NHS Funding

Lord Patel Excerpts

Monday 31st October 2016 Lords Chamber

[Lord Prior of Brampton]

I entirely agree with my noble friend that the independence of NHS England has been very important. Had the NHS plan been developed by politicians it would have had a lot less credibility. I entirely agree that prevention and public health are hugely important, but of course it takes a long time for public health initiatives to have an impact, so I do not think that any reductions in them in the last two years will have any major impact over the five-year period. Clearly, it will have an impact over a longer period. As for the changes to Health Education England, those savings have largely been generated by moving from a bursary system for nurses to a loans system, which will actually deliver more nurses and therefore help to deliver the five-year forward view.

[Lord Patel (CB)]

My Lords, is the Minister saying that there are no financial pressures on the NHS? If he is, that is contrary to every piece of evidence that the House of Lords Select Committee on the Long-Term Sustainability of the NHS has heard. Furthermore, it is the lack of a settlement in social care that is killing healthcare. Is it not time that we had a new settlement for both healthcare and social care that is sustainable in the long term?

[Lord Prior of Brampton]

My Lords, I acknowledge that there is tremendous pressure on all parts of the health service and in social care, but if there is not pressure, there will not be change. Getting the radical, fundamental change we need in the health service will not be achieved if we just pour more money into the existing system: we have to have change.

Health: HIV

Lord Patel Excerpts

Monday 5th September 2016 Lords Chamber

[Lord Patel (CB)]

My Lords, I thank the noble Lord, Lord Black, for initiating this debate. I agree with him and the noble Lord, Lord Maude, that prevention, testing and treatment are part of the same healthcare, which needs to be joined up. We are talking today about prevention, particularly the use of PrEP, the pre-exposure anti-viral treatment to reduce the incidence of HIV. This debate is about the elimination of HIV. We now have the possibility to do that. However, we will fail to do so if we do not address this issue urgently.

Reducing the incidence of and eliminating HIV requires biomedical, behavioural and structural intervention. However, we also have to adopt any new treatments or preventive treatments that come along. I was interested to read what the Health Committee had to say about our public health strategy in its recent report, published last week:

“We welcome the focus on public health but recognise that reducing health inequality will also need to address the wider determinants of health, such as … the environment. This will require cross-Government working. We recommend that a Cabinet Office minister be given specific responsibility … at national level”.

Will the Minister comment on what the Health Committee said? It also said:

“Local authorities face a number of challenges and have had to cope rapidly with major system change. In addition they face real terms cuts … of £200 million … Cuts to public health and the services they deliver are a false economy as they not only add to the future costs of health and social care”,

as exemplified by the cost of treating a patient with HIV as opposed to the cost of prevention, as many others have mentioned.

The committee goes on to say:

“Commissioning for certain services is divided between different bodies, creating the potential for confusion and fragmentation. Where … progress on resolving them is in the best interests of patients and the public. Sexual health provides a clear example of such fragmentation”.

The committee refers to the,

“responsibility for and funding of preexposure prophylaxis, PrEP, for HIV”,

as many other noble Lords have mentioned.

I come back to why PrEP is so important. Others have mentioned the evidence that is now public in two studies, one conducted by PROUD and the other by Ipergay. They both found that PrEP was 86% effective, as has already been mentioned—that is, it stopped 17 out of every 20 HIV infections. They tested different ways of taking PrEP. In the case of the PROUD study, it was a daily dosage. In the Ipergay study it was an intermittent dosage. Despite that, both ways of taking PrEP are effective, so it does not have to be taken daily. Studies with heterosexual men and women equally show that PrEP works well in people who are able to take it consistently. For example, an African study showed that it was 75% effective—that is, it stopped 15 out of 20 HIV infections that would have occurred without PrEP.

PrEP is needed if HIV infections are to start going down in the UK and even to be eliminated, especially in gay men. It is estimated that 2,800 gay men in the UK acquired HIV in 2014—about eight gay men got HIV every day. PrEP is necessary in England because while condoms, testing and treating HIV-positive people are just about containing the HIV epidemic at its current level, infections in gay men are not decreasing, and more and more gay men are living with HIV every year. PrEP will save money, as has already been mentioned, because the cost of treating HIV patients is so high compared to prescribing.

