Health: Neurological Services
Lord Ribeiro Excerpts(7 years, 3 months ago)
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Lord Ribeiro (Con)
My Lords, I thank the noble Baroness, Lady Gale, for securing this debate and for returning to a subject which affects millions of people in this country. I will focus later on the 127,000 people who suffer with Parkinson’s, and the increasing number of them who have benefited from deep brain stimulation surgery.
As a surgical trainee in the 1970s, my experience of neurosurgery was through performing “burr holes”, a modern version of trephining. This was a skill performed by the Incas, normally to allow evil spirits to leave the brain—whereas, in my case, it was to take pressure off the injured brain after a head injury. Forty years on, with the advent of modern diagnostics and specialisation, general surgeons no longer operate on the brain.
The question I want to ask is: do we have enough neurologists and neurosurgeons to deliver what is now an increasingly complex service? In June, the noble Baroness, Lady Gale, raised the questions she addressed in her opening speech around the services that were to be provided. The noble Baroness, Lady Finlay, who is in her place, made reference to the fact that one of the factors that affected this was the low numbers of neurologists and neurosurgeons—factors which would influence delays in diagnosis, poor outcomes and a widened variation in access and treatment.
Epilepsy is a case in point. Sir Muir Gray, in his Atlas of Variation, made reference to a twofold variation in emergency admissions of patients with epilepsy and a fourfold variation in elective admissions—important differences for those who have to access epilepsy surgical programmes. Delays in diagnosis for neurological patients in general is an issue. Over 42% of patients see their GP five or more times before they see a neurological specialist, and 20% wait a year before seeing a specialist at all.
Information I have received from the Royal College of Surgeons suggests that there has been a sharp rise in the number of patients waiting longer than 18 weeks, particularly in neurosurgery. Since February 2016, neurosurgery has been the worst-performing surgical speciality in terms of waiting times. There are also regional variations. For example, of the 717 patients waiting for neurosurgery in Plymouth last October, 59% had been waiting longer than 18 weeks, compared to an average of 16.5%.
In the past 10 years, the number of neurologists in the NHS has grown by 5% to 650 full-time equivalent consultants. However, they are not well distributed. Currently, also, 30% to 50% of new consultant posts remain unfilled due to a lack of specialist neurological trainees. Can the Minister say why NHS England believes that the current rate of growth is unlikely to change in the coming years, and what can be done to improve recruitment? I believe that NHS England is due to report on the availability of neurologists and on variations in access in hospitals in April 2017. He may wish to throw some light on this and give the House a heads-up on what it is likely to say.
I welcome, through the National Institute for Health Research, the £816 million that has been provided to 20 NHS and university partnerships—seven of which expressed interest in neurosciences and neurological conditions. Sheffield University, in particular, specifically identified translational neuroscience for chronic neurological disorders as one of the things it would do research in. However, 50% of the funding went to the usual suspects—Oxford, Cambridge, UCL and Imperial—which took up the major slice of the money.
When I was president of the Royal College of Surgeons I became aware of the work of Professor Tipu Aziz and Professor John Stein at Oxford and I went to visit them. They had started and had been using deep brain stimulation in primates as part of their research, and then subsequently for patients with Parkinson’s disease. As a result of Professor Aziz’s use of primates in his research, they suffered abuse and attacks from animal rights activists. In fact there was a protest, which some noble Lords may recall, when students in Oxford came out in support of the research because of the benefits for patients.
I subsequently saw Professor Aziz silence his critics on a BBC programme, discussing the ethics of animal research. Many in the audience spoke against any form of animal research. A gentleman quietly got up, rose to his feet and extolled the virtues of surgical research. He looked no different from anybody else in the audience. Suddenly, in mid-sentence, he threw a switch and changed from his normal persona to a man with an uncontrolled tremor, violent shakes and a complete change in his demeanour and persona. He was demonstrating symptoms of Parkinson’s that had been kept under control with his deep brain stimulation. I personally had never seen such a transformation on live television, and I am sure that it did a lot to demonstrate to people what surgical procedures can achieve.
There are currently 16 centres in the UK: one in Scotland, in Glasgow, and the rest dotted around England, mostly clustered, as I said, around the golden triangle—I think there are about five or six in London—and in the Midlands and the north of England, in Newcastle. In the south, which is usually the part of the country that is heavily supplied with healthcare, there is nothing other than in Bristol.
NHS England has produced policy documents on deep brain stimulation for movement disorders such as Parkinson’s, in 2013, for chronic neuropathic pain, in 2014, and, more recently, in 2016, for central post-stroke pain. Will the Minister tell us what the likely outcome is of these policy documents? What impact will they have on improving access and reducing variation?
