EU: Healthcare

Lord Kakkar Excerpts

Wednesday 11th January 2012 Lords Chamber

Asked By

[Lord Kakkar]

To ask Her Majesty’s Government what assessment they have made of the impact of the European Union on healthcare in the United Kingdom.

[Lord Kakkar]

My Lords, I am very grateful for the opportunity to introduce this Question for Short Debate on the impact of the European Union on the delivery of healthcare in the United Kingdom—a subject on which I have spoken in your Lordships' House on a number of previous occasions. In doing so, I wish to draw noble Lords’ attention to my entry in the register of interests as a practising surgeon, professor of surgery at University College and active biomedical researcher. I would also like to take this opportunity to thank those noble Lords who have kindly added their names to the speakers list and who will make a contribution to this short, time-limited debate.

The impact of European Union directives and regulation on the delivery of healthcare in our country is an important issue. It is not primarily an issue of politics but of the well-being and safety of patients in our healthcare system. If there have been unintended consequences of the adoption of regulation and directives into domestic legislation, it is important for Governments to recognise this and ensure that appropriate measures are taken to overcome them.

We can consider the impact of legislation from Europe on the delivery of healthcare in our country in three broad areas. The first is directives and regulation that have already been incorporated into the laws of our country. The second concerns how directives and regulation that are under consideration should be incorporated into domestic legislation. The third covers areas of broader concern connected with potential consequences, particularly with regard to European Union competition law and the intended purpose of the Health and Social Care Bill.

As regards the first category, it is well recognised that the European working time regulation has had a detrimental impact on the training of our young doctors, particularly those who are training to pursue careers ultimately as independent practitioners at consultant level in the craft specialties, such as my own of general surgery. A restriction to 48 hours’ working per week has resulted in trainees feeling that they have insufficient experience at the end of their training to be certain that they can perform independent consultant practice in the way that it is envisaged in our country rather than models for the delivery of clinical practice in other European countries, to the extent that there is genuine concern that we may be producing generations of consultants less able to deliver the rigorous and demanding practice that we have always expected and have been fortunate enough to receive in our country.

There is also the question of the additional cost of providing locum cover to ensure that rotas are compliant with a 48-hour working week. In an important piece of work published last year, the Royal College of Surgeons identified an additional £200 million a year cost in providing locums to ensure that rotas were 48-hour compliant after the first year of the introduction of the final European working time regulation.

There has also been considerable concern about the problem of language and competence testing. I think most noble Lords would agree that the same standard should apply to every doctor and healthcare practitioner working in our country with regard to their ability to speak the English language and be able to communicate appropriately with patients. There is no doubt that the ability to communicate is a hugely important part of the delivery of healthcare. Equally, it is only right that patients in our healthcare systems are able to expect that all doctors and other healthcare professionals who have the privilege of treating them in our hospitals and other healthcare environments practise to the same level of competence. At the moment it is impossible for the national regulatory bodies in our country to ensure that doctors who are registered elsewhere in the European Union meet the same standards as we expect of our own graduates or graduates from elsewhere in the world.

There are real concerns that the first year after qualification from medical school—formerly known as the house job year, now known as foundation year 1 —which is an essential part of completing the process for full registration with the General Medical Council, has now been opened up to competition from medical graduates across Europe as part of the free mobility of labour in the European Union. However, this first year of clinical practice remains an important element of ensuring that our young medical graduates can complete their training and can ultimately register to practise in our country. The issue is very simple: if they are unable to take that year, they are unable to fully register and will not be able to practise in our country. This is a huge waste because these talented graduates should remain in our country and serve our nation, ensuring that the debt they have is repaid through practice in the National Health Service. In this year’s round of appointment to that first foundation year, some 52 potential graduates have not been given a foundation year 1 post and some 113 practitioners from the European Union have taken places on those foundation year 1 schemes. How do Her Majesty’s Government propose to ensure that this problem does not result in our graduates being unable to complete that essential first year after they have qualified from medical school?

There are also important concerns about the impact of the European clinical trials directive in terms of reducing the competitiveness of the biomedical science and research science output of our country. It is estimated that in the year 2000, 6 per cent of all patients who entered clinical trials around the world came from our country. Soon after that, in 2003, the clinical trials directive was incorporated into our domestic legislation, and the problems associated with its bureaucracy have resulted in a reduction in this country to just 2 per cent in 2006 and 1.4 per cent in 2010 of the number of patients included in clinical trials around the world.

