NHS: Junior Doctors’ Pay

Lord Walton of Detchant Excerpts

Wednesday 27th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, yes; the Secretary of State takes this matter incredibly seriously, and as part of the contract that is under negotiation with the BMA at the moment we are looking very much at the number of hours that junior doctors have to work. Many have worked for too many hours in the past and we want to put a cap on the number of hours they will work in future.

[Lord Walton of Detchant (CB)]

My Lords, I declare an interest as in 1950 I was elected chairman of the BMA’s Registrars Group, the predecessor of the present Junior Doctors Committee. I express the fervent hope that the current negotiations between the BMA and the Government will quickly be concluded to the satisfaction of both parties. In my view and in the view of many doctors it is a matter of considerable concern that there is a suggestion of further industrial action, which is inimical to the ethos of a caring profession. Will the Minister accept my view that the alleged threat by the Secretary of State to impose a new contract of employment on all junior doctors without agreement is outrageous?

[Lord Prior of Brampton]

My Lords, I think the whole House will agree with the noble Lord that we all very much hope to avoid another strike. The Secretary of State has asked David Dalton, the very distinguished chief executive of Salford Royal—the noble Lord, Lord Turnberg, will know him extremely well—to head up those negotiations with the BMA, and we are very hopeful that a conclusion to this dispute will be reached before there is any more strike action.

Health: Liver Disease

Lord Walton of Detchant Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, there was quite a lot in that question. Some 6,000 babies suffer from foetal alcohol syndrome and it is a shocking and appalling by-product of alcohol. Canada has increased the floor price of alcohol and I understand it has seen some reduction in alcohol-driven disease as a result of that. We are watching what happens in Canada carefully. Of course, Scotland is considering a similar move although it is awaiting the outcome of a court case in the European Union. I gather that Wales will possibly follow suit if that court case goes accordingly. We will watch what happens in those other countries, study it and then make up our minds accordingly.

[Lord Walton of Detchant (CB)]

My Lords, my former medical colleagues in Newcastle upon Tyne, including several distinguished hepatologists are gravely concerned by the increasing incidence of alcohol- induced liver disease in young people. The problem is that in Newcastle—in the centre of the city and on the quayside—many organisations sell what are called, “cheap shots” with a very high alcohol content. Surely the time has come, yet again for the Government to give urgent consideration to the introduction of a statutory minimum price per unit of alcohol.

[Lord Prior of Brampton]

My Lords, there are strong arguments for minimum unit pricing. However, other consequences might flow from minimum unit pricing to do with illicit alcohol sales and the fact that the cost of that would fall very heavily on those least able to afford it. As I said earlier, it will continue to be kept under consideration by this Government and we will study with great interest what happens in other countries which are introducing minimum unit pricing.

Health: Adult Pneumococcal Vaccination

Lord Walton of Detchant Excerpts

Tuesday 8th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the principal role for pneumococcal vaccination—the subject of the Question—lies with GPs. Take-up of the PPV for those aged over 65 is 70%; for those aged over 75, it is 80%. For young children, the rate is more than 95%.

[Lord Walton of Detchant (CB)]

My Lords, one of the great advantages of the pneumococcal vaccination programme is that it is widely believed that a single injection gives lifelong protection—or at least substantially lifelong protection—against pneumococcal pneumonia and pneumococcal meningