Health: Medical Innovation

Lord Rennard Excerpts

Wednesday 16th January 2013 Lords Chamber

[Lord Rennard]

My Lords, I first declare my interest through the work that I do with the British Healthcare Trades Association, as in the register. However, the issue that I was asked to raise in this debate is specifically about the provision of insulin pumps.

I am one of the 2.9 million people in this country already diagnosed with diabetes. As a type 2 diabetic, I was first told that my treatment would only be in the form of tablets, but in common with many people who are diagnosed at a relatively early age with what they used to call “mature onset diabetes”, I found that after 10 years or so I also needed insulin injections every day. Now, as our understanding of dealing with diabetes grows, I am advised by my excellent diabetes specialist nurse that I may well need an insulin pump in another 10 years or so in order to be able to maintain good control of my condition.

The prevalence of diabetes is growing, and the period of time over which people need treatment is growing substantially. I am, therefore, concerned that many people with diabetes, who might benefit considerably from the provision of insulin pumps, do not currently find them available on the NHS. A survey not very long ago showed that the average rate of insulin pump provision for people with type 1 diabetes in this country was 3.7%, compared with the then 12% benchmark recommended by NICE and in comparison with other countries, such as the USA, where such provision is estimated at 35%, and Sweden, France and Germany, where it is estimated at 15-20%.

Good diabetes management is, of course, crucial to reducing diabetes-related complications, such as hypoglycaemic episodes and potentially fatal conditions such as heart disease and strokes. Greater use of technologies such as insulin pump therapy can deliver much better outcomes for patients. It can also help to reduce cost savings for the NHS by improving diabetes control, reducing primary care contacts, and reducing hospital admissions and hospital outpatient contacts.

However, the provision of insulin pumps is very patchy and inconsistent. Many healthcare professionals are not trained in supporting patients on insulin pump therapy and, as a consequence, are reluctant to recommend it as a treatment option. The position seems much better in Scotland. The Scottish Government announced in February 2012 that they would invest over £1 million to deliver insulin pumps to patients with diabetes. Over the next three years, their NHS boards will increase the number of insulin pumps available to under-18s, in addition to tripling the number of pumps available across Scotland.

Patients must of course be given accurate information about self-managing their condition, which should include advice on insulin pumps as a treatment option. It is imperative that healthcare professionals are trained in supporting patients to use insulin pump therapy.

NHS: Diabetic Services

Lord Rennard Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Rennard]

The 3 million people living with diabetes in the UK will share my gratitude to the noble Lord, Lord Harrison, for securing this important debate today. So, in particular, should the 850,000 people in this country who have the condition but are unaware of it, and the 7 million people he referred to who are at high risk of developing type 2 diabetes.

I wish, first, to declare an interest as the director of communications of the British Healthcare Trade Association, but my personal interest in diabetes is longstanding. My father was an insulin-dependent diabetic. It was possibly the shock of losing a leg when wounded in the First World War that brought on his diabetic condition. He was, therefore, one of the first people in the world to benefit from insulin, as far back as the 1920s. Without it, obviously, I would not be here today. My father went on to live a relatively long life. Indeed, he was 71 when I was born and 73 when he died.

I was myself diagnosed with type 2 diabetes at the relatively early age for this condition of 34, some 18 years ago, and I have been dependent on insulin for the past seven years. I am personally grateful to the staff at St Thomas’s hospital, just across the river from here, for their help and support in managing this condition, especially when I let it get significantly out of control for a long period several years ago. I had to work hard and change things in my life to achieve better control. However, the issues surrounding diabetes are of great concern not just to those who may be directly affected or those closest to them but to everyone because of the growing scale of the problem, its consequences and the costs of trying to deal with it.

The number of people with diabetes in this country is expected to increase by 23% to 3.8 million by 2020. This will have a huge impact on NHS resources unless the efficiency and effectiveness of existing services are improved. We all know about the commitment to £20 billion of efficiency savings under the Nicholson challenge. The biggest challenge in diabetes will be how to commission cost-effective care while at the same time improving the quality of services and delivering excellent outcomes for patients. To do this, we need to recognise the growing scale of the challenge. Since 1996 the number of people living with diabetes has increased from 1.4 million to 2.9 million. We need to look at the weaknesses in the system at present. In England, almost half of the people with type 2 diabetes—47 per cent of them—are missing out on the nine basic health checks recommended by NICE, such as foot care and retinopathy screening.

