affluence but, as I will say later, they also strike the poorest in the world.
I am very grateful to the distinguished noble Lords who are taking part in this debate and I know that they are bringing great expertise and knowledge in the fields of mental health, diet, cancer and coronary heart disease. I am particularly delighted that my noble friend Lady Hayman is returning to speaking in the House. My task is to set the scene, identify some of the key strands and ask just a few questions of the Government. Let me start with the context of the diseases.
I am not going to give your Lordships a lot of statistics but will try to limit myself to a few which scope and shape the problem. Now, 60 per cent of deaths in the world are due to these diseases—twice the number due to communicable diseases. This has changed markedly in recent years and is growing fast. While these diseases are associated with ageing, as they are with affluence, it is noticeable that a quarter of the deaths from them globally are in people under the age of 60. If we look at the UK, a quarter of the deaths from these diseases are in people under the age of 70. They are what we in the Department of Health and elsewhere would tend to call, or have called, preventable deaths. If I might take one example to show the pace of growth, diabetes is one of the fastest growing diseases and there are now 300 million people in the world affected by it. It is estimated that there will be 500 million by 2030. The numbers are vast: in India, it is 52 million people; here in the UK, it is something like 2.8 million people and growing fast. I believe that the noble Lord, Lord Kennedy, will have more to say on this.
These diseases are often called diseases of affluence. Indeed, as societies develop more of these diseases become more prominent. In Europe, 85 per cent of deaths are now due to these diseases but they hit the poorest population in a society worst. If we think of those causal factors such as smoking, diet and so on, we can understand that. Globally, Africa is the fastest growing area for non-communicable diseases. This is not just about death. It is also about disability and dependency, and the long-term and economic impacts in both the treatment of these diseases and lost productivity. This has been authoritatively estimated as being of the value of $47 trillion over 20 years. One-third of that is in mental health and I am sure that my noble friend Lady Murphy will have more to say about that. What is also noticeable about those costs is that $7 trillion of them are in low and middle-income countries—in other words, it is disproportionately hitting their economies.
I have already alluded to the fact that perhaps the most significant issue here is prevention. Up to 40 percent of cancers, 80 per cent of type 2 diabetes and much of heart disease and stroke are preventable or can be delayed to the advantage of both patients and of costs. I have already mentioned the causes which, again, your Lordships can see in one simple statistic: 7 per cent of UK hospital admissions are due to or related to alcohol, diet, exercise, smoking and, of course, obesity. I know that the noble Lord, Lord McColl, will be talking more about obesity and diet but in the UK 25 per cent of people are now in the category labelled as obese. In India—this may be much more surprising— 45 per cent of children in its cities are underweight and 25 per cent are overweight, so they are being affected by both aspects of the problem. I read an extraordinary story in the newspaper, perhaps reminding me that I should not always believe what I read there, that something like half of the Indian Cabinet has had gastric bands fitted—in other words, surgical devices to restrict the size of their stomach to prevent overeating.
So we have here a picture of a set of diseases that are distinguished by applying to us all, rich and poor, in every country in the world. They are driven by social factors as well as others, require a massive focus on prevention and, crucially, cannot be handled in the same way as the diseases of the previous century. Diseases have changed since health systems were set up. Our systems in the UK, for example, based on hospitals and doctors, were set up largely around episodes of care coming in and being dealt with—being killed or cured, if you like—whereas another way of thinking about these non-communicable diseases is to talk of them being long-term conditions. Those conditions last, and we live with them, for many years. Over those years a typical patient will have some acute episodes where maybe they need to be in hospital, they will have a lot of self-care and they will get care from neighbours and social services as well as from health services. They need a completely different pattern of care from the ones that our systems deliver.
The South African Minister of Health, Dr Aaron Motsoaledi, says that incentives in all our systems are in the wrong place. In talking about diabetes, he asks why we pay only a certain amount to the people who prevent diabetes, much more to the people who treat diabetes and the highest amount possible to those who deal with the complications of diabetes. We have a system that incentivises the highest level of treatment as opposed to one that incentivises prevention. I know that there are no simple answers, no one has the answers and the situation is changing all the time, but here is a real opportunity for global learning and working with others around the world on how to deal with this growing epidemic.
