Health: Secondary Care

Lord Kakkar Excerpts

Thursday 26th June 2014 Lords Chamber

[Earl Howe]

My noble friend is right. This is absolutely central to raising our performance as a country in successfully treating cancer. We are doing several things. We have piloted a tool to help GPs to identify patients whom they might not otherwise refer urgently for suspected cancer. The tool covered lung cancer, as well as others. Across England, 502 GP practices took part in the pilot. Initial indications are that the tool is extremely helpful. There is also an e-learning tool that offers accredited professional development for GPs. The Royal College of General Practitioners has also identified cancer as an enduring priority. It is working with Cancer Research UK and other partners in promoting models of best practice.

[Lord Kakkar (CB)]

My Lords, I declare my interests as professor of surgery at University College, London, and chairman of UCLPartners. Better integrating primary and secondary care is crucial to ensuring patient safety, improved clinical outcomes and the most effective resource utilisation. What progress has been made in defining whole pathway metrics for integrated care to best inform rational commissioning of these services?

[Earl Howe]

Several things are in train. One of those, as the noble Lord will know, was reflected in the legislative reform order that we debated in the Moses Room two days ago. It will cut down the administrative burden of joint commissioning by NHS England and CCGs, as well as the burden currently being experienced by CCGs in joint commissioning between themselves. More importantly, we need to incentivise the system for integrated care, and that is what the better care fund is designed to do. It will ensure that patients receive joined-up care, whether that is in acute settings, in the community or, indeed, from social care.

Health: Innovative Medicine

Lord Kakkar Excerpts

Tuesday 1st April 2014 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I congratulate the noble Baroness, Lady Thomas of Winchester, on securing this important debate. In so doing, I declare my own interests in healthcare, in particular that I am chairman of UCLPartners and the UK business ambassador for healthcare and life sciences. I, too, congratulate Her Majesty’s Government on their early access scheme, recently announced, which is important for patients and healthcare professionals and in securing the ecosystem around the delivery of life sciences in our country. That is vital not only for the delivery of innovative healthcare, advancing clinical outcomes and improving the ability of our patients to benefit from advances in medical research, but because the life sciences sector in our country plays such an important role in the economy more broadly.

As we have heard from the noble Baroness, Lady Thomas, the scheme is fundamentally driven to ensure that innovative medicines that have undergone a degree of thorough scrutiny by way of clinical evaluation could be made available to patients with life-threatening and debilitating conditions before they would normally have received their full licensing, which is very important. I ask the noble Earl how Her Majesty’s Government plan to ensure equity of access to the scheme, bearing in mind that these innovative products will not, at the stage when they will become available as part of the scheme, have had approval for cost-effectiveness through the processes of the National Institute for Health and Care Excellence. Therefore, it is important that careful attention is paid to ensuring that, if those innovative medicines are to be provided as part of a specialist commissioning infrastructure within NHS England, it is done in such a way that patients throughout the NHS in England can avail themselves of those important innovations, because they will be some of the most vulnerable patients whom we see with life-threatening conditions or chronic disabling and debilitating conditions.

In that regard, I wonder whether the noble Earl can give a view on the potential role that academic health science networks, such as UCLPartners, might play in promoting access to innovative therapies as part of the early access scheme. As part of their original designation and licence obligations, the academic health science networks had to give undertakings with regard to the diffusion at scale of innovation across the populations for which they have responsibility. Do Her Majesty’s Government see a role for the academic health science networks in the early access scheme with regard to those diffusion of innovation obligations? If so, does the noble Earl believe that the arrangements for funding the academic health science networks, bearing in mind that the scheme will run for a number of years, are sufficiently secure?

Beyond the important contributions that Her Majesty’s Government have driven over the past four years in innovation in healthcare, through the development of the academic health science centres and networks and through the promotion of the National Institute for Health Research and its translational medicine research elements, which are vital to the early access scheme by encouraging industry and other biotechnology partners to work with the institute to undertake the research evaluation that will bring those innovative medicines more quickly to bear in the management of patients in the most desperate of circumstances, there is also the important question of the legal framework within which innovation can take place. That relates to innovation not across the system but to an individual clinician innovating for an individual patient and, therefore, the culture of innovation in our healthcare system.