These are all well proven areas where Her Majesty's Government need to develop a strategy to address the problems that have been experienced. However, there are also important matters relating to directives that are currently being considered by the Department of Health for inclusion in domestic legislation. There is a directive on transplantation which, if incorporated, will add bureaucracy to the delivery of transplantation services in our country, resulting in added cost. Those responsible for the delivery of these services believe that our standards that are highly regarded throughout the world are of sufficient quality and that any potential European directive must not be gold-plated and undermine an already successful service.

With regard to energy efficiency, a directive that is currently under regulation has caused considerable concern to the NHS Federation. This directive requires the building stock of all public bodies, including the National Health Service, to be improved on an annual basis, and for 3 per cent of floor space to be addressed each year. This will cost some £70 million a year, and the NHS, given the severe financial constraints it is facing, can hardly afford this.

Then there is the ongoing concern that European competition law may inadvertently be applied and in some way affect the proposals of Her Majesty's Government in the Health and Social Care Bill. Clinical commissioning groups, in wishing to take forward the development of new services to improve the clinical outcomes and care of our patients, could be disrupted in doing that through the application of European competition law.

In October last year, the Prime Minister indicated that all government departments should look at European regulation to determine how it might be adversely impacting on the work of those departments and the life of our country. There is no doubt that in the area of healthcare, the training of our young doctors, the innovation and delivery of biomedical research, and the delivery of healthcare itself have been detrimentally affected. It is absolutely essential that Her Majesty's Government are sensitive to the concerns—repeated on several occasions by those with responsibility for the delivery of healthcare in our country—and act as a matter of priority.

[Baroness Northover]

I remind noble Lords that this is a time-limited debate and that all speakers, except for the Minister, have two minutes. When the clock displays two minutes, noble Lords have had their two minutes. I note that we are without at least one speaker in this debate.

Health and Social Care Bill

Lord Kakkar Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Kakkar]

My Lords, I shall speak to Amendment 83 in my name and that of my noble friend Lord Patel. This amendment proposes that:

“Regulations must require the Board to commission services for veterans who have lost limbs”.

The purpose of the amendment is to ensure that those who have served our nation and who have quite rightly received the highest standards of care—both in theatre in the battlefield at the time when they sustained horrific injuries, then during their immediate aftercare back here in the United Kingdom and thereafter while remaining members of the Armed Forces receiving ongoing rehabilitation—can be certain that, once they are discharged from the services and return to civilian life, they are able to avail themselves of the necessary specialist services for years and decades hence. There is no doubt that what is achieved in battlefield salvage is quite remarkable, and those who sustain horrific injuries that some time ago would not have been survivable are now saved and can continue, from a young age, with the prospect of a good quality of life. However, the injuries, particularly the limb losses and multiple limb losses that they have suffered, will require ongoing specialist care.

Her Majesty’s Government have recognised the importance of this area and the noble Earl’s honourable friend the Member for South West Wiltshire, Dr Andrew Murrison, has recently published a report, A Better Deal for Military Amputees, in which he reviews both what is achieved acutely for these brave servicemen and what their ongoing clinical and other needs may be. He makes a number of important recommendations in the report. He suggests that a nationally commissioned service for veterans is the best fit for service-attributable amputees and, of the options he puts, looks at the option most likely to deliver the most for the wider amputee community. He goes on to make a specific recommendation that:

“Ministers should take appropriate powers to provide for national commissioning of specialist prosthetic and rehabilitation services for amputee veterans through a small number of multi-disciplinary centres in England, adequately resourced and determined through a tendering exercise”.

He puts the question that:

“Ministers will have to consider the extent to which existing legislation and the Health and Social Care Bill which is currently before the House of Commons”—

it was at the time—

“permit the national specialist commissioning of special provision for amputee veterans, tabling any necessary secondary legislation or amendments to Clause 11 in the Health Bill”.