This debate is timely. I was extremely fortunate to be successful in the ballot because two weeks ago, on 19 and 20 September, there was a UN summit on non-communicable diseases, which was attended by virtually every country in the world and 34 heads of state. This got very little reporting in the UK, which was understandable, given what else was going on at the time, including the economic situation, but I am pleased to have the opportunity with this debate to draw a little attention to this set of issues and to what happened at that summit.
The summit was important; it was part of a process of the world, as it were, starting to agree what will replace the millennium development goals when they come to fruition in 2015. As noble Lords will know, those goals were set in 2000 for reducing deaths from TB, HIV/AIDS and malaria, as well as reducing child and maternal mortality. These are wholly admirable and there has been a lot of progress. We always need priorities. However, one of the negative impacts of priorities is that other things are deprioritised, and over these years we have seen that as more money has gone into communicable diseases and, rightly, into child and maternal care, systems and resources have moved to those areas at the cost of non-communicable diseases. We have seen systems broken up as priority has been given to those areas. In due course, we will need to move beyond the MDGs and think about global targets and priorities for non-communicable diseases. I suspect that over the next two or three years there will be other debates in your Lordships’ House around these issues as the collective will moves towards some target-setting.
The UN summit identified six strands of action. The first was that this is not purely a health problem; it is a problem for the whole of government and society—industry, civil society and NGOs as well as health.
The second area was about reducing risk factors and creating health-promoting environments. Of course a lot of this is about individual responsibility for what we eat and drink but there is a lot that can be done through regulation and nudging, through lateral thinking and creativity. To take one terribly simple example, it is about how we design our buildings. Somebody drew to my attention the other day that, in most of our schools, children now stay in the same classroom all day. I was used to a system where I moved from one classroom to another, sometimes quite considerable distances during the course of the day. That meant that, just through the act of being at school, children were doing a certain amount of exercise. The design of a lot of our public buildings and spaces is important.
The second area is about reducing risk factors and creating health-promoting environments. The third is about national policies and systems. The fourth is about global collaboration on regulation, trade and development policies. The fifth is research and development, and the sixth is monitoring, evaluating and learning. The outcomes from that summit are that, by the end of 2012, the Secretary-General must report back to the United Nations Assembly on what is happening. This is starting to move.
The UK has a proud record in development, with what was achieved under the previous Government and, indeed, during the current Government. I am a great admirer of the work of DfID and the priority that has been given to it by this Government. The UK played an enormous role in the development of the millennium development goals. It is globally influential and can play an enormous part in giving this new agenda the priority that it needs.
The Minister knows that I am not, however, an admirer of the NHS Bill, in part because it does not put these long-term conditions and non-communicable diseases absolutely at the centre of priorities. If it had, integration of services would not be an add-on. We would see much closer integration of health and social care, and all the carers together. Nevertheless, there are many good policies in the UK on treating non-communicable diseases and dealing with this problem. I look forward to hearing the Minister say more about that.
I have four questions and challenges for the Government if they are to play this leading role. The first is aimed more at DfID than the Minister’s department, and I will understand if a reply comes later. There is a problem not just of prevention but of access to treatment. In Zambia, for example, 90 per cent of people with diabetes do not have access to insulin. This leads them to a major problem. The World Trade Organisation agreed in 2001 that, in the event of a public emergency, countries could apply for exemption to international patents relating to essential medicines so that they could be produced generically and, therefore, much more cheaply.
In the run-up to this high-level summit, the EU and the US and the pharma-companies argued that this should apply to non-communicable diseases. What is the Government’s position on this? What is the Government’s policy on the use of these exemptions of essential medicines relating to real crises and public emergencies in low-income countries?
The second question applies both to the UK and to the global situation. What do Her Majesty’s Government believe is the role of industry in non-communicable diseases, specifically the food industry? It must be involved, but I note that it is being given quite a prominent position. How will self-regulation work and what evidence is there that self-regulation will have the desired effects? Thirdly, what are the Minister’s views on the research that is required here, and how we can link together non-communicable and communicable diseases?
