Health: Rheumatoid Arthritis
Lord Turnberg Excerpts(11 years, 9 months ago)
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Earl Howe
My Lords, I pay tribute to the National Rheumatoid Arthritis Society, which is organising Rheumatoid Arthritis Awareness Week this week, between 16 and 22 June. I am aware that Public Health England has run early diagnosis campaigns, which up to now have focused largely on cancer. However, I understand that a broader focus on earlier diagnosis is currently being considered. What might be done to tackle other conditions or symptoms has yet to be decided, but I will keep the noble Baroness informed of developments.
Lord Turnberg (Lab)
My Lords, one of the problems is that there are still far too many single-handed general practices, which have great difficulty providing a full range of services. Are the Government doing anything to try to bring them into bigger groupings?
Earl Howe
My Lords, we are encouraging single-handed practices not to disband but to federate themselves—if that is a good word—with other practices in the area, and certainly to seek the support of their clinical commissioning group. That would ensure that the range of professional training available is utilised and that there is peer support where appropriate. Therefore, while many single-handed practices do a very fine job, there is scope for them to collaborate with their colleagues in the local area.
National Health Service: Hospital Beds
Lord Turnberg Excerpts(11 years, 9 months ago)
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Lord Turnberg (Lab)
My Lords, is the noble Earl aware that we have one of the highest rates of bed occupancy in the EU, approaching 90%, and yet we have the lowest average length of stay? All this makes it extremely difficult to think about reducing bed numbers still further.
Earl Howe
In fact, average annual bed occupancy rates have been stable at around 84% to 87% since 2000. Of course, that rate goes up and down. We know that winter sees greater pressure on bed occupancy, but the NHS has long experience in managing peaks in demand, particularly over the winter. We do not set optimum bed occupancy requirements on the NHS. As the noble Lord knows well, that is a matter for the local NHS to manage.
Elderly People: Abuse
Lord Turnberg Excerpts(11 years, 10 months ago)
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Lord Turnberg (Lab)
My Lords, I, too, am grateful to the noble Baroness, Lady Cumberlege, for raising this important issue. We cannot say we have not been warned about abuse of the elderly. Numerous detailed reports have been published over many years, and we have not neglected to talk about it in your Lordships’ House either. The Government’s response to the Francis report on the Mid Staffs affair was well meant and the Care Bill we passed last week is very helpful, but to my mind, neither of them is aimed at the right targets, nor are they sufficient. They both place far too much emphasis on inspection and punishment for wrongdoing, which of course is essential, and far too little emphasis on measures to prevent bad behaviour happening in the first place.
It is possible that we do not recognise often enough how difficult and taxing, both physically and mentally, the job of caring for elderly people really is. Quite apart from the nature of the job of feeding, toileting and cleaning physically disabled people, many of whom may be mentally disturbed and sometimes resistant or even aggressive, we have to face the fact that these jobs are spectacularly underpaid and underappreciated. They are not appealing jobs and they attract only very specific types of people: those who are dedicated to caring, angelic individuals who are devoted to looking after others. We are fortunate that there are many who fit into that category, but we should not take advantage of these remarkable people by giving them such poor recognition and little to bolster their self-esteem. No wonder there is a high turnover and absentee rate. Job satisfaction depends on being appreciated and there is no doubt that, where carers are appreciated, those who they are caring for gain the benefit. So what can we do to attract carers, and having done so, give them a sense of esteem and job satisfaction?
First, we must pay them better. Jobs in care homes are among the lowest paid anywhere. I fear that the profit motive of some care home operators may be just too strong and the low wages on offer will put off many whom we want to bring in. Also, local authorities are so cash-strapped now that, after a 30% drop in their funding, their services are clearly failing to keep up with rising demand. Poorly funded and understaffed services, leading to rushed overworked carers, are hardly conducive to the sort of care we aspire to.
Secondly, there is then the problem of a lack of professional training and qualification for care workers. We have gone some way along that route, with the help of the noble Earl and with a recognition that training should be an essential part of these posts. However, we are still some way off offering registration to allow care workers that self-satisfaction that comes with belonging to a qualified profession. We have been trying for some time in this House to correct this anomaly and I have no doubt that we will hear more about this topic.
Thirdly, there is the big problem of poor supervision in care homes and hospital wards. There seems little doubt to my mind that a well qualified, competent and active person supervising care at that level is of enormous benefit. These people are the key element in the mix leading to high-quality care. However, here again, recruitment to these posts and retention of people in them is dependent on making them attractive. Nursing sisters in charge of hospital wards should be recognised as having career-grade posts, so that these nurses are not attracted by the prospect of promotion off the ward after a year or so. They should be rewarded appropriately.
