Health: Cancer

Lord Kakkar Excerpts

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My noble friend is absolutely right to raise the point. To support the NHS in tackling regional variations in cancer survival rates, we are providing data to providers and commissioners that allow them to benchmark their services and outcomes against one another and to identify where improvements need to be made. Surgical resection is currently the best curative intervention for pancreatic cancer, and through the National Cancer Intelligence Network we have already made available data collections on the survival rates and surgical resection rates across a range of cancers, including pancreatic cancer.

[Lord Kakkar]

My Lords, what proportion of patients diagnosed with pancreatic cancer is managed in specialist centres by a specialist, multidisciplinary team? What proportion of patients in those centres is entered into clinical trials? We all recognise that participation in clinical research improves clinical outcomes in these centres.

[Earl Howe]

My Lords, the UK now has the highest national per capita rate of cancer trial participation in the world, which is something that not everybody realises. We have improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I will write to the noble Lord with information about specialist centres, but he will know that surgery for pancreatic cancer is a complex business and needs to be undertaken by those who are very well versed in that particular line of clinical activity. I am sure that a high proportion will be treated in those centres but I will find out more if I can.

NHS: Clinical Networks

Lord Kakkar Excerpts

Wednesday 12th December 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to my noble friend. As regards cancer, it is important to look at what the Government are doing across the piece. As the noble Lord may recall, the cancer strategy that we published a while ago is backed by more than £450 million of investment. This is specifically to target earlier diagnosis of cancer; to give GPs increased access to diagnostic tests; to allow for the increased testing and treatment costs in secondary care; to support campaigns; and so on. That is a large sum of money and it is committed.

[Lord Kakkar]

Does the Minister envisage a role for the to-be-designated academic health science networks in delivering clinical networks in the future? I declare my interest as chair for quality, University College London Partners academic health science partnership.

[Earl Howe]

My Lords, yes. National guidance is being produced by the NHS Commissioning Board, setting out the different areas of focus for academic health science networks, health and well-being boards, local education and training bodies and clinical senates. The defined geographies of the 12 network support teams have been developed precisely to gain close alignment and therefore promote close relationships and co-operation with the other structures in the new system—including academic health science networks.

Nursing Quality and Compassion: The Future of Nursing Education

Lord Kakkar Excerpts

Tuesday 11th December 2012 Grand Committee

[Lord Kakkar]

My Lords, I join in thanking the noble Baroness, Lady Emerton, for securing this important debate and in congratulating the noble Lord, Lord Willis of Knaresborough, on his excellent report. I declare my own interests as professor of surgery at University College, a practising surgeon at University College London Hospitals NHS Foundation Trust and a member-elect of the General Medical Council.

The report that we are considering today is both reassuring and worrying. It is reassuring because it speaks with great optimism about the talented, dedicated and committed people who are still attracted to the vitally important profession of nursing. However, it is worrying because in describing the background that resulted in the necessity for this report, it highlights a worrying deterioration of organisational culture and values that have allowed patients to be characterised as statistics and consumers rather than as vulnerable and anxious human beings coming into our healthcare system and look at healthcare in terms of episodes of delivery of care rather than the delivery of healthcare in terms of compassion and dignity.

This report, rightly, identifies that providing an undergraduate basis for initial training in nursing is not attended by any inability either to develop the clinical skills and standards necessary for this important profession or to ensure that nurses qualify with the appropriate level of commitment and compassion that is vital to delivery of this important profession. The evidence available in the published literature from the United States and Canada shows that for every 10% increase in the number of nurses on the workforce who have reached a bachelor’s degree standard there is a 5% reduction in overall institutional patient mortality. If you look, for instance, at outcomes in surgical practice, the larger the proportion of highly educated nurses, the lower the perioperative mortality. In Canada, there is evidence looking not at surgical patients but acutely ill medical patients: those with heart attacks, strokes and acute respiratory problems. A similar pattern is demonstrated—the greater the level of nurse education, the greater the overall improvement in outcomes, with lower mortality. If one looks specifically, again in Canada, at discharges from acute medical wards, one sees that for every 10% increase in the number of nurses on staff having achieved a baccalaureate or higher level of education, so there is an improvement in survival, with nine fewer deaths per 1,000 patients discharged.

There are four issues in this important report on which I would like to seek further guidance from the Minister. First, preceptorships are very much like the original one year of house jobs prior to full registration with the General Medical Council for doctors, now reflected in the foundation year 1. It has been suggested that these preceptorships should potentially be extended from the original recommendation of four months. However, as is the case with newly qualified doctors, should it be necessary for the dean of the nursing school to have to sign off the graduated candidate at the end of this period of preceptorship before they can achieve full registration with the Nursing and Midwifery Council? This would ensure that those being delivered from the undergraduate programme could demonstrate that they have all the skills necessary to continue to full registration, having had to perform in a potentially stressful clinical environment for a period of time after immediate qualification.

The second area is one of graduate training to ensure that the most able and talented leaders in nursing can rapidly move through their period of post-qualification training and development to take up leadership roles such as those at ward sister level, while still being in a position to deliver front-line clinical care throughout that process.

At University College London Partners, where I chair the quality outputs, we have developed a programme called Excel which does exactly that. It takes the most talented nurses across the organisations within the partnership through a programme of development that will shorten the time from an average of seven years to just four years, in which they can take on senior nursing positions within our organisations, while continuing to maintain a strong clinical focus. Will Her Majesty’s Government support similar programmes across other academic health science networks when they are established, to ensure that we fast-track nurse leaders, helping them to continue their professional development, while maintaining a focus on the compassion and kindness which is ultimately the fundamental basis for all healthcare delivery?

In this debate we have already considered mandatory registration for healthcare support workers. This is a vitally important requirement. As we start to look at teams delivering care, with teams of different skill mixes, it is vital that all members of that team have to perform to a similar level and are able to command the same confidence from members of the public coming into hospital. It does not seem right that only some members of the team are subjected to statutory registration and not others. Have Her Majesty’s Government changed their mind on this? Are they now in a better position to recommend and provide a statutory basis for such registration?

Finally, on revalidation for nurses, as we move to a graduated profession it will be vitally important that, as we see with revalidation for doctors, nurses are also subjected to revalidation to ensure that the skills that they have developed early in their career are maintained throughout it. At the moment, registration requirements are reflected in 450 hours of practice in a specialist area over three years, and 35 hours of continuing professional development on an annual basis. But revalidation means much more than this. Will Her Majesty’s Government provide a statutory underpinning for revalidation of the nursing profession?

NHS: Diabetic Services

Lord Kakkar Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Kakkar]

My Lords, I join others in congratulating the noble Lord, Lord Harrison, on having secured this important debate and declare my own interest as professor of surgery and consultant surgeon at University College London Hospitals NHS Foundation Trust. We have heard during this debate about the profound burden of diabetes in our country. Some 24,000 excess deaths are reported in those with diabetes annually, some 13,000 strokes, 11,000 heart attacks and more than 4,000 minor and major amputations, in addition to the complications seen in the eye, the kidney and the nervous system. All have a profound impact on the individuals who suffer from this potentially devastating disease. As a result, and quite rightly, diabetes has received an awful lot of attention, not only in clinical practice and research but in government during the past 10 to 12 years, with the growing recognition that the burden of this chronic disease on society and the National Health Service will be profound.

The recent inquiry by the Public Accounts Committee in the other place failed to reach a consensus position with Her Majesty’s Government on the cost to the National Health Service of diabetes, but the figures range between some £4.6 billion and £10 billion, looking at the broad impact of the disease on NHS services. This is quite striking at a time when the service needs to spend its resources more efficiently and effectively. Among the issues raised in that report are: how diabetic services should be commissioned, why commissioning to date through primary care trusts appears to have failed patients and how looking at the new arrangements for the delivery and commissioning of NHS services as a result of the Health and Social Care Act 2012 might be used to improve outcomes for diabetic patients.

What we know in terms of reports and strategies such as the national service framework in 2001 and the production of NICE clinical standards in 2011 is that simple interventions provided annually for patients with diabetes can have a profound impact on improving their clinical outcomes. These include, for instance, annual examination of the eyes to determine whether patients are developing retinopathy; annual, or more frequent if necessary, examination of the feet to guard against diabetic foot complications; regular measurement of the blood sugar, particularly glycosylated haemoglobin, to determine whether the longer-term management of sugar is appropriate; the evaluation of blood lipids and blood pressure, because cardiovascular complications in diabetics can be more devastating and occur with greater frequency; and, of course, testing the urine for protein and testing the blood for creatinine to determine whether the kidney is being affected by diabetes and whether more careful clinical attention needs to be paid to protecting that important organ. In addition, it is well recognised that education of diabetics is vital. Of course, the preparation of women with diabetes for pregnancy is vital, too, to ensure that we do not see the devastating potential complications of diabetes during pregnancy.

