Learning Disabilities: Premature Deaths

Lord Hunt of Kings Heath Excerpts

Wednesday 30th July 2014 Lords Chamber

[Earl Howe]

My Lords, I can assure the noble Lord that there is currently a whole-system response to the recommendations in the review. As I said earlier, this is a response from NHS England, Public Health England, local organisations and, indeed, Ministers overseeing the Learning Disability Programme Board. I shall take away the noble Lord’s question about a formal annual review, consider it carefully, and write to him.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Earl recognise that the confidential inquiry showed that there are great failings in the health treatment given to many people with learning disabilities, which probably contributes to their very poor life expectancy? He will be aware that my own former trust, Heart of England, appointed specialist liaison nurses who could help people with learning disabilities find a pathway through their healthcare. Would he advise other NHS trusts to follow that example?

[Earl Howe]

My Lords, the noble Lord makes a good point. Following the recommendations of the UK review of learning disabilities nursing, we have set up an independent collaborative to address that workforce’s needs. We are also working with Health Education England’s 13 local education training boards to develop greater links with the independent and voluntary sector which will help with workforce planning. This year Health Education England increased its national commissions for student learning disability nurses by 4.5%. We are working on a number of initiatives to raise the profile of learning disabilities nursing and promote the profession as an attractive career choice.

Health: Dental Implants

Lord Hunt of Kings Heath Excerpts

Wednesday 23rd July 2014 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Baroness, Lady Gardner of Parkes, is one of our most active Members and I am sure we all owe her a great debt in bringing this matter to our attention tonight. I declare an interest as a member of the Faculty of Dental Surgery at the Royal College of Surgeons. Last Friday, I attended a celebration of the 50th anniversary of the fluoridation of the water supply in Birmingham. Will the noble Earl join me in congratulating the great city of Birmingham on this achievement? It is interesting that, when one looks at health outcomes, Birmingham is often towards the lower end of the table, but it is way up in the top 10 in oral health. Whatever one’s views on fluoridation—and I also declare my presidency of the British Fluoridation Society—there is no question that it has had a very positive impact in Birmingham and the West Midlands in terms of the number of children who have to go into hospital because of oral issues, which was a point raised by the noble Baroness.

As the noble Baroness said, the use of dental implants has grown rapidly across the UK in the last few years. That has been very welcome to many patients but we know that, on the other hand, alongside this rise, the General Dental Council has seen an increasing number of complaints, particularly regarding the lack of informed consent for treatment, damage to the tissue and bone surrounding the implant, and failures. The noble Baroness was very explicit about some of the health issues that can arise. I have looked very carefully at the briefing provided by the Faculty of Dental Surgery at the Royal College of Surgeons. It makes four points that I will put to the noble Earl, alongside the questions raised by the noble Baroness.

Essentially, the briefing says that it is very important for patients to be given adequate information about the risks and alternative options for treatment. Secondly, patients should be aware that periodontal and peri-implant checks are essential to ensure that problems are detected early. The stability of the implant is threatened by diseases such as the one mentioned by the noble Baroness. I do not dare attempt to repeat its name, although I believe that the noble Earl, Lord Howe, is perhaps braver than me on that. However, this is why checks are essential.

Thirdly, the GDC should consider ensuring that peri-implant assessment and maintenance is part of the normal undergraduate course. Fourthly, I would like to mention the Law Commission draft Bill. We are not to see the Bill, but it contains proposals to give regulators the power to annotate their registrar and indicate specialisms or other qualifications. Given that we are not going to have the Bill—I know that there will be some Section 60 orders—perhaps I could make a plea that this might be considered if a dental order is to be brought forward.

Finally, I refer to a very interesting note I received from the Faculty of General Dental Practice about the standards of training in implant dentistry. This is available from a wide variety of providers in the UK, including universities, royal colleges and hospitals. These standards have been developed to ensure patient safety and protection, and I understand that they also serve as a reference point for the GDC in consideration of patient complaints. The only question I wanted to put to the noble Earl about this is that, although this seems to be absolutely fine, how can we ensure that more dental teams take up these training opportunities?

Clearly, we have a good system where standards are very much developed. The providers have to provide training in line with those standards, and the General Dental Council is there to follow up complaints when there are indications that dentists are not practising according to those standards. I wonder whether the noble Earl thinks that there is an issue of some dental practitioners not doing that, which then has an impact on their provision of clinical services.