Finally, it is good to see in the Care Bill a duty on local authorities to investigate accusations of abuse. However, again, this is after any abuse has occurred and it is rather more important for those commissioning services to take greater care in ensuring that standards for the care that they commission are up to scratch. I look forward to the noble Earl’s response.
National Health Service: Nursing Staff
Lord Turnberg Excerpts(11 years, 10 months ago)
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Earl Howe
My Lords, as regards specialist nurses, the Government have supported the development of a range of specialist roles within the profession. In the end it is for local NHS organisations, with their knowledge of the needs of the local population, to invest in training for specialist skills and to deploy specialist nurses. We recognise that more could be done by some local healthcare organisations in this area, and Health Education England is able to support employers with continuing personal and professional development—but within clear limits. The planning process has created an opportunity for employers, through the LETBs—local education and training boards—to prioritise investment in this area.
Lord Turnberg (Lab)
My Lords, the number of nurses may have gone up a little, but the main problem is the marked reduction in the number of senior nurses on wards. These are the women and men who are in charge of a ward and make sure that care is properly delivered at the ward level. Does the noble Earl consider that this particular loss is because we do not reward and value these key individuals well enough to recruit or retain them?
Earl Howe
My Lords, as the noble Lord will be aware, finances in the NHS are tight. However, as I said earlier, there are now 5,100 more nurses on our wards than there were in May 2010. That must indicate that nursing is still an attractive profession for the brightest and the best of our young men and women.
Care Bill [HL]
Lord Turnberg Excerpts(11 years, 10 months ago)
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Lord Turnberg
“(b) biomedical and health research.”
Lord Turnberg
My Lords, I am grateful to the Minister for that full and helpful description of the background to this whole area of the use of confidential information. There is little doubt that public confidence in the uses to which their confidential information may be put has been badly shaken. For example, a number of recent revelations that access has been gained by one means or another by commercial organisations, insurance companies and so on has made the public—and many general practitioners—very wary and anxious.
That is why I want to put my own amendment, Amendment 45C, into the context of Amendment 45F, proposed by the noble Lord, Lord Owen, which emphasises a much stronger oversight by a statutory body: similar to, but stronger than, the Confidentiality Advisory Group chaired by Dame Fiona Caldicott, who commands such public respect and confidence. That is why I intend to support it if he moves it.
It is only against that background—of strong oversight and carefully controlled and limited access to such sensitive data—that we can even consider the very specific circumstances in which we can allow their use: not only legitimate use, but those uses which are vital for the benefit of the public and their health.
Lord Turnberg
My Lords, I was rather encouraged by the noble Earl’s initial remarks about strengthening Dame Fiona Caldicott’s committee and making clearer what role it might be able to play.
The problem I wanted to address in Amendment 45C is the uncertainty in the ways in which the words “promotion of health” may be interpreted. I know that the noble Earl has said that they cover research, for example. What about research that does not immediately seem to promote health? It is this rather vague term that I wanted to clarify. It is not about trying to unravel the legislation, as someone has suggested. It is about making it absolutely clear. I am afraid I was not very convinced by the noble Earl, and I beg leave to ask for the opinion of the House.
NHS: Bed Capacity
Lord Turnberg Excerpts(12 years ago)
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Earl Howe
Yes, my Lords. As ever, the noble Baroness makes an extremely good point. It is heartening that infection rates have come dramatically down in hospitals over the past few years, but we can never be complacent and it is important that when a patient is moved the infection question is always considered.
Lord Turnberg (Lab)
My Lords, is it not the case that we have the lowest number of beds per head of population of any OECD country, bed occupancy rates of approaching 90%—a dangerously high level—and, despite all that, the shortest lengths of stay of any European country? Does the noble Earl agree that the idea of closing wards or hospitals can only worsen the situation, unless, of course, we are able to build up the community services before we do any of that?
Earl Howe
I agree with the principle that the noble Lord has articulated. Certainly, commissioners and providers of care should reduce beds only where it is clinically safe and appropriate to do so. The NHS is very experienced at flexing the number of beds it has available; it does this every year and every winter. As a principle, I would agree with the noble Lord but I come back to the point that bed occupancy rates have, in fact, remained stable over the past 10 years, fluctuating between 84% and 88% on average, and increasing slightly over the winter period.