Mental Health and NHS Performance Update
Lord Ribeiro Excerpts(7 years, 4 months ago)
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Lord Ribeiro (Con)
My Lords, from these Benches I welcome my noble friend to his new position on the Front Bench and pay credit, as he did, to the work that the noble Lord, Lord Prior, did before him.
The Statement suggests that, during this period of exceeding challenge to the hospital sector, with clinical leaders attempts will be made to,
“suspend elective care, including, where appropriate, suspension of non-urgent out-patient appointments”.
I was rather distressed to hear on the “Today” programme of a patient with oesophageal cancer having either his treatment or his admission delayed—it sounded like it was his admission. As a surgeon, I felt particularly uncomfortable about that. I hope that the Minister can give some reassurance that when it comes to treating patients with cancer, irrespective of the pressures a hospital is under, provision must be made to admit those patients, because any delay can have a long-term effect on them.
Although I accept that there have been 11,400 more doctors since 2010—and that is a very reassuring figure—we must also remember that the intake into medicine has changed significantly over the past 10 or 20 years. There is now probably a majority of female doctors coming into medical school, so the workforce is feminising and changing. Whether we like it or not, many of them will have children, will have family commitments and will wish to work part-time, or less than full-time. When we talk about numbers, it is important that we talk about whole-time equivalents rather than the ballpark figure. It looks like a lot of doctors coming into the system, but we must take into consideration that many of them will work less than full-time, so we may well need to increase the medical workforce, perhaps asking them to work in a different way than they do currently.
I would be grateful if the Minister would comment on that, but I welcome his comments about mental health. I hope that greater provision will be made to ensure that patients with mental health issues have as much support as possible, as he said.
Lord O'Shaughnessy
I am grateful to my noble friend for his kind words of welcome. On the specific issue raised on the “Today” programme, which I believe is the subject of a documentary, and how it relates to the Statement made by my right honourable friend, there is an important distinction, which is that it is at the discretion of local clinical leaders. It is not a blanket mandate to delay treatment where the ethical and clinical responsibilities of those treating a given patient require it to be done speedily.
On the issue of the workforce changing, I take my noble friend’s point about what in the education world we called FTEs—full-time equivalents—and will make sure that the workforce figures I use are always expressed in those terms.
Smoking-Related Diseases
Lord Ribeiro Excerpts(7 years, 8 months ago)
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Lord Ribeiro (Con)
My Lords, I thank the noble Lord, Lord Faulkner, for taking on this debate from my noble friend Lord Young of Cookham.
The Wanless report in 2011 warned of a sharp rise in avoidable deaths if we did not take prevention seriously. The NHS Five Year Forward View identified the future health of millions of children, the sustainability of the NHS and the economic prosperity of Britain as dependent on a radical upgrade in prevention and public health. The Government are to be congratulated on achieving their targets under the old plan. Targets for adult smoking rates down to 18.5%, smoking rates among 15 year-olds down to 12% and smoking rates in pregnancy down to 11% have all been met. It is an excellent record but more is needed to achieve the Prime Minister’s stated aim to reduce inequalities in health and the gap between rich and poor.
Smoking prevention can also be achieved in acute settings. Anesthesiology noted in 2011 that smokers were 38% more likely to die after surgery than non-smokers. In my own specialty of colon and rectal surgery, smoking was a predictive factor in causing anastomotic breakdown and poor wound healing. I was accused of being draconian for advising my patients to stop smoking before surgery. However, we have evidence to show that stopping smoking two months before surgery provides the most benefit for patients and reduces complications. It strikes me that this would be a good time to offer a smoker an e-cigarette—preferably on prescription. This approach was endorsed by the Royal College of Physicians and the Royal College of Surgeons and others in a joint briefing in April 2016, which encouraged healthcare providers to be proactive in supporting those who want to use e-cigarettes. We must of course be careful not to encourage young people to try them. We must use every means, including mass media, as the noble Lord, Lord Faulkner, mentioned, and social media to change public attitudes to tobacco smoking. A campaign to stop smoking in cars with children present was a case in point. Can the Minister say what plans he has to consult the public on a new tobacco control strategy?
Junior Doctors: Industrial Action
Lord Ribeiro Excerpts(7 years, 8 months ago)
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Lord Prior of Brampton
I am not sure the Government ever made that promise. That was a promise made by the Brexit campaign. The Government have committed to putting an extra £10 billion into the NHS over the course of the Parliament, but they are certainly not in any way committed to fulfilling promises or pledges made by the Brexit campaign.