Health: Midwives

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My Lords, I do not have information on the confidential enquiry in my brief but, according to international statistics, the NHS remains one of the safest places in the world to give birth. The latest independent CQC survey found that maternity care in England has improved, with women reporting a high level of trust and confidence in the staff caring for them. I shall gladly let my noble friend know the latest that my department has on the issues she has raised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, did the noble Earl see the report in the Times this morning that the Nottingham University Hospitals NHS Trust maternity unit closed 97 times in a period of 12 months due to pressure? Freedom of information requests have shown that some 62 maternity units were forced to close because of pressures in 2013. Is that not a firm indication of a shortage of midwives? Does it not show that the Government are less than active in seeking to put this right?

[Earl Howe]

It is up to commissioners to ensure that facilities are available to meet the needs of women who are due to give birth. There may be limited occasions when a maternity unit cannot safely accept more women into their care. That is why we have seen some temporary closures of units. Any decision to redirect women is made by a clinician as part of a carefully managed process. It is not something that suddenly happens. However, commissioners need to be alert to the risks for provider facilities that a bulge in births can create.

Learning Disabilities: Community-Based Support

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd July 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they are taking in the light of the events at Winterbourne View hospital to ensure that people with learning disabilities inappropriately placed in hospital are able to move to community-based support.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government are working with health and care system partners, self-advocates, family carers and other stakeholders to improve safety, quality of care and outcomes for people with learning disabilities, including reducing significantly reliance on in-patient care, by reviewing people’s care and moving them to alternative, community-based support where appropriate.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Earl for that. Can he confirm that the Government set a deadline of 1 June for the transfer of thousands of people with learning disabilities out of institutions such as Winterbourne View? The latest figures show that only one in 10 such residents has actually been so moved. Will the noble Earl accept responsibility for this and tell the House what the Government intend to do about it?

[Earl Howe]

My Lords, the Government’s mandate for NHS England in the current year includes an objective which covers Winterbourne View concordat commitments. He is right that the deadline was missed. We are not satisfied with that and we are working very hard with NHS England to set out our expectations for progress and improved rates of discharge from in-patient settings. NHS England is going to produce an action plan this August but, in the mean time, it is doing three things. It is complying with the transforming care and Winterbourne View concordat commitments, which we have tasked it to do. It will set out what progress it expects to make and by when, with milestones, and it will provide real clarity on what success looks like—an important issue if we are trying to hold it to account—and how progress will be measured.

NHS: Ambulance Response Times

Lord Hunt of Kings Heath Excerpts

Monday 21st July 2014 Lords Chamber

[Earl Howe]

My Lords, I am aware of a number of those tragic cases. It is, of course, up to each response team to decide on the configuration of personnel and the skill mix on each ambulance that goes out. That judgment often has to be taken quickly. Sometimes it is a difficult judgment and, tragically, it is not always the right judgment. However, I know that every ambulance service in the country is mindful of the need to reach patients in emergencies with the greatest possible speed and the right professional skills.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the noble Earl confirm that the average waiting time for the most urgent 999 calls has lengthened in all parts of the country on average in the past three years? What are the Government doing to improve ambulance performance, and particularly could he comment on the very poor performance of the East of England Ambulance Service?

[Earl Howe]

The noble Lord is right. Ambulance trusts are experiencing high demand and we realise that a handful of services have experienced difficulty. Broadly, we are taking action in the short term and in the medium to long term. In the short term, we are supporting trusts with operational resilience plans so that they are better equipped to manage peaks in demand and we are providing clinical commissioning groups with additional funding, as I mentioned in my original Answer. Over the longer term, the NHS England review led by Sir Bruce Keogh is considering whole-system change, incorporating ambulance services.

With regard to the east of England, I met the East of England Ambulance Service NHS Trust’s chief executive, Dr Anthony Marsh, on 8 July to discuss performance since his appointment in January, and he assured me that the trust is now in recovery stage. Having seen his detailed proposals, I accept that judgment.

NHS: Hospital Waiting Times

Lord Hunt of Kings Heath Excerpts

Thursday 10th July 2014 Lords Chamber

[Earl Howe]

Yes, she is. I have known the new president of the royal college for some years. She is a very considerable surgeon, and I agree with what she has said. Clinical priority is the main determinant of when patients should be treated, and should remain so. Clinicians should make decisions about the patient’s treatment and patients should not experience undue delay at any stage of their referral, diagnosis, or indeed treatment. That is why we have moved away from targets to standards—to signal the importance of clinical priorities, which doctors should always feel able to act on.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Earl agree that, whatever he says about targets, the previous Labour Government reduced the maximum waiting time for in-patient treatment from 18 months to 18 weeks? Was that not a substantial reduction? Is the Minister not concerned that if we take a whole raft of measurements, it shows a health service now under great pressure financially and in terms of waiting times?