Fewer than one in five people with diabetes are achieving the recommended standards for controlling blood glucose, blood pressure and cholesterol levels. We have to recognise that variations in the quality of care for diabetes patients cannot be explained by need or spending alone, and are influenced by the way in which local health services are organised and managed. We have to look at the human cost of diabetes and the adverse effects of the disease. The mismanagement of diabetes can lead to heart disease, stroke, blindness, kidney disease and amputations that in many cases could have been prevented. More than 100 amputations take place in England every week due to diabetes, while 4,200 people in England are blind due to diabetic complications, and this figure increases by 1,280 each year. There are 24,000 people with diabetes in England who die each year from causes that could have been avoided through better management of their condition.

It is estimated that already almost 10% of the NHS budget is spent on diabetes, around £10 billion a year. When we factor in the loss of working days, early death and informal care costs, the cost of the condition to the NHS will rise to almost £40 billion by 2035. When we look at the current situation for diabetes patients, we learn from the Public Accounts Committee that NHS accountability structures have failed to hold commissioners of diabetic services to account for poor performance as they have no mandatory performance targets like those in place for other conditions such as cancer.

The committee also found that information on diabetes is not being used effectively by the NHS to assess the quality of care and to seek to improve it, and that many people with diabetes develop avoidable complications because they are not effectively supported to manage their condition.

So, what must be done? Inequalities exist in the quality of diabetes care across the country and they need to be addressed if we are to develop better outcomes for patients and improve efficiencies in the NHS. The National Institute for Health and Clinical Excellence quality standard for diabetes should act as a benchmark to improve the quality of diabetes care.

The National Audit Office report on the management of diabetes in the NHS called for a review of the current system of incentives, so that GPs are paid for diabetes care only if they ensure that all nine care processes are delivered to people with the condition. Other recommendations call for greater collaboration and co-ordination between the new organisations and levers of the reformed NHS, such as the NHS Commissioning Board and Public Health England.

I know that NHS Diabetes is developing an implementation guide for treating diabetes patients in the NHS, which, in contrast to the diabetes action plan, will examine how diabetes care is commissioned and its implications for patients. We need to ensure that it addresses the health and economic impact of diabetes-related complications. In particular, I hope that the implementation guide will address how to reduce the variations that exist in diabetes care and the outcomes across the country.

Raising awareness of the causes, symptoms and consequences of diabetes is also crucial for increasing understanding about the disease and improving outcomes. I know from my own experience that diabetes specialist nurses play an essential role in helping patients to manage their condition and are a key source of information and advice for patients. Their posts should be protected during the current transition and all patients should have access to a named diabetes specialist nurse during their treatment.

I hope that the Government will make a commitment to the delivery of a national approach to addressing diabetes from 2013, set out by clear milestones and procedures for delivery, and using the recommendations of the National Audit Office as a guideline. The development of integrated care pathways should be encouraged as a means of reducing the postcode lottery of care for diabetes patients and reducing adverse outcomes of the disease, including mortality. Local health and well-being boards should scrutinise local commissioning plans to ensure that the delivery of diabetes services is joined up across public health, the NHS and social care. Finally, local commissioners should implement the NICE quality standard for diabetes and, where commissioners are not complying with the standard, they must be made to set out their reasons in their commissioning plans.

Tobacco: Control

Lord Rennard Excerpts

Tuesday 19th June 2012 Lords Chamber

[Earl Howe]

My Lords, across government we recognise the need for Ministers or officials from other government departments to meet the tobacco industry within the parameters set under the framework convention. There may be legitimate operational reasons why such meetings might be necessary—for example, Her Majesty’s Revenue and Customs sometimes meets the tobacco industry to discuss measures to reduce the illicit trade in tobacco. So it is not as if all government departments have closed their doors, but there is a very specific issue to do with Health Ministers and health officials.

[Lord Rennard]

My Lords, I declare my interest as an unpaid director of Action on Smoking and Health. Does the Minister recognise that any dealings he has with the tobacco industry will be with an industry that is responsible for the deaths of around 300 of its own consumers every day in this country alone, and that any claims that that industry makes must be treated with very great scepticism given its knowledge over many years of the connection between smoking and lung cancer and the addictive properties of nicotine—facts which it well knew but denied for many decades?

