Health: Sepsis

Lord Turnberg Excerpts

Thursday 14th September 2017 Lords Chamber

[Lord O’Shaughnessy]

I am sorry to hear that sepsis has affected the noble Baroness’s husband in that way and I am glad to learn that he is not one of the more than 40,000 people who die from the condition every year. Public awareness is critical and, as I say, we are looking at new ideas for how to get the message across using a range of routes. The point about clinical awareness is also very important. Until a couple of years ago, there was no widespread clinical awareness of the symptoms of sepsis and how to assess and then treat people, but we have seen quite a big improvement. I can give one example. For those presenting with symptoms in emergency departments, previously only around half were assessed for sepsis; the figure is now up to nearly 90%. I see that as good progress, but clearly there is much more to do.

[Lord Turnberg (Lab)]

My Lords, one of the major difficulties with sepsis is the fact that it is so speedy. It can kill within a few hours. Awareness of this speed is vital—for the public and for practitioners.

[Lord O'Shaughnessy]

That is absolutely right but I draw the attention of the noble Lord to a couple of things. First, in the NICE quality standard published yesterday there are some very clear statements about the speed with which people suspected of these symptoms should be treated. Those are quite robust in terms of getting intravenous antibiotics to people within an hour, being reassessed by a senior clinician if they then fail to improve within an hour and so on. That is very clear and there is implementation guidance going through. Another thing announced yesterday is quite important. It is a slightly odd phrase but “safety netting” is where someone has been assessed on whether they have sepsis, does not have it but is sent away with materials that show what the symptoms might be and how to report back if their condition deteriorates.

Health Workers: Training

Lord Turnberg Excerpts

Wednesday 18th January 2017 Lords Chamber

[Baroness Hollins (CB)]

My Lords—

[Lord Turnberg (Lab)]

My Lords—

[Lord Bird (CB)]

My Lords—

--- Later in debate ---

[Lord O'Shaughnessy]

The Prime Minister has been incredibly clear on this point—and was again yesterday. It is our intention to do so, and to agree that early with our EU partners. But that is something that needs to be reciprocated.

[Lord Turnberg]

My Lords, we certainly need more doctors and nurses. The problem is that we are not retaining as many as we should, and there is no doubt that they feel denigrated and devalued. They really need to feel appreciated rather than kicked around all the time. Are the Government going to help them in any way whatever, or are they going to be constantly criticised?

[Lord O'Shaughnessy]

I do not believe that we are criticising. To take the noble Lord’s point, he is right that there is often negativity in the media about the performance of health professionals. But it is worth pointing out that in a recent poll earlier this week, those who believe that the NHS provides a high standard of care is now at 71%, up 13% since 2013. That is a huge testament to the amazing work that our NHS does.

Health and Social Care

Lord Turnberg Excerpts

Thursday 24th November 2016 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I also congratulate the noble Baroness, Lady Finlay, on securing the debate and giving us this opportunity in her usual clear and erudite manner. I refer noble Lords to my interests in the register.

It is pretty obvious that the noble Lord, Lord Hunt, could not be here today. I am sure he is almost as unhappy as I am that he is not here, but this has been rather a depressing debate. Of course, this is not the first time we have had a debate on this topic. When we had our earlier debate in July, the noble Lord, Lord Prior, suggested that we should have another debate in three or four months’ time, when he must have presumed that we would have more clarity on the Government’s thinking. I therefore very much look forward to hearing what he has to say today.

Two messages are clear from virtually every noble Lord who has spoken. First, the NHS and social care are in dire straits. Every report we see and everything we hear from people working in these services say the same thing. Even the National Audit Office and the Public Accounts Committee say that we cannot go on as we are. The Chancellor did nothing yesterday to offer any relief.

On top of that, we are threatened by the possibility of losing the support of our EU immigrant staff on whom we rely so heavily—a double whammy. Everyone who has spoken today, and everyone both inside government and outside it, say the same thing: that these staff represent an invaluable asset and provide vital support for the NHS and social care.