I will also address some of the other issues that have come out in the debate on who pays: NHS England or the local authorities. Instead of having a debate about who pays, we have got confused about the clinical efficacy of PrEP. Absolutely convincing, good studies show that it is highly effective, so that should not cloud judgment about who pays. Concerns have been expressed that it could lead to other unintended consequences; for example, what about condoms and PrEP? There is little evidence that providing PrEP will result in big changes in condom use. People who use condoms carry on using them. People who do not use them, particularly gay men having sex with other men, need to be targeted. Another concern was about other sexually transmitted infections—none of which, by the way, are as serious as HIV. There is little sign that PrEP causes rises in other STIs.

Side-effects were also mentioned, but PrEP rarely causes them. Clinical resistance to the drug was another issue, but there is no evidence that PrEP will lead to many more cases of HIV drug resistance. The cost-effectiveness models have already been mentioned but, in the studies conducted, other, different cost-effectiveness models were used, and all of them were found to be effective.

The bottom line is: given to gay men at high risk of HIV, PrEP will be cost effective or could even start saving money now, especially if it is as effective as it was in the PROUD study and if at least a proportion of users take it intermittently. Even taken intermittently, it is effective. Therefore, there is no reason why we should not introduce this now. The argument about who pays needs to stop. The same taxpayer pays at the end of the day. The only issue is who tells whom to start introducing this treatment. I hope that the Minister will respond positively to that.

Junior Doctors: Contract

Lord Patel Excerpts

Thursday 5th May 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I think there is general recognition that many of the issues that lie behind the dispute over the contract are not actually involved in the contract itself. It is about how junior doctors are trained, valued and integrated into hospitals and the workforce. These are much broader issues than just the contract, and I assure the noble Lord that the Government are fully aware of that. Once this dispute has been settled, we can start to resolve those bigger, deeper and more fundamental issues.

[Lord Patel (CB)]

My Lords, I am surprised but delighted at the news this morning that the Department of Health has agreed to enter into discussions with the junior doctors. I hope that both sides will enter into them in the spirit of finding a resolution, rather than finding faults. I am sure that the talks will resolve the issue, because as far as I am concerned striking is not the answer. Anything that prolongs the exercise is detrimental to patient care.

[Lord Prior of Brampton]

My Lords, I wholly, 100% agree with the words of the noble Lord.

Health: Hepatitis C

Lord Patel Excerpts

Thursday 28th April 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I do not think I can answer that question as I do not fully understand it. Perhaps I could meet the noble Baroness outside the Chamber. All I can say is that NHS England is funding the new interferon-free treatments in accordance with the NICE technology appraisals, and is prioritising people on the basis of unmet need. I think the modelling assumption shows that 10,000 people will receive the new treatment in the coming year. I cannot answer the specifics of the noble Baroness’s question but I will follow it up outside, if I can.

[Lord Patel (CB)]

My Lords, an estimated 220,000 individuals in the United Kingdom are chronically infected with hepatitis C virus. Deaths among the under-60s from end-stage liver disease and liver cancers due to the virus have doubled over the last decade. We have in the interferon-free treatment a drug that is effective in successfully treating the disease, as it reduces the viral load in 98% of patients treated to virtually zero in the whole spectrum of genome of hepatitis C virus. Therefore, it is an effective preventive drug for developing end-stage disease. It has the potential to eradicate the disease in the population. In that scenario, why would we treat only 10,000 patients per year, as the guidance says, for the next two years and not treat every patient who is a chronic carrier of hepatitis C virus?

[Lord Prior of Brampton]

My Lords, there is clearly a budgetary constraint. The noble Lord mentioned 220,000 people—I thought it was slightly less than that—and this drug costs many tens of thousands of pounds per treatment. Clearly, however much we would like to treat 220,000 people, it is just not feasible to do so. That is why we have NICE, which has produced its appraisals and said that, using its modelling, the number of people who need to be treated in the coming year is likely to be between 7,000 and 10,000, rising to 15,000 by 2021. However, I agree with the noble Lord that this interferon-free treatment is a massive improvement on previous treatments, with a very high cure rate.

