Resistant Hypertension
Lord Patel Excerpts(1 week, 2 days ago)
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Baroness Merron (Lab)
Looking to the future, obviously, one can only act on clinical guidance. Renal denervation, as I mentioned to my noble friend, is an emerging option for carefully selected patients at the moment, as the noble Lord said. What matters now is that evidence is emerging, and that is why it is being reassessed. We will not have to wait too long to see what the future will bring in this regard, but it certainly has a role to play.
Lord Patel (CB)
My Lords, I will refine the previous questions. Resistant hypertension occurs when the blood pressure does not respond to standard treatment of two, three or even four drugs—hence we call it resistant hypertension. The reason why the renal system is involved is because the sympathetic nervous system acts between the kidneys and the brain. That controls vasodilatation and the production of hormones that raise the blood pressure. By denerving the renal system, which are nerves on the arteries of the kidneys, you can cut out one of the nervous system’s interactions between kidneys and the brain. What is important, therefore, is that people who suffer from resistant hypertension are treated by specialists at a specialist centre that considers denervation as one of the options, because it is not always the only answer. Therefore, does the Minister agree that people with resistant hypertension should be treated in a specialist centre?
Baroness Merron (Lab)
I certainly would agree with that. Indeed, those who are diagnosed with resistant hypertension—and the noble Lord has, as ever, outlined how that is defined in a far better way than I could have done—can be referred by their GP to secondary care hospital hypertension services, so, to answer the point made by the noble Lords, Lord Patel and Lord Evans, that does mean in-depth investigations and expert management. The House can be assured of that.
NHS: Dementia Treatment Trials
Lord Patel Excerpts(1 week, 4 days ago)
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Baroness Merron (Lab)
Yes, indeed. I am feeling positive about the way we are moving forward, about increasing research and about developing a frailty and dementia modern service framework by the end of this year, as the noble Baroness, Lady Casey, has called for. On the question of drugs, to which the noble Lord has referred, I can confirm that NICE is currently evaluating two licensed disease-modifying treatments for Alzheimer’s disease; it will meet to consider that on 8 July.
Lord Patel (CB)
My Lords, if our intention is to increase the diagnosis rate of early dementia, normally what we would do is to find a screening test that would identify people at risk of any disease. There is one called Mini-Cog; it takes three minutes to administer and uses word registration and recall and a clock to diagnose early dementia. Why do we not use that as a screening test, easily implemented by trained people to increase the rate of diagnosis of dementia?
Baroness Merron (Lab)
That will be considered. We have the Dame Barbara Windsor dementia goals programme, which very much aims to speed up the development of new treatments for dementia and neurodegenerative conditions by accelerating innovations, including in clinical trials. I agree that we need diagnosis that is effective and thorough, and the point that the noble Lord raises will of course be considered in all that.
Prostate Cancer Screening: AI
Lord Patel Excerpts(2 weeks, 1 day ago)
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Lord Patel (CB)
My Lords, several trials are assessing the use of AI for prostate cancer screening and diagnostics, as well as testing the accuracy of digital imaging and histological imaging of biopsies to understand better the progression of disease. Some of them are well funded. For instance, the screening programme has £42 million of funding. Similar trials are conducted for lung, ovarian, breast and pancreatic cancer. The common issue that comes out is that we need digital transformation throughout the NHS to deliver any of these uses of AI for cancer. We need a workforce that is trained to use it, and I hope that the workforce strategy that the Government are about to publish will specifically include how the workforce will be trained to use AI in healthcare.
Baroness Merron (Lab)
As I said, your Lordships’ House will not be waiting too long for the workforce plan, but I certainly recognise the noble Lord’s points. He describes the transformed service set out in the 10-year health plan, and the workforce plan will support that.
Compassionate Use Medicine Schemes: VAT
Lord Patel Excerpts(2 weeks, 3 days ago)
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Lord Patel (CB)
My Lords, going back to the question about access to compassionate medicine, as I understand, the Minister just stated that medicines that are not yet authorised or licensed can be issued if companies agree to provide them for free, and that HMRC charges VAT on them. If the medicines are free, how do you calculate VAT? If a shop gives away free chocolates, does it have to pay VAT?