I sit on the Select Committee on the Long-Term Sustainability of the NHS. While the ostensible purpose of that committee is to gain an idea of what the future will bring for the NHS in 20 or 30 years, we have been unable to get any of the innumerable witnesses who have come before us to engage in anything but the immediate problems they face today. They are entirely taken up with how they are going to survive this next year and cannot lift their heads up from firefighting today.

I shall not reiterate the catalogue of uncomfortable data that we have heard today which emphasise the size of the problems we face, save to mention just a couple of the most glaring facts. My noble friend Lord Lipsey spoke so clearly about social care, where the 25% cuts that we have seen over the past few years are causing the most acute problems. According to Age UK, 1.8 million elderly people are not receiving the care they need—the noble Baroness, Lady Brinton, spoke of 1.2 million; I do not know which figure is right, but both are awfully large numbers.

Last week’s debate in the other place spelt out in unhappy detail the dire problems due to the cuts in local authority funding. Now the CQC and the Local Government Association talk of social care services being at “tipping point”. In the NHS, eight out of 10 hospitals say that they cannot ensure a safe rota of nurse care throughout the day and night. The Royal College of Paediatrics and Child Health tells us that it cannot fulfil its rota arrangements as its paediatric vacancy rates rise. Everyone, from the royal colleges, the King’s Fund, the Nuffield Trust and now even the GMC, is warning of the impact of the cumulative shortfall on standards of care—the noble Lord, Lord Warner, laid it all out in depressing detail.

This week, I met a young doctor working in a large London teaching hospital who told me that he had just spent a 10-hour stretch without a break in the A&E department. When I asked him how many of the patients whom he saw did not need to come to that department, he said that the great majority should have been dealt with by their GPs if only they did not have to wait a couple of weeks for an appointment. What a sad state of affairs. Now the public are waking up to the problems, as newspapers begin to show pictures of queues of patients lying waiting for hours on trolleys in A&E departments.

It is against that background that we have to face the possibility that 5% or 10% of the workforce might be lost if we do not take action to prevent the potential damage of Brexit. We have heard the figures: a vulnerable 5% overall and a particularly severe impact in London and the south-east, where 10% of the workforce are EU immigrants. The figures are frightening. In London, more than 40% of social care workers are immigrants. In nursing, already with 23,000 vacant posts, they are desperate to reassure and retain the 33,000 nurses trained outside the UK who now feel rather insecure. Midwifery is no better off. A striking example of its vulnerability is UCH, 32% of whose midwives are qualified in the EU outside the UK.

Among the 30,000 doctors on the UK medical register and who qualified in other EU countries there are many vulnerable specialties such as surgery, psychiatry and so on. There is a particular case in the large teaching hospitals that are so attractive to academic clinicians from abroad. Overall, 15% of academic clinicians in our hospitals qualified in the EU. They can go almost anywhere in the world to work. Will we be able to keep them here and will we continue to attract a continuing stream of them? We will certainly be at a disadvantage if we lose our capacity to attract them. The noble Lord, Lord Bilimoria, spelled out the need for scientific collaboration.

We have heard all sorts of encouraging words from the Secretary of State, the Prime Minister and the noble Lord the Minister about how much they value the contribution of our immigrant staff and how important it is to reassure them that their future is safe. However, there remains considerable uncertainty in the minds of many and this perception is not helped by the way that the Government keep their negotiating cards so close to their chest. There is a feeling among our own EU staff that they are being used as bargaining chips in the negotiation to strengthen the position of UK expats living in other EU countries—that if they can stay there then we can allow EU healthcare workers to stay in the UK. That may be a cynical view and it will probably be denied, but that is certainly one perception that is difficult to dispel.

Let me briefly outline a couple of other areas of concern. First, in public health, we rely on the European Centre for Disease Prevention and Control to work closely with our own Public Health England laboratories for the rapid detection of outbreaks of infectious diseases and the sharing of information about them. As the noble Baroness, Lady Finlay, said so powerfully, infections, unlike immigrants, know no borders, and we can ill afford a barrier to the flow of information. What discussions are being held to ensure that we can maintain this vitally important link?