The noble Lord, Lord Saatchi, recently promoted the Medical Innovation Bill, which is intended to address the important question of whether a legal impediment to innovation resulting from an accumulation of case law has changed the way in which clinical practice is discharged. I know that on 22 November 2013 the Secretary of State recognised, in a Written Statement, that there may well indeed be unintended consequences of the way in which case law is now interpreted that will stifle innovation with regard to the individual clinician providing care for the individual patient. As a result, Her Majesty’s Government are currently undertaking a broad consultation on the question of whether a Bill to help to clarify those ambiguities in law is necessary. Can the noble Earl provide some further insights into how the consultation is proceeding and where Her Majesty’s Government’s thinking is with regard not only to dealing—as they have done effectively—with the systems issues about innovation at scale and pace for large populations, but to the ability of individual clinicians to practise innovative care in a responsible and structured framework for the individual patient in front of them, often making use not only of personalised medicine and the revolutions in genomic medicine that will drive individual decision-making for patients, but also of this impressive early access scheme?

Medical Act 1983 (Amendment) (Knowledge of English) Order 2014

Lord Kakkar Excerpts

Tuesday 11th March 2014 Grand Committee

[Baroness Finlay of Llandaff (CB)]

My Lords, I rise, somewhat cautiously, as the third medical speaker in a row. I welcome the order.

It is worth noting that in 2013, the GMC had 13 fitness- to-practise cases that involved concerns about the language skills of doctors. In its 2011 review, the England Revalidation Support Team found 66 cases where the responsible officer has dealt with linguistic concerns. Part 3 of the order is therefore particularly important because it relates to fitness to practise. I hope that we will have an assurance today that in a fitness-to-practise procedure the doctors will not themselves be paying for the English language competence test. I have a bit of a concern, if they are paying for it themselves, that there may be a seeking out of a centre that is different from another centre, so it has to be fully conducted by the GMC, although it seems completely reasonable that the payment for the test prior to licence to practise is borne by the person applying for a licence to practise.

I understand from the GMC that it will be using the International English Language Testing System—IELTS—which costs from £130 to £145 depending on where you sit it, and that that will remain valid for about two years, on the recommendation of the Commonwealth. There is evidence that language skills, if they are not used, begin to decay after about two years.

It is also important to recognise that in this order we are talking about “ordinary” English language; we are not talking about testing medical English. It has been suggested that the dictionary for medical English is about the same size as the dictionary for another European language. It is a huge language. However, many of the words are very similar across the different European languages—although, of course, they are very different in some other languages.

We are talking about the ability of a doctor to take their medical knowledge and translate it into what you could call everyday English so that they can communicate it to patients. One point that I hope will be part of a fitness-to-practise procedure, however, is a recognition that communication involves far more than language. In terms of communication skills and communicating, although about 20% of communication is verbal, much of it is non-verbal. When you look at complaints against doctors in relation to the way they have communicated, although they sometimes have very good English language skills, other aspects of their non-verbal communication might reveal an attitude that is below the standard that one would expect from somebody on the GMC register.

I have to say, from my experience of teaching postgraduate students, that at Cardiff University they are required to sit the IELTS. It is a good test of English language skills. Since it was introduced as a statutory requirement by the university, we have found that it has become easier to teach and to mark the work done by those whose first language is not English. When teaching communication skills, it is easier to separate out the non-verbal problems from the verbal problems.

My view is that this is an important regulation. The ability to look back at those currently practising in the UK about whom there are concerns is crucially important and the GMC needs to be empowered to do so. I would just sound a note of caution following on from the remarks of the noble Lord, Lord Turnberg; of course we do not know what is set out in the curricula of different places. Medical students can graduate from some universities with almost no patient contact at all. If they are moving into training jobs, there is a concern that the baseline level of their medical training may be very different. This order may be the first step towards looking at the competences that we expect of a doctor coming from anywhere in the world in relation to practising in the UK.

[Lord Kakkar (CB)]

My Lords, I declare my interest as a member of the General Medical Council and I would like to take this opportunity to congratulate the noble Earl and Her Majesty’s Government on dealing with this important issue in what I think we can all agree is a very sensitive way. There is no question but that our health services are vitally dependent on a steady flow of doctors coming from all parts of the world, including the European Union. Not only can they learn from our healthcare system, they can also serve in it. But it is absolutely right that a professional regulator must enjoy the confidence of the public, and it is the responsibility of the General Medical Council first and foremost to ensure that patients are protected and that clinical practice in our country is safe.

For that confidence to exist, the public have to be sure in their own minds that the elements of what they would consider to be essential clinical practice—the ability to practise in a responsible and safe way—are met and tested by the General Medical Council whenever it feels the necessity to do so. The ability to communicate effectively, and therefore to use our language in a way that the public and patients appreciate and would expect, is an essential part of the responsibility of the regulator of the medical profession. As we have heard during this short debate, it is anomalous that the GMC is able to ask that question of potential registrants and licensees from outside the European Economic Area, but has not been able to do so of those who come from within the European Union. It is quite right that the Government have focused on this issue and decided to act in this fashion.