So there is a broad recognition by those who have been commissioned by Her Majesty’s Government to look at this issue. The commissioning of specialist services for amputee veterans to ensure their long-term good clinical outcomes—that they may avail themselves of advances in the future, which are going to be dramatic and important in the decades hence and which could have an important impact on their ability to function—and that they have a high quality of life will only be achieved through national specialist commissioning of amputee services.

The Prime Minister, in his response to the report, stated the following:

“I am passionately committed to our Armed Forces. As a country and as a Government we have a particular duty to servicemen and women injured on operational duty. This report maps out a clear strategy for ensuring that those brave people can be confident they will receive the same levels of access to prosthetic limbs and specialist care from the NHS as they do at Headley Court. They deserve nothing less. Based on the recommendations in this report, this Government will make the resources necessary to meet that need”.

This amendment provides an opportunity to ensure that those needs are met. I strongly believe that only through the specialist commissioning of these particular services will the long-term interests of our brave service personnel, who have lost multiple limbs and who have to contend with that in their veteran lives, be properly secured. I hope very much that Her Majesty’s Government and the noble Earl will consider this amendment seriously.

[Baroness Pitkeathley]

My Lords, having put my name to Amendment 79, I support the powerful case made by my noble friend Lord Warner for the inclusion of long-term conditions and integrated services in the Bill. I particularly draw your Lordships’ attention to those long-term conditions that can be fluctuating as well as progressive. While it may be progressive in an overall sense, an illness such as multiple sclerosis has periods of varying intensity, when needs are different, and even periods—sometimes quite long periods—of remission. It is very important, therefore, that services are not only commissioned across health and social care—it is very important that there is a whole package of support; that is of such significance to users and their families—but also that those packages of care are flexible enough to cope with the varying progress of these illnesses.

The last thing that an MS sufferer, for example, wants when a period of remission suddenly ends with a fresh attack, as it frequently does, is to go back to square one on clinical commissioning, especially as far as the integration of clinical and social care commissioning is concerned. They do not want to go back to starting the assessment process or back to judgments about need and the abilities of their families to care for them, and so on, with all the delays and distress associated with reassessment and all the unnecessary expense that these processes involve. That applies very much also to those with certain mental health conditions, which are also fluctuating in their intensity. So proper care across integrated services not only prevents acute episodes but also helps to support caring families to participate in care effectively, as they wish to do, thus saving scarce resources as well as meeting the needs of those who are suffering.

Health Professionals: EEA and Non-EEA Citizens

Lord Kakkar Excerpts

Thursday 8th September 2011 Lords Chamber

[Lord Kakkar]

My Lords, I join other noble Lords in congratulating the noble Viscount on having secured this important debate. I will confine my remarks to medical practitioners and declare my interest as a practising surgeon.

For practitioners who have qualified outside the European Union, the situation is clear: our national regulatory body, the General Medical Council, is obliged to test their language skills and competency and is fully entitled to inquire into the content and quality of their medical education and training. For practitioners from the European Union, this is not the case: the GMC is not able to test language skills, is unable to make an assessment of their competency and is unable to inquire into their training and education. Clearly this is not acceptable, but the situation is worse even than that because, for practitioners who are registered elsewhere in the European Union and who, as we have heard, are entitled to come to the United Kingdom and practise, and for whom the General Medical Council is obliged to provide the opportunity for automatic registration, there is no obligation on the part of their home regulatory bodies to report any concerns that they may have about the practice of the individual—whether they have been suspended or whether there are any inquiries into their practice. That is an intolerable situation. It is not right for fellow practitioners who have to work with these individuals, but most of all it is not right for the citizens of our country who, at times when they are unwell and are becoming patients in our healthcare system, need to be absolutely certain that the practitioners to whom they are exposed are competent, meet the standards required of medical practitioners in our country and therefore can, with certainty, provide the quality of care that citizens in our country deserve.

There is a simple way forward. On language testing, I understand that a change in domestic legislation will allow immediately for the General Medical Council to move forward and assume responsibility for ensuring language competence. On professional competence, there will need to be changes at the European level. I know that the General Medical Council—and I am sure medical practitioners in our country—would warmly encourage the Government to pursue discussions at a European level of professional competence training, but in the mean time it would be most helpful if Her Majesty’s Government would consider looking at language testing and determining whether a change to domestic legislation could ensure that that particular problem is overcome. Ultimately this should not be a matter of politics or even of European relations: it is simply a matter of patient safety and providing for the people of our country the certainty they deserve in knowing that when they are unwell, the practitioners who will look after them all meet the same standard, whether they have been trained in the United Kingdom, in a European country or elsewhere in the world.