[Earl Howe]

My Lords, my noble friend makes some very powerful points and he is right. Smoking is the biggest preventable cause of death in England. It causes more than 80,000 premature deaths every year. Tobacco use is a significant cause of health inequalities in the UK. One in two long-term smokers will die as a result of smoking. That demands that we take this issue very seriously indeed.

Health: Diabetes

Lord Rennard Excerpts

Wednesday 1st February 2012 Lords Chamber

[Earl Howe]

My Lords, much will depend on the way in which primary care engages with those in social care to ensure that the residents of care homes, who need diabetes care management, receive it properly. We very much want to see that joined-up commissioning arise from the reforms that we are currently in the process of debating in your Lordships' House. The noble Lord makes a very good point. We have many tools at our disposal. There is no shortage of guidelines in this area. Much will depend on the training of care home staff and a lot of work is going on under the aegis of the National Clinical Director for Diabetes in this area.

[Lord Rennard]

My Lords, does the Minister agree with the 15 checks or services promoted by Diabetes UK that every person with diabetes should receive or have access to? In particular, does he agree that they should have access to high-quality, structured education, firmly embedded in the NHS, based on a programme such as that for type 1 diabetics, promoting dose adjustment for normal eating?

[Earl Howe]

My Lords, the answer to my noble friend is yes. Those checks and services are firmly supported by NICE, by the National Service Framework and by the NICE quality standard. I also agree with him that structured education is fundamental if we are to ensure that patients can self-manage. A number of tools are available for that. He mentioned one for type 1 diabetics that has the acronym DAFNE—dose adjustment for normal eating—and for type 2 diabetics there is DESMOND—diabetes education and self-management for ongoing and newly diagnosed.

Health: Diabetes

Lord Rennard Excerpts

Tuesday 1st November 2011 Lords Chamber

[Earl Howe]

I agree fully with the noble Baroness that sugar and the sugars contained in alcohol are a major feature in the obesity problem and in the incidence of type 2 diabetes.

[Lord Rennard]

My Lords, will the Minister undertake to look at the report published today by the Primary Care Diabetes Society on keeping people with diabetes out of hospital? Will he agree to look in particular at evidence suggesting that greater provision of insulin pumps or more use of bariatric surgery may be very cost effective to the NHS and, in the wider economic sense, a significant saving to the public purse rather than an expense?

[Earl Howe]

I shall certainly do so. In relation to insulin pumps, we know that more has to be done to increase the uptake, in line with NICE recommendations. The current operating framework highlights the need to do more to make these devices available. Bariatric surgery should be seen as a last resort, but in some cases it is the right option. It is not an easy option because surgery comes with risks, and anyone undergoing it needs to make significant lifestyle changes. But I am sure that my noble friend’s messages are well taken in the medical community.

Health: Diabetes

Lord Rennard Excerpts

Thursday 14th July 2011 Lords Chamber

[Earl Howe]

The noble Lord, Lord Harrison, is quite right. England, along with the devolved Administrations, leads the world in this area. It is the first time that a population-based screening programme has been introduced on such a large scale. We are committed to continuing it. More people with diabetes are now being offered retinopathy screening than ever before and to higher standards, despite the increasing number of people with diabetes. The latest data that I have show that 98 per cent of people with diabetes have been offered screening for diabetic retinopathy during the past 12 months.

[Lord Rennard]

My Lords, is the Minister aware that people with diabetes are twice as likely to be admitted to hospital as people without diabetes? Will he undertake to look at best-practice models, such as that of the University Hospitals of Leicester, where diabetes specialist nurses have been stationed in the accident and emergency department and are able, in many cases, to advise against admission to hospital and provide more appropriate treatment and support? This is believed to have saved the University Hospitals of Leicester around £100,000. Diabetes UK estimates that, if rolled out nationally, such good practice might save the NHS up to £100 million a year.

[Earl Howe]

My Lords, I am aware of that excellent beacon of good practice in Leicester, which is an example that we welcome. It is an approach that is already being taken in other parts of the country. The NICE quality standard for diabetes states that people who have the condition, and who have experienced hypoglycaemia that requires medical attention, should be referred to a specialist diabetes team for advice and support to reduce admissions in exactly the way that my noble friend described.

