Health: Non-communicable Diseases

Lord Rea Excerpts

Thursday 6th October 2011 Lords Chamber

[Lord Rea]

My Lords, I congratulate the noble Baroness on returning to the Benches; she has shown that it will be greatly beneficial to all of us by the quality of the speech that she has just given. I would also very much like to congratulate the noble Lord, Lord Crisp, on securing this debate so soon after the recent high-level conference on NCDs that we have been talking about. If your Lordships will forgive me, I am going to use the abbreviation for brevity and to save tongue-twisting.

This topic has been growing in importance for more than 50 years, since communicable diseases came more under control. NCDs are now the major public health problem of the developed world. More recently, as the noble Lord, Lord Crisp, has pointed out, there has been a major increase in these diseases in the developing world, where they now cause around 60 per cent of deaths, which in total numbers greatly exceed NCD deaths in developed countries because of their greater populations. A higher proportion of these deaths in developing countries occur in people under 60 than in the developed world. The rapid increase of NCDs in the developing world was the main stimulus for the UN conference two weeks ago.

I come to this debate from a background in UK general practice but with a particular interest in public health. This was triggered by a three-year stint working with children in Nigeria where I came face to face with the importance of the environment and particularly nutrition in giving rise to childhood disease and high mortality—of course, in that case from communicable disease. I declare an interest as current chairman of the all-party Associate Parliamentary Food and Health Forum and as a trustee of the respected National Heart Forum, an NGO that brings together more than 50 organisations with an interest in the prevention of heart disease. Because the risk factors which lead to cardiovascular disease are very similar to those underlying most NCDs—smoking, faulty diet and lack of exercise—the National Heart Forum has recently widened its remit to embrace NCDs other than heart disease. It has published numerous reports, tool-kits and interactive programmes to help NCD prevention activities throughout the world, and two members of the National Heart Forum team were delegates at the New York conference.

NCDs are age-related diseases; they are degenerative in nature, but they do not affect everyone. Some people and populations develop these diseases much earlier than others. Some of these differences are due to increased genetic susceptibility; for instance, people of South Asian origin are particularly prone to diabetes and heart disease and those of West African origin are more likely to have high blood pressure when exposed to the typical Western diet of high salt, sugar and saturated fat. The external risk factors that favour their development are well known, as many noble Lords have pointed out, and affect many more people than the genetic causes. As has also been pointed out, these can be reduced or eliminated—in other words, these diseases are largely preventable.

Apart from the basic three risk factors I mentioned earlier—physical inactivity, faulty nutrition and smoking—other conditions that result from these factors are themselves risk factors; for example, as well described by the noble Lord, Lord McColl, obesity results from a combination of faulty diet with, to a lesser extent, lack of exercise. Obesity is a risk factor for some forms of cancer and particularly for type 2 diabetes, which often leads to cardiovascular, kidney and other diseases; high blood pressure can lead to stroke and heart disease. In the developed world, mortality rates from NCDs have come down considerably, partly through preventive measures, particularly tobacco control legislation, but also because it is now possible to palliate and control many of these conditions, though not to cure them, because of their degenerative nature. So we are left with many if not most of our older citizens, including quite a high proportion of your Lordships’ House, on some form of medication or living with a prosthetic limb or organ. This is very expensive and a major reason why the costs of the National Health Service continue to escalate.

In the past, heart attacks and stroke—or apoplexy, as it was known—were the preserve of the well fed and wealthy: but not any more—in fact the reverse is the case. The better off and better educated you are, the less likely you are to suffer from an NCD. If you do, it will hit you later in life than those at the other end of the social scale. They provide a prime example of health inequality.

This is even more the case in low and middle-income countries where diabetes and its complications are probably the most common form of NCD. There, the costs of treatment are borne mainly by sufferers themselves or their families as state health budgets are meagre. NCDs are therefore important contributors to poverty, as well as vice versa, and have a major economic impact. The reasons for the rapid escalation of these diseases in the developing world are well encapsulated in the words of Jean Claude Mbanya, the new Cameroonian president of the International Diabetes Federation. He said:

“We have moved away from our traditional cultures towards a Western lifestyle associated with prosperity. It is good, but it brings a trend to be more sedentary, not eat the right foods, not exercise enough, and to drink and smoke more”.