I mentioned the need to attract academic clinicians, but what is the Government’s plan to deal with the fall-out when the European Medicines Agency moves out of the UK, as is now inevitable? We will certainly lose jobs, but currently we have very close and invaluable access to the EMA by industry and researchers engaged in clinical trials. This will be lost unless we can make special arrangements. What thoughts have the Government given to dealing with this problem?

The European working time directive has had its critics, but its aim to improve the health and safety of our staff should not be readily jettisoned. Will we be able to retain it or something similar?

Several other actions the Government could take might offer some mitigation. For a start, they could certainly be more open about their intentions for this particular group of workers. The suggestion that they do not want to reveal their negotiating hand too early really does not wash. Surely starting with a strongly stated and clear position on what we require can only strengthen our position.

What about the status of the Migration Advisory Committee? I understand that it maintains a shortage occupation list that provides for certain groups of staff to come to work in the UK from abroad, and that this includes nurses. Will the noble Lord consider the prospect of expanding that committee’s list of permitted staff to include a range of threatened and vitally important NHS staff?

To reiterate the plea from the noble Baroness, Lady Finlay, about the Medical Training Initiative that we currently operate for non-EU specialists to come to the UK for two years’ training before they return home, is there a prospect for that scheme to be expanded to incorporate EU doctors across all specialties?

As far as doctors and nurses already here are concerned, can the Minister confirm that if they are now on the register they will continue to be recognised and as a result will be able to continue to work here? That would go an enormous way to reassure them. There are many steps the Government might take to reassure both our services and our immigrant staff. I hope that the noble Lord, Lord Prior, will be able to offer some comfort.

Bread and Flour Regulations (Folic Acid) Bill [HL]

Lord Turnberg Excerpts

Friday 8th July 2016 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, the usual folate aficionados speaking in this debate do not need me to talk about all the nasty effects of neural tube defects, spina bifida and the impact on children’s lives and that of their parents, or repeat that folic acid given early in pregnancy is an extraordinarily effective preventive measure akin to vaccination and immunisation. There is no argument anywhere against that. We also know that if it is to work, folic acid must be taken before a woman knows she is pregnant because the neural tube forms in the first 28 days. Taking it when she confirms that she is pregnant is just too late. All that is accepted.

The argument for fortification has been made many times and, indeed, as we have heard, has been accepted in very many countries. Now many millions of people across the world have been eating bread made with fortified flour for very many years, and it seems that Scotland is about to follow. So what are the arguments against fortification in the UK? These rely on two major premises. First, this would be a case of mass medication and we should avoid that whenever possible. That is not unreasonable. It is a type of philosophical argument about free will and freedom of choice, and I understand that. However, I cannot accept it in this case. We already fortify our flour with iron, calcium and Vitamin B1—thiamine—without a peep from anyone.

I hope that I do not offend noble Lords if I say that I have just had a sandwich in the Bishops’ Bar, and that I do not scare them when I tell them what was in the sandwich. In the white bread there was some wheat flour—that was useful—with added calcium, iron, niacin and thiamine. There was water, yeast, salt—that is reasonable—emulsifier, E472e, soya flour, preservative, E282, rapeseed oil, flour treatment agent—whatever that is—and a smidgen of E300. We add these things, and many others, despite the fact that the case for these sorts of fortification, especially of vitamin B1, are not nearly so compelling as that for folic acid. Vitamin B1 deficiency was something we saw in concentration camp victims. In normal life and normal diets, it is as rare as hen’s teeth. Folate deficiency, on the other hand, is common, and its potential to cause devastating disease is there for everyone to see and accept.

The second argument against fortification is that folic acid, when taken in excess, can cause unpleasant side effects. That, too, is a rather specious argument. The amounts we are talking about, and the form in which it is added to flour, have been shown to be perfectly safe. Just look at the control trial in which the whole population of North America—many millions of people—took fortified flour for 10 or more years. You might have expected some of the threatened changes and dangers to have emerged, but there has been none. Large doses of folic acid may possibly be problematic, but then large doses of iron are also dangerous, yet we have carried on with iron fortification. Large doses of almost anything are dangerous. However, what we are talking about here is a small dose—a minute dose—that would pose no conceivable danger to anyone else and would prevent a very nasty disease.

