Health: Detection Dogs

Lord McColl of Dulwich Excerpts

Thursday 17th September 2015 Lords Chamber

[Lord McColl of Dulwich (Con)]

Is the Minister aware that diagnosis may be helped not only by dogs, but by ants in India? One way in which to detect diabetes is to get the patient to urinate up a wall, and if the ants crawl up the column of urine it means that there is diabetes because sugar is there, and ants like sugar. It is a very cheap way to diagnose diabetes.

[Lord Prior of Brampton]

I seem to remember a noble Baroness asking a question about ferrets climbing up someone’s trousers. Now we have ants climbing up people’s trouser legs. We are open to all sensible suggestions.

Health: Lymphoedema

Lord McColl of Dulwich Excerpts

Wednesday 9th September 2015 Lords Chamber

[Lord McColl of Dulwich (Con)]

My Lords, I am grateful to the noble Lord, Lord Hunt, for introducing this debate on the subject of lymphoedema, which arises when the lymphatics fail to regulate the fluid balance in the tissue spaces. That results in oedema, usually of the arms and legs. For example, normally in the legs there are four or five lymph channels each measuring one millimetre in diameter travelling up the inside of the leg to the lymph nodes in the groin, and from there they go up into the chest where the lymph is discharged into the veins in the chest.

Lymphoedema can be due to underdevelopment of the lymphatics, known as primary lymphoedema, which usually manifests itself in a person’s 20s or 30s. But if the lymph channels are completely absent, the symptoms of the condition appear much earlier. That is due to a genetic fault. Secondary lymphoedema is where there is a blockage in or removal or disease of the lymphatics, and is far and away the commoner of the two. The blockage can be due to cancer infiltrating the system or to worms—a condition called filariasis, which is quite common in the Far East. It is transmitted by mosquitoes, but noble Lords can be reassured: one has to be bitten many times by many mosquitoes before one gets the disease. The condition is common in Sri Lanka, but in the old days of the British Empire it was pretty well eliminated by reducing the mosquito population, which also reduced the incidence of malaria.

Lymphoedema occurs when the lymphatics are removed in certain cancer operations such as the old radical mastectomy or operations where the lymph node system is removed or reduced. As I mentioned, primary lymphoedema is due to underdeveloped or—rarely—absent channels. The first symptom is a slight swelling of the front of the foot. But if that is not dealt with, the whole leg can become enormously swollen and the skin grossly thickened—maybe as much as a centimetre in thickness. The legs become huge and very heavy, which makes it difficult for the patient to walk. To reduce the symptoms, an operation was designed by the surgeon Mr Charles, where the skin is resected, all the subcutaneous tissue is removed and then the skin is put back. The cosmetic results are not good, but the procedure does enable the patient to walk. That kind of radical surgery is rarely necessary these days.

As the noble Lord, Lord Hunt, has already emphasised, the important point is to have early diagnosis so that the swelling can readily be reduced by elevation and the use of close-fitting elastic stockings. The treatment has to continue for life and it is important that the patient understands this. The elastic stockings have to be applied before the patient gets out of bed, and this requires a lot of attention to detail. It is also important to avoid infections of the skin because they can make the condition worse by interfering with the underlying lymphatics. Elevation, compression, massage and physiotherapy are extremely important.

It should also be stressed that primary lymphoedema due to the genetic affection of the lymphatics is actually fairly rare. People are critical of doctors if they do not diagnose the condition right away, but it should be pointed out that the initial symptoms of puffiness can be due to a hundred and one different conditions. Primary lymphoedema is not often seen in general practice but, as I say, people are critical if doctors do not spot rare diseases immediately. However, a GP may not see one of these cases in a lifetime.