The political declaration agreed by the UN summit two weeks ago describes the problem with impressive thoroughness as well as the action needed in its 65 paragraphs and 36 sub-paragraphs. It correctly concentrates on prevention, emphasising the need for a comprehensive approach and, as the noble Lord, Lord Crisp, said, the need to create “equitable health-promoting environments”. It draws attention to the WHO’s framework convention on tobacco control, its global strategies on diet, on physical activity and health, and on reducing the harmful use of alcohol and its recommendations on the marketing of foods and non-alcoholic beverages to children. To my mind, its main benefit is that it flags up the importance of NCDs and puts them firmly on the international agenda. What I regret is that it does not come up with any suggested targets to stimulate action, such as the millennium development goals. That is put off to a future date. Some of the action suggested could well be taken to heart by our own Government—of course, some of it is. For instance, paragraph 43(f) includes the words:

“Research shows that food advertising to children is extensive, that a significant amount of the marketing is for foods with a high content of fat, sugar or salt and that television advertising influences children's food preferences, purchase requests and consumption patterns”.

That research was carried out in this country by Professor Gerard Hastings at the request of the Food Standards Agency.

Another paragraph suggests that Governments should:

“Promote … interventions to reduce salt, sugar and saturated fats, and eliminate industrially produced trans-fats in foods, including through discouraging the production and marketing of foods that contribute to unhealthy diet”.

Unfortunately, under pressure from industry, it does not mention how these interventions are to be made. Long experience in public health, backed by research, shows that voluntary agreements with industry or commerce to act in this way are usually ineffective. But our Secretary of State, Andrew Lansley, appears sincerely to believe that bringing industry on board through Responsibility Deals is the way to do it. This is a course of action that one delegate likened rudely to “letting Dracula advise on blood bank security”.

NHS Future Forum

Lord Rea Excerpts

Thursday 15th September 2011 Lords Chamber

[Lord Rea]

My Lords, I thank my noble friend Lady Wheeler for providing us with an overture, if you like, to our forthcoming debates on the Health and Social Care Bill and for her excellent speech. I apologise for missing part of it. There was an unexpected closure of the Jubilee line, which I am afraid is not uncommon.

Despite the listening exercise and the Future Forum report and a huge raft of government amendments for Report state in the other place—there were 700 amendments just for changing commissioning consortia into clinical commissioning groups—the Bill remains largely intact, not altering its unstated aim of opening up the NHS to a wider range of providers, including, not exclusively, the profit-making private sector.

There have been some improvements arising from the Future Forum report. I welcome the inclusion of hospital doctors, public health specialists, nurses and lay members in the clinical commissioning groups. Will the Minister confirm that they will have among their members or closely advising them an expert healthcare public health specialist, whether clinical or non-clinical? It is vital in helping them to plan.

I think there are too many loose ends in Schedule 2, which describes the membership and structure of the clinical commissioning groups. Too much has been left to regulations. Surely the composition of the groups should be stated in the Bill or in a schedule and some indication of the number of CCGs should be given. Are there going to be 100, 150 or 300? There should also be some indication of their catchment populations. As my noble friend Lady Pitkeathley has just said, it is going to be very difficult to arrange for coterminosity with CCGs being based on practice populations. Many feel that the population of 300,000 covered at present by the average PCT is too small for proper planning purposes, and some are already merging. Doubtless these issues will be covered in much more detail during the passage of the Bill.

A further change, which has been welcomed, is in the wording of the duties of Monitor. As the noble Baroness, Lady Jolly, has said, “duty to promote” competition has been converted to “prevent uncompetitive behaviour” in contracting. In practice, I think the changed wording may not be very different. Uncompetitive tendering or contracting surely means that before a contract is made with an NHS body, the independent and third sectors must be asked to make a bid. There are now a large number of British, European and American for-profit healthcare corporations ready and waiting to put in such bids. As we all know, many are already working inside the NHS. I do not think the change of wording is very meaningful. It enshrines in law what has been going on at an increasing rate since the Government of the noble Baroness, Lady Thatcher, first introduced compulsory tendering in the mid-1980s.

Private corporations have an advantage over third sector or in-house NHS bids because the complexity of public contract regulation and case law is now quite formidable and developing further. There are quite draconian remedies and penalties for breach of regulations. There is a real risk that there will be a deficit of suitable expertise within each commissioning group. They will probably have to bring this expertise in from outside, although I understand there are words in the Bill that seek to prevent this. Perhaps the Minister will comment on that. Like clinical commissioning groups, third sector or NHS bodies are also unlikely to have enough in-house expertise in procurement law and may not have the resources to bring it in from outside. Commercial organisations, on the other hand, need to have recourse to it in their everyday work in order to survive in the commercial world and large firms will have considerable in-house expertise. This gives them an advantage in making attractive proposals that are compliant with regulation, and of course they may also be loss leaders—the more likely the larger the firm.

I do not have time to go through every change following the Future Forum’s report. Nick Clegg, for the Lib Dems, has said that 13 of their 15 requirements for the Future Forum have been secured. Closer scrutiny of these shows his assessment to be somewhat overoptimistic. One example concerns cherry picking by private providers. The Liberal Democrats had a requirement that new private providers should be allowed,

“only where there is no risk of cherry picking, which would destabilise or undermine the existing NHS service relied upon for emergencies and complex cases, and where the needs of equity, research and training are met”.