NHS: Midwives
Lord Turnberg Excerpts(12 years ago)
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Earl Howe
The noble Baroness is quite right. Helping commissioners to reduce unwarranted variation in service delivery is one of the key roles of the maternity and children strategic clinical networks, as I am sure she is aware, which are being established and supported by NHS England. Clinical commissioning groups are responsible for commissioning maternity services locally, but they work with local authorities and in conjunction with provider partners to give assurance that processes and service specifications are in place which ensure that midwifery staffing is appropriate for the locality.
Lord Turnberg (Lab)
My Lords, the number of births has gone up by 25% in the past 10 years. The vacancy rate among midwives is about 11%. That is the long-term vacancy rate. There seems to be a problem with recruitment and retention. Despite the figures that the noble Earl has cited, we are in some difficulty.
Earl Howe
The noble Lord is right. We recognised that issue at the outset of the Government, which is why we were determined that the number of midwives in training should be increased. It is now at a record number of 6,000. The number of trained midwives is increasing—that is, full-time equivalent midwives practising in the NHS rather than just on the register. We are heading in the right direction, but there is a long way to go.
Alcohol: Calorie Labelling
Lord Turnberg Excerpts(12 years ago)
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Earl Howe
No, I do not, but it is worth noting that 49 businesses have signed up to the voluntary responsibility deal pledge on awareness of alcohol units, calories and other information. Those organisations have published calorie information on their websites about every single alcohol product. If one is buying online, it is possible to compare one product with another.
Lord Turnberg (Lab)
My Lords, is the noble Earl aware that alcopops are rearing their heads again? These sweetened drinks have sugar added to them to make them attractive, in a cynical attempt to bring the young on board to alcohol. They contain more than 170 calories a bottle—about the same as a sweetened chocolate milk drink—as well as the alcohol. Is there anything we can do to bring this to the attention of the supermarkets? I believe Sainsbury’s has alcopops on its shelves now.
Earl Howe
My Lords, in fact, sales of alcopops are in marked decline, to such an extent that the market for these products looks like disappearing in the next few years. Nevertheless, I take the noble Lord’s point. It is always a concern if people are putting their health at risk by drinking too much alcohol or consuming too much sugar. At the same time, one should not always assume that an alcopop is a high-calorie drink. For example, ready-mixed gin and tonic is technically an alcopop, but very often low-calorie tonic goes into it.
Regenerative Medicine: S&T Committee Report
Lord Turnberg Excerpts(12 years ago)
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Lord Turnberg (Lab)
My Lords, I am delighted to reiterate the remarks of the noble Lord, Lord Patel, in congratulating the noble Lord, Lord Krebs, on chairing our Select Committee so ably, and on the support of his expert adviser and secretariat. I also commend the noble Lord, Lord Patel, for introducing this topic and for explaining so clearly the enormous potential of regenerative medicine to cure diseases that are hitherto incurable, and for pointing out the considerable benefit we have from our expert scientific base in the UK.
I express my interests as scientific adviser to the Association of Medical Research Charities, many of whose members have strong interests and involvement in regenerative medicine.
It is worth noting that our report was produced last summer after taking evidence for more than a year and that things have moved on since then. It is a rapidly moving field and some things have changed for the better while others have been thrown into starker relief. There have been more advances in the science; clinical applications are being developed; the mood in the investment community, oddly enough, has improved—I am told that there is a greater appetite among venture capitalists to take the risks needed to invest in the field; and there is some hope that we will see some of the recommendations of our report being put into action.
However, I want to focus on only three aspects: the complex regulatory framework; the MHRA and MEA approval processes; and our capacity to manufacture and scale up production.
First, on the regulatory framework, I hope to build on the words of the noble Earl, Lord Selborne, and I know that the noble Lord, Lord Willis, will also take up the cudgels on regulation. Under the regulatory framework, a researcher or a small biotech company wanting to take a discovery forward for further development in a clinical trial or commercialisation will be faced with no fewer than 11 regulatory bodies that they may have to apply to. This morass of bodies, with a mix of acronyms from the HFEA to the HTA, from GTAC to the MHRA, from the EMA to the HRA—to say nothing of having to jump through the hoops of NICE—is extremely confusing, and not only to the novice. The UK has many more regulators than virtually any other country in the world, and certainly more than the USA, which seems to have one.
Our recommendations focus on the need to take a grip of this complexity and suggest that the Health Research Authority should expand its current role in streamlining the regulatory process. The HRA is doing an admirable job within its limited resources. It is under the expert guidance of Professor Jonathan Montgomery, and in a pilot study that it has already carried out, it has demonstrated that it could do much more. The authority has shown that it could provide a sort of one-stop shop for researchers so that a single application made to the HRA would be fed through a gateway for approval by the authority where it has the competence to do so or distributed to those other bodies that need to give their approval. This would be a remarkable achievement if it could be done and would transform the atmosphere for researchers. However, of course, it requires more funding for the HRA. It would not need vast sums, and could indeed be achieved with a modest investment, while the gains made, both financially and in saving wasted time, would be enormous. My first question for the noble Earl is whether he will examine whether there is some way to find the modest extra money needed. I know that a bid from the authority has gone in to the department, and it would be helpful if he could tell us how far it has got.