I strongly support this Bill and am grateful to the noble Lord, Lord Rooker, for his persistence and tenacity. I hope that the Minister will think again about this whole thing.

NHS: Junior Doctors’ Contract

Lord Turnberg Excerpts

Wednesday 6th July 2016 Lords Chamber

[Lord Prior of Brampton]

Safety was clearly a major consideration in the minds of junior doctors when the original contract was negotiated, but the leadership of the BMA agreed with us that their safety concerns had been fully taken into account in the new contract. As far as numbers of doctors are concerned, we have plans to train a further 5,000 GPs over the next four years, but unquestionably there are gaps in many rotas around the country, and we do rely heavily on doctors from overseas to fill those gaps.

[Lord Turnberg (Lab)]

There has been much made of the fact that the junior doctors are extremely disillusioned. I think that is undeniable. It is perhaps not so well recognised that “junior doctors” includes a large number who are well into their 30s, who are very well trained and on whom the NHS relies entirely.

[Lord Prior of Brampton]

One fact that has come over very loudly to me during the past year is that the whole definition of “junior doctors” is an absurd one. Many junior doctors have been in training for many years and we rely on them to deliver much of our front-line care. It is just another reason why it is so important, as other noble Lords have mentioned, that we rebuild the trust of junior doctors.

NHS: Bursaries

Lord Turnberg Excerpts

Wednesday 25th May 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the reason for the discrepancy is that at the moment the bursary system effectively caps the number of student places for nursing. One of the purposes of moving to the loan system is to remove that cap and our estimate is that by so doing an additional 10,000 places will be created between 2017 and 2020.

[Lord Turnberg (Lab)]

My Lords, if you go to any nursing graduation ceremony you will see lots of 30 and 40 year-old women who have been carers and who now wish to retrain as nurses. This is a very valuable asset for the health service, and yet they are just the people who may be disenfranchised by this policy. Is it not crazy to do this?

[Lord Prior of Brampton]

My Lords, the loan will be available to mature students as well as to students taking their first degree. The loan structure is such that if someone will not be working for as long as a younger nurse they will not in all likelihood repay the whole of the loan, which will be written off at the end of the period. I agree entirely with what the noble Lord says; we depend heavily on mature students coming into nursing. Our view is that this will not put off those people.

Health: Neural Tube Defects

Lord Turnberg Excerpts

Monday 21st March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I cannot answer the latter question, but I will try to find out and write to the noble Baroness. She is right that Scotland is considering this and looking at the practical issues around implementation. She is right that other countries in the world—I think 50—have done this, but many others have not, including all European Union countries.

[Lord Turnberg (Lab)]

My Lords, I realise that the noble Lord is in the hands of his scientific advisory committee and cannot say anything without it, but I ask him to draw to its attention the fact that it may be using outdated research evidence if it believes that adding the small amounts of folic acid to bread has the same metabolic effect as taking 1 milligram of tablet a day. It does not. The very remote possibility that there is danger in taking 1 milligram of tablet a day is eliminated completely if you add it to food and take it during the day. Will he draw that to the committee’s attention and ask it to think again?

[Lord Prior of Brampton]

I will certainly draw that point to the attention of the SACN. It would be surprising if it was not already aware of that fact, but as I said I am addressing not really the science but whether it is right or proportionate to fortify bread for everybody to reach such a small number of people.