In fact, private providers will be able to cherry pick by choosing to take on classes of patients with fewer complications, and will remove these patients from NHS hospitals which will thus lose the tariff payment that they would otherwise get. Unfortunately, there is no time to go through the other 12 Lib Dem requirements. Suffice to say that I am happy to supply any noble Lord with a list of these.

In conclusion, this has been a useful preliminary canter for our forthcoming debates. I hope that we will get further suggestions from the Future Forum regarding what has been discussed by a number of noble Lords; that is, research and training opportunities, and regulations and changes which will solidify the role of the Government in promoting these activities.

NHS: Reorganisation

Lord Rea Excerpts

Thursday 16th December 2010 Lords Chamber

[Lord Rea]

My Lords, in thanking my noble friend Lord Touhig for initiating this debate, I apologise to him for missing the first part of his speech because the business moved a little faster than I had been led to believe. In my allotted time I shall talk about the new arrangements for commissioning patient care that are proposed in the White Paper. To illustrate the current situation, let us suppose that Andrew Lansley, the Secretary of State, is a fruit farmer, with PCTs as the trees producing the fruit, which are patient services. The Health Select Committee report on commissioning published in March this year found that some of the trees—the PCTs—were not in good health, with which the incoming Government agreed. Some of the trees were yielding well, but others were in bad shape. They were in need of heavy pruning as they contained a lot of dead wood. However, the Select Committee did not recommend cutting all the trees down. Properly pruned and treated with fertiliser, which can be equated with clinical input, and insecticide, which can be equated with statisticians and healthcare public health specialists—about which I shall say a bit more later—it was felt that the trees would recover and yield adequately.

However, it seems that Farmer Lansley is determined to cut all the trees down and plant new ones of an untested variety that he, an amateur plant breeder, has developed. He thinks they might be of superior taste without seeing first whether they would thrive on his land. Admittedly, he is now nurturing a rapidly growing form of the new variety called “pathfinder”, but this is being grown in special conditions under glass and there is no guarantee that it will grow successfully on a large scale in the open. A new problem has recently arisen; the main PCT orchard has developed a fungal disease popularly known as planning blight, so that yields may well be less for the next few years. This is an especially unpleasant condition in that healthy and productive branches—the most skilled and experienced managers—are starting to drop off and disappear elsewhere. That is because these managers are easily able to find new employment.

By deciding to grub up and remove the current orchard, Mr Lansley has involved himself in considerable expense—much more expense than pruning and treating the existing trees would have incurred. This is before the new variety has even been market-tested and at a time when loans to cover the interim period are very hard to come by.

To leave the analogy for a moment, I mentioned earlier the healthcare public health specialists. These are doctors or other healthcare practitioners who receive special training in assessing the healthcare needs of whole populations and how they can best be met using evidence-based interventions. These are the very skills that are required by commissioning organisations, whether they be PCTs or consortia. Although I am a former GP I believe, like the BMA, that the clinical membership of new commissioning bodies should include representatives of all the healthcare professions, not only GPs. They should perhaps more properly be called clinical consortia. However, I take the point made by the noble Baroness, Lady Williams, that due attention should be paid to the representation of patients and the community on commissioning boards.

One of the criticisms of PCTs made by the Select Committee at paragraph 194 is that:

“PCTs employ large numbers of staff, but too many are not of the required calibre”—

the dead wood, perhaps.

“PCTs need to become better at collecting data, for example of the needs of their population, and at analysing it. In particular, it is essential to exploit existing and developing data sources to provide comparative performance information in terms of cost, activity and outcomes”.

These are exactly the skills provided by healthcare public health specialists, but they are in scarce supply. There are perhaps enough of them to staff the current PCTs, and if they are established in roughly the same numbers, they might be able to cover the new consortia, but their skills will also be needed at the local level to act as directors of public health or as their advisers. Therefore, very careful thought needs to be given to where they are appointed and the powers given to them. Perhaps they should have an executive rather than merely an advisory role, so central to policy are their assessments of the healthcare needs of the population that is to be covered.

There is a lot more about this White Paper that I would like to say, but that will have to wait. I would like just to recommend that the noble Earl passes on to his right honourable friend the Secretary of State two documents, both of which are serious contributions to the current debate. They are Public Health Support for GP Commissioning, which is published by the British Medical Association, and the parliamentary briefing sent to all of us by the King’s Fund in preparation for this debate. It is very sound in its assessment of the situation and in its considered advice to the Government.