We have heard a lot of discussion about teaching on this subject in hospitals and medical schools. Of course they teach it. Swelling of the ankles is a very common condition and there are many different reasons for it; they are gone into in some detail. Discussion about a national strategy would be interesting, but what one must really emphasise is that diagnosis has to be made early on. There are computer-assisted ways of helping in diagnosis which alert the doctor as early as possible when someone comes into the surgery with, say, a puffy ankle or front of the foot. Diagnosis can be made early and suitable treatment started right away. Lymphoedema of the arms is usually due to previous cancer surgery and is less common today as radical surgery for cancer of the breast has been replaced by more conservative surgery along with radiotherapy and chemotherapy.

Early diagnosis must be encouraged before the swelling becomes severe, and effective treatment must be initiated in the form of elevation, physiotherapy, compression, exercise and meticulous attention to detail to prevent infection. Also, of course, obesity should be avoided; it is the greatest epidemic affecting this country for 95 years.

Health: Obesity

Lord McColl of Dulwich Excerpts

Thursday 26th February 2015 Lords Chamber

[Earl Howe]

Yes, my Lords, that is being factored in, but I do not think that we should confuse that point with a certain sort of fatalistic approach to obesity. There are things that people can do with their lifestyle to influence their own states of health in all sorts of areas and we have to help people understand what those things are.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that this report is a model of its kind? It is brief and free of waffle and it emphasises the important point that obese people do not need to increase their activity one iota in order to lose weight; all they have to do is to eat less.

[Earl Howe]

I agree with my noble friend. We should recognise that increasing physical activity is important for our health, but for people who are overweight and obese, eating and drinking less has got to be the key to weight loss.

Health and Social Care (Safety and Quality) Bill

Lord McColl of Dulwich Excerpts

Friday 6th February 2015 Lords Chamber

[Lord McColl of Dulwich (Con)]

My Lords, I thank Jeremy Lefroy for starting this Bill and the noble Lord, Lord Ribeiro, for bringing it here so expertly.

I would like to address one or two aspects and look back to how we dealt with them in the past. First, on the issue of protecting the public from avoidable harm, as a young house physician, the first problem I came across was a situation where a number of young ladies had attempted suicide—which of course was a criminal offence in those days. I was astonished to see the police hovering around, insisting on interviewing them. I explained to the police that the patient was not completely compos mentis and was in no fit state to be interviewed by anyone, certainly not the police. This created a great deal of trouble for me and I was summoned before the senior superintendent of the hospital and the local inspector of police. They harangued and shouted at me. I realised that they were just common bullies—and that one of my jobs was to protect patients from bullies.

We then came across the problem of operating on the wrong patient or operating on the wrong side. As a young surgeon I thought that there must be a way of preventing this, so I used an indelible pen to write the name of the operation at the site of the operation. Sometimes this presented problems, and arrows had to be put in to show roughly where it was, but it worked well. However, one day I went into the operating theatre and the anaesthetist said, “I wish you’d make up your mind which operation you’re doing on this patient”. I replied, “Look, I have written on his groin ‘right inguinal hernia’”. He said, “Yes, but look at this”, and he pulled the sheet down to reveal a dotted line across the front of the patient’s neck with a big arrow pointing at it, and on his chest, in big letters, were the words, “Cut here”. It was a tattoo that he had had put on 20 years before. Apart from that, the system worked very well indeed.

We developed at Guy’s Hospital something that had been done in many other hospitals. We would meet every week to discuss all the complications and deaths that had occurred in the previous week. Surgeons, junior staff, students, nurses and even some administrators would come. It was the most amazing and enjoyable meeting of the whole week, and it was relevant to what was going on. You could not hide anything because people knew what was going on. Complications would be presented, and we were very fortunate in having a very senior surgeon to chair these meetings. He had a good sense of humour and he was both brilliant and humble. When some poor junior surgeon would stand up and explain a complication for which he was responsible, the chairman would say, “That’s nothing, old chap. Only the other week…”, and he would go on to describe a complication for which he had been responsible. What he was cleverly doing was creating an atmosphere that was friendly and unthreatening, thus encouraging people to be absolutely honest. It was a great learning experience. It became rather like the general confession and was just as therapeutic.