[Earl Howe]

Yes, of course, the previous Government did an enormous amount to reduce waiting times. I also hope, though, that the noble Lord will give us credit for what we have done to reduce waiting times for those who have been waiting the longest, who were never targeted under the previous Government. I acknowledge that the system is under strain at the moment, but we have plans for the short, medium and long term to address that situation.

Health and Social Care Act 2012: Risk Register

Lord Hunt of Kings Heath Excerpts

Wednesday 9th July 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

Referring to the noble Lord, Lord Marks, methinks the Lib Dems are trying to rewrite history. They underpin this dreadful change that the 2012 Act brought to the NHS and they bear responsibility for the shambles that it has caused. I am very confused by the approach of the Department of Health. It has berated the National Health Service for not being open and transparent; in fact, it published a league table of those who are good and those who are not good. The NHS bodies are required to publish risk registers, so why should it be different for the Minister’s own department?

[Earl Howe]

The Government of which the noble Lord was such a distinguished member took the same approach to risk registers. Of course, transparency is an important principle in health and care. It is important to drive up performance and expose institutional failure, and I believe there is a revolution taking place in the level of transparency and access to health and care information. I am sure we are agreed on that. The point that I sought to make earlier is that when it comes to policy-making within government, Ministers and civil servants are entitled to some safe space, so the principle of transparency has to be moderated to a certain extent. That is the balance that we have struck.

Health: Cancer

Lord Hunt of Kings Heath Excerpts

Wednesday 9th July 2014 Lords Chamber

[Earl Howe]

Yes, my Lords. Radiotherapy, particularly of this kind, is highly cost effective when it is clinically indicated. In fact, SABR is available in eight radiotherapy centres in England. The number of centres providing this treatment is increasing, with over a quarter having equipment capable of delivering the treatment. Current evidence supports treating only a small number of patients with this treatment: that is, in early-stage lung cancers for patients who are unsuitable for surgery. That is about only 1,000 patients a year.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Earl will be aware of a pledge made by the Prime Minister last October that this kind of treatment would be available to cancer patients who needed it. He will also be aware of a statement by Mr Lawrence Dallaglio, who was asked by the Government to help in this. He described it as a “national disgrace” that NHS England reneged on a deal to fund these cancer treatments. Is the noble Earl absolutely certain that the reason the number of treatments has fallen is due entirely to clinical reasons?

[Earl Howe]

Yes, my Lords: that is the advice I received. It goes hand in hand with other advice around other forms of radiotherapy treatment that are increasing very dramatically. For example, intensity-modulated radiotherapy is a similar form of radiotherapy for different types of cancer—head and neck cancers, principally. The use of that radiotherapy has grown very considerably, partly as a result of considerable investment by the current Government.

NHS: Rural General Practitioner Dispensing

Lord Hunt of Kings Heath Excerpts

Tuesday 8th July 2014 Lords Chamber

[Earl Howe]

My noble friend makes a good point. That is why the rules contain an exception for those who find it difficult to travel and who may therefore wish to have medicines dispensed from their own dispensing GP practice. Those rules do apply to disabled people and to those whom my noble friend describes.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the Minister not regard it as somewhat ironic that yesterday we had the Government trumpeting their Deregulation Bill but today he defends what essentially is an uneasy truce between the BMA and the pharmaceutical interest, in which often the public are the losers? Is it not time for that to be reviewed again?

[Earl Howe]

I simply ask the noble Lord why his Government introduced those rules when they were reviewed only a few years ago, before the current Administration came to office.

Health: Polypill

Lord Hunt of Kings Heath Excerpts

Monday 7th July 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they will take to encourage the use of the polypill by the National Health Service.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful for this opportunity to put some probing questions to the noble Earl, Lord Howe, and perhaps ask for his help with something that I am rather puzzled about. I detect a less than enthusiastic response from the medical and health establishment to the development and potential of what is being called the polypill. Perhaps the noble Earl will share the reasons for it and helpfully suggest a way forward for some more constructive engagement on the issue, if that is at all possible.

As we know, strokes and heart disease remain a major public health problem. Across the population as a whole, the chance of having a heart attack or cerebrovascular accident rises as people get older, and age is the single most important predictor of future cardiovascular disease. But we know now—there is robust evidence—that the consumption of fixed-dose polypills containing effective combinations of low-cost off-patent statins and blood pressure medicines can safely cut the rate of unwanted vascular events by 70% or more in otherwise untreated subjects, whatever the initial combined level of their blood cholesterol and other disease risk factors. The use of such a preventive technology across the general population, with access determined by age alone, would prevent the need for much more costly and inefficient risk-testing, and maximise the health gains. Clearly, it is aimed at people in their 50s and 60s who would not at the moment meet any treatment threshold.