Medical Profession (Responsible Officers) Regulations 2010

Lord Rea Excerpts

Tuesday 23rd November 2010 Lords Chamber

[Lord Alderdice]

My Lords, it is always difficult when new Governments come into place and want to make important and sometimes radical changes to structures and arrangements while, at the same time, valuing some of the work that had been begun but not completed by a previous Government. As other noble Lords have said, the previous Government, and perhaps even an earlier one, moved towards revalidating doctors. This is a very complicated and difficult issue, but the Government moved in that direction; timetables were set but became a little delayed. However, if the Secretary of State in this new Government were to take the advice that has been proffered—that until PCTs and strategic health authorities are set aside and the new arrangements are in place we should not move to the appointment of responsible officers—we would be looking at 2014 or 2015, or after the next general election, before we could move forward. It is understandable that people should quite reasonably say that there is a dilemma here, but we must try to keep up the momentum, which is the point that the GMC has made.

It is perfectly correct that a number of matters are not yet clear and resolved. Some affect me, and I shall advert to them in a moment. The proposals for the reform of the NHS have not worked through the process—they have been announced but are not yet through Parliament—and it is not only possible but almost certain that there will be significant changes and developments. I hope my noble friend will be able to clarify some of the issues, but it would be expecting rather a lot for him not only to clarify how matters stand at the moment but to predict how they might stand further down the line when some things may have changed.

In the present situation, in most cases but not all, appraisal processes are already going on. Up until earlier this year, every year I produced a huge lever arch file containing details of all the things that I had been through. So the process is already in place and it is the responsibility of medical directors in trusts to make sure that it is in place. However, they cannot possibly carry it through themselves because so many need to be appraised. They therefore have to devolve the responsibility for the detail and the face-to-face work to someone else. Exactly the same thing will happen to the responsible officer.

Are there potential conflicts of interests? There already are because those who are responsible for the appraisals are also responsible for clinical merit awards of various kinds, for the recognition of a person’s work and for the creation or demolition of their clinics. All these conflicts are already there. That is not to set them aside and say they are unimportant—they are very important and very difficult—but we are facing something that is not in itself radically new but a problem with which we have been struggling for quite some time. Further orders may well come subsequent to this that will help to take the matter forward, but that does not mean that we should delay the current regulations.

Let me put to my noble friend a dilemma of my own on which he may or may not be able to help. What will happen to those who do not necessarily operate all the time only in the NHS in England, Scotland and Wales? I note that Northern Ireland is not included in this and, of course, the movement backward and forward between this part of the world and the Republic of Ireland is substantial. What happens if a doctor qualifies and works here for a while, then goes to work for three or four years in the Republic of Ireland and then comes back to work in the United Kingdom but the process of validation has not operated in quite the same way? Of course, we have free movement not only in these islands but throughout the European Union. What happens to those who have operated outside the UK? These are real dilemmas that have to be dealt with.

We have often heard it said that it is better to start, pilot and work your way through than to produce something that has not been tested out but is a fiat—a fait accompli. My noble colleagues on the Cross-Benches have expressed reasonable concerns and a determination to keep up the momentum for revalidation. In supporting these regulations, that is also very much my mindset, and I hope to see further developments over the next year or two.

[Lord Rea]

My Lords, I simply report that the two professional organisations to which I belong, the Royal College of General Practitioners and the BMA, basically support the regulations. That is in spite of some doubts about the timing and some of the other points that noble Lords have raised today. It is good that responsible officers will be appointed before the detailed work of setting up the revalidation process is completed. They will play an important formative role before later acting as scrutineers or umpires—I hope not inquisitors—in the revalidation process. I shall be interested to hear the Minister’s response to the cogent questions that my noble friend and almost all other noble Lords have raised.

NHS: Prebiotics

Lord Rea Excerpts

Wednesday 17th November 2010 Lords Chamber

[Lord Walpole]

My Lords—

[Lord Rea]

My Lords, could not a strong case be made for the Department of Health to commission a suitably designed pilot study of prebiotics to see whether they are beneficial in the prevention of Clostridium difficile and other conditions?

[Earl Howe]

My Lords, as I have said, we will continue to look at the matter with interest. Of course the department has a very sizeable clinical research budget, which is open to all bids of a high quality. There is no reason why a bid should not be made on this issue as well.

Healthcare

Lord Rea Excerpts

Thursday 28th October 2010 Lords Chamber

[Lord Rea]

My Lords, I will use my four-minute slot to talk about the role of health professionals—one of the aspects mentioned in the noble Lord’s Motion. I am a former cog in the NHS machine, so I have some knowledge of working there. When my noble friend Lord Darzi spoke of increasing the involvement of clinicians in NHS decision-making about three years ago, he was thinking of drawing on their experience of the realities of front-line medicine and surgery. Now what is proposed is the greater involvement, especially of GPs, in the complex process of commissioning care. This requires many skills which are outside the training and interest of the majority of practising doctors. It is true that many PCTs are not up to speed and we have heard that some of them are remote.