Finally, I notice that DfID uses MDGs as a method for determining what funds are awarded. Given that people in DfID understand as well as I do that this is the coming epidemic, what will be their role in exercising greater flexibility on this issue, and paying more attention to these diseases in the future? I beg to move.
Lord Crisp
My Lords, I said at the beginning that it was a privilege to introduce the debate, and it has certainly been a privilege to listen to it and to hear the wisdom, insights and wide range of interests of the noble Lords who have spoken. I think that we have all learnt something; I certainly have. It has been very good to have insights from the patients’ perspective as well as from clinicians and everybody else.
This will be a continuing theme. The UN summit to which we have all referred was described as the end of the beginning. Non-communicable diseases will now be a major global theme of those sorts of global meetings. In due course, we will no doubt start to see some targets being set. For the time being, however, I beg leave to withdraw the Motion.
Drugs: Prescribed Drug Addiction and Withdrawal
Lord Crisp Excerpts(14 years ago)
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Earl Howe
My Lords, I am not sure that I can answer the latter part of the noble Baroness’s question but GPs are clearly in an important position in this context. They are responsible for identifying patients who need help and for supporting them. I do not think that there is any reliable evidence that doctors are failing to comply with guidelines on the prescribing of benzodiazepines but I am aware that the Royal College of General Practitioners is updating its guidance at the moment. It is working hard to produce that very shortly.
Lord Crisp
My Lords, given the importance of making visible the number of people who are addicted in this way, when will the Government calculate the true number of people addicted to and withdrawing from legally prescribed drugs? That information could be made available from GP computer records. Does the Minster agree that both the NAC and the NTA reports confuse the number of patients taking legal prescriptions with the number of users of illegal drugs?
Earl Howe
I agree with the noble Lord that it would be very nice to have a better handle on the numbers here, but the two reports found that nationally available data do not actually provide a definitive prevalence estimate of dependence on prescription and over-the-counter medicines, much as we would wish otherwise. The reports, not unreasonably, consider the full spectrum of need in relation to the issue of addiction. The key point here is that, while different people might start taking these medicines for different reasons and may present with a different range of needs, no one at all should be excluded from the treatment and support that they require. The reports distinguish between the two groups of patients, not just those who are dependent on prescription and over-the-counter medicines but also those who are dependent on illegal drug use. That enables us to make some useful comparisons.
NHS: Front-line and Specialised Services
Lord Crisp Excerpts(14 years, 5 months ago)
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Lord Crisp
My Lords, I am grateful to the noble Lord, Lord Turnberg, for giving us an early run at one of the key questions coming out from the Government’s proposals—a question which I might rephrase as: will they work where it really matters, at the front line? I, too, congratulate the noble Baroness, Lady Jolly, for giving us such an eloquent description of why they matter.
There is a great deal to be said for the Government’s proposals—not least the continuation of a 20-plus year policy for a primary care-led NHS and for decentralisation, although, as some noble Lords have pointed out, there need to be limits to both of those. There are of course risks. It will be no surprise that I shall concentrate on the more managerial issues. The Minister knows, but I should say for the record, that I was chief executive of the NHS and Permanent Secretary of the Department of Health for six years; so I am afraid that I know a bit about reorganisations and may be seen by some of my clinical friends in the House as one of the villains of the piece.
I read the Command Paper that came out before Christmas with great interest, particularly where it talked about how to manage the transition. It was well written, as I would expect from former colleagues in the Department of Health, but there were some fundamental gaps that are fundamental risks. I will mention three of them.
The first is the capability of consortia. I have no doubt that there any many good, talented and skilled GPs and people working in primary care who can and will take the lead in this area. I did not find anything in the paper that described how the capabilities of those consortia to discharge that role would be in any way tested. Your Lordships will no doubt know that foundation trusts and NHS trusts go through a critical scrutiny as to whether they are capable of discharging their functions, and that is to be continued under these proposals. As an NHS trust chief executive 15 years ago, I remember going through just such a tough process where people from outside the organisation tested whether our ambition to do something was matched by reality. The optimism of our will to do it was tested against the pessimism of whether we could actually deliver—were we up to the job? I do not know why that is not being put forward here for GPs unless the Government are too eager to get the GPs involved and do not want to frighten them off at that stage. It is important that some testing is done to secure the success of what is intended here. How will the department test the capability of consortia before they are given free rein?