Tobacco Advertising and Promotion (Display and Specialist Tobacconists) (England) (Amendment) Regulations 2011

Lord Rennard Excerpts

Monday 11th July 2011 Lords Chamber

[Lord Rennard]

My Lords, I begin by declaring an interest. It is a non-financial interest, in that I am an unpaid trustee and director of the charity Action on Smoking and Health. In terms of interest, I could talk at much greater length about the damage done to me and my family by the tobacco industry. Time does not allow a lot of personal background this evening, but I set out some of the reasons why I am so personally opposed to the promotion of tobacco in the debate on the Bill of my noble friend Lord Clement-Jones on banning tobacco advertising. For noble Lords or others who may be interested, this can be found at col. 1683 of Lords Hansard of 2 November 2001. In two sentences this evening, I simply point out that my mother was a heavy smoker and when she died aged 53 of hypertensive heart disease, smoking was undoubtedly a factor. I was 16 at the time and my brothers and I became orphans, as our father had died some years earlier and smoking may have contributed to his death also.

In spite of this background, however, I am not arguing for a complete ban on a legal activity—even though very few people around now would think that tobacco would be made legal if it was not already a legal product. I am simply against forcing people to suffer the ill effects of other people’s smoking, I am against encouraging anyone—especially young people—to take up smoking and I am in favour of supporting people who have given up and want to give up. In our debates on the Health Bill two or three years ago, there was a genuine debate in the House about the relative merits of different measures to restrict tobacco consumption and promotion. Some noble Lords put the argument for plain paper packaging, others argued for a ban on point of sale advertising, but it seems very clear now that the reaction of the tobacco industry is so vociferously opposed to both measures that they must both be rather effective at reducing consumption.

I was therefore very pleased not very long ago to see the Government’s tobacco control plan. This makes clear the basic commitment to ending tobacco displays and will look further at plain paper packaging, which I hope will follow. The plan makes it plain that there cannot be any responsibility deal with those who make and sell cigarettes. Tobacco seems to be an almost uniquely hazardous product that kills half of the people who use it when they follow the manufacturer’s instructions.

Arguments have been made today about the rights of smokers, but few smokers who I know think that it is right to encourage young people to smoke. Arguments are put forward, directly or indirectly, by the tobacco manufacturers, but these are the same people who denied for decades that there was any link at all between smoking and cancer. Their arguments should have no credibility whatever in these sorts of debates.

Small shopkeepers have been misled. They were told that the display ban would cost them thousands of pounds when in fact the costs would be minimal, perhaps a few hundred pounds. They should also consider that many of their customers might live rather longer if they did not smoke, and that would surely be good for business.

Claims have been made—bogus claims—that tax revenue from tobacco might fall and sales of illicit cigarettes might increase. Common sense tells us that if this were the case, the tobacco manufacturers would not be so bold about these measures. If more tobacco is consumed, they have more profit but less tax is paid. Other measures must be taken to deal with the illicit trade in tobacco. As my noble friend Lady Tyler has pointed out, evidence from other places that have introduced such bans on point-of-sale advertising shows sales falling but at the same time increases in tax revenues and a fall in illicit sales. The evidence that further measures to restrict the promotion of tobacco would be a good thing is clearly shown by the vociferous opposition to it that we have spoken about today.

Earlier today, I heard the Prime Minister, David Cameron, talk about closing the gap in life expectancy between the richest and the poorest in this country. During his campaign to become leader of my party, I heard the Deputy Prime Minister, Nick Clegg, speak frequently and powerfully, particularly about the gap in life expectancy of people in the poorer parts of Sheffield compared to those in the more affluent parts of Sheffield, just a few miles away. These gaps relate to the prevalence of smoking as much as to any other factor, so it must be right that the Government continue to pursue all the measures set out in their tobacco control plan.

[Lord Faulkner of Worcester]

My Lords, I am delighted that my noble friend Lady Thornton has given us this opportunity to debate the tobacco display regulations. This goes over old ground a bit, as a number of noble Lords who are taking part today will recall. I welcome the noble Baroness, Lady Tyler of Enfield, to our discussions; her speech was outstanding, and I hope that we are going to hear from her again on this subject. She said what many of us agree with and believe needs to be said in this debate.