Health: Treatment Rationing

Lord Patel Excerpts

Tuesday 26th April 2016 Lords Chamber

[Lord Prior of Brampton]

Yes, my Lords. The noble Lord has quoted almost verbatim from the recommendations of the Royal College of Surgeons report, which I have in front of me. I agree with him completely.

[Lord Patel (CB)]

My Lords, does the Minister agree that CCGs should be obliged to publish their evidence base for their policies? If he does not, will he say why not? Further, what recourse does a patient have to challenge their CCG when they do not receive surgical treatment because of the latter’s policies?

[Lord Prior of Brampton]

My Lords, the noble Lord will be aware of the Atlas of Variation, which encompasses a new programme, Right Care; it looks at variations in medical and surgical practice across different populations and tries to spot unwarranted variation. That is the best way to identify where different CCGs are not delivering the kind of care that we would expect. In view of what we have just said, I am tempted to say that where an individual does not get the treatment he expects, he should complain to his local Healthwatch. That would be one way to do it but every hospital has a PALS and he could always write to his MP. There are lots of ways in which individuals can raise concerns if they wish to do so.

Junior Doctors: Industrial Action

Lord Patel Excerpts

Monday 25th April 2016 Lords Chamber

[Lord Prior of Brampton]

On mortality rates at weekends, the noble Lord is absolutely right that there has been confusion about the difference between the terms “excess mortality” and “avoidable mortality”—the two are clearly very different. However, having said that, I think it is widely recognised that the lack of senior cover and diagnostic support, particularly at weekends, is not at all satisfactory. Certainly Bruce Keogh and others have looked at this—I think that there have been six very detailed studies looking at mortality at weekends. The fact that there is a higher level of mortality than you would expect is ground for providing greater support at weekends. As for the suggestion that there should be a pilot scheme to study the contract, I tried to answer that in my response to his noble friend and I have nothing else to add to that.

[Lord Patel (CB)]

My Lords, what will happen tomorrow and the day after is unprecedented in the history of the NHS: junior doctors will withdraw their services from emergency care. Despite some of my own family disagreeing with me, I, as a doctor, could never have contemplated taking that action. But the junior doctors today do feel hard done by for many reasons, which the Minister has stated, about how they and their training are valued—and that is an issue that we need to address. I am not allowed to make a speech today, and I will not, so let me come to the crucial point. The Minister said that the crucial issue is that of Saturday pay. It cannot be impossible for both sides to agree to sit down to break this deadlock and discuss these pay issues. Otherwise, where are we going to go? We have to find a solution. On the one hand, the junior doctors are saying, “Do not impose the contract on us”, and on the other hand, the Secretary of State is saying, “I have to impose the contract because you won’t agree with my pay conditions”. There has to be a solution. What solution does the Minister think we might have?

[Lord Prior of Brampton]

My Lords, we have discussed this issue outside the Chamber. Although one must never give up hope, I find it hard at the moment to see how a negotiated, agreed solution might be found. We have had three years of negotiations; we have had 75 meetings. We came within a hair’s breadth of a solution, with the Government making concessions around how much of Saturday should attract premium pay, but we were unable to do the deal. Sir David Dalton, a very distinguished, well-respected chief executive of Salford Royal, led those negotiations and his advice to us afterwards was that he could not find a way through it. His advice then was that we had no choice but to impose the contract. None of us wanted to impose the contract; we all wanted to find a solution. But with the current BMA executive we found that impossible. Much as I regret it, as things stand this evening, I do not see a solution.

NHS: 111 Service

Lord Patel Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

There have been a number of terrible tragedies. The most recent of these was William Mead, a very young baby who died as a consequence of not getting the right treatment quickly enough. NHS England has done a root-cause analysis. Some of the problems lay within 111 but others were with the out-of-hours service and with diagnosis by the GPs concerned. The noble Lord is wrong to say that the 111 service is not operating well throughout the country. Some 90% of all those who use 111 believe they get a good service from it.