The final report of the Health Committee of the previous Government said that PCTs,

“employ large numbers of staff, but”,

too many are not of the required calibre. It went on to say that PCTs need to become, “better at collecting data”—for example, on the needs of their population—and at analysing them. That is not a very flattering remark, but are these weaknesses enough to justify closing down all PCTs and replacing them with GP-led consortia, with all the upheaval and chaos—not to mention expense—which is caused by such a major reorganisation? I think not, because the skills in which the Select Committee found PCTs to be weak are not skills possessed by the average practising GP, whose training lies in assessing and treating the health problems of individual patients and families.

Of course, some have developed a wider outlook and are interested in public health and preventive medicine, and some have considerable entrepreneurial skills, as the department knows well, but these are a minority. The expertise needed properly to commission healthcare for a given area includes an ability to assess the health needs of whole populations, not simply those on GP practice lists, as well as managerial and planning skills—the very skills which the Select Committee found wanting in many PCTs. GP consortia are likely to have the same or greater shortcomings, even if they re-employ all the most expert staff now working for PCTs because of the disruption of working relationships which will follow the abolition of the PCTs. Also, staff with these skills are those whom the newly empowered directors of public health—which, with provisos, I greatly welcome—working with local authorities, will require to assist them in their enhanced new role in local government, so there will be competition for staff with the appropriate training and expertise.

As the noble Lord, Lord Hunt, said, independent consultants and healthcare firms are waiting to step in to fill the breach—at a price, of course. Sometimes one wonders whether this was the main purpose of the whole exercise. Perhaps it is too much to hope that the Government might think again considering the very hostile reception that this proposal has received from nearly all health professionals and health think tanks, including the King’s Fund. In the final seconds of my speech, may I ask the noble Earl whether he can assure us that the newly empowered directors of public health, who will be working with local councils, will be fully funded, that this funding will be protected and that they will also have a statutory role in their work with local government?

Food: Regulation and Guidance

Lord Rea Excerpts

Thursday 7th October 2010 Lords Chamber

[Lord Rea]

My Lords, I thank the noble Earl for giving us a little light relief in a debate on rather a serious topic. I especially thank my noble friend Lord Whitty for bringing this subject to our attention. Faulty nutrition today is of huge importance for public health. As almost every other noble Lord has said, it plays an important part in causing obesity, type 2 diabetes, arterial disease and high blood pressure, which lead to coronary heart disease and stroke, as well as some cancers.

Today it is mainly overnutrition with the wrong nutrients, rather than undernutrition, which is the main problem. However, too many elderly people are undernourished when they are admitted to hospital and sadly still are when they are discharged. Evidence is also emerging of the importance of nutrition for mental health and behaviour, particularly in corrective institutions. I declare an interest as chairman of the All-Party Food and Health Forum, a trustee of the National Heart Forum and a former trustee of the Caroline Walker Trust, a charity that aims to improve “public health through good food”.

The history of public health in the UK since Edwin Chadwick’s monumental report on The Sanitary Conditions of the Labouring Classes in England in 1842 has been one of regulating or restricting activities or products that are harmful to health, and setting up local and national bodies to ensure that necessary measures are taken to achieve those aims. We benefit to this day from some of the subsequent results of the Public Health Act 1848, including London's water supply and sewerage system. That is only now being replaced, so well was it built by Joseph Bazalgette. His project was hastened by the “great stink” of 1858, when Parliament had to cease its activities until the weather changed and it was washed away.

These early measures, such as sewerage and clean water, were driven by the need to control illness caused by pathogenic bacteria, although to begin with it was not known that they were the cause of such illnesses. It has been so successful that now infection, while still with us, has been supplanted in importance by chronic diseases, mainly affecting adults in the second half of life. However, it has been shown that these conditions, like mental health problems, often have their origins in early childhood. Poor nutrition in infancy, and even pregnancy, can plant the seeds of chronic disease later in life. That was fully discussed earlier by my noble friend Lady Finlay.

Improving public health may mean restricting the freedom of individuals and commercial enterprises; Chadwick’s Public Health Act 1848 had many enemies. If these restrictive measures result in loss of livelihood or lower profits, they will naturally meet with resistance, and they do. After all, we live today, as in 1848, in a competitive, capitalist world dependent on profit whether we like it or not. This resistance may take the form of denial of the deleterious effects of the product or activity concerned. Considerable resources may be put into efforts to discredit the evidence and disprove the need for public health measures. The long-running rearguard action of the tobacco industry is one of them. It is still running in resisting the banning of tobacco displays in shops and the banning of vending machines. Another example was the initial reluctance of the food industry to accept that high salt intake was a cause of hypertension.