I turn now to the processes by which new treatments are assessed by the Medicines and Healthcare products Regulatory Agency. Here the timescale is almost always very long, and sometimes it can several years and involve large and expensive phase III trials. However, for treatments such as those using regenerative medicines, stem cells and the like, such a lengthy process is quite inappropriate. This has been recognised in Japan and the USA, where a much more flexible approach has been taken. In Japan, as the noble Earl, Lord Selborne, mentioned, the law has recently been changed so that approval for regenerative medicines can be based on phase II trial evidence alone, without the need for phase III trials. In the USA, the FDA has introduced what is called a breakthrough therapy designation that provides a similar phase II-only requirement. I know that the MHRA recognises the need for something similar here, and it would be extremely helpful if the noble Earl could indicate how far the expert group set up by the MHRA has progressed in its efforts to develop an adaptive licensing system to speed up approval of these types of innovative treatment. The Government are paying much more attention to the need for innovation in healthcare, and certainly those in the field would find the efforts of the MHRA encouraging. It would allow us to keep up with our rivals around the world.
Finally, I come to another concern. Our report described a reluctance among venture capitalists to invest in biotech in general and in regenerative medicine in particular, and I mentioned earlier that the situation here may be changing. The so-called valley of death between invention and commercialisation may not be as deep as we thought, even though we remain way behind the more adventurous investors in the USA. However, as prospects for investors are now improving and more cell-based therapies appear to be coming on stream, the problem of the lack of manufacturing capacity to take these advances to the market has been shown to be much more obviously rate-limiting than had been thought. We have drawn attention to this problem in several of our recommendations and we have had supportive responses from the Government and others, but much more needs to be done. Our ability to scale up the production of these highly specialised treatments so that they can become available to large numbers of patients is sorely lacking. I feel that the UK Regenerative Medicine Platform, which has been asked to take this on and which could have had all this in hand, has been just a touch complacent. In this light, can the noble Earl tell us how far the Ministerial Industry Strategy Group, which met in November, got with its discussions on manufacturing capacity? What recommendations, if any, emerged as a result of that meeting?
I note that the Cell Therapy Catapult is gathering evidence on capacity, but that alone will not solve the problem if we do not offer some inducement to those who need to build up our manufacturing capacity. It is also the case that the resources available to the catapult are limited and will only go a little way in offering this inducement. Is there any prospect that the Technology Strategy Board will offer more support for this purpose? Will the UKTI Life Science Investment Organisation play a role in helping fill this gap? It will certainly be offering advice and information to potential investors overseas. What practical encouragement will it be able to offer companies that they will be supported if they come here?
The potential for regenerative medicine to transform healthcare in the next few decades is enormous. We must take advantage of the lead we have in basic research and convert it into therapies for patients and economic benefits for the UK. There are encouraging signs, and the Government are clearly aware of the importance of investing in this area, but there is much that remains to be done. In particular, we must make sure that we have a regulatory environment that is efficient and fit for purpose, that we keep up with the competition with a responsive and speedy approval system, and that we are well prepared with the capacity to manufacture to scale these potentially remarkable treatments.
Medical Act 1983 (Amendment) (Knowledge of English) Order 2014
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Lord Walton of Detchant (CB)
My Lords, I cannot say how welcome this order is. Forty-three years ago I was elected dean of the medical school of the University of Newcastle. By virtue of that election, I was immediately appointed to the General Medical Council. I became a member of its education committee and three years later I became the chairman of that committee. By virtue of being chairman of the education committee of the GMC, I was then appointed, under the new arrangements for the European Union, to the Advisory Committee on Medical Training, which met twice a year in Brussels and was required to make recommendations on basic medical education, specialist medical education and the mutual recognition of qualifications.
That was an interesting experience. Under the treaty of Rome, the first directive derived from that treaty said—I am not quoting exactly but the meaning is clear—that in the movement of doctors across the European Union there should be mutual recognition of qualifications and registration should be granted, but that it should be up to the host country to see to it that the incoming doctor had such ability to communicate with patients to make him or her safe to practise. That seemed to give us at the GMC full authority to embark upon establishing a language test.