The use of the polypill focuses on primary prevention, whereas the majority of current medical activity is focused on secondary prevention. Of course, if a first heart attack or stroke is prevented, there is no second one to prevent. My understanding is that if people take this daily from the age of 50, one in three people would benefit and would gain an extra eight years of life without heart attack or stroke—similar to the benefit achieved by stopping smoking in middle age.

I suppose that the polypill can be thought of as a form of drug-based vaccination that reduces vascular disease rates. However, unlike the situation with vaccines, there is no threshold level of use needed to ensure herd immunity—the higher proportion of healthy people taking the polypill, the greater the benefits—but no one needs to be encouraged against their personal judgment to take it if they do not wish to do so.

An article in the BMJ in April, which contained research news, said:

“Inconsistencies in the design of studies investigating the potential of polypills to prevent cardiovascular disease make the impact of these pills difficult to prove, a systematic review by the Cochrane Collaboration has found. However, the reviewers are confident that polypills do have a role in protecting large populations against cardiovascular disease”.

One would have thought that there would then be a great rush of enthusiasm by the NHS and indeed the medical and health sector generally to use the polypill. But as far as I can see, we have had mostly silence and in some cases downright hostility. There has clearly been difficulty making a polypill with a licence for the primary presentation of cardiovascular disease, and pharmaceutical companies see little commercial advantage because the components of the polypill are all generic. I understand that they are also put off by the uncertainty and cost of obtaining regulatory approval.

I wonder whether we are seeing here a parallel to the statin debate, which, as a lay person, I have found utterly confusing. I pick up the sense among some sections of the medical profession, particularly the public health profession—and I stand here as president of the Royal Society for Public Health—that pills are not really virtuous. It feels as though there is a puritanical approach which suggests that healthy living is the only appropriate policy to adopt in the prevention of stroke and heart disease. I also suspect that doctors fear the workload implication of this kind of medication when it comes out. Perhaps they also fear losing control. In a sense, the use of polypills could be seen as the public very much taking ownership of their own health.

There is no evidence that the use of polypills would lead to increased vascular disease risk-taking. I understand that the available studies imply that health-promoting behaviours tend to be positively correlated with one another, as might be the case with health-damaging behaviours. As with vaccines, the introduction of a general polypill prevention programme within the NHS would probably require a positive, proactive approach, possibly in the form of some government/private partnership.

I was interested in the Government’s approach to antibiotics last week. Clearly, the current mechanisms—the factors that lead pharmaceutical companies to make major investments—were simply not going to produce the goods and the Government felt that they had to step in. Will the Minister consider whether his department might at least play a somewhat more active role in this debate than it has done hitherto? Would he, at the very least, be prepared either to convene a study or an objective, independent review of the potential of the polypill? Would he, at the very least, be prepared to meet me and colleagues to discuss whether there is a way to take this forward?

I am puzzled that, on the face of it, the polypill could lead to a major reduction in the number of heart attacks and strokes that occur in this country, yet the combined efforts of the medical, health and pharmaceutical establishments seem to want to look the other way. Why?

--- Later in debate ---

[Lord Turnberg]

Those are very good points. The doses used in polypills are very low, in fact—20 milligrams of simvastatin, when the normal dose is 40 to 80 milligrams. The other drugs in the polypill are half doses. The point is that, if you have raised LDL cholesterol or raised blood pressure, you should certainly be on the treatments; they have been shown to be effective. It is people who do not have raised cholesterol or raised blood pressure who we are aiming to treat—or to prevent their diseases—so it is a different situation. The point about safety is important. It is clear that we need and should have proper clinical trials of those doses, but the impact of such doses, from what we know about them in this combination, is that they are likely to be safe in the vast majority of cases. What we do not know is the number who will get side-effects.

[Lord Hunt of Kings Heath (Lab)]

My noble friend, and other noble Lords, mentioned the importance of clinical trials, which I am sure is absolutely right. Is not the problem here that in fact no pharmaceutical company will conduct a clinical trial because all the drugs used in combination in the polypill are off-patent, so there can be no protection of that research by any company taking it forward? So there is, if you like, a block here, although people can see the potential benefits. Rightly, noble Lords are asking for clinical research, but there is no possibility of that happening unless the Government take a hand themselves, which is why the debate on antibiotics is interesting. They are completely separate subjects, but the Government had to step in there because, at the moment, the market simply cannot respond to the issue.

[Lord Turnberg]

I agree entirely. I think that it will be difficult for the drug firms themselves to conduct trials because these are generics and they are manufactured by a number of companies. The only way forward, I suspect, if we are to have a clinical trial, is through NHS funding—that sort of trial. My final remark is that I very much look forward to the noble Earl’s response.