As many noble Lords have pointed out, it is unlikely that voluntary guidelines will be followed if they have an impact on profits. There must be legislation, or the serious prospect of it—the sticks—or, on the other hand, incentives—the carrots—to encourage or enforce compliance. This does not apply only to the private sector. A rather sad example of this, recently described by Sustain, is the series of programmes, taskforces, plans and packages which have exhorted hospital trusts to improve the quality of the food given to patients over the past decade. There is no evidence that they have had any lasting effect, despite costing at least £54 million. The quality of hospital food is still poor in many hospitals, as we know, particularly also in care homes. The proportion of malnourished elderly patients admitted to hospital is still high and has not changed much in the past decade. Department of Health figures reveal that in the past decade 2,600 patients died in hospital in the UK directly as a result of malnutrition. More important were the many others whose poor nutritional state may have contributed to deaths from other causes. The exact size and impact of the problem is not known and urgently needs research. I hope that the noble Earl will urge that to be done. The Conservative Party said that malnutrition in hospital needed to be tackled when it was in opposition. I hope that it will now look into this matter and do something about it. Hospital food could be immediately improved if standards were made mandatory rather than relying on well-meaning but rather ineffective guidelines.

A major difficulty in improving eating patterns today is the high proportion of our diet that consists of processed food, as other noble Lords have pointed out. It is impossible to tell by appearance or taste alone how much salt, sugar, saturated fat, trans fat, preservatives, artificial colouring or flavouring is incorporated in many popular brands; hence the need for a clear, easily understood system of food labelling, which was also discussed by many other noble Lords. The Food Standards Agency’s research found that the simple traffic light system was the most popular among consumers, and some retailers have adopted it—about half of supermarkets—but it is not popular with the food industry since a red light label indicates that a product should be consumed sparingly. The industry’s preferred labelling system, using the RDA or recommended daily amount, is more confusing and shoppers find it difficult to understand. Some retailers use a combination of both. The labelling system in use is voluntary and therefore inconsistent. Progress is slow as we have had to conform to EU guidelines, as has been said. However, there are ways around EU regulations by citing particular public health problems. The Government could explore how that provision could be used more fully.

Many manufacturers market healthy versions of their products, thus indicating their social and ethical responsibility. They may hope to attract a greater market share. These healthier options, such as low saturated fat, low trans fat, low sugar or low salt products, may indicate the direction that ideally the rest of their products, and those of other manufacturers, should follow. The food industry would then become part of the solution, not part of the problem. However, progressively increasing the market share of these good foods is likely to be very slow or incomplete unless the healthy ranges cost less than the standard range. Unfortunately, the reverse is usually the case. The National Consumer Council, before it changed its name, reported in 2006 that many economy-range foods contained more salt, fat and sugar even than the standard products. Thus the poorer sections of the population, the people on tight budgets who most need an improved diet, will continue to buy this energy-dense, less nutritious, obesogenic—I like that word—food, thus perpetuating the increasing health divide in obesity, heart disease and cancer.

If statutory regulations were to ensure that all manufacturers sold food products that conformed to an optimum standard, this problem would be solved. In fact, several manufacturers and at least one major catering firm, Compass, have said that they would welcome legislation of this sort. It would not end competition, but all products would have to conform to the nationally agreed standards. These standards should be set by the Food Standards Agency—of which more later—which should act on the expert advice of the Scientific Advisory Committee on Nutrition.

This brings me to an important question for the noble Earl. In the bonfire of the quangos that was trailed in the Daily Telegraph two weeks ago, SACN was included among the 170-odd bodies to be abolished—as was the School Food Trust and a number of other health-related organisations. If these are to be abolished, what is to take their place? The Government will always need expert advice, particularly now that we have major nutrition-related health problems. I hope that the noble Earl will assure us that these useful—I would say vital—watchdogs will be retained. If not, I hope that he will explain what is to take their place.

A crucial feature of scientific advisory committees is their independence from government and from industry. How is this to be retained? Perhaps the noble Earl will bring us up to date on the future of the Food Standards Agency. Which of its functions will be retained by the part of it that remains and which will be merged with existing departments? The current information is that its nutrition division is to go to the Department of Health and its food safety responsibilities to Defra. If so, this would be a backward step indeed, since the FSA was created in part to take this responsibility away from Defra following its mishandling of the BSE epidemic. What will happen to the much admired independence and transparency of the FSA?