Although we are debating a Motion of Regret, I would quite like to give the Government a pat on the back for their tobacco control policy. It is a pity that the noble Earl does not have any Conservative supporters behind him supporting the policy. His support is coming from the Liberal Democrat Benches, the Cross Benches and this side of the House, and it would be nice if some of the Conservative supporters of the policy were there too. The Government are sticking pretty closely to the policy of the previous Administration in their approach to the dangers of smoking and in their dealings with the tobacco industry and its lobbyists.

Like my noble friend, I believe that the Government are wrong to delay the introduction of the point-of-sale regulations, not least because there is huge public support for measures designed to make it more difficult for young people and children to start smoking. I remind noble Lords that over 50,000 people signed Cancer Research UK’s “Out of Sight, Out of Mind” petition in support of these regulations, and that over 80 per cent of the 96,000 responses to the Department of Health consultation also supported them.

I commend the determination of the Secretary of State to do something that I wish our Government had done but which they shied away from—the introduction of plain packaging for cigarettes. It is no great secret that that was scuppered under the previous Administration at the insistence of the Department for Business, Innovation and Skills. I remember, too, that BIS was not very keen on these point-of-sale measures either. It is good that the Government are pressing on with these because they will have a significant effect on tobacco consumption and particularly on the appeal of tobacco to young people.

I also congratulate the Government on winning a series of legal battles against Imperial Tobacco over the ban on cigarette vending machines. That was another tobacco control measure introduced by the previous Government. It too is important because it will make it significantly harder for children and young people to buy cigarettes.

They have also done the right thing in reaffirming their support for the World Health Organisation’s framework convention on tobacco control. I remind your Lordships of the Written Answer in the other place on 16 June by Anne Milton, the noble Earl’s colleague and Minister for Public Health. She said:

“The FCTC places obligations on parties to protect the development of public health policy from the vested interests of the tobacco industry. We have made our commitment to this very clear in Chapter 10 of ‘Healthy Lives, Healthy People: a Tobacco Control Plan for England’”.—[Official Report, Commons, 16/6/11; col. 916W.]

This means that Ministers should not meet representatives of the tobacco industry. I suggest that it is pretty unwise of them to accept hospitality from it as well.

This is not a lawful product like any other. This, as the noble Lord, Lord Rennard, said, is a product that kills if it is used exactly as the manufacturer recommends. It is different from alcohol or chocolate or other fattening foods. Tobacco is a killer when used properly, which makes it quite different from all those other products. That is why the Government are right to say that they will not deal with the tobacco industry when framing health policies related to tobacco.

This debate comes just after the fourth anniversary of the smoke-free legislation that came into effect in England. I am pleased that my noble friend Lord Borrie supported it. It was undoubtedly the most important contribution to public health since the Clean Air Act of the 1950s. Such progress is being achieved against a background of consistently strong support from the public and almost total compliance and acceptance by businesses. Despite this, as we have heard from other noble Lords this evening, the tobacco industry still refuses to accept that the party is over. We have all been on the receiving end of a campaign of misinformation, based on lies and fear, that it has funded and orchestrated. The industry’s aim, which it admits in documents that have been lodged in the United States, is to throw sand in the gears of regulatory reform wherever it can. One of the ways that it does this is by covertly funding front organisations, covering up its involvement where it can.

For example, the industry is behind the Save our Pubs and Clubs campaign, which seeks to link the decline in the number of pubs to the smoke-free legislation. When your Lordships receive letters from this organisation, bear in mind that it is funded by Japan Tobacco International and FOREST, perhaps the most mendacious lobby group of all in this area. As we have heard this evening, the industry has also attempted to conceal its involvement in the retail newsagents’ lobbying campaign against the proposed point of sale restrictions. To begin with, British American Tobacco denied that it was doing it. On 27 April, the Guardian carried a report in which a spokeswoman for BAT said:

“To accuse us of underhand tactics and the funding of an independent retailer organisation … via a PR agency that we use solely for work related to the European wide problem of tobacco smuggling, is untrue”.

One day later, on 28 April, a second report appeared in the Guardian under the headline:

“British American Tobacco admits funding campaign against display ban”.