At that time, for historical reasons, some doctors from outside the European Union—from Commonwealth countries such as Australia, New Zealand, the West Indies and many others—had enabled the General Medical Council to inspect their examinations and qualifications so they were automatically granted full registration under the Medical Act. But doctors from many other countries who had not had that ability to have inspections were required to apply for temporary registration if they wished to come to the UK, and they had to take a test set by the Professional and Linguistic Assessments Board, which established tests of not only clinical and academic competence but language capability. That was the so-called PLAB test.
It is important to make the point that the rights of doctors graduating in any other member country of the European Union applied only to those who had graduated in those countries but who were also nationals of EU member states. For instance, if a doctor from a country outside the European Union graduated from, say, Heidelberg, they were not entitled under that treaty to come to the UK and had to go through the same procedure as a doctor from India, Pakistan or other parts of the world.
Indeed, there was one such doctor, an Iranian, who qualified in medicine in Heidelberg. He applied for registration with the General Medical Council and was turned down. He took the GMC to a judicial review. Of course, he lost because he did not qualify. The result of this was that I was interviewed by Special Branch because he had made serious threats against my person, including threats of violence. However, we will leave that alone for a moment.
The point I wish to make is that it is so important that we have this language test. We at the GMC, having read what the directive said, tried to impose a language test on incoming doctors from the European Union, but we were threatened with being taken to the European Court because we were told very clearly by our lawyers and by the lawyers from Europe that this was contrary to the treaty of Rome. We tried again 10 years later when I became president of the General Medical Council, again with a total lack of success. All we were able to do then was to persuade the employing authorities in the UK, through the Department of Health, that they could impose a language test as a condition of employment. Regrettably, that agreement with the Department of Health was never properly or widely fulfilled across the UK, so a language test as a condition of employment for European doctors was not widely employed. Our attempts at that time were lost.
The great thing about this order is, first, that it makes it clear that the GMC can properly design and employ a test of the language ability of an incoming doctor from the EC as a condition of registration. Secondly, the responsible officer can make certain that any doctor coming up for revalidation speaks English adequately. Finally, when any doctor who is already a specialist from the EC or is working either in general practice or in a specialist grade and is brought before the GMC on the question of fitness to practise, the fitness-to-practise procedures can take note of the doctor’s ability to speak English. These are extremely welcome developments. Perhaps I am wrong about the condition of registration but the GMC, I think, is hoping that that is the effect of this order. Perhaps the Minister can clarify it for us. The whole process set out in this paper is extremely welcome and long awaited.
Lord Turnberg (Lab)
My Lords, it is always a challenge to follow the erudition of my noble friend Lord Walton, who certainly has no difficulty with the English language. I am sorry to add to the noble Earl’s load of potential medical speakers this afternoon but it is a pleasure to welcome this initiative which at long last gives the GMC the powers to ensure that doctors coming to work in the UK can speak and understand English. It has been long awaited and although it has always been part of the assessment of non-EU doctors it will now be a requirement for EU doctors too. After all that, it might sound a little churlish to say that there remain some things to be done about long-running issues that are not addressed in this statutory instrument. I hope the noble Earl will forgive me for mentioning them here.
I go back a little while, not quite as long as my noble friend Lord Walton, to when I was chairman of the Specialist Training Authority and the EU directives were being produced in the 1990s. Since those directives governing the free flow of workers across the EU came in, doctors trained in other member states can come to practise in the UK quite freely. However, we recognised from the very beginning that we know relatively little about the training of specialists in other EU countries. We have no knowledge of the curriculum they go through or the skills and knowledge of, for example, cardiologists, neurosurgeons and paediatricians from a selection of EU counties such as France, Italy, Spain and Germany. They may be perfectly fine, of course, and they probably are, but apart from knowing that they have spent a certain minimum number of years in training, we are not allowed in the UK to assess any of their knowledge or skills before they are put on the register of specialists. That is not the case for specialists coming from, say, America, Australia, New Zealand or any other non-EU country; they have to have their training and skills properly assessed and they may be required to take more.
Questions about the safety of our patients as far as EU doctors are concerned have been raised in this House in the past, but I have little confidence that we will be able to change the arrangements now when we would, it seems, have to convince the other EU member countries of this problem. Will the noble Earl seek advice from the GMC on how it intends to check on the safe practice of specialists from other EU countries? It is possible that its system of responsible officers may help. However, the GMC can act only after a doctor is already on the specialist register. There is a question of whether there is sufficient capacity in the responsible officer network. It would helpful if this issue could be aired a little further. I hope that the noble Earl will be able to find out from the GMC how far it can go on this.