Mesothelioma

Lord Ribeiro Excerpts

Thursday 5th December 2013 Lords Chamber

[Earl Howe]

I am sure that the noble Lord wants to take advantage of this opportunity to raise that particular issue, but it is a rather different one from the Question posed by the noble Lord, Lord Alton. However, I will take his question away and ensure that a letter is sent to him in response.

[Lord Ribeiro (Con)]

My Lords, the Government are to be congratulated on introducing the Cancer Drugs Fund, but how do they anticipate that the vital research which needs to be done into mesothelioma will continue to be funded without legislation to compel those insurance companies which so far have not stepped up to the plate to make a contribution?

[Earl Howe]

My Lords, as my noble friend will be aware, four insurance companies have stepped up to the plate with funding of £3 million, which admittedly is nearing its end, but I do not think that we can belittle that contribution. My noble friend may be interested to know that the MRC and the NIHR together spent more than £2.2 million on mesothelioma research in 2012-13, which is a larger sum than for many other disease areas. I say again that the issue is not the lack of funding because the research funding in both the MRC and the NIHR has been protected. What is lacking are suitable proposals.

Tobacco: Packaging

Lord Ribeiro Excerpts

Thursday 28th November 2013 Lords Chamber

[Earl Howe]

My noble friend makes a very important point. She is, of course, right that the tobacco companies protect their commercial position with great vigour. We will indeed keep an exceedingly close eye on the actions of the tobacco industry and, should we decide to introduce regulations, we will do all we can to ensure that they are watertight.

[Lord Ribeiro (Con)]

My noble friend should be congratulated on his leadership in taking forward this proposal on plain packaging. He will be aware that I have introduced a Bill on banning smoking in cars where children are present. I recognise the difficulties that that presents for the Government, but after this three-month period of consultation, if the recommendations of Sir Cyril Chantler, who, I agree, is a very highly respected clinician, are accepted by the Government and legislation is introduced, I hope that that will give an impetus to the Government to think again about the importance of banning smoking in cars where children are present.

[Earl Howe]

I pay tribute to my noble friend for his championing of this cause. I am sure that the main reason people smoke in cars is that they do not understand how harmful second-hand smoke can be for children. Of course we would like to see smoking in cars carrying children eradicated entirely but, at present, we are not convinced that legislation presents the most effective or proportionate approach. Rather than create new offences, we prefer to promote and encourage positive behaviour change, and there is emerging evidence that we are succeeding on that score.

NHS: EU Legislation

Lord Ribeiro Excerpts

Monday 21st October 2013 Lords Chamber

[Earl Howe]

My Lords, it is the impact on our health service that we want the Royal College of Surgeons to look at specifically. In the coalition agreement, we committed to limiting the application of the working time directive in the UK, including in the NHS. Nobody wants to go back to the bad old days of tired doctors, but it is important for the working time directive to have more flexibility for a health service that operates on a 24-hour basis. Increased flexibility for the NHS would allow it to take account of local needs and practices, while at the same time ensuring the health and safety of the workforce. We stand prepared to work with partners in Europe to that end. I believe there is strong support in the NHS for this.

[Lord Ribeiro (Con)]

My Lords, I thank my noble friend for acknowledging the role that the president of the Royal College of Surgeons is playing to ensure that the European working time directive is not having an adverse impact on patient care. In the United States, the duty hours that surgeons work are limited to 80, although flexibility has been introduced into their working so that trainees nearing independent practice can work more flexibly and for more hours. As 80% of surgical trainees currently work more than 48 hours a week, is it not time that we applied some flexibility to the European working time directive?

[Earl Howe]

My noble friend speaks, as always, with great authority on these matters. The independent review is by clinicians and of clinicians, looking specifically at the issues associated with the implementation of the directive. It means that any issues that are identified and can be acted on without needing to change the law—which was one of the points underlying my noble friend’s question—could lead to swift and effective action. In addition, my noble friend might like to know that the review will be looking at how the directive interacts with the junior doctors’ contract. It is intended to provide a sensible front-line view of doctors’ working hours.

Care Bill [HL]

Lord Ribeiro Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Ribeiro]

My Lords, following the disruption of medical education that followed on from the MTAS debacle in 2007, one of the outcomes, which was a positive one, was the development of schools of surgery—a concept that we took on from the anaesthetists. This required personnel from the Royal College of Surgeons and the deaneries to take responsibility for the delivery and planning of training and education. However, this was very much confined to trainees. There was no requirement to extend it to consultants in terms of CPD.