The fact that this order makes provision not only for the question at the time of licensing of a professional, when concerns about language skills might have been raised during the provisional registration process, but also that the new category of considering the ability to use language and to communicate becomes part of the broader question in fitness-to-practise considerations, is vitally important. It means that not only at the time of coming on to the register and being licensed to practise in this country, but throughout the practice itself, the public and patients can now feel confident that the General Medical Council will be in a position to act if it needs to do so. The importance of that cannot be overestimated.

We have heard about the additional question of competence skills, which is a matter that your Lordships have considered in the course of a number of debates in the Chamber over the past few years. The issue remains to be addressed, but I think that most would agree that ultimately, wherever a doctor comes from in the world, whether they have trained and qualified in our own country, elsewhere in the European Union or elsewhere in the world, they should be expected to demonstrate their skills to the same standard and to deploy those skills throughout their professional career in a way that enjoys the confidence of the people of our country.

[Viscount Bridgeman (Con)]

My Lords, I rise with some diffidence as the first layman to address your Lordships in this debate. I, too, thank the Minister for his statement and pay tribute to his department for the leadership that it has shown in securing from the Commission the remedying of what was a glaring and potentially dangerous anomaly in the 2005 directive. The Commission has produced a very satisfactory outcome.

I believe the United Kingdom is among the first member states, if not the first, to incorporate the changes introduced by the revised directive into legislation. I note that the order is headed:

“Health Care and Associated Professions”.

I hope the new language-testing arrangements will be incorporated as early as possible into other branches of healthcare—I have nursing in mind in particular. I think it is the experience of many that nurses from the EEA are almost invariably pleasant, caring and considerate. They of course play a huge role in this country, but I know that many patients have had difficulty in communicating and in making themselves understood.

There are many reasons why this is a matter of some urgency, but I will suggest just one. I think I am right in saying that the practice of putting great emphasis on patients’ notes goes back a long way in the UK; possibly more emphasis than some other member states, even those with advanced healthcare arrangements. It is therefore all the more important that nurses from the EEA are proficient not only in spoken but in written English, a point which the noble Baroness, Lady Finlay, made in connection with doctors. As one facetious journalist put it,

“the difference between a microgram and a milligram is a coffin”.

I hope the Minister can give your Lordships the assurance that progress is being made in extending the provisions of the revised directive right across the healthcare profession, not least with nurses. I hope that this will include the fitness-to-practise hurdle, which is so important in reinforcing the ongoing responsibility of the relevant regulators for their members.

NHS: NICE-appraised Medicines

Lord Kakkar Excerpts

Thursday 27th February 2014 Lords Chamber

[Earl Howe]

It is important to distinguish between a technology appraisal, where, if favourable, there is a clear funding direction for the NHS—in other words, it must fund the drug if the doctor thinks that it is appropriate for the patient—and a clinical guideline, where NICE issues best practice advice for the NHS. There is no funding direction attached to that. However, clinicians are expected to take account of NICE guidelines in everything that they do.

[Lord Kakkar (CB)]

My Lords, I declare my interest as chairman-elect of University College London Partners, one of the designated academic health science partnerships. Is the noble Earl content that the funding arrangements to be put in place by NHS England for the 15 designated academic health science networks are appropriate and will ensure that they can discharge their substantial obligations under their licence agreement, including the adoption of NICE guidance among the populations for which they are responsible?

[Earl Howe]

The noble Lord asks a very important question. It is slightly wide of the Question on the Order Paper, which relates to a particular set of statistics. However, I can tell him that I am broadly satisfied with the level of funding for AHSNs, and NHS England has given its commitment to maintain its support for them going forward.

NHS: Patient Data

Lord Kakkar Excerpts

Tuesday 25th February 2014 Lords Chamber

[Earl Howe]

I entirely agree with the noble Lord. This is a vital programme which will bring real benefits to patients. It has major potential benefits for research and public health. It commands generally wide stakeholder support. However, there is no doubt that concerns over how this has been explained to patients have been raised and those concerns need to be addressed. I agree that the next six months will be crucial in pursuing that aim but it is essential that this programme commands public support.

[Lord Kakkar (CB)]

My Lords, I declare an interest as professor of surgery at University College London. What assessment have Her Majesty’s Government made of the proposed European data protection regulation which, if passed, has the potential to impact seriously on our national strategies with regard to health informatics and biomedical research?