I think that noble Lords will see where I am coming from. If we wish to see an improvement in the nation's health, more use must be made of statutory regulation of food manufacturing, advertising and marketing. This is another area that I would like to cover, but I have not got time. The noble Lord, Lord Whitty, spoke about advertising, as did other noble Lords. I think that regulation will be effective, even sometimes without being enacted, if the industry feels that there is an imminent possibility of its introduction. That may set the ball rolling, as we have seen in the case of salt reduction. However, here, as other noble Lords have said, there is still a long way to go.

In conclusion, I think that the Government would be wise to follow more closely the independent scientific advice which is available on the action that needs to be taken to improve our diet and thus reduce the burden of chronic illness.

Health: Diet

Lord Rea Excerpts

Tuesday 13th July 2010 Lords Chamber

[Earl Howe]

My Lords, I do not know whether the noble Baroness saw my right honourable friend on television recently talking about this issue, but this is a good opportunity for me to put the record straight. He has not criticised Jamie Oliver’s work on school meals: on the contrary, he has applauded Mr Oliver and the many people who have worked very hard to improve the standard of school meals. The point that he made was that a very important initiative started by Jamie Oliver to make people more aware of what healthy eating is all about turned into a kind of prescriptive, top-down management process from Whitehall—and that is counterproductive.

[Lord Rea]

My Lords, how will the Government ensure that the principles of openness, independence and scientific accuracy in their pronouncements and advice, developed by the noble Lord, Lord Krebs, when he was the chair of the FSA, will be continued by whatever successor bodies are appointed to carry on the tasks of the FSA?

[Earl Howe]

My Lords, the noble Lord is assuming that the Food Standards Agency is going to disappear. I have seen those reports but do not recognise the stories at all. As I have told the noble Lord, Lord Krebs, and others, no decisions have been taken about the future of various functions within the Food Standards Agency, but we are clear that there has to be a role for a body setting standards objectively in the way that he has described.

Health: Primary and Community Care

Lord Rea Excerpts

Thursday 24th June 2010 Lords Chamber

[Lord Rea]

My Lords, I thank the noble Lord, Lord Mawson, very much for raising this important topic, and particularly for his inspiring description of his Bromley by Bow project. It reminds me of the Peckham health centre from pre-war days, which was a concept ahead of its time. It is now, sadly, closed. There is much we can learn from the noble Lord’s project and his words this afternoon.

The noble Lord has worded his Motion constructively, concentrating on recent changes and the lessons to be learnt; basically, what has worked; what has not worked; and what might work better. If we were to start with a blank sheet, we would need first to look at the kind of health and social problems which the population presents—of course, the two are inseparable—both nationally and locally and then try to fit services best to tackle these problems. However, we have to build on what we have. As the noble Lord has described, this is far from ideal, but I am an optimist and I think that it is getting better. It is already a lot better than in many other countries.

Of course, we have an age pyramid typical of a western developed economy, getting top heavy with older people such as myself—there are more and more of them—and they are living longer and, sadly, becoming increasingly disabled, needing more care. Other than this demographic problem, the other main public health problem, which we share with the rest of the world, is the difference in health status between the best off and the worst: health inequality, in other words. This gradient applies throughout the social spectrum from top to bottom. We need to improve the health not only of the poorest but also of the middle of the range who have worse health than those on the next rung of the ladder and so on, as Professor Michael Marmot has recently re-emphasised. To restrict services such as Sure Start to the really poor and deprived does not tackle the relative health problems that exist, for example, between skilled and non-skilled manual and non-manual workers. There is work to be done right across the board.

Ideally there should be a gradation of health and social service funding taking into account the age and social structure of each community. To be fair, there has for many years been a serious attempt to do this, but the inverse care law still persists and it needs an even greater share of resources than we have so far allocated to it to reverse it. This might be politically difficult since if this was done on a tight budget, as now, and was in some years past, relatively well-off communities might have to accept a reduced budget. These communities know how to fight their corner, so it is a difficult situation. The health problems of ageing and inequality are deep-seated and have their root causes in the nutritional, physical and social environment of early childhood, which is largely outside the scope of the community health and social services. Even so, it is these services that have to cope with the lasting legacy: the social problems of young adults, including drink, drugs and crime and the chronic ill health of older adults.

Though those with chronic degenerative illness often need periodic admission to hospital, most of their care is appropriately and better done in the community. In a minority of cases “hospital at home”, including procedures such as intravenous drips, is sometimes possible, avoiding admission or enabling early discharge rather than treatment as an as an in-patient. However, the Royal College of Nursing is concerned that the development of specialist home nursing teams such as advanced nurse practitioners, community matrons, specialist nurses, and consultant nurses concerned with managing serious illness at home is having a knock-on effect in reducing the recruitment of community nurses and health visitors, who are still vital in overall community care, particularly for the disabled elderly at home, and in providing mother and child care and preventive services. The transfer of much hospital care to primary and social care at home has long been part of government policy but is not always cheaper. Patients may be discharged too early and need re-admission—a process perhaps encouraged by the payment by results scheme, which can result in a hospital being paid twice, once for each admission.