These complications and the measures are well understood. What is often forgotten is the fact that diabetics entering hospital for management of other conditions will often have complications at a much higher rate and frequency as a result of having diabetes. One of the most important is, of course, the development of infection in hospital, which is seen more frequently in patients in whom diabetes is not appropriately controlled. It is quite right to say that multidisciplinary care is vital.

To return to the NICE care standards and processes described—simple, authoritative measures—if we ask how frequently and successfully those are being applied to patients with diabetes in communities around the country, the data are quite startling. For interventions that could prevent a heart attack, stroke, amputation or early death, we find that only 50% of diabetics have all nine simple care measures applied on an annual basis. In two PCTs, less than 10% of patients have those nine standards assessed on an annual basis, and in the best PCT only 69% have those measures conducted on a regular basis. The reality of the situation is that the Department of Health, giving evidence to the Public Accounts Committee in the other place, stated that 100% achievement of these nine care processes was unrealistic and a more realistic target was only 75%. That seems rather disappointing, bearing in mind the burden not only for the individual patient but for society more generally and the NHS in terms of its resources attending complications of diabetes.

It is clear that the current arrangements for holding commissioners to account have failed. Of course, we will see the disappearance of those arrangements—and of primary care trusts—on 31 March next year. The provision of these appropriate care measures to much larger numbers of diabetic patients would be a first, early and important test of the new commissioning arrangements through the NHS Commissioning Board and the clinical commissioning groups.

With that in mind, is the Minister able to say what progress has been made with regard to putting at the centre of diabetic care the provision of integrated care pathways? It is quite right for a chronic condition that the majority of care should be provided in the community setting but it is also very clear for diabetics that provision of or access to ancillary services is vital. We have heard about feet and eye services, but there is also access to specialists in hospital because diabetes is much more than a disease of blood sugar. It is a complex metabolic condition with profound cardiovascular, neurological and peripheral vascular implications. It is very important that any commissioning arrangements incentivise excellent care in the community but also make it mandatory for early referral to more specialist centres for early intervention on developing complications.

In this regard, will the quality outcomes framework in primary care be modified to incentivise integrated care? Will payment by results for secondary and tertiary care providers ensure that integrated care across multiple providers in the community and in hospital becomes the norm rather than the exception for the provision of the management of diabetes? In addition, if more care is to be given at the primary care level, it is vital that general practitioners are properly trained and continue to receive ongoing training and professional development to ensure that appropriate care is given to diabetic patients, and that we have an emphasis on ongoing research in both the primary and secondary environments if more patients are to be managed out of hospital.

Finally, the question of the role of Public Health England has been raised. This is a major societal problem with major public health implications. It is critical that Public Health England takes as one of its early priorities the question of screening for diabetes in high-risk populations—for instance, in certain ethnic minority communities, as we heard about from the noble Lord, Lord Harrison—and sees that every opportunity is used to ensure that patients who develop diabetes can be identified early rather than later and that intervention can be provided to avoid potentially devastating complications.

NHS Commissioning Board: Mandate

Lord Kakkar Excerpts

Tuesday 13th November 2012 Lords Chamber

[Baroness Cumberlege]

My Lords—

[Lord Kakkar]

My Lords—

--- Later in debate ---

[Earl Howe]

My noble friend makes a series of extremely important points and I agree with everything she said about maternity services. Emergency services will be commissioned at a local level by clinical commissioning groups but that cannot be the end of the story. She rightly implied that paramedics and trauma care doctors require skills in sometimes very sophisticated techniques of maintaining life at the scene of an accident, for example, and hospital procedures. These skills must be maintained and improved. The short answer to her question is quite consciously missing from this mandate. This is the need for Health Education England to work very closely with the board because the Centre for Workforce Intelligence and Health Education England will have to ensure that we have not only the right numbers in the NHS workforce but those with the right skills and the right level of skills. As she rightly said, we also need to educate the public that the health service does not consist of a series of buildings; it consists of a network of services. We will have advanced considerably if the public can understand rather better than they generally do that the continuation and improvement of services matter, rather than bricks and mortar.

[Lord Kakkar]

My Lords, I declare my interest as Professor of Surgery at University College London Hospitals NHS Foundation Trust. I very much welcome the noble Earl’s indication that the five objectives of the mandate are now clearly linked to the five parts of the outcomes framework. However, successful and meaningful commissioning decisions will critically place intense focus on the development of metrics in the outcomes framework. Local commissioning will be completely meaningless without objective metrics set as part of the commissioning process at a local level and without the ability to measure those outcomes. With specific emphasis on chronic conditions, what progress has been made on integrated care pathway metrics for integrated care both in the community and in the hospital? If there is little progress, when will we ensure that we have integrated care pathway metrics available to ensure that we drive forward meaningful local commissioning decisions?