Lord Ribeiro (Con)
My Lords, we can all be gratified that the junior doctors have decided to postpone their strike. I am sure that this is partly as a result of the pressure being put on them by senior doctors. They are the ones who know the consequences for patient safety because they are ultimately responsible when things go wrong. David Watkin, a past president of the Association of Surgeons, has written a letter to the Times today in response to Simon Wessely’s letter. He makes the interesting point that there is a real issue about the way our junior doctors feel supported—or should I say unsupported. There has been the loss of the firm structure whereby junior doctors worked part and parcel in a team, and they and a consultant knew each other, trusted each other and could rely on each other. As mentioned by the noble Lord, Lord Hunt, that has gone partly because of shift working, rota gaps and the need to fill those gaps.
Brexit provides an opportunity, whether we like it or not, to take time and look again at two regulations: the European working time directive, and the new deal. The main thing about the European working time directive is that some junior trainees—particularly in my specialty, surgery—wanted to work longer than 48 hours a week. For all other specialties you have to acquire knowledge, but for surgery, cardiology, nephrology and some other specialist areas, you have to learn the skills. Learning and acquiring skills takes time. Can we look at Brexit as an opportunity to assure some of our junior doctors, who feel unloved and unsupported, that there may well be a way to look at and improve their working practices?
Lord Prior of Brampton
My Lords, the origins of this dispute and lack of trust go back many years, to the end of the old firm structure. Many junior doctors feel a lack of support. It is easy to lob bricks at the Government, but the senior doctors and the royal colleges need to look at themselves pretty carefully and pretty hard in the mirror because they have some responsibility for this as well. I hope they will be very much part of working through some of these non-contractual issues, along the lines my noble friend suggested.
Junior Doctors: Contract
Lord Ribeiro Excerpts(8 years ago)
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Lord Prior of Brampton
My Lords, we now have a pause for five days. This is not dogma; we have two parties who have different views about a small part—about 10%—of the existing contract. Over the next five days we have a chance to resolve that.
Lord Ribeiro (Con)
My Lords, while the whole House welcomes this pause, I hope that, whatever happens, there will be an opportunity for an independent review to look at the very points that were made earlier about the lack of appreciation of and support for junior doctors. If there is one thing last week’s dispute has shown, it is that when consultants man the front door of a hospital, services are very much better. Will the Government consider having an independent review after this dispute to look at the future workforce?
Health: Treatment Rationing
Lord Ribeiro Excerpts(8 years ago)
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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.
Lord Ribeiro (Con)
As a surgeon, I had cause to cancel or delay operations on patients who were obese or were smokers, but those decisions were based on clinical grounds from the knowledge I had of the individual patient. Clinical commissioning groups can give guidance but they should not provide diktats. What assurance will the Minister give that clinical decisions will be left to those who have the best interests of the patient at heart and who know their patients?
Junior Doctors: Industrial Action
Lord Ribeiro Excerpts(8 years ago)
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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.
Lord Ribeiro (Con)
My Lords, as a junior doctor in 1975, I went on strike, so I can understand why junior doctors might feel the way they do. The difference between 1975 and now is that we did not withdraw emergency cover. That is the point we should concentrate on, because I fear that, on Tuesday and Wednesday, people will be denied care irrespective of the cover provided by consultants and we will see some deaths occurring. When they do, the blame will fall squarely on both parties, which is most unfortunate. Something needs to be done. It is late and, as the noble Lord, Lord Patel, said, we are talking about a sticking point over Saturday. Surely we could agree that emergency care starts at 1 pm with premium pay. Perhaps that would be both sides meeting in the middle.
When this is all over—I regret that I think that tomorrow’s strike will go ahead—may I please ask that we have an independent inquiry and review? This is about the sustainability of a workforce that does not use junior doctors at the front door to deal with all the work. We need a workforce that will put senior decision-making at the front door of a hospital so that the juniors can have more time to be supervised and trained.
Lord Prior of Brampton
My Lords, I completely agree with that. When the dust has settled, we have to take a wholly new and independent look at how junior doctors are trained. As the noble Lord will know, Sue Bailey, chair of the Academy of Medical Royal Colleges, has been asked to look at this, but I do not think it is possible to do that sensibly while the dispute is ongoing. We need the full co-operation of junior doctors in that review. I would personally welcome an independent assessment of the way we train junior doctors once this dispute has been settled. I share my noble friend’s views entirely: it would be wonderful if the junior doctors would agree to provide emergency cover on Tuesday and Wednesday this week. But it is now 8.15 pm on Monday and time is rapidly running out.