We are all fellows of the Royal College of Surgeons, the Royal College of Physicians, the Royal College of General Practitioners and so on—but what is fellowship? Fellowship is sharing experiences, both good and bad. That is part of the fun of medicine. Another thing about those meetings was that they did not cost anything and we did not have bureaucrats from above directing and inspecting us. Local accountability is the answer.

The second thing I want to talk about is the appropriate sharing of information and the question of identification of patients. Years ago, I suggested that one solution to the problem of sharing information would be to give the patient his or her medical records. This was objected to on the basis that people could not be trusted and that they would lose them. A friend of mine gave away 20,000 medical records over a period of 20 years, and only three were lost. One was lost in a fire, one in a flood, and the third was eaten by the dog. That is a pretty good loss rate when we consider that some medical records departments were losing around 20% of their records at any one time.

Another thing we started doing was inviting patients to keep their operation note so that they could take it with them. One day I had to operate on a patient who had been operated on in Edinburgh in 1935. It was a complicated operation in the abdomen. I asked the patient if he had any idea what the surgeon had done. “Yes, I do”, he said, and he pulled from his pocket a piece of paper with the most beautiful diagram of all the plumbing that had been operated on inside his abdomen. The patient had kept the piece of paper safe for all those years.

The third thing I would like to talk about is something that has been aired quite a bit: will the Bill leave healthcare workers reluctant to treat or operate on poor-risk patients? Some years ago we conducted a big research project in four London hospitals. We measured the quality of care by what the doctors were doing to the patients—process—and the outcome of that. The third method was to ask a friendly, knowledgeable person in each of the four hospitals to put the consultants in order of merit. The three systems gave the same answer. People in a hospital know what is going on.

To make it fair, we measured 12 variables to find out whether the patient’s contribution to his illness would have any effect on the result of the operation. We recorded blood pressure, anaemia and other things, including marital status—whether they were married or had a stable relationship. Strangely enough, the only one of those variables that had any effect on the outcome of treatment was whether or not they were married or had a stable relationship. That was not an original finding; it had been established for some time.

The fourth thing I will talk about is the whole culture of blaming other people for what is going on. Of course, in medicine we have been guilty of this. If we could not establish the diagnosis in a patient, there was a tendency to say, “Ah well, it is in the mind. It is psychiatric”. Of course, that is quite wrong. Psychiatric diagnosis should be a positive thing, not a diagnosis of exclusion. We must not blame the patients for what is going on.

Of course, one thing that has happened in recent years is the obesity epidemic, and what have they done? They have blamed the people who closed the playing fields for children not getting enough exercise. But of course the obesity epidemic is simply due to people eating too much. That is perfectly straightforward.

The Bill concentrates on the vital overarching duty to protect the health, safety and well-being of the public —and these things we must continue to fight for.

--- Later in debate ---

[Earl Howe]

I would be happy to do so.

[Lord McColl of Dulwich]

Before the Minister sits down, could I ask him about the WHO checklist? When I go into an operating theatre, the operation cannot start until that list is completed by the surgeon, the anaesthetist and the nurses. Could that be put into regulations?

[Earl Howe]

My Lords, I am sure that anything is possible, but I would hesitate before giving a commitment along those lines because it seems to me too granular to be included in statutory regulations rather than in guidance or best-practice manuals.

NHS: Accident and Emergency Services

Lord McColl of Dulwich Excerpts

Thursday 15th January 2015 Lords Chamber

[Lord McColl of Dulwich (Con)]

My Lords, I thank the right reverend Prelate for initiating this important debate. He has set exactly the right tone—let us keep petty party politics out of this and concentrate on the patients. It is important to stress that the staff in A&E departments—nurses, doctors and administrators—are doing a very good job indeed under difficult circumstances. Having worked a lot myself in accident and emergency departments, I know only too well how difficult it is. Patients come in, one is not sure what is going wrong with them, and it takes a little while to sort them out.