[Earl Howe]

The noble Lord has alighted on an extremely important area. We have been very careful in constructing the outcomes framework to make sure that we define deliverable outcome indicators. The NHS Commissioning Board is satisfied that the indicators are realistic but I have to be candid with him. This represents work in progress as the precise way in which the board will demonstrate that it has made progress against each of the indicators has not been defined in every case. I can assure him that it will be. It will be up to the board, however, to construct a system of local accountability to ensure that the clinical commissioning groups are held to account against realistic demonstrable indicators which match those of the NHS outcomes framework, not least in the area of chronic conditions. The patient pathway is work in progress, too, but much of its quality can be measured by reference to the patient experience. That is one of the central domains of the outcomes framework, on which a lot of work has been done. I would be happy to write to him on that.

NHS: Professional Qualifications Directive

Lord Kakkar Excerpts

Monday 15th October 2012 Lords Chamber

Asked by

[Lord Kakkar]

To ask Her Majesty’s Government what progress they have made in negotiations at European level on the working time and recognition of professional qualifications directives in the light of their impact on the delivery of care in the NHS.

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

My Lords, negotiations on both directives are ongoing. The Government remain of the view that both measures should support labour-market flexibility without imposing significant extra costs on member states to ensure that any negative impacts that we have seen are ameliorated and, most importantly, to ensure that patient safety is maintained.

--- Later in debate ---

[Lord Kakkar]

My Lords, I declare an interest as professor of surgery and consultant surgeon at University College London Hospitals. In today’s Daily Telegraph the presidents of the Royal College of Surgeons and the Royal College of Physicians make an urgent plea for action on these two elements of legislation to halt a devastating deterioration in clinical training and patient safety. Do Her Majesty’s Government collect data on the number of patients harmed as a result of the implementation of these two directives, for instance from coroners’ inquests where they have been implicated in patient deaths, and on the financial consequences in terms of the employment of locum doctors in the NHS to ensure that hospitals are 48-hour-week compliant? If these data are not collected will the Minister commit to organising for their collection in the future to better inform this Parliament and to add impetus to the Government’s negotiations with their European partners?

[Earl Howe]

My Lords, it is the responsibility of individual NHS trusts to ensure that service rotas are compliant with the working time directive. In line with the Government’s coalition agreement to reduce duplication and resources spent on administration, the department reduced bureaucracy for the service by removing the burden of central monitoring of compliance and we are leaving this role to organisations at local level. The last assessment of the working time directive was undertaken in January 2010 and reported that nearly 99% of doctors’ rotas were compliant with the directive but we are in no doubt about the concerns that exist within the medical professions about the inflexibilities within the rules of the directive. As regards the mutual recognition directive, the department does not plan to collect directly any data relating to it. The professional regulators. who are the competent authorities, collect data in respect of the number of people applying for recognition under the directive.

NHS: Health Workers

Lord Kakkar Excerpts

Thursday 19th July 2012 Lords Chamber

[Lord Kakkar]

My Lords, how will clinical leadership be developed to secure the appropriate culture and values essential for delivery of safe, effective and dignified care for all NHS patients?

[Earl Howe]

There is a clear role here for the professional bodies. Training should be done in the right disciplines and numbers and in the right way. I am sure I do not need to tell the noble Lord that in virtually all the medical royal colleges and through the Royal College of Nursing, there is an increasing emphasis on leadership backed by resources from the Department of Health. We are seeing a drive forward for innovation and the breaking down of professional barriers, which is another aspect of this issue.

Health: Local Healthwatch Organisations

Lord Kakkar Excerpts

Monday 11th June 2012 Lords Chamber

[Earl Howe]

My Lords, the noble Lord is absolutely right to raise the question of the cost-effective commissioning of Healthwatch and I have no doubt, from the Local Government Association, that both the efficient and effective functioning of Healthwatch is something that is well within its sights. The noble Lord has raised a series of hypotheses which I think are somewhat extreme, of local Healthwatch organisations parcelling out their functions all over the place. Our aim is to have as locally inclusive a body as possible in each local Healthwatch area to enable Healthwatch to perform its functions as much by itself as with the aid of others. Indeed, the pathfinder events to which I have referred have been clear that there is a local appetite to do that.