[Earl Howe]

My Lords, we take that concern extremely seriously. The draft text that has been published by the so-called LIBE committee would, if enacted, pose serious obstacles for our research effort in this country. We are taking every opportunity and using every effort to persuade both the Parliament and the European Commission that the original text is the one we should go with. That work is on-going and the Ministry of Justice is leading on it.

Mesothelioma: Research Funding

Lord Kakkar Excerpts

Thursday 16th January 2014 Grand Committee

[Lord Kakkar (CB)]

My Lords, I join in congratulating the noble Lord, Lord Alton of Liverpool, on having secured this important debate, and in so doing declare my own interest as professor of surgery at University College London. Responding to discussion on Report on 17 July last year, the noble Earl, Lord Howe, made a number of important points with regard to the opportunity to build capacity in the research base available to address the important problem of mesothelioma. I would like to explore first with him what progress has been made in the four specific areas that he kindly mentioned during that debate.

The first was the opportunity for the National Institute for Health Research to seek the assistance of the James Lind Alliance to determine priorities with regard to mesothelioma research, bringing together not only the research community but patients and other stakeholders. Secondly, there was a commitment that the National Institute for Health Research would be in a position to issue a highlight notice to the research community identifying that the institute—in consultation, I assume, with the Office for Strategic Co-ordination of Health Research—had identified mesothelioma as a key national priority research topic, thereby activating not only research groups with a specific ongoing interest in mesothelioma but those with peripheral interests that could be brought to bear to address the question of mesothelioma research. I wonder whether that notice has been issued and, if not, when it is planned that it would be.

Thirdly, there was the offer that the National Institute for Health Research would make its research design service available to the research community, specifically to start identifying designs of clinical studies that could be undertaken to help to advance our understanding of mesothelioma research. Lastly, there was a commitment to bring together interested parties in research funding, particularly Cancer Research UK and the Medical Research Council, to have a conference of experts and those parties interested in mesothelioma research to determine how a national co-operative effort could be taken forward. I wonder whether any of those undertakings have indeed happened or in what timeframe it is planned that they might be discharged.

It is clear that the situation in which mesothelioma research finds itself is nothing new. At many times, and for many other diseases, there has been recognition that a new strategic research focus needs to be developed at national level. I would argue that with the National Institute for Health Research now well established and in place in the NHS in England, we are uniquely positioned to take forward a strategic approach, not only to building research capacity but in ensuring collaboration across those groups devoted at the moment to mesothelioma research and other groups who have technologies and interests—we have heard peripheral examples of the management of acute myeloid leukaemia—so that they are brought together with some strategic focus and direction. I wonder whether the Minister is able to provide your Lordships with an understanding of what point those discussions have reached.

In addition, we now have across the NHS in England well established academic health science networks, 15 of which cover the entire country. I declare my interest as chairman elect of University College London Partners. I wonder whether opportunities might be brought to bear for promoting research and collaboration between academic institutions, the NHS and industry, which are at the core of the purpose of the academic health science networks. Those 15 networks would then be asked to see how they might contribute, through their participant organisations, in a national research effort to promote further understanding and a more accelerated research programme on mesothelioma.

Tobacco: Packaging

Lord Kakkar Excerpts

Thursday 28th November 2013 Lords Chamber

[Earl Howe]

My Lords, it is clear from the debates in the other place and from our debates in Committee on the Children and Families Bill, that there is emerging evidence that needs to be considered. That evidence has emerged since the consultation. I am not in a position to make a judgment on that. I think Sir Cyril Chantler is the best person to do it.

[Lord Kakkar (CB)]

My Lords, I declare my interest as a member of the board of UCL Partners, currently chaired by Sir Cyril Chantler, and I congratulate Her Majesty’s Government on the excellent choice of Sir Cyril to lead this important review. Can the noble Earl confirm that Sir Cyril will be completely free to define both the methodology that he will apply for the review and the question that he will address?

NHS: Accident and Emergency Units

Lord Kakkar Excerpts

Tuesday 26th November 2013 Lords Chamber

[Lord Kakkar (CB)]

My Lords, I join noble Lords in thanking the noble Baroness, Lady McDonagh, for having secured this important debate. I declare my interest as professor of surgery at University College London and chairman-elect of UCLPartners Academic Health Science Partnership.

No consideration of the future plans for accident and emergency departments can take place without recognising the important factors that are driving demand in A&E. The most important of these is the growing number of frail elderly patients with multiple comorbidities, as my noble friend Lord Patel has already mentioned. The population aged over 85 has grown at more than three and a half times the rate of the rest of the population in the past 10 years. It is striking that 9% of those aged over 75 have experienced an emergency admission through accident and emergency in the past year. This demonstrates that there is considerable demand and that this considerable demand will grow.