[Lord Patel (CB)]

My Lords, what suggestions does the Minister have for improving the performance of the 111 service?

[Lord Prior of Brampton]

My Lords, there are two things which we need to do to improve the 111 service. First—and this is in response to part of the Question asked by the noble Lord, Lord Hunt—we need to have more clinicians within the 111 hubs. Secondly, people need to have access to the patient’s electronic summary care record so that they can see what has gone on before coming to a final judgment.

NHS: Hospital Overcrowding

Lord Patel Excerpts

Tuesday 15th March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, clearly, step-down facilities, including community hospitals, have a very important role to play. The whole thrust of the five-year forward view is to treat more people outside acute hospital settings. That is the NHS’s plan, which the Government support.

[Lord Patel (CB)]

My Lords, does the Minister agree that there needs to be a reform of the tariff paid for the workload that A&E departments now bear? If there is an appropriate tariff, the hospitals will invest in better facilities and better staffing, such as collocation of out-of-hour GP services, pharmacies, and even mental health assessment services, alongside A&E departments. Does he therefore agree that there needs to be a reform of the tariff paid to A&E?

[Lord Prior of Brampton]

My Lords, the tariff has been changed. Acute hospitals now receive 70% of the tariff, rather than 50%, for the excess numbers of people coming into A&E departments. The noble Lord is absolutely right, though, that those hospitals that have collocated GPs and A&E departments, and have invested in psychiatry liaison nurses and other people, have seen huge improvement. The question is: do we want to invest? Are A&E departments the right places to invest, or ought we to be putting that investment into primary and community care? That is the big issue that will be decided over the next five years.

NHS (Charitable Trusts Etc) Bill

Lord Patel Excerpts

Friday 26th February 2016 Lords Chamber

[Lord Patel (CB)]

My Lords, I know why noble Lords are all laughing. I have to follow that. Many a bigger man than me would have found that difficult. It is a privilege to follow my noble friend Lord Bird, and I thank him on behalf of the House for his remarkable, moving, humorous and rather unusual maiden speech.

[Lord Bird]

You chose me.

[Lord Patel]

It will go down in the records of maiden speeches. I do not know what words will be used—astounding, eccentric, and I hope not to be repeated. My noble friend has educated noble Lords in words they have not heard for many a decade; they will have to go and look them up in the dictionary. My noble friend is also a truly remarkable person. Today really is a Big Issue day.

My noble friend’s personal story is, as he described, also remarkable. If I can encapsulate it in one sentence, I would say that it is poverty to purpose.

[Lord Bird]

You have stolen my line.

[Lord Patel]

Brought up in a slum, raised as an orphan, illiterate to start with and sleeping rough, my noble friend Lord Bird went to jail several times. But he has inspired millions. He is a trailblazer. He is a social entrepreneur. He has a mission to provide a hand up to thousands of people who are too often forgotten by society.

My noble friend was awarded an MBE in 1995 for services to homeless people and he is a doctor, holding an honorary doctorate from Plymouth Business School at the University of Plymouth. He also tried to stand as Mayor of London—there is a vacancy coming up. Then, as he told us, in 2010 he was asked what his guilty secret was. He said, “I am really a working-class Tory”. He also said that he would actually like to be a Liberal because they are nice people, but that that would be too much like hard work. I cannot repeat what he said about being a socialist. Noble Lords will have to look it up because the language he used cannot be repeated here.

He was also asked whether he has any ambitions, to which he replied that he would like to write a book; I hope that that is correct. The book was to be a different version, or a replacement, of Fifty Shades of Grey. I do not know how many here have read the book; it is an education in itself. Noble Lords might not be surprised to learn that the title is Why Drawing Naked Women is Good for the Soul. I have given the noble Lord a plug for his book because I am sure that the sales will now go up by millions.

I welcome my noble friend Lord Bird to this House. We look forward to many contributions from him. They are obviously going to be challenging, colourful and, dare I say it, enjoyable.