Secondly, as a subset of that, I was again interested to know how consortia would be accountable. I see in the text that there is somebody called an accounting officer who is not really defined other than as the person who will account to the NHS commissioning board and then upwards to Parliament for the expenditure of the consortium. It need not be a doctor, we understand, but there is a question about what their responsibilities and powers are. In some ways it looks like going back to the old system of consensus management that we had 25 years ago where you basically had a doctor and an administrator in charge and you had to get the two of them to agree to get any change going. This was the sort of situation of which Roy Griffiths, in a report for the Conservative Government of the 1980s, said that, were Florence Nightingale back today, she would be wandering the corridors of the hospital wondering who was in charge. That question is still there. How will that arrangement work for accountability?
The third gap, to which my noble friend Lady Finlay alluded, is that these consortia will turn for expertise to private sector organisations, some of which will be from abroad. We know that GPs are saying that, and that it is already happening. They will, for example, turn to people with experience in insurance systems. We have a social contract system: we expect to be able to go to our doctor and know that they will do their best for us, looking at a comprehensive care with some exceptions rather than an insurance system that too often specifies what you can have. There is a big difference between the two. My worry is that there will be a change in the attitude of mind and behaviour in that relationship.
I have one positive suggestion here which the Minister may or may not like. Although there are pathfinders and there is preparation under way, I have not seen anything that suggests there will be any large-scale simulation of these proposals—getting people together and, over a period, encouraging them to play out the various roles to see what will happen. That has been done in the past, and it is an effective way. The question need not be whether these proposals will work but what you need to do to make sure they work as effectively as possible. Can the noble Earl say whether the Government propose to do any such simulation of these proposals before bringing them fully into effect?
NHS: Global Health
Lord Crisp Excerpts(14 years, 6 months ago)
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Lord Crisp
To ask Her Majesty’s Government how they will ensure that the subject of global health is included in the education of all health professionals.
Lord Crisp
My Lords, it is a great pleasure to be able to open this debate. I am delighted to see how many noble Lords have decided to take part in it, and I know that a number of others, for reasons of snow and the fact that we already had a large list, have decided not to take part. There is a lot of interest in this subject, and it is something on which there is a great deal of agreement both in your Lordships' House and outside. That agreement is partly the point of the debate, because what we need now is some action.
Professional education in the 20th century has done a wonderful job, not least in the United Kingdom. Life expectancy in the world as a whole has doubled in the century, but the outside world has changed, which means that there is a need for a change in education. There is a broad consensus on what needs to happen, and we can see it happening in many of our leading schools already. As Richard Horton, the editor of the Lancet, has put it:
“health professionals today are not adequately prepared to address the present and coming health challenges—aging populations, chronic diseases, cultural diversity and higher public expectations”.
It is, if you like, the necessary move from a purely doctor and hospital-based model to something much more diverse and local, more community and more person-based. That was a goal of the last Government and I know that it is a goal of this Government. The difficulty as always is to make it happen.
This Question is about global health and the emerging new discipline of global health. Let me explain why I think it is relevant here. I am talking about global health, not international health, which is what we talked about in the last century when we talked about the health of other people. Global health is about the health of all of us—all the issues that affect us all, wherever we are in the world. It is about our interdependence in terms of disease and how it can fly around the world very quickly; in the 14th century, it took three winters for the Black Death to get across Europe, whereas it took three days for SARS to get around the world earlier this century. We are also interdependent in our use of the same staffing and resources and interdependent in terms of the environment and climate change. All kinds of issues affect our health and we began to understand them much better in this past decade than we ever did before.
The second reason is that the diseases from which we suffer have been changing. There are many more non-communicable diseases, and in that context context itself is vital. We are beginning to understand better the social, behavioural, cultural and economic aspects of global health, and the emerging discipline is about taking on these issues and about understanding and acting on the wider determinants of health. Education needs to do this as well.
Thirdly, global health is about recognising that health is about health systems and how healthcare is delivered to individuals and populations. It is not just the theory of the laboratory and lecture room but the reality of the clinic and the community.