Baroness Merron (Lab)
I am sure that the noble Lord would not want me to be quoted as suggesting that VAT should be charged on chocolates given free in shops, so I will not. The way in which VAT is calculated is a long-standing arrangement that companies are aware of. The medicines are treated as taxable deemed supplies, which means that VAT is applied even when no payment is made. VAT is worked out by calculating the value of those products, but if there is nothing similar, then an assumption is made. This is a usual way of dealing with that. I should also emphasise that VAT is a matter for His Majesty’s Treasury and has been for all these decades.
Miscarriage Care
Lord Patel Excerpts(1 month, 2 weeks ago)
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Baroness Merron (Lab)
The 10-year women’s health strategy is absolutely focused on ensuring that services and support are available equally, no matter where people live. They are variable, and that is not where we want them to be. I have just spoken about the bereavement services, for example. As of January this year, all ICB areas are expected to provide a seven-day-a-week bereavement service across maternity settings. That was not in place earlier, and it gives a sense of the trajectory.
Lord Patel (CB)
My Lords, in an era of more personalised medicine, it is important to note that the care of women who have miscarried is dependent on several factors: the gestation age when miscarriage occurs, the age of the mother, and any existing diseases. It is not just about the number of miscarriages the mother has had when the investigation starts. There should be more personalised aftercare for every mother who loses a baby.
Baroness Merron (Lab)
I hesitate to say “of course”, but the noble Lord is of course right. As I mentioned earlier, there is a range of reasons why miscarriage may be taking place. It therefore requires that whole-system approach, but also the life-course approach that I spoke of. I am also glad that through our research arm, the NIHR, we are funding research through Tommy’s, which we have spoken about already, on the beneficial effects of progesterone, to give one example. It is important that we continue, as we are doing, to invest in this research.
Healthy Life Expectancy: England
Lord Patel Excerpts(1 month, 2 weeks ago)
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Baroness Merron (Lab)
As I mentioned in an earlier answer, this is a long-term and complex matter which has developed over a number of years. It is totally unacceptable that a woman in Hartlepool, for example, will enter ill health some 19 years earlier than a woman in Richmond-upon-Thames. It is about embedding action on health in policies across government. However, as I mentioned, it is also about redesigning the system around the three shifts: emphasis on prevention rather than on sickness, in particular, but also a move to community-based health services, so that people can access healthcare where and when they need it, and, of course, digital access, too.
Lord Patel (CB)
My Lords, healthy life expectancy is a mix of two data: a more precise life expectancy and a much cruder self-reporting of the stages of health. This leads to a confusing interpretation and therefore is not helpful in policy-making decisions. We have to find and seek better information about healthy life expectancy and the parameters that affect it, to be more effective in policy decisions. Does the Minister agree?
Baroness Merron (Lab)
I definitely agree. That is why data, particularly that which drives us to make funding decisions to get funding to where it is needed most, is absolutely crucial. I find the term “healthy life expectancy” more useful than what used to be called “life expectancy”. That, to me, was always only one side of the coin. However, I take on board the point that the noble Lord makes.
Women’s Health Strategy
Lord Patel Excerpts(2 months, 1 week ago)
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Baroness Merron (Lab)
I thank my noble friend for echoing the warm response we have had from the Royal College of Obstetricians and Gynaecologists and from a number of the other royal colleges. I put on record my thanks to the royal colleges, including RCOG, for their engagement throughout to help us get to where we are. That is another reason I have confidence in this renewed strategy.
I absolutely agree with my noble friend about the centrality of the workforce and the need for a comprehensive workforce plan. The trajectory, which I looked into, is on the way up for consultants in obs and gynae: we have 3.8% more than we had in 2025 and—I was rather shocked by this figure—81.5% more than we had in 2018. That is not to say the matter is over. The workforce plan will be published in the spring—we are currently in that season, so that gives some idea to noble Lords. We have discussed in this House many times how long spring goes, but we are definitely still there.
I have just one other point. I do not wish to speak for my noble friend Lady Amos, who is conducting an independent inquiry into maternity, which the noble Lord, Lord Kamall, also referred to, but I am sure she will have a number of things to say, including about workforce.