Sugar Tax
Lord Ribeiro Excerpts(8 years, 4 months ago)
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Lord Prior of Brampton
My Lords, the Government have taken into account a range of evidence from Public Health England, the McKinsey institute, the SACN and others in coming to their strategy. The noble Baroness is absolutely right that the response will need to take into account issues such as reformulation, portion size, availability and a whole range of other issues that affect sugar intake.
Lord Ribeiro
My Lords, while the sugar tax for fizzy drinks is a regressive tax, the very people it would target stand to benefit from such a tax because, leaving aside obesity, which is a long-term problem, dental caries are a short-term problem. There is no doubt that sugary drinks are causing a massive amount of dental caries, the cost of which falls on the NHS, as these unfortunate children have to have dental extractions which will affect their well-being and quality of life for years to come.
Lord Prior of Brampton
My Lords, reduction of sugar is a critical part of the Government’s obesity strategy. It has been made clear by the reports of Public Health England, the McKinsey institute and others that there is no silver bullet. It is not just a question of passing a tax and getting the results that you wish to have. If a tax were to come in, it would be part of a whole range of other measures.
Health: Liver Disease
Lord Ribeiro Excerpts(8 years, 5 months ago)
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Lord Prior of Brampton
My Lords, as part of the responsibility deal, a financial contribution was made by some of the alcohol companies. I accept that it was a small contribution. I shall have to take this under advisement as I am not sure how much the industry does contribute to the victims of alcohol disease. I agree with the noble Lord’s premise that the damage done to many people through excessive alcohol consumption is a cause of great concern.
Lord Ribeiro (Con)
My Lords, does my noble friend agree with recommendation 3 in the report, which requires the establishment of liver units in district general hospitals, acting in a hub-and-spoke network with specialist hospitals? This is important to provide access to people, particularly in the north-west, where, sadly, there is very little access to specialist hepatology units.
Lord Prior of Brampton
My Lords, the recommendations in the report about a hub-and-spoke approach, to which my noble friend refers, with district general hospitals having some hepatology services but being linked into a specialist centre are absolutely right. It is the right model; I have no doubt about that. We have established 22 operational networks for hepatitis C treatment, which are all linked into specialist treatment centres. We believe that that may be a model for the future.
Mesothelioma (Amendment) Bill [HL]
Lord Ribeiro Excerpts(8 years, 5 months ago)
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Lord Ribeiro (Con)
My Lords, I too thank the noble Lord, Lord Alton, for introducing the Bill, and my erudite medical colleagues for their lectures and exposition on the research which supports work on mesothelioma. I confess to being a bit of a cowboy movie fan. One of my idols was Steve McQueen, whom noble Lords may remember in “Bullitt”, “The Great Escape” and “The Magnificent Seven”. The noble Lord mentioned Navy workers and the involvement of the noble Lord, Lord West, and others in this. Steve McQueen enlisted in the United States Marine Corps in 1947. In those days, warships coming out of the war were covered in asbestos. It was in every single compartment: the roofs, eating messes, everywhere. He was also required to strip out asbestos from the old ships. He died, at the height of his acting career, at the age of 50 of abdominal mesothelioma. We do not know exactly when he contracted the disease—it could have been at any time, but it was presumably between 1947 and 1950 when he was in the Navy. He was also very interested in racing cars and in those days they had asbestos masks in case of fire. It is most likely that it took 30 years before the disease was diagnosed in December 1979. He died less than a year later, in 1980, aged 50. He had malignant mesothelioma of the peritoneum, to which the noble Lord, Lord Winston, referred earlier. He tried desperately to find a cure, going to Mexico and other countries to do so, but sadly he died. His death was a huge shock to those of us who admired his acting skills, and it raised the profile of the disease of mesothelioma. It is a shame that you need such icons to bring people to understand how deadly such a condition is.
As a surgeon, I had very little experience of mesothelioma. I did a cardiothoracic job in which most of the time would be spent draining fluid from around the lungs, because this condition would compress the lungs as it spread around the pleural cavity and cause all sorts of problems. Unlike pleural problems due to tuberculosis, where we would strip off the pleura and try to stop any further fluid collecting, with mesothelioma, whatever you did made very little difference. All we could do was effectively to palliate. So my experience of the disease was very limited.