The fourth point that drives very many people is that experience in other countries is extremely valuable to us in the UK. Many who are involved in global health are driven by a passion to do something in poorer countries, but it is good for the UK as well. It develops people personally and they can learn from new examples and new experiences, and of course learn about some of the people living in their own country whose origins may have been far away.
Let me refer to the recent Lancet commission report that was published at the end of November, called Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World. The commission was chaired by Julio Frenk of the Harvard School of Public Health, and by Lincoln Chen of the China Medical Board, of which I was privileged to be a member. This was the first such attempt to look globally, with a global set of commissioners, and to learn from innovation everywhere in the world—not just Europe and America—and to do so across all professions on which we could collect data. It draws out some key lessons about how education needs to happen in the future: about how it needs to be interprofessional and transprofessional, going across disciplines and outside them to involve the public. Education needs to be competence-based, systems-based and IT-enabled.
The report also shows how our institutions need to change, breaking down barriers and connecting not just across disciplines but going outside health across locations and countries. Let me mention just one example that brings it alive: the IHI Open School. There are now 80 chapters in universities across world in 28 countries. This is a coming together of medical students to learn via the internet about subjects that are not covered in traditional courses: quality improvement, systems thinking and such like. They are studying in one school, maybe in the UK, but adding to it from elsewhere. This is the sort of model that I think we will continue to see.
The final point about the report is that it talks about transformational education: the effort to create professionals who are able to lead and make change in today's changed world. A brief illustration of the wide-ranging thinking on this in this country can be seen from the activities of two groups: Alma Mata and Medsin. Alma Mata is a 1,000-strong group of junior doctors and young health professionals from other disciplines. Medsin is also about 1,000-strong and made up of medical students. They advocate precisely that global health should be included in the syllabus and set out their vision for the doctor of the future, which is very important as they are the doctors of the future.
It is encouraging to see that the establishment is responding, including the Royal Colleges—and we have two former presidents of Royal Colleges speaking in this debate. To take one example, the Royal College of Obstetricians and Gynaecologists is very concerned about the lack of support for junior doctors who want to work overseas and who want to include that in their training and not be disadvantaged in their careers by doing so. There are also organisations such as the London International Development Centre, which works with six London institutions and runs, among other things, courses of students as global citizens. There is a very much wider view here about what needs to change. Indeed, developments in partnerships between institutions are very ably supported by THET, and I am delighted to know that Her Majesty’s Government through DfID have launched an even more substantial scheme to promote these partnerships.
There is a lot happening in the UK, but this is a worldwide phenomenon and things are moving faster in the US and Scandinavia than here. I can imagine the Minister saying, “Very good, we’re happy to encourage this, but what has this got to do with Government and the Department of Health?”. My answer is that it really does have an impact on us. I stress that this sort of activity is not just for the benefit of foreigners; it is about creating better health professionals who are better able to care for people of this country with our 21st-century diseases and lifestyles.
I suggest three actions. The first is extremely practical. I ask officials in the noble Earl’s department to report to him on what more can be done to help trainee doctors to spend some time abroad as part of their training and to do so in some numbers, not with the odd one or two who take a risk with their careers. That would make this much more mainstream and much more positive.
Secondly, the Minister’s department should meet the universities and the professional education schools of medicine and nursing and the wider health schools to consider the findings of the Lancet commission and decide what action might jointly be taken to develop the education of health professionals and to get some impetus and coordination behind the moves that are happening all over this country.
My third request is that the Minister’s department provides active support for the involvement of NHS people and organisations in the DfID programme of partnership, recognising that this is a difficult time for the NHS but making it clear from the top that this is good thing for people to be engaged in. It is about the future, and there may even be ways of looking at things like the newly announced early retirement scheme, which might actually help in developing these sorts of programmes.
Health: NICE
Lord Crisp Excerpts(14 years, 8 months ago)
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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.
Health: Primary and Community Care
Lord Crisp Excerpts(15 years ago)
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Lord Crisp
My Lords, I, too, congratulate my noble friend Lord Mawson on inviting us to reflect on primary care over the past 10 years and more. I know he is hopeful that his timing is such that the Government’s policy is not yet so rigid that they cannot listen to new ideas and the practical lessons that he and others want to mention. I have to declare an interest. Most people know that I was chief executive of the NHS in England for six years. There is a lot that I could say, but I will concentrate on the same areas as my noble friend; namely, the integration of care, particularly thinking about social care, education and other boundaries around the whole person.