[Lord Kakkar]

My Lords, how do Her Majesty’s Government propose to mobilise interest, enthusiasm and participation in local Healthwatch organisations by patients and members of the public?

[Earl Howe]

We are working with the Local Government Association and the Care Quality Commission to provide support for the implementation of local Healthwatch organisations. As I mentioned, the LGA is running a series of master classes for local authority commissioners. It has published 15 case studies taken from the 75 Healthwatch pathfinders, and a small number of Healthwatch experts will be available to help spread learning. As regards making the public aware, it will be very much for local authorities to decide what is appropriate in their particular areas in order to ensure that patients and the public are engaged in the important work of Healthwatch and understand what the statutory remit of local Healthwatch consists of, because that is the only way in which local Healthwatch will make its voice truly heard.

NHS: Health Tourism

Lord Kakkar Excerpts

Monday 28th May 2012 Lords Chamber

[Earl Howe]

My Lords, the Home Office, with our agreement, drew up a list of high-risk countries where TB was prevalent. In those countries, if someone seeks a visa to come to this country for six months or more, they will have to undergo TB testing. Questions on other medical conditions are not relevant in this context. We do not screen for other things. TB is an exceptional case because it is an airborne disease and poses a public health risk.

[Lord Kakkar]

My Lords, what assessment have Her Majesty’s Government made of potential future health tourism from eurozone countries facing imposed austerity measures and cuts to their own local healthcare provision?

[Earl Howe]

The best answer I can give the noble Lord is that this entire area of health tourism is one which we in the department are looking at extremely closely. A review has been carried out by officials and Ministers are considering the recommendations flowing from that. It is a complex set of issues but clearly the context to which the noble Lord rightly refers will need to come under the spotlight.

Health: Pancreatic Cancer

Lord Kakkar Excerpts

Monday 23rd April 2012 Grand Committee

[Lord Kakkar]

My Lords, I join other noble Lords in congratulating my noble friend Lord Aberdare on having secured this important debate. In so doing, I declare my own interest as a practising surgeon and professor of surgery at University College London, where we have an important interest in the management of pancreatic cancer.

I shall focus on four issues in the time available. The first is to explore the problem of the diagnosis of pancreatic cancer in primary care. As we have heard from noble Lords, nearly 30 per cent of patients have three or more consultations with their primary care practitioner before a putative diagnosis of pancreatic cancer is made, along with referral to a specialist for further investigation. Are there any opportunities, or have arrangements been made or strategies considered, for trying to improve the ability of those practitioners in primary care to be sensitive to the rather non-specific symptoms attending the early presentation of pancreatic cancer, so that they might improve diagnostic strategies?

The second issue relates to specialist treatment. Improving the outcomes guidance, which has driven the cancer strategy over the past 10 years, has provided an emphasis on a focus on the management of patients with pancreatic cancer in specialist centres. What proportion of patients with pancreatic cancer is being managed in specialist centres with specialist multidisciplinary teams, comprising hepatobiliary surgeons with expertise in pancreatic cancer, specialist radiologists and specialist medical oncologists, who could well be in a position to provide the best care for patients once diagnosed, in terms of both understanding how later-presenting disease might be downstaged and of course providing the best curative surgical or palliative radiological procedures for these patients?

The third area is innovation. Your Lordships’ Science and Technology Select Committee, chaired by my noble friend Lord Patel, presented an interesting report in 2008 on genomic medicine, which was widely appreciated. What arrangements have been made about the application of genomic and personalised medicine in the area of pancreatic cancer, particularly with reference to the chief executive of the NHS’s recently published review on innovation and the putative development of academic health science networks? Will these networks provide an opportunity for the early adoption of innovation that might improve both the diagnosis of pancreatic cancer and, potentially, the development of biomarkers or other personalised medicine screening tools to improve therapeutic options tailor-made for individual patients to improve their outcomes with pancreatic cancer?

How many trials are open in the National Cancer Research Institute’s portfolio of clinical trials specifically dealing with novel therapies in phase 2 or phase 3 for pancreatic cancer? What impact has the European Clinical Trials Directive, adopted some years ago, had on participation with regard to trials in pancreatic cancer? We know generally that, in our country, participation in clinical trials has fallen from 6 per cent prior to adoption of the European Clinical Trials Directive—that is 6 per cent of all patients in the world participating in clinical trials coming from our country prior to adoption of the directive—to only 1.4 per cent last year. Has the Clinical Trials Directive impacted on clinical research in pancreatic cancer?