However, we all know that health education does not end with certification; it is a continuum that occurs throughout one’s career as a professional doctor. It is a requirement to keep up to date. It is a requirement by the GMC to ensure that one knows what is happening within the wider medical field. One of the problems for doctors is having the time to go away and attend courses to improve one’s CPD. The amendment of the noble Lord, Lord Patel, places an obligation on HEE and the LETBs to support CPD and, in doing so, to allow the release of NHS staff, as he quite rightly said, to attend courses and educational programmes. It is also important to provide consultants and medical personnel of all disciplines with the opportunity to work in the wider NHS. It has been one of the basic tenets of the NHS that contributions in the wider NHS benefit not only the NHS but the participants, who learn a lot more about its workings. That, too, can improve and enhance one’s continuing development.

In that context, I welcome the suggestion made today several times by speakers—certainly by the noble Lord, Lord Hunt of Kings Heath, in that he made reference to the Francis report. One thing that came out of the Francis report was a clear statement that he would recommend that the GMC and the royal colleges work together in providing visits to educational centres. That was stopped some time ago. I think that there is a real opportunity to reintroduce that and I hope that the Minister, in responding, will address that issue. Here again is an opportunity, because in the past lessons were learnt by consultants visiting hospitals and looking at the education provision.

The very presence of peer groups in a hospital often helps to raise standards. Therefore, not only would CPD provide another training opportunity for those who participate but it would improve local education provision. The quality assurance of the training it would provide would ensure that, in the long term, patients benefited from such visits. For that, if nothing else, I support the amendment of the noble Lord, Lord Patel. We need to include something on continuing professional development because the whole emphasis of HEE is very much on training and trainees and it has very little to do with those who continue right through to retirement.

[Lord Turnberg]

My Lords, I, too, strongly support the amendment of the noble Lord, Lord Patel. Like him, I am concerned and rather surprised that there is no mention in the Bill about the need for trusts and other providers to support their staff in continuing professional development. We really cannot afford to have any staff working in front-line clinical services not keeping up to date when we know that clinical practice changes rapidly from month to month.

New tests, new diagnostic methods and new treatments are coming along fast and furious. Unless members of staff are given the time and facilities to keep abreast of all of those, we will get poorer and more out-of-date care. As the noble Lord, Lord Patel, said, it is unfortunately the case that when health budgets are stretched, as they almost always are, CPD budgets are the first to go. Time off to attend courses or to engage in appraisals disappears quickly, as everyone in the service is rushed off their feet.

It is in just those circumstances that a stand should be made. The amendment of the noble Lord, Lord Patel, makes it clear that the LETBs must include the need for employers to allow the time for CPD development of their staff. How else will doctors, for example, be able to comply with the mandatory requirement of the GMC to revalidate at regular intervals? We have struggled both long and hard to get revalidation mandated and we cannot afford to see it eroded now at the same time as the responsibility for funding CPD is falling to employers. LETBs must be given the teeth to insist that time and support for CPD are included in their educational contracts with trusts.

Health: Cancer

Lord Ribeiro Excerpts

Monday 20th May 2013 Lords Chamber

[Lord Ribeiro]

My Lords, we have 11 cancer registries in the United Kingdom and Public Health England is due to merge eight of the English cancer registries with the National Cancer Intelligence Network this year. The United States and Sweden have national registries, and the benefit of that is that they are able to establish not only the diagnosis and causation but also the impact of treatment on patients and provide much more information to improve the quality of outcomes for patients. Is it not time that we had a national registry, mindful that independence for Scotland may put this at some risk?

[Earl Howe]

My noble friend raises a very important issue. I agree that it is important to draw together as much information as we can about causes of death from across the country. However, I am advised that the question of whether a cancer-related death can be attributed to the underlying disease or to the treatment cannot be answered comprehensively from information collected as part of the death certification process or the cancer registration process or, indeed, a combination of both. However, as I hope my previous answer indicated, I am sure that this is a developing science.

NHS: Out of Hours Service

Lord Ribeiro Excerpts

Tuesday 26th March 2013 Lords Chamber

[Earl Howe]

My Lords, of course, the results from the Patients Association report are a matter for concern. We are absolutely committed to improving access to GPs and, from 1 April, responsibility for making sure that that happens will pass to the NHS Commissioning Board. We have outlined a clear set of objectives around patients’ experience of local primary care services in the mandate to the board; we have launched marketing campaigns in each of the new NHS 111 areas, which we are confident will facilitate better access to out-of-hours care; and we will publish information regularly, so that patients can see how their practice is performing and feed back to their practice when it is not performing.

[Lord Ribeiro]

My Lords, at a time when nurses are being urged to wash their patients, is it not time that the GP contract was renegotiated so that GPs can be responsible for the out-of-hours care of their patients and, in doing so, perhaps relieve the pressure on our A&E departments?

[Earl Howe]

Increasingly, this is likely to happen, because our changes to the GP contract this year are bound to make sure that GPs think more about long-term integrated care for their patients. The recommendations from NICE underpinned the new arrangements in the GP contract, and my noble friend is absolutely right that that has to remain very squarely in the sights of all GPs.