Curiously enough, we still see advertisements featuring Steve McQueen, with him advertising watches or driving a Ford Mustang. His image is still there. But the condition that he died from is not as well known as it should be. I would hate people to think that, just because this was something that happened before restrictions came into being, we will not see more of this condition. A projected figure of 60,000 deaths has been given but, as the years go by, although there may be a slight fall, I predict that there will be many more. It is also important to remember that it is not just in this country that the deaths will occur. Many countries do not have the regulations or restrictions on the use of asbestos that we have. It is important that we take a lead in trying to discover the causes of mesothelioma and getting to the bottom of how to treat it in order to benefit not only us but many people overseas.
I do not know how many noble Lords have accepted the offer of a tour of the basement of the House. If they have not, I suggest that they do, as they will find evidence of asbestos in this building that they will not believe. We are all likely to be exposed to it. The noble Baroness, Lady Finlay, mentioned her time as a medical student. When I was a medical student, I worked in a hospital where we would walk through underground tunnels with asbestos pipes along the sides. The hospital porters would push the patients on trolleys down those tunnels, bang into the asbestos and bits would fly off. As medical students, we often had a game of rugby as we went flying through the tunnels and, again, chunks of asbestos would come off. To my knowledge, one medical student who never worked in the industry subsequently died of mesothelioma. I can only assume that that was associated with exposure to the asbestos. We have it right beneath us in this building and we should all be very aware of it.
Noble Lords will remember the valiant attempt by the noble Lord, Lord Alton, to introduce his amendment the last time round. On that occasion, the Government suggested that a more voluntary approach was the way forward, with contributions being made on a voluntary basis, but the noble Lord demonstrated clearly that that has not come about. At that time, four insurance companies were bearing the burden of providing payments to sufferers of the disease. That number is now down to two—Aviva and Zurich, which have both contributed £1 million towards research, but only for two years. There are 150 other insurance firms actively involved in employers’ liability which have yet to step forward. It should not be the responsibility of two insurance companies to shoulder the burden of this condition, and it is extremely important that we find a way through this.
I know that charities are able to raise huge amounts of money towards the treatment of cancer. We are all well aware of breast cancer—it is visible and we all know of people who have been affected by it. Hundreds of millions of pounds are spent on research into breast cancer and other cancers. Mesothelioma is an insidious condition that has a sinister outcome, yet very little research has been done into it. Perhaps it is not a very sexy area for researchers to go into. I am afraid that most people do medical research because they wish to explore a particular area for which they have a passion. If we are to generate the necessary funding for this disease, it is important that we stimulate more people to take an interest in it.
There are questions to be asked. Why does a wife who launders the clothing of her husband, who works in an area with asbestos, contract and die of mesothelioma whereas her husband does not? Why can some people survive for up to 20 years? The current longest survivor is a man who contracted the disease 18 years ago and is still going strong. Why is that? Clearly the answer lies in the genes, and we need to do genetic research. Testa et al in Nature Genetics reported in 2012 research suggesting that people with a germline mutation on their BAP1 gene are at a high risk of developing mesothelioma. We need to follow through such areas of research to try to get the answers. My erudite medical colleagues have explained to the House some of the stages that need to be gone through.
I wish to mention the British Lung Foundation, which I worked very closely with when I took through my Private Member’s Bill on banning smoking in cars with children present. It has done a huge amount in supporting the battle against mesothelioma, and it needs to be recognised, acknowledged and supported. As was mentioned, one of its researchers, Dr Peter Campbell, receives a grant for work on identifying the important genes to target for mutations in mesothelioma. Notwithstanding what the noble Lord, Lord Winston, said about the need not just to target one area but to recognise that high-level research may benefit many other conditions and not just mesothelioma, this area needs far more support than we have seen hitherto.
On the previous occasion when this matter was debated, the noble Lord, Lord Alton, missed taking through the proposed levy by just seven votes. It was a very narrow vote and he had a lot of support in the House but, unfortunately, it did not go through on that occasion. At that time, the Government assured us that it would be possible to achieve the ends we wanted through a more voluntary approach. To date, those 150 insurance companies have not stepped up to the plate and we need to do slightly more than rely on that approach. A levy is the missing piece of the puzzle. It is key to essential research into this killer disease, which, as we all know, affects tens of thousands of people. It is important to discover its exact causes and how we can benefit patients in the future.
Why does the UK have the unenviable record of the highest mesothelioma mortality rates in the world, and what are we doing wrong that we could do better? I believe that only research can answer these questions. As I said, it cannot be left to charitable organisations to raise the money for such research, and it is important that we find a way of achieving the necessary funding. Winston Churchill once said, “Action this day”. I think we have reached the point where we need to move towards “action this day”, and I hope the Minister, having listened to the debate and the comments that have been made, will be more inclined to take a harder line on this and to consider finding a way of introducing a levy on the insurance companies.