There were some political shenanigans some years ago when there were complaints about people waiting on trolleys far too long in casualty. I produced a paper when I worked in No. 10 entitled Off Your Trolley. The answer was that if you are really ill and they do not know what is wrong with you, stay in the casualty department where all the expertise is—the expert equipment and the doctors and nurses—until an accurate diagnosis has been made. If it worries people that they are on trolleys, they should take the wheels off after 20 minutes and the trolleys will then constitute a bed, so people will not fuss about it.

Things have improved enormously in this service from the days when I first worked in casualty. I remember once going through the accident and emergency department of a hospital that shall be nameless, where there was a man groaning on a trolley. I went up to him and asked how he was, and he said, “I’m in terrible pain in my shoulder, it’s dislocated, I’ve been here for three hours and I have not seen anyone”. I said, “I could put you in a very comfortable position where you’d be free of pain. Would you like that? I’m not working in the department, but we can get on and do it”. So I put him on his face with his arm hanging over the side of the trolley and the moment when he was in that position he said, “Ah, I’m free of pain”. I said, “Now you’re free of pain, the muscles will relax and the thing may go back on its own, without any anaesthetic—so you go off to sleep and I’ll come back in half an hour and see how things are”. When I came back, he was sound asleep and snoring, so I crept up on him and very gently manipulated the arm. Suddenly, clunk, it went back—and he woke up and said, “Oh, it’s gone back”. I said, “Yes, you can go home now, but perhaps we ought to tell somebody what we’ve been doing”. Things are much better than that now, because we have rapid assessment. Somebody senior goes around the A&E departments, assessing things quickly, so that sort of thing no longer happens.

There has been an enormous increase in the number of people attending, and we do not know why. As we do not know why, it is quite wrong to start blaming any group of people. It is very demoralising if you are a doctor, nurse or administrator working for the NHS and people start attacking and accusing you of this and that when they really do not know the cause of the increase in the work. What is true is that more resources are being put in and more staff are being recruited, which is good news. But we must stop blaming people and pointing the finger. The blame culture has to go, and we have to be more constructive.

What is the answer? Preventive medicine is one of the great emphases in the Department of Health, and it certainly helps. We have the worst epidemic that we have had for 95 years in this country—the obesity epidemic—and we need to get people thinned down. They have to eat less and take more exercise. We have to improve people’s health, which will tend to reduce the problem. But we also have to have an alternative way of funding the NHS.

Alcohol: Addiction

Lord McColl of Dulwich Excerpts

Monday 12th January 2015 Lords Chamber

[Earl Howe]

My Lords, the Royal College of GPs has a special focus at the moment on giving advice to GPs. We are also dramatically increasing the number of health visitors, who are, of course, highly instrumental in influencing the behaviours of mothers-to-be and young mothers.

[Lord McColl of Dulwich (Con)]

My Lords, does the Minister accept that although alcohol was until recently the commonest cause of liver disease, the commonest cause is now the obesity epidemic, which is killing millions of people? Some 13 million people in this country are suffering from obesity—far more than are suffering from alcohol problems.

[Earl Howe]

My noble friend is absolutely right. More than 90% of liver disease is due to three main, preventable and treatable risk factors—alcohol, hepatitis B and C, and obesity. Alcohol accounts for 37% of liver disease deaths, but obesity is indeed a major factor in this.

Children: Obesity

Lord McColl of Dulwich Excerpts

Monday 20th October 2014 Lords Chamber

[Earl Howe]

My Lords, first, I commend the all-party group for its report. Tackling obesity is one of our major priorities, as it is for Public Health England. We have a well developed and wide-ranging programme of actions to tackle obesity. We have set a national ambition for a downward trend in excess weight in children. We are delivering the programme through initiatives such as Change4Life, the National Child Measurement Programme, school sports funding and the School Food Plan, and through voluntary partnerships with industry. As regards co-ordination, Public Health England is a leader of the public health service and numerous government departments are contributing to the anti-obesity agenda. We have a Minister for Children, and we have already established the Obesity Review Group, which brings together a range of experts and delivery partners from across the system to try to co-ordinate efforts to meet our national ambitions.

[Lord McColl of Dulwich (Con)]

My Lords, will the Minister acknowledge that the Department of Health and NICE misled Parliament and the nation in saying that the obesity epidemic was due to lack of exercise? Will the Minister acknowledge that in fact obese people do not need to increase their activity one iota in order to lose weight? All they have to do is to eat or drink fewer calories.

[Earl Howe]

My Lords, although physical activity can have a role in maintaining a healthy weight, the Government agree with my noble friend that its health benefits are nevertheless subsidiary in those who are obese to the need to eat and drink less. My noble friend may be interested to know that NICE is currently consulting on its draft public health guideline on maintaining a healthy weight and preventing obesity among children and adults. It currently expects to publish this guideline in February next year.

NHS: Hospital Waiting Times

Lord McColl of Dulwich Excerpts

Thursday 10th July 2014 Lords Chamber

[Earl Howe]

My Lords, the noble Lord knows of the economic constraints that this country has to contend with at the moment. Despite that, the Government are increasing the NHS budget over the course of this Parliament by £12.7 billion. That should indicate to the noble Lord the priority that we are giving to the NHS.

[Lord McColl of Dulwich (Con)]

My Lords, the Minister mentioned that the strain on the NHS is due to old people getting older, but is it not true that the strain is due to young people getting fatter and fatter? Is it not true that the Department of Health misled the nation by saying that the obesity epidemic—the worst for 90 years—is due to a lack of exercise when really it is due to people eating too much?

[Earl Howe]

My noble friend is a very eloquent advocate of this particular issue and he is of course right.

NHS: General Practitioners

Lord McColl of Dulwich Excerpts

Wednesday 26th February 2014 Lords Chamber

[Earl Howe]

The noble Baroness is quite right. The NHS is seeing an extra 1 million patients in A&E compared to three years ago. Despite the additional workload, it is generally coping very well although we know that departments are under strain. This is not just about A&E, as the noble Baroness will be aware, but about how the NHS works as a whole: how it works with other areas, such as social care, and how it deals with an ageing population and more people with long-term conditions. Dealing with all that means looking at the underlying causes, and that work is going on at the moment in NHS England.

[Lord McColl of Dulwich (Con)]

Does the Minister agree that it was very unfortunate indeed that certain politicians, who shall remain nameless, said to the general practitioners: “We know what you’re doing. You should have been working but you were on the golf course and, from now on, we’re going to pay you only for what you do”? The general practitioners thought this was a rather good idea, because it resulted in a substantial pay rise.

[Earl Howe]

My Lords, there is no doubt that the general practitioners bit the Government of the day’s hand off, 10 years ago, and they had every reason to do so with the money that was being offered to them. However, while a feature of that contract was the quality and outcomes framework, which was a good idea in itself, it has resulted in a lot of box-ticking for GPs and it is that element which we have drastically reduced in the contract for next year. That will be helpful in freeing up GPs’ time.

Public Health Responsibility Deal

Lord McColl of Dulwich Excerpts

Tuesday 14th January 2014 Lords Chamber

[Earl Howe]

My Lords, I shall take that request away and write to the noble Lord.

[Lord McColl of Dulwich (Con)]

Does the Minister approve of the letter, which will shortly be sent to all Members of this House and of another place, asking them to measure their waist and to ensure that it is less than half their height? That would apply to quite a few Members opposite, who are clearly eating too much of the gross national product.

[Earl Howe]

My Lords, we should welcome any measure that encourages us all to improve our diet, to reduce physical inactivity and to be aware of what we need to do to keep our weight under control. I do welcome that letter.