Health: Cancer

Lord Kakkar Excerpts

Thursday 11th November 2010 Lords Chamber

[Lord Kakkar]

My Lords, I thank the noble Baroness, Lady Finlay of Llandaff, for having secured this important debate. I congratulate the noble Lord, Lord Howard of Lympne, on his excellent maiden speech, defined by the strong values that have characterised his contribution to public life over three decades.

I propose to contribute today on the subject of thrombosis blood clotting, which is common in cancer patients, and in so doing refer your Lordships to the entry in the register of interests where I state that I am a practising cancer surgeon; that I am director of the Thrombosis Research Institute in London, where I lead a large programme of research globally on the problem of thrombosis in cancer patients; and that I have a scientific advisory role to a number of pharmaceutical industry organisations involved in thrombosis research.

We have heard about the important advances in clinical outcomes that have attended many cancers over the past two or three decades; that is welcome. That has been achieved through a better understanding of the biology of many cancers, which allows us to characterise them in more detail and to ensure that targeted therapies can be provided to patients, so improving both survival and quality of life. As we have heard, improvements in the outcomes for patients with malignant disease have also been achieved through earlier diagnosis. That is critical, because many of the advances in surgical practice can be applied only to those patients who present with earlier-stage disease, where radical interventions can in some cases cure, and in other cases ensure long-term palliation.

Advances are available beyond intervention in surgery, through new therapies. One of the exciting developments over the past five to 10 years is targeted biological therapies, which definitely improve outcome and survival but are frequently associated with a high frequency of unintended complications. The agents will improve outcome but can be associated with problems such as infection/febrile neutropenia and, of course, thrombosis blood clotting. Blood clots in any patient population develop in the deep veins of the legs and can often grow up the venous system of the leg, break off and pass to the lung, where they occlude the circulation from heart to lungs and can frequently be fatal. In the United Kingdom, the Health Select Committee of the other place in 2005 undertook a report into thrombosis and blood clots in hospitalised patients—a world first for a parliament—and identified it as a problem, with 30,000 deaths a year associated with thrombosis unnecessarily after hospital discharge.

As a result, we now have a system available throughout the NHS of risk assessment for patients coming into hospital, so that those at the highest risk of developing a blood clot can be provided with appropriate interventions to prevent them. One of the most important risk factors for developing a blood clot is the presence of malignant disease. Some 20 per cent of the total burden of thrombosis is seen in patients with cancer and, regrettably, cancer patients who develop a thrombosis are three times as likely to develop recurrent blood clots during the course of their natural history. Even though they are provided with anti-clotting drugs, they are twice as likely to develop major bleeding complications as a result of their use, so it is a problem.

While cancer patients are in hospital, they will be subjected to risk assessment in the perioperative environment or if they are admitted to a hospital bed for other management of their malignant disease. However, the management of cancer patients extends well beyond a short period in hospital. There are important opportunities to improve clinical outcomes through extending risk assessment into the other care environments where patients with malignant disease are managed. As we have heard, that is at home, potentially in hospice, or in other care environments such as ambulatory care for receipt of chemotherapy in the community. The National Institute for Health and Clinical Excellence has excellent guidelines at the moment on the prevention of venous thromboembolism in all patient populations. When it reviews that guidance, will it take the opportunity to look specifically at the problem of thrombosis in patients with malignant disease outside the hospital setting, and undertake some review of the available evidence with regard to risk assessment in the out-of-hospital environment and the potential use of anti-clotting drugs to prevent thrombosis and potentially improve clinical outcomes?

I ask that of the Minister because cancer patients who develop a thrombosis regrettably have a much poorer prognosis than those patients who never develop one during the natural history of their cancer. With so much emphasis directed rightly on early diagnosis and the provision of surgical intervention or chemotherapy and biological interventions to improve clinical outcomes, we also need to pay attention to avoiding unnecessary complications and to ensuring that the whole spectrum of supportive care for those with malignant disease means that they can benefit from increased quantity and quality of life.