The other day, an American friend said to me, “We love you in England because you keep changing the way you develop primary care. You are a wonderful laboratory. You have tried out lots of different ways of doing it”. I guess that that is true. But I guess that there is a reason for that, which is not just a wish to meddle. It is that, as other noble Lords have mentioned, a lot has changed in the 70 years since the 1940s, when we set up the primary care system we have now. The three big changes have been referred to by others. The diseases are different. Seeing patients is much more about dealing with non-communicable diseases. They are about elderly people with complex or multiple problems. The patients have changed. They are much more demanding, but their behaviour is much more important in so many ways in terms of the management of care for diabetes or whatever. In addition, technology has changed. All those changes mean that our old model has led to shift. As we have noted, there have been many ways in which people have tried to make that shift. It is really important that we learn the lessons from those attempts to change and to make improvements.
Before this debate, the Royal College of Physicians wrote to me and, I suspect, to others saying that it was really important that we did not lose sight of the fact that primary care, secondary care and tertiary care need to join up. We need to have that all within the frame. It is interesting to reflect that the separation between primary care and secondary care is largely in legislation that is about 70 years old. It is not writ that a GP shall be this and a consultant shall be that. It was an organisational change. The way in which parts of the medical profession relate can change and some organisations, as I think that the noble Lord, Lord Alderdice, mentioned, employ or involve both. There is nothing rigid about this.
However, I want to talk about integration around the patient. Let me go back to the simple point that most patients today in richer countries are people whose needs often may be clinical, but alongside that there is a need for independence. I think that I have mentioned in this House before that my elderly father fell and broke an arm. Clinically, it was very easy to deal with, but the real issue was whether he could remain independent and live at home by himself. That is the sort of situation we are talking about in terms of many of the patients that the NHS deals with. Indeed, many patients with the highest expenditure in the NHS are those with complex problems that span clinical, social and other needs. So it is welcome to see primary care playing a major role in prevention and in helping patients find their way around the system.
Primary care is not just about GPs, and it is important to keep the two separate. There are different roles for many different people. One of the saddest pieces of research I have seen was published some years ago. It concerned young people suffering from depression and how they were treated in primary care and whether they were able to be taken seriously. There were too many accounts of people going to GP surgeries and being told to come back in three months if it was getting worse. In effect, they were being turned away. We need different routes in primary care for those who sometimes find it difficult to express their needs.
That takes me on to the issues raised by the noble Lord, Lord Mawson, about health and social care, and other areas such as health in education. He asked how far we should go to ensure that we have health provision in schools, whether in the form of health services or whether they are designed into the architecture of schools. He also asked if we should have local partnerships that are able to focus on what is needed. The noble Lord concentrated on social entrepreneurs, but I know that he, like me, is interested in how local partnerships made up of the right groups of people can have an enormous impact on a local environment in terms of health benefits and the related issues that go alongside them. By local partnerships, I am not just talking about individual organisations that bring health and social care together, but about partnerships that bring together everyone who has something to offer in this area. These can be quite difficult to conceptualise and describe in order to determine the policy that will promote them, so I would encourage the Government to look at some of the ones that work.
As I said, the noble Lord, Lord Mawson, referred to a number of social entrepreneurs and one or two exceptional GPs who have set up extraordinary practices that go way beyond what we would traditionally think of as healthcare. But I think that some of our PCTs have done exceptional things in trying to address inequalities, particularly in areas like mental health where we know that among the best things you can do for patients is help them to get jobs and housing. Among the range of entrepreneurial PCTs let me mention one particular group I know of and declare an interest in. Something like 20 UK PCTs are part of a group called Triple Aim. They are working alongside similar organisations in Scandinavia and the US, facilitated by an American organisation called the Institute for Healthcare Improvement. Here I declare my interest because I am working with the organisation in Africa rather than in this country. It would be interesting for the Minister and the Department of Health to look at what these PCTs are trying to do by taking on a triple aim—to improve the health of the population, improve the care given to individuals, and reduce costs. They are doing so by trying to integrate with local partners. There are some good examples that we can build on and, taking a completely different example, a number of schools in this country have health facilities within them. So I urge the Government to look not just at the social entrepreneurs referred to by the noble Lord, Lord Mawson, but at the organisational people working within the system who are trying to make these things work; they go very much together.