NHS: Mid Staffordshire NHS Foundation Trust

Lord Ribeiro Excerpts

Monday 11th March 2013 Lords Chamber

[Lord Ribeiro]

My Lords, like other noble Lords, I express my gratitude to the noble Lord, Lord Patel, for introducing this debate so eloquently. I would like to address some of the recommendations in the Francis report that relate to education and training.

Recommendation 155 requires the General Medical Council to set out a standard requirement for routine visits to acute hospitals that train doctors. It asks for postgraduate deans to assume responsibility for managing the process, for royal colleges to support visits and provide relevant specialty expertise, and for the presence of lay and patient representatives on visits—something that the Royal College of Surgeons has done since 2006. Such visits should be co-ordinated with the work of the Care Quality Commission.

There is a sense of déjà vu about some of these recommendations, because before 2005 hospitals were visited regularly by colleges—some would say too regularly. None the less, the purpose of visits was to inspect and accredit training posts. After each inspection, the visiting team met with the chief executive, the medical director and the clinical tutor and talked about any deficiencies that it had found on its visit and the impact that these would have on service provision. Where problems were discovered the trust was advised that a follow-up visit would be required to ensure that the recommendations were implemented.

I was president of the Royal College of Surgeons in 2007 when the college was asked by Mid Staffordshire NHS Trust to undertake an invited review of its surgical services. Our report did not offer “false assurances” to the trust, as it suggested. Rather, the report identified a lack of leadership, an absence of essential protocols, and issues around attitude and the competence of at least one surgeon. These were all issues likely to impact on patient safety and were just the sort of concerns that could have been picked up in the old-style college visits, where face-to-face interviews of trainees were carried out, with the assurance of confidentiality. The trainees were thus able to speak freely about their training and to flag up any concerns they had. That process did not prevent the tragedy of Bristol, but we have learnt lessons since then.

In his evidence to Francis, Mr John Black, my successor as president, said:

“In the course of such a visit the nature of the service would be investigated as much as the training, because we cannot provide a high standard of training unless there is a good service”.

One junior trainee in his final year in accident and emergency medicine, Dr Turner, said that the pernicious effect of the four-hour waiting target created substandard care in the A&E department. Nurses were bullied into moving patients before they breached the four-hour target, often transferring patients to inappropriate wards and some without their medication. Reports of nurses emerging from management meetings in tears were all too common. Dr Turner’s complaints to his educational supervisor in the trust got nowhere. He identified a lack of commitment to education in a department which had only one consultant despite a college recommendation for four. The ability to express concerns to an external visiting body in confidence is essential if whistleblowing on substandard care is to have any effect.

Restoration of properly structured and co-ordinated college visits are long overdue and I welcome recommendation 155, which seeks to link the regulation of hospitals using professionals and the quality assurance of education and training. Triangulating data about the quality of education and the quality of care would help to paint a fuller picture of the patient’s experience in hospital. The first report of the Royal College of Surgeons on Mid Staffordshire in 2007 mentioned a lack of leadership. In his evidence to the House of Commons Health Select Committee on the Francis report on 5 March last week, Sir Bruce Keogh made this observation:

“I have been on the council of the RCS on two occasions and I have watched the leadership organisations of various tribes...and interest groups slowly feeling that they have been relegated to the position of commentators rather than participants”.

My question to my noble friend is: what steps do the Government propose for bringing these leaders back into the mainstream of NHS delivery and how can we ensure that the doctors and nurses rediscover their voices and act as advocates for patients?

Health: Medical Innovation

Lord Ribeiro Excerpts

Wednesday 16th January 2013 Lords Chamber

[Lord Ribeiro]

My Lords, I add my thanks to my noble friend Lord Saatchi for bringing this debate on a matter that is very personal to him. I chair the research panel of the Pelican Cancer Foundation based in Basingstoke. One of our members, Professor Bill Heald, pioneered a new technique for removing rectal cancer in the early 1980s. Total mesorectal excision, or TME, reduces the incidence of a recurrent tumour in the pelvis after surgery. Despite many publications, presentations and lectures on his technique, it was not adopted in the UK. The Scandinavians, however, were more convinced of the benefits, and Professor Heald developed a national training programme with them, which was adopted in the Netherlands, Norway and Sweden in the early 1990s. It became part of routine practice, resulting in improved outcomes for rectal cancer patients. It was to take another 10 years before TME became accepted as a routine procedure and best practice in the UK, despite it having been first pioneered in England.