For many years, GPs have increasingly come to accept that they need to work in teams—not all, I agree, but the trend is there—including other health and social workers to give a really effective service. There are still a few Dr Finlays out there who prefer to work on their own. They are very different from my noble and professional friend on the Cross Benches. The primary care team is now the norm and is encouraged by the National Health Service. As the noble Lord said, my noble friend Lord Darzi proposed a network of polyclinics in which there were more services and links with hospitals than in most group practices, but this proved to be a bridge too far for many GPs and their professional organisations. However, the concept has become more acceptable, provided that the centres are GP-led and tailored to local needs and development. Many GPs are concerned, however, that the polyclinic concept will lead to primary care groups being taken over by private profit-making healthcare companies. This has occurred already in some PCT areas. The one that I know is in Camden PCT, where the contract for practice was awarded to United Health in preference to a local GP group which was offering a better and fuller service, but at a slightly higher price. The results have not, as far as I am aware, been fully evaluated, but the local feedback is unfavourable.

The new contract for general practitioners brought about major changes, as well as a rather generous package for most GPs. The BMA had a sharp negotiating team and the Government needed the GPs to be on board. The biggest change was to remove the obligation to provide 24/7 out-of-hours clinical cover for registered patients. PCTs had to take on this responsibility. They have not found it easy and have often farmed the work out to private companies. Patients are not always happy to be seen by a strange, often foreign, doctor who does not know the area; and of course there has been the occasional tragedy, as we all know. This is a far cry from the days when I was a general practitioner, when we were responsible for after-hours care. Our group made it tolerable by collaborating in a consortium or rota, with other local GPs. In fact, the BMA negotiating team was prepared to continue with the responsibility, if the money had been right. In the end, however, the cost to the PCTs of providing the service was much higher than estimated; in fact, according to my information, it was greater than the amount that the BMA had originally asked for.

The other important part of the new contract was the QOF—the rather grandly named “quality and outcomes framework”—whereby GPs receive a payment for each procedure in a list of measures which assist in monitoring, and thus improving, the health of their patients. They include weighing, taking blood pressure, keeping disease registers and so on. I and some of our colleagues were sad that GPs had to be paid for measures which many of us regarded as part and parcel of good practice, and should have been part of any contract. However, it is clear that this carrot has increased the capacity of general practice to anticipate serious illness. The standard of practice has improved and some lives may well have been saved through, for instance, control of blood pressure and weight reduction. However, I am sceptical about the accuracy of some of the numerical extrapolations that have been made about lives saved. It would be good to know whether, without the financial incentive, this exercise will result in permanently better practice by GPs.

An alternative or addition to the polyclinic model has been suggested by the Royal College of General Practitioners. It proposes primary care federations, which are associations of primary and community care teams, as a legally binding enterprise. I am sure that that concept is not unfamiliar to the noble Lord, Lord Mawson. The college cites three examples: the Croydon Federation, consisting of 16 practices; Lincolnshire General Practices, which has14 practices; and Epsom Downs Integrated Care Services, where 20 practices are collaborating. These hold considerable promise, but I should like to see more involvement of social services and mental health teams, as well as appropriate parts of the voluntary sector. This is very much in line with the proposals of the noble Lord, Lord Mawson. As it is, these projects provide better-integrated primary and community care as well as more emphasis and better facilities for preventive medicine and health education. They could also help to form, through their PCT, a nucleus for practice-based commissioning, which so far has had little impact on services provided by hospital trusts.

Local collaborations such as this, which very much fit the ideas of the noble Lord, Lord Mawson, including voices from all the caring professions, are more likely than top-down decisions to provide or commission good services for their communities.

Health: Government Spending

Lord Rea Excerpts

Monday 14th June 2010 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Countess, particularly given her wealth of knowledge and experience in this area, for putting forward that suggestion, which I shall certainly take back with me.

[Lord Rea]

My Lords, if the Food Standards Agency is to be wound down, which would be regrettable since it would mean the loss of an important, independent voice, will its science-based public health work on nutrition continue to be funded at least at the present level, if not augmented, which it needs to be?

[Earl Howe]

My Lords, the Government fully recognise the important role that the Food Standards Agency plays in food standards, nutrition and food safety. Public health is a priority, and I reassure the noble Lord that the function that the FSA currently fulfils—to advise the Government and the public on nutrition—is one that we believe is equally important.