We know that the way that we plan and deliver services for those who are frail, elderly and have multiple comorbidities is not providing the kind of service, the degree of confidence and the relief of anxiety that these patients require. We also recognise that those who are cared for in nursing homes and care homes, who find themselves in an acute situation, will be attended to by excellent paramedics and the ambulance service, but the default position will always be to take these individuals to hospital and very frequently for these individuals to be admitted and then to spend long periods of time in hospital. This is wrong.

With regard to the plans of NHS England, can the Minister tell us what advice is now being provided to local commissioning groups in terms of the commissioning of more holistic and integrated services that recognise the needs of the frail elderly in the community and can better understand how those needs are met, and how the services are delivered in an integrated fashion with local hospitals, while avoiding admission through accident and emergency?

What discussion has taken place about addressing the important problems of workforce development, to help us ensure that we have a medical and paramedical workforce developed for the needs of these large numbers of frail elderly patients with multiple comorbidities? What position has Health Education England taken, and how is this central advice being delivered to local education and training boards to ensure that an appropriate workforce is delivered, able to deliver multidisciplinary care to reduce the demand on accident and emergency services and manage patients rather better in the community?

Finally, may I ask the Minister how much progress has been made on the development of locally sensitive information technology projects that allow a connection between information held on frail elderly patients with multiple comorbidities in different care environments, be it in social care, in primary clinical care in the community or in hospital care? Such information could be shared effectively to reduce the burden on accident and emergency departments.

NHS: EU Legislation

Lord Kakkar Excerpts

Monday 21st October 2013 Lords Chamber

Asked by

[Lord Kakkar]

To ask Her Majesty’s Government what recent assessment they have made of the impact of European Union legislation on training and service delivery in the National Health Service.

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

We are aware that concerns exist about the impact of EU legislation on some areas of training and service delivery within the NHS. That is why we recently announced the review of the implementation and impact of the working time directive, to be led by the Royal College of Surgeons. This follows the balance of competences review for health, which included concerns about the impact of this directive on continuity of care and doctors’ training.

[Lord Kakkar (CB)]

My Lords, I declare an interest as professor of surgery at University College London. In 2010, the then Secretary of State for Health and Secretary of State for Business, Innovation and Skills were due to commence robust negotiations with our European partners on the working time regulations. Despite the welcome announcement of the current Health Secretary’s further review of the impact of those regulations, do the Government stand by their commitment to repeal this detrimental legislation as it applies to healthcare? This is now increasingly cited by coroners as having contributed to patient harm. Moreover, our trainees tell us that it is now undermining their ability to acquire the necessary skills for future independent consultant practice. Patients and doctors alike now blame these regulations for a destruction of professionalism in our health service.

[Earl Howe]

My Lords, it is the impact on our health service that we want the Royal College of Surgeons to look at specifically. In the coalition agreement, we committed to limiting the application of the working time directive in the UK, including in the NHS. Nobody wants to go back to the bad old days of tired doctors, but it is important for the working time directive to have more flexibility for a health service that operates on a 24-hour basis. Increased flexibility for the NHS would allow it to take account of local needs and practices, while at the same time ensuring the health and safety of the workforce. We stand prepared to work with partners in Europe to that end. I believe there is strong support in the NHS for this.

NHS: Accident and Emergency Services

Lord Kakkar Excerpts

Thursday 25th July 2013 Lords Chamber

[Earl Howe]

My Lords, there are many factors at play here. There is no doubt that the GP contract severed the legal responsibility that individual GPs had to look after their patients out of hours. It would be idle for me to stand here and say that that has had no effect on A&E attendances. Patients are confused now about whom to contact out of hours and many turn up at A&E when perhaps they should not have done so.

[Lord Kakkar]

My Lords, I declare my interest as professor of surgery at University College London and chair of quality for University College London Partners. What progress has been made in the commissioning of integrated care services across hospitals and the community for frail, elderly patients with multiple co-morbidities, who frequently have to attend A&E for the lack of such services?

[Earl Howe]

Not for the first time, the noble Lord hits on an extremely important aspect of the problem that we are facing. It is the frail elderly who often turn up at A&E with a crisis in their health when that crisis could have been averted. That is why Sir Bruce Keogh has been tasked to look across the piece at the whole system to see how we can ensure that the frail elderly in particular are served better by the health service, not least to prevent the exacerbation of long-term conditions.