So how can we speed up the take-up of new procedures? How can we accelerate translational research? In 2007, the national cancer action team and the Department of Health introduced the LAPCO training programme for teaching laparoscopic colorectal surgery. The Royal College of Surgeons promoted and delivered the programme through its new skills centres and, now, through specialist hospitals throughout England. This initiative proved so successful that I was recently asked to give a keynote lecture in the United States to offer our experience of teaching and disseminating laparoscopic colorectal surgery to the surgical community, and our methodology for assessing skills and accrediting competence to practise the procedure. The invitation letter said:

“It is my understanding that the UK has done this in a more proactive and safe fashion than we have in the States”,

an acknowledgment that central direction, as occurred with TME in Scandinavia and now with LAPCO, can produce best practice and innovation.

For a national programme of laparoscopic colorectal surgery for cancer, we will need about 460 surgeons trained in the technique. This is because we have a large NHS caseload, and it is required to meet the NICE guidelines on laparoscopic bowel resection. We currently have half that number. We need to be able to release doctors and surgeons to train innovative procedures. This requires incentives, the support of the base hospital when they have to go away to learn techniques, recognition of their efforts through clinical excellence awards—which I am pleased to say have been reinstated—and other marks of recognition. These efforts definitely show that you can improve the outcome for patients, and the benefit to them is real.

In a report in 2001, From theory to theatre: Overcoming barriers to innovation in surgery, the Royal College of Surgeons recommended that surgical trainees should be encouraged to participate in ongoing research and to work with multidisciplinary teams. With the support of CMO Dame Sally Davies, who was mentioned earlier, the Royal College of Surgeons has committed to funding five surgical trial centres from 2013, with the aim of recruiting thousands of patients for these trials. As surgeons, we are often criticised for not getting involved in randomised control trials; the comic opera referred to as “surgeons trying to do research” perhaps refers to this.

It is necessary today for us to carry out these trials because the number of trials carried out in surgical discipline comprises less than 10% of those done in cardiology. The trials units will provide expertise to develop multi-centre surgical trials, offer technical support and speed up the delivery of clinical trials. As surgeons, we are trying.

In order to speed up the process, from theory to theatre, it is vital that we involve patients in decisions about innovative treatment. Patients must understand the potential risks so that they are able to give full, informed consent. The process for doing this is in place—we have study design, ethical approval and patient involvement—but it needs to be expedited. We all know how long it takes to get approval to start a new trial. It is important that we do not have to wait the length of time that Professor Heald in Basingstoke did to introduce a procedure which has clearly saved many patients’ lives.

NHS: Research and Development

Lord Ribeiro Excerpts

Monday 17th December 2012 Lords Chamber

[Earl Howe]

I agree with the noble Lord. The Government are providing a record £800 million over five years for NIHR biomedical research centres and units as from April of this year. The centres are based within the most outstanding NHS and university partnerships in the country; they are leaders in scientific translation; and they will play an integral part in the life sciences strategy which the Government published last year.

[Lord Ribeiro]

My Lords, may I declare an interest as a surgeon and say that surgical research attracts less than 2% of the total funding that goes into research? There may be those in this House who feel that surgeons just cut and do not actually do an awful lot of laboratory work, but the truth is that research is an integral part of surgery. We are there to bring translational research from the lab to the patient and to produce results, particularly in the field of cancer. I would therefore be grateful if my noble friend could assure me that there will be much greater emphasis on providing support for surgery?

[Earl Howe]

I agree with my noble friend about the importance of surgical research. The NIHR funds extensive research in surgery across a wide range of funding streams. The most recent estimate of its spend on directly funded research relating to surgery was £7.3 million, but that is a rather historic figure which goes back to 2009-10. In February this year, the NIHR issued a call for research on the evaluation of technology-driven implanted or implantable medical devices and decisions will be made on that next March. Twenty million pounds has been invested in the NIHR Surgical Reconstruction and Microbiology Research Centre, which is an initiative between my department, the Ministry of Defence, the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. I hope that my noble friend will agree that that is a positive development.

NHS: Women Doctors

Lord Ribeiro Excerpts

Tuesday 6th November 2012 Lords Chamber

[Earl Howe]

My Lords, there is no evidence that there is a problem with female recruitment into the health service. Indeed, the male-to-female gender balance over the past few years has decreased from 1.83:1 in 2001 to 1.25:1 in 2011. However, I recognise that we should not be complacent. Even with the increased participation of women in medicine, we appreciate that more can be done to improve the selection of senior doctors into senior positions.

[Lord Ribeiro]

My Lords, I declare an interest as a member of the committee chaired by the noble Baroness, Lady Deech. In 1998, I introduced the first job-sharing scheme for female trainees in London and Essex. This involved two girls who both had children and managed to complete their training before the 48-hour week was introduced. What efforts are the Government making to encourage job-sharing and less than full-time training?

[Earl Howe]

My Lords, the Government fully support flexible working. We encourage organisations to take account of the recommendation made by the noble Baroness, Lady Deech, on that subject and adopt working arrangements that are amenable both to doctors who are parents and doctors who are carers.