I now move on to my contribution to the NHS (Charitable Trusts Etc) Bill. Before I do so, I hope that the whole House will join in me congratulating the noble Baroness, Lady Massey, not because she is introducing this Bill but because today is her and her husband Les’s 50th wedding anniversary—I have let the secret out, Doreen, and I offer my congratulations.

[Noble Lords]

Hear, hear!

[Lord Patel]

I support this Bill wholeheartedly. As has been said, it was previously introduced by Wendy Morton, the Member of Parliament for Aldridge-Brownhills. I support the two main aspects of the Bill. It will allow for greater independence of NHS charities, which has to be welcomed. Many NHS charities have expressed concerns about demonstrating their independence when they have to fulfil the governance requirements of both NHS and Charity Commission legislation. The arrangements as described in the Bill will also help to remove the perception widely held by both individual and corporate donors that when they donate money to an NHS charity, it simply adds up to a bit more for the healthcare budget. It is important to remove this perception, and I believe the Bill will do that.

We are all familiar—no more so than the likes of me, who worked in the NHS—with the tremendous support given by the NHS charities and the people who work in them. As the noble Baroness, Lady Blackstone, mentioned, they provide funds that are often not available, particularly for early phase research and equipment. Research councils do not provide funds for the earliest stages, and I personally have benefited on several occasions from such funding. They support individual volunteers and charities like the network of League of Friends for hospitals. What they give to local communities is tremendous and valuable. I am very familiar with the work of such organisations and I declare an interest: I have the great honour to be the current president of the charity Attend. Many other noble Lords are familiar with it because several are past chairmen, presidents, vice-presidents or have served on its governing body. Attend responds to, respects, and gives care. It is an umbrella organisation representing more than 29,000 volunteers who give their time to health and social care issues. Last year, Attend volunteers provided more than 4.3 million hours of their time, equivalent at the minimum wage level to around £21 million. In addition, they raised some £41 million for health and social care needs in local communities. The contribution to making other people’s lives better cannot be measured only in money terms. Attend also brings about effective partnerships with organisations like the League of Friends and others. I hope the Bill will give further publicity to the valuable work being done by such charities and the individuals within them, thus encouraging more people to offer their support to their local NHS charity—not just financially but by getting involved personally.

The Bill will allow NHS charities to grow and develop their charitable activities, and in my view it will also act as a catalyst to bring about greater engagement by the public with their local health providers. In conclusion, I strongly support the Bill.

Access to Medical Treatments (Innovation) Bill

Lord Patel Excerpts

Friday 26th February 2016 Lords Chamber

[Lord Patel (CB)]

My Lords, I am delighted to support this Bill and hope that it will have a swift passage through this House and become legislation. I congratulate the noble Lord, Lord Saatchi, on presenting it in great detail and in his usual style, and—given the difficulties his predecessor Bill had—on his tenacity in listening to people in and outside this House and getting to the position whereby the Bill is now acceptable to all the professionals I have spoken to.

Perhaps I may briefly go off the Bill and come on to some comments that have been made. Before I do that, I will declare my interests. I am, as everybody knows, a doctor by background. I am the chancellor of the University of Dundee, which is one of the key UK universities for life sciences. I chaired until recently the UK cancer research centre in Dundee. I now chair, as a board member, another research group in Dundee that is looking at the scientific evidence as to why cancer outcomes can be worse among people from a poorer background, where they are disastrously worse. I was also responsible in this House for chairing a report on genomic medicine. That led, thankfully, to the developments in genomic medicine in the United Kingdom and the research centre which the Government support through the research councils.

It is true that as we learn more and more about genomics and genetics, we will need to have a huge database from which we can learn. What the noble Lord, Lord Ryder, said is correct: there will be patients who would be appropriate for stratifications of medicines that we know now and which are found to be effective because they are used more generically. If we learn from genomic medicine that stratification makes them more suitable for that treatment, because of their genetic make-up, such drugs will be very beneficial.