This revelation that the campaign was funded by BAT is significant. Under the international guidelines to which I referred earlier, the United Kingdom Government are obliged to ensure the drafting of all legislation is free from the influence of the tobacco industry.

We have heard of research from Ireland that shows that the implementation of these measures there has not harmed small businesses. It also shows that tobacco point-of-sale displays influence young people’s perception of smoking as a normal, adult activity. We know that the majority of people start smoking before the age of 19. Therefore, it is crucial that we do all in our power to ensure that young people do not see smoking as cool or a social norm. It is a pity that these regulations have been delayed, but I strongly support what the Government are doing elsewhere on tobacco control policy, and I hope that they will press on with it.

Health: Diabetes

Lord Rennard Excerpts

Thursday 4th November 2010 Lords Chamber

[Lord Rennard]

My Lords, I, too, congratulate the noble Lord, Lord Harrison, on securing this debate on a topic that is so important to so many people. Like many noble Lords present, I am a diabetic, so I begin by thanking the diabetic team at St Thomas's Hospital, who have done so much to help me and from whom I have learnt a great deal about diabetic management.

Whenever I talk to some of my American friends about how our NHS has supported me in this regard, they agree that we have a wonderful and cost-effective system of providing healthcare to all our citizens, and they share my amazement at the hostility shown by some in the United States this week to the principle of universal healthcare and the option of the public provision of health services. These are things that we are right to regard as hallmarks of a civilised society, so we are rightly very proud of the NHS in the United Kingdom.

I want to use this debate to raise a number of points about the current NHS reorganisation that may be of concern to the millions of people in this country who know that they have diabetes, the millions who either have it but for whom it has not yet been diagnosed or who may develop it in the future, many people who have experience of diabetes in their families, and the health professionals who support them all.

The stark fact that Diabetes UK has drawn to our attention in its report Putting Feet First is that 100 people a week in the UK have a limb amputated as a result of diabetes. The costs of these amputations, which can be measured in very many ways, are very large. The noble Lord, Lord Harrison, referred to the total costs of treating people with diabetes, which amount to approximately 10 per cent of the NHS budget. And the prevalence of diabetes is growing rapidly, so all issues concerned with it must be addressed very seriously.

On the planned NHS reorganisation, I recently spoke to many NHS professionals who say that the advent of GP commissioning in particular both provides opportunities for and threatens better provision of support for people with diabetes. To promote best practice, when there could be a greater number of GP consortia than the current number of PCTs, will make information-sharing between consortia absolutely essential. We know that there is already a problem in that knowledge of the issues about diabetes and best practice vary significantly between GP practices. It will therefore be very important in future that all GP consortia are properly aware of the sort of issues raised in the Diabetes UK report if best practice is to be spread and every GP practice is able to respond appropriately.

The new consortia may need to work together along the lines on which many good primary care trusts work now, otherwise knowledge and efficiencies may be lost. I should be particularly grateful if the Minister could comment on how relevant information and best practice will be shared among the GP consortia in future. In the new arrangements, there may need to be incentives and guidance for GPs who are not experts in diabetic care to involve other health professionals in this aspect of the care of their patients. This is something that a GP recognised in my own practice when I was fortunate enough to be referred to St Thomas's. We need to ensure that the new arrangements do not provide disincentives for such referrals when they are desirable. In funding arrangements, there needs to be recognition that diabetes is significantly more prevalent in certain communities—often those that tend to be most unhealthy generally—and in many ethnic minority populations, to which the noble Baroness, Lady Hussein-Ece, has just referred.

The provision of insulin pumps varies greatly across the country and the United Kingdom lags behind many other countries in such provision. I believe that funding arrangements should recognise that there may be a much greater need for such provision in some areas. There may be significant long-term savings overall to be looked at because of the cost of poor control and diabetic complications, such as amputations and blindness.

We need to make sure that all the consortia recognise the value of diabetic specialist nurses. A specialist team can be the catalyst and driver for improved services and for involving patients properly. The consortia need to be informed about what specialist diabetes services and expertise are available to them. They need to make sure that diagnosis remains a key area for improvement. As Diabetes UK states:

“The delivery of high quality specialist foot care is an essential component of every local diabetes service”.

The human and financial costs of failing to do these things will be very great.