Lord Patel (CB)
My Lords, my interests are well known in regard to women’s health. I congratulate the Minister on this report, which I think is a good one. The gaps are in how, in some places, it will be delivered on. But I also recognise her personal commitment to improving women’s health, and I applaud that.
I hope she will forgive me, but I observe that the strategy is called The Renewed Women’s Health Strategy for England, so there is a suggestion that there was one before. And the Command Paper number is 1558. That was the year Queen Elizabeth I came to the throne, so I presume the strategy had not been renewed since then—but I joke.
The important point I want to make is related to research. Many of the issues recognised in the report are because of failure of research, conducted over a long period of time, in better understanding the biology and molecular basis of these diseases. They are treated empirically, and when they are treated empirically, the treatment cannot always be right. We need a strategy in research that focuses over a longer period on better understanding the biology of some of these diseases and finding treatments for them. One way to do this is not by project grants in areas of research, as this report suggests, but by promoting long-term research through what are known as programme research grants. These are given over a longer period of time and competitively allocated into academic institutions to address the issue of understanding the biology of diseases in women’s health and find treatments.
Polygenic risk scores sound sexy, but they will not be the answer. They are exactly what they say they are: they are based on scores. Some of them are evidence-based, and some are not. What we need is better evidence. My suggestion and question to the Minister is this: would the Government look at the possibility of investigating, with their research institution, developing programme grant funding for a longer period for research in women’s health? If she would like a more detailed conversation, I would be delighted.
Baroness Merron (Lab)
I am very grateful, as ever, for that offer and the engagement of the noble Lord. To his point about Command Paper 1558, I do not think that is the year the first one or this one were published. I understand there have been that many Command Papers, but this is a cracking one, and I am glad that the noble Lord has welcomed it.
Research is extremely important, as the noble Lord identified. Through the strategy, our approach will be to research and development that actually works for, but also empowers, women. That is why I am glad we will be launching a femtech challenge fund. We want to accelerate the adoption of innovations and make sure they transform women’s healthcare. There is also an accelerator for female founders, and that is also key. I can confirm that the NIHR will be applying its new sex and gender policy. That will make sure that research is inclusive—as it has not always been in the past, as the noble Lord says—and is representative of women, and I welcome that.
On the point about the long-term research and programme grant, as we develop this work I will ensure that my colleague, Minister Ahmed, builds this in. I also offer the noble Lord a discussion, because this is an important point.
Cancer Outcomes in the UK
Lord Patel Excerpts(2 months, 1 week ago)
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Lord Patel
That the Grand Committee takes note of cancer outcomes in the UK and of plans to improve them including diagnostic care and research.
Lord Patel (CB)
My Lords, sitting on the same side as the Minister does not mean that I am on her side. I thank all noble Lords taking part in the debate and look forward to their contributions. There is a formidable array of talent, so the Minister should get a good response. I thank her for making time to respond to the debate, although, at the end, she might wish that she had not done so.
No one can be in any doubt that poor outcomes for patients with cancer in the UK need urgent attention. Today is World Acute Myeloid Leukaemia Day, which observes a blood cancer with low survival rates, primarily because of late diagnosis. One in two people in the UK—
Baroness Bottomley of Nettlestone (Con)
Is it possible for the noble Lord to speak a bit louder? We old, deaf people back here find it quite hard to hear him.
Lord Patel (CB)
Can everyone hear me now? Can the noble Baroness, Lady Bottomley, hear?
Lord Patel (CB)
Thank you. One in two people in the United Kingdom will develop cancer. Being born with cancer is rare, but a new cancer diagnosis is made every 75 seconds. The UK consistently ranks near the bottom of the table for survivals and deaths from cancers. That is despite several cancer plans and strategies for change, which are often heralded as world class. In 2011, we had Improving Outcomes: A Strategy for Cancer; in 2015, we had Achieving World Class Cancer Outcomes; and in 2019, we had a plan to make cancer a priority. None of those plans delivered the promises made. The result is that cancer outcomes have not improved much in England for nearly two decades.