Finally, I come back to the issue of primary care trusts and GPs. I have seen some statements from the Government about giving GPs and doctors more control. I understand and appreciate that. One of the great merits of the NHS that shows up in any comparison with other systems around the world is its primary care. This is one of our great strengths, among others, and we must preserve it. But however wonderful some GPs are, not all of them are. They are not all capable of taking on all the roles that we might think we would like them to. I pay tribute to the last Government because they were concerned about variations in performance between hospitals and did a great deal to bring the performance of the poorest up to the best. Among GPs, not surprisingly because there are so many of them, that range of variation is much wider. Sometimes we talk about GPs as if they are all the same, but to me that feels like something of a mistake.
Another issue in developing policy around GPs in the context of primary care is the potential for conflicts of interest, and again I suspect that the Department of Health has good examples of where, by putting more money into primary care decision-making hands, potentially and only in some areas you end up with conflicts of interest about how the money is spent. But—and it is a very big but—we have also seen great benefits from having primary care and GPs taking a lead. In particular, it is interesting that in a number of practices where the GPs have budgets and have taken a bigger lead around commissioning, they have changed the services they provide and the job roles of people. Increasingly you see people other than individual GPs when you attend a GP practice. That is all for the good, in both quality and cost terms.
I am reminded that 15 years ago we were trying to get more GPs into east London and tried to do so by recruiting salaried GPs—in other words, by moving away from the current model of GPs being self-employed. We were told we could never do that: it was not what GPs were about and it was essential that GPs were independent. I see the noble Lord, Lord Rea, nodding his head. However, we succeeded to some extent in making that happen but now it has all changed. Today, in practices where GPs are responsible for budgets and direct care, there are many salaried GPs and many people doing different kinds of jobs. That would not have been possible had you tried to make those changes from above. Indeed, GPs in London complain that they cannot get jobs as partners any more; there are now salaried jobs but the partnerships are being kept in fewer and fewer hands.
While that may be a downside, the important point is that doctors, as part of the entrepreneurial culture to which the noble Lord, Lord Mawson, referred, have the ability to make changes that mere managers, politicians and others from outside would find it difficult to make. It is important to build on that.
I hope that, like the noble Lord, Lord Mawson, the Government will look back on the years of change and development and learn the practical lessons. I should like to ask two specific questions. Will the Government look at innovative PCTs as well as innovative entrepreneurs, and perhaps consider Triple Aim as an example? How will the Minister clarify the relationship between PCTs and GPs in the future? I suspect this is one of the areas in which there is some confusion in the service at the moment over how primary care will be led, planning will be done and life will move on over the next few years.
NHS: Patient Targets
Lord Crisp Excerpts(15 years ago)
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Earl Howe
My noble friend is right because, when all is said and done, many of the centrally imposed targets were quite arbitrary. For example, why 18 weeks, not 17 or 19? It is worth saying that the targets that clinicians and managers set themselves are often a great deal more stringent than the ones that politicians are likely to set.
Lord Crisp
My Lords, as the chief executive of the NHS in England from 2000 to 2006, I think that I had better declare an interest on this matter. Although what the Government announced recently were some minor and probably quite sensible changes to targets, they also sent a big message. The message is about localness, which is very welcome, but there is also a very risky message, which is that waiting no longer matters. I know that the noble Earl understands very well that the NHS listens to what Ministers say. How will he ensure that people in the NHS understand that waiting is still a very important issue?
Earl Howe
My Lords, the noble Lord is absolutely right. I believe that the message that he wants sent has been sent by the NHS chief executive in his letter to NHS bodies. It is certainly a message that the Government want to send. Timeliness is important. A great deal has been achieved. We do not want to squander that, but we think that clinicians should now be given the responsibility to prioritise patients and treatments for themselves, not have central performance management dictated from above.