General Practitioners: Appointments

Lord Turnberg Excerpts

Thursday 17th March 2016 Grand Committee

[Lord Turnberg (Lab)]

My Lords, I am extremely grateful to the noble Earl, Lord Attlee, for bringing this important subject to debate. I fear that it is now widely acknowledged that the situation in primary care is dire. However, I have to say that my own general practice seems to be an exception; perhaps because it is in leafy Hampstead, perhaps because it has enough partners and staff to withstand the buffeting of the rest of the NHS, and perhaps because it has such excellent leadership. Or, most likely, because it has all three. Elsewhere, in much of the country, general practice lacks all three and the picture is less than rosy. Many practices are small, with two or three partners, and if one goes off sick, retires early or goes abroad, the remaining one or two are stuck in an almost unsustainable situation.

One young GP I know is struggling with just such a burden. She is about to lose her partner, who is retiring early, and she is now running her practice with little or no support. She is finding it impossible to attract any staff to join her and cannot find another GP to come into her practice. There are just too few around who want to work in a less than affluent part of London, despite the Government’s blandishments. It is very hard for her to find other staff too. Meanwhile, she is running around, sitting on committees and the local CCG, as well as dealing with the mound of NHS-inspired paperwork and trying to look after her young family at the same time. Working from eight in the morning until eight at night is an impossible burden to place on anyone. I fear that that is the experience of far too many GPs and it is not much wonder that too many are leaving early and too few are willing to join.

It is absolutely vital that the Government rethink their efforts to encourage and support GPs. Whatever they are doing now is clearly not working properly. Of course, every area of the NHS is suffering from underfunding but primary care, once the beacon of the service, is now merely a flickering candle. If there is anywhere that the NHS needs to see reignited, it is primary care. Of course, a move to larger group practices, with added support, where that can be achieved, would help. But too many practices are too small at the moment. Some GPs gain comfort from being salaried rather than self-employed. That at least cuts down their administrative burden. If it can be made a more attractive option—something the Government might pursue—it offers advantages to some.

Finally, I will say just a few words about research in primary care. I express my interest as scientific adviser to the Association of Medical Research Charities, an organisation whose member charities well understand the valuable role that GPs can play in research. But at the moment too many GPs are so stretched and overworked that there is no way that they can even think about research in the face of everything else they are asked to do. If we are to achieve what Ministers, the Chancellor and even the Prime Minister have spoken about, which is to embed research in the NHS as a major function, and if we are to see what is mandated in the Health and Social Care Act 2012 on making research an inextricable part of the NHS, we are going to have to give GPs all the support necessary for them to be able to fulfil their part. We are still way off that and if, as I understand it, NHS England has not even signed off its research strategy for last year, never mind this year, what hope do we have that we will see any change here? Is there anything the Minister can do to persuade NHS England to do more to support research in primary care and, incidentally, stimulate it into publishing its long-awaited research strategy?

To return to the main thrust of my remarks, is there anything the Minister can do to persuade the Government to look at how we can get general practice out of the black hole it is heading for before it is too late?

E-cigarettes: Regulation

Lord Turnberg Excerpts

Monday 7th March 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, as I said, these new products are not perfect but are substantially better than smoking cigarettes. One of the purposes of the new directive is that there should be proper labelling on the products.

[Lord Turnberg (Lab)]

My Lords, the noble Lord dismissed the idea of an excise tax, but there is a strong rumour that the EU intends to impose a tax on these products. Will the Government do everything they can to counteract this counterproductive suggestion?

[Lord Prior of Brampton]

My Lords, as I said, there is no proposal for an excise duty as part of the tobacco directive, as I understand it. I would agree entirely with the intent behind the question, which is that we should be promoting this product not discouraging it.

NHS: Junior Doctors’ Pay

Lord Turnberg Excerpts

Wednesday 27th January 2016 Lords Chamber

[Lord Turnberg (Lab)]

Is not the reason why young doctors and not-so-young doctors are threatening to go on strike not so much the pay but because this is the last straw in a continuing series of alienation, and of feeling undervalued and underappreciated by the management from the Secretary of State down?

[Lord Prior of Brampton]

I agree. I do not think that this dispute is fundamentally about pay; it is much more profound than that. It is about a feeling among many junior doctors, which is shared by many senior doctors as well, that they are not properly valued and fully appreciated. That is the underlying cause of the problems we are facing.