It is also true that innovations occur in the United States at a faster rate—the noble Lord, Lord Ryder, referred to this—because the processes of the different trial phases there are much more efficient. Some say they are too quick; I do not subscribe to that view. Let me give one example. The noble Lord referred to this concept briefly. Some of the breast cancer treatments do not work in all women. We know that the drug that is given will work but that it cannot be given in the quantities required because most drugs, as we know, are poison. You can use it in a dosage that will treat the disease but if you exceed that dose, you are likely to do more harm than good. But if you can limit that treatment to only the cancer cells, those drugs will be effective. We now have innovations whereby this can be done by identifying the molecular make-up of the cancer and then loading the drug with that molecular marker, so that it will attack only the cancer cells and leave the normal cells alone.

We need a different way of innovating. My own university also has a drug discovery unit. We have contributed to the development of several drugs, two of which would be regarded as blockbuster drugs, through understanding the science of disease processes—the biology of disease. Such understanding is crucial before you develop a treatment.

However, we need to move away from that to other ways of developing drugs. We try to do this by using 70,000 compounds that were previously identified by pharmaceutical companies but not used because they were not found to be effective in treatment. We are seeing if any could be used for the treatment of so-called tropical diseases that are not infectious, which a huge number of people are affected by. We do this in collaboration with other countries by supplying them with these compounds. I agree that we need to look at different ways of innovating drugs and treatments, particularly as the science develops. There will be other ways of dealing with diseases, such as gene-editing, which was how Layla, a young girl in Great Ormond St, was treated. That may also require the development of other drugs to make sure that side-effects are suppressed.

The point I am trying to make is that the Bill may well act as a catalyst. The noble Lord, Lord Saatchi, should be pleased that people are thinking more widely and outside the box. We have an opportunity to develop good databases, as the noble Lord indicated, and to use them for innovative development of treatments. I hope this will happen. I hope that the Government will bring in wider legislation on the issues that the noble Lord, Lord Ryder, referred to, such as better ways of conducting clinical trials. We need transparency and openness. I do not think the medical profession is averse to that, and it is what the public need. We have to be honest: not all the treatments we try will work, but if we try harder, we will find treatments that work which we have been ignoring.

I have to admit to something here, which I hope the GMC does not hear me say—although it might, and if it does, I do not care. I have used off-licensed drugs on several occasions, with the full consent of the patients I was treating, when no other treatment was working. Lots of my colleagues do this. If any doctor stands up and says they never do it, I would not suggest that they might not be telling the truth, but I would be surprised if they were innovators in the true sense.

Then, there is research. I have done research that I am not very happy about and that I wish I had not done, but at the time I did it with a clear conscience. In retrospect, I now know that it probably did not work as well as expected and was probably not all that good for the patient—I hope it did not do any harm—but if I had not tried it, I would never have known. It is important that we stop arguing at length and trying to regulate and control in the minutest detail innovations in medicine that we can drive forward. We do this more easily with innovations in surgical and other procedures. We are much freer about that and clearly understand that, as doctors, you work with people in other countries to introduce the same procedures and use a common database to learn.

[Lord Hunt of Kings Heath (Lab)]

Would many current surgical procedures have been authorised if they had had to go through the kind of clinical trial process that medicines do?

[Lord Patel]

We would not have had stents put in hearts, bypasses, ablations—

[Lord Blencathra (Con)]

Marie Curie.

[Lord Patel]

Yes, we would not have had Marie Curie’s radiation treatment. One of my children is an oncologist, so I know what they do. The noble Lord is quite right: fortunately, such procedures do not have to go through this stringent process. Some argue that they should, but that would be a backward step.

The only minor concern the professional organisations have had is to clarify the definition of medical innovations. It is true that practitioners must clearly understand that they cannot bypass current regulations on patient safety; I have no doubt that the Minister will confirm that. The other matter, which has been mentioned and on which the noble Lord, Lord Saatchi, convinced me in his introduction, is that the database has to be transparent and shared and there must be clear stewardship of it. I hope the Minister will confirm that.

I strongly support the Bill and wish it a speedy passage.