Cancer care is a touchstone of the wider NHS, which itself is also delivering poor performances. It is in that environment that we will discuss the plan. We now have the Government’s National Cancer Plan for England: Delivering World Class Cancer Care. What is different about this plan? The Government say that
“it heralds a full modernisation of our approach to cancer care … fit for the future”.
The report is ambitious but lacks detail on implementation plans, which I hope the Minister will tell us about today.
What are the key commitments? The first is to improve five-year survival rates, so that, by 2035, three in four people with cancer will live more than five years, either cured or living well. The second is to restore performance in meeting cancer waiting-time standards by 2029. The third is to expand screening programmes, including lung cancer screening, by 2030. The fourth is to increase genomic and genetic testing, so that genetic tests are to be reported within 10 days for 96% of patients. The fifth is to accelerate the use of AI, robotics and modern imaging for early diagnosis. The sixth is to reduce variation in accessing new treatments and technologies and to address inequalities. The seventh is to strengthen cancer alliances among system leaders and to boost research and clinical trials.
I have mentioned but a few. All of that and more is being promised when cancer services are under immense pressure. Demand continues to rise, with a complex case mix. Most importantly, staff shortages persist, particularly in radiology, oncology, cellular pathology and cancer specialist nurses.
The shortfall in workforce in critical areas of cancer care is significant. In radiology, it will be 39% by 2029; in oncology, it will be 19%. For nursing and specialist nurses in cancer care, there is a 10% shortage in most trusts. There is a shortage of 4,000 specialist cancer nurses and 6,000 nurses in community diagnostic centres. In histopathology, only 3% of departments say that they have adequate staffing. The Royal College of Radiologists and the Royal College of Pathologists say that, with the shortage, the workforce will not be able to deliver on the needs in the cancer plan. To do so, the workforce may need to grow by as much as 45% by 2035. In radiology alone, that may cost £1.5 billion a year. I ask the Minister when the Government will publish a fully funded workforce plan for cancer care. We look forward to that soon.
I will now pick up on some of the key commitments, as I do not have time to go through them all. On the commitment for three in four patients to survive five years by 2035, the current average survival for five years is 55% to 60%. Of course, it varies with cancer types: it is good for prostate and skin melanoma, but survival rates are much lower than in many other countries for equivalent cancers across the board. On restoring performance for standards of, for instance, early diagnosis at stages 1 and 2 in 80% of cases by 2029, that is improving: it has now improved to 72.8%. Sixty days from the first referral to treatment is a standard that has not been met since 2015. For treatment in 31 days from diagnosis, the target is 96%; currently, it is not doing badly at 93%.
On expanding screening programmes and eliminating cervical cancer by 2040, the increase in HPV vaccination and self-diagnosis HPV kits is the way that the Government hope to meet that target. The current uptake of the HPV vaccine is 75.5% in girls and 70.5% in boys, with huge regional variation: for instance, in London, it is only about 64%. What plans do the Government have to improve uptake of vaccination and how will the elimination target be met? As far as the HPV kits are concerned, what happens if a woman self-tests and finds that she is HPV positive? The services need to match up to what the patient might need.
Another target is increased genetic and genomic tests. The plan suggests that there might be value in testing whole-genome sequences, the so-called polygenic risk scores aligned with the lifestyle, but they are of no value because the risk is not yet identified or valued. It is different if you are testing for inherited genetic diseases, such as if a patient has a BRCA gene, as then you might follow up with others in families. But the value of whole-genome sequences as polygenic risk scores cannot be right.
Genome testing for mutations in cancer, of course, is important for personalised treatment, and the target is for 98% in 10 days. Currently, it meets this for 68% of patients, because of the workforce issues. What might be the implications if the treatment is delayed because these tests are not reported in time? For instance, a four-week delay in treatment increases risk of death by 6% to 8%, so it is important that these tests are reported quickly. These days, without genomic mutation testing, treatment cannot be started with cancers.
Another target is to accelerate use of AI, robotics and modern imaging for early detection. It is true that in the trials carried out using the triad—it is important to use the triad of AI, robotics and modern imaging—it is quicker to obtain a tissue sample, for instance, but these have to be done together and there are costs of equipment, training and robotics.
The Government hope in the report to increase the use of robotics from 70,000 currently to half a million by 2035. Small studies show benefits, because it fuses metabolic and structural data for better staging and treatment of cancers, but the digital pathology staff remain a key workforce required for this. Can this be standardised across the whole NHS rather than in specialist units alone?
The next issue is funding. Together with staffing, funding is a critical issue. The Government have made a commitment of about £6.5 billion, rising to £15 billion depending on progress. However, estimates from the Health Foundation suggest that, to roll out AI, robotics, modern imaging and digitisation across the NHS, we will need £14.5 billion to digitise the NHS, capital infrastructure worth £5 billion, one-off implementation costs of £2.5 billion and recurring costs of £1.5 billion. Does the Minister think that this is realistic and that the Government will be prepared to fund it?
The main other issue is reducing inequalities in cancer care. We must reduce inequalities in cancer outcomes for deprived populations. The biggest challenge is in the 20% of deprived people, because there is a 60% higher death rate in this population. Late diagnosis is more common in this population, there are low treatment rates, people are more likely to have cancer diagnosed in an emergency in the A&E department and there are low screening rates. Focusing on reducing inequalities in cancer care will be key to meeting the targets set in the plan.
Who is going to do this? The suggestion is that the cancer alliances will be responsible for planning and tracking the delivery of cancer services in deprived areas with an extra £200 million in funding. Is that likely to be adequate funding, knowing that it will require new staff to man these services? I ask the Minister, therefore, what the metrics for the improvement in care of the deprived population will look like.
The developments in technology, drugs and diagnostics in healthcare and cancer care come thick and fast. Many are mentioned in the report. Some of them are not even yet validated. Treatments are very expensive. For instance, CAR T-cell immunotherapy would cost in the region of £280,000 per treatment per patient. The technology is expensive. The current percentage of people getting chemotherapy, radiotherapy, cell and gene therapy and immunotherapy in England is lower than in countries with better cancer outcomes. Implementing what works and improves outcomes for the whole of the population—early diagnosis and prompt treatment, with the workforce to deliver that—will result in better outcomes. I repeat that, knowing what we know, early diagnosis and prompt treatment will improve outcomes well before we use these technologies. They are important, but we need to do that first. Patchy introduction of state-of-the-art technology, early-phase research into the practice of untested diagnostics, science fiction and a promise of personalised nirvana tomorrow will not be the answer.
The plan is thin on the prevention of cancers apart from on tobacco control, which I applaud—and we all applaud. Treatment using GLP-1 and GLP-2 blockers for obese people is not stopping obesity; it is treating obesity, at a cost. In the plan, there is nothing about what the Government will do to reduce obesity, or on the reduction of alcohol consumption, but we know that 40% of cancers are related to lifestyle issues. Can the Minister explain why the report is so thin on prevention?
I will make a comparison to one country. Much of the cancer plan comes from learning from the Danish model. Denmark, some 25 years ago, had similarly poor outcomes for cancers. It embarked on an incremental cancer plan to the point that it is now recognised as the country with the best cancer outcomes. Its latest plan is to focus on helping people living with cancer and those in end-of-life and hospice care. I am sure that the noble Baroness, Lady Finlay, wants to know when England will get such a plan. To invest in this, Denmark is to spend 690 million Danish kroner. It does not sound like big money, although its population is small.
The key feature of the Danish plan and the better results is political consensus. The noble Earl, Lord Howe, might remember that, in a debate that we had about the long-term sustainability of the NHS, I said that the NHS’s survival depends on a political consensus. The then opposition Health Minister, the noble Lord, Lord Hunt of Kings Heath, laughed and said, “Dream on”. I guess that that is still the problem. If we do not have political consensus, we will just have more problems.
Funding was the other issue. All the five-yearly plans in Denmark were funded. Importantly, there was a promise to the people that the service would deliver early diagnosis within 14 days or less and that treatment would start within 14 days or less. The promise was that, if you did not get that, you could go to any other region in Denmark for your treatment or even another country. Would the Government make such a promise to the population of England?
The Government’s plans are ambitious, but will the Government maintain a consistent commitment to delivery no matter what it takes? Otherwise, in three to four years’ time, we will debate a new cancer plan that will be even better and world-class. However, I wish the plan well and I hope that we begin to get results quickly.
Lord Patel (CB)
My Lords, I thank the Minister for her comprehensive response. She might reflect on some of the other points that she was not able to answer, such as the one on isotopes, which is very important. We have debated that before. One or two noble Lords quite rightly mentioned children’s cancers, which the report mentions very thinly. There is an issue with children’s cancers, including the suggestion that a well-run, efficient children’s cancer unit is under threat of being shut down. That cannot be so, and it needs to be investigated.
Aside from that, I thank all noble Lords. The Minister is quite right: there is a daunting array of them, even to me, and I have six double-sided pages of the important contributions made. If I were to summarise, your Lordships would not like me because they would be here for a long while, so I will not. Each and every contribution was brilliant. I thank noble Lords not just for turning up but for making such a good contribution. To me, the summary of it was that there were constructive, helpful comments to help this national plan, which on the whole each and every speaker welcomed. They were not criticising it overtly—apart from me—and I am sorry that I teased them at the beginning.
The noble Earl, Lord Howe, made a comment about me and the way I have engaged with him over time in debates. The problem is that, with his silken charm, you never know whether he is being kind to you or about to put a dagger in you. But it is always delightful to listen to him, and he made some important points, again in a helpful way. I hope we will soon see the workforce plan. It is absolutely crucial to have a workforce plan focusing on cancers again to deliver the workforce we require for all the things we want to do. I thank all noble Lords, and I thank the Minister very much. I agree with the comment made by one Member that we are lucky to have her as a Minister.
Migraine Care: 10-year Health Plan
Lord Patel Excerpts(3 months, 1 week ago)
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Baroness Merron (Lab)
We very much recognise the concerns that people may face unnecessary hurdles when trying to access CGRP treatments. NHS England is working with integrated care boards to ensure that the pathways being followed are consistent and timely. It would perhaps be helpful for me to mention some of the national tools, such as NHS RightCare’s headache and migraine toolkit and the Getting It Right First Time recommendations; they also speak to the clearer referral rates that the noble Lord called for and reduce variation. We want people to receive appropriate treatments; we do not want them to be delayed.
Lord Patel (CB)
My Lords, migraine as a symptom is a manifestation of a whole spectrum of different diseases, both neurological and vascular, and some are based on allergies. The important aspect of treating migraines is correct diagnosis, and advances in diagnostic techniques, including some of the treatments that the Minister mentioned, are now making that easier. Does she agree that, in addition to having a community-based service, it is important to train the right people to make the right diagnoses, so that patients can get the right treatment at the right time, no matter who dispenses or prescribes it?
Baroness Merron (Lab)
I certainly agree. NICE’s headache guidelines and the Royal College of GPs’ training modules support that better recognition and management.
Unpaid Carers: Patient Hospital Discharge
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Baroness Merron (Lab)
The whole system needs to do better, as the noble Lord outlines. It will be helpful that we are also looking at commissioning research in this area to look at best practice, as well as barriers and solutions, regarding the involvement of unpaid carers—I think that has been somewhat overlooked, if I am to be honest with your Lordships’ House. We have regional teams that have issued very practical toolkits to help hospitals implement their legal duties; we should remember that there are legal duties in this response. In addition, that is why we are involving the LGA’s better care fund support programme, as I said, as well as seeking to publish a cross-government action plan. These will be steps in the right direction, but I very much acknowledge that we do not start in a good place.
Lord Patel (CB)
My Lords, although the better care fund is a help, its success depends on how hospitals and the LGA work together. Would the Minister agree that the fund is still used to fund short-term gaps, particularly winter pressures, and that the yearly funding cycle does not help for longer-term planning? Could that be improved?
Baroness Merron (Lab)
I can see the pressure and difficulties that can bring. There is a range of reasons why discharges do not take place in a timely fashion—not just processes but the interface between health and social care, and capacity. As we look at how we involve carers and improve discharge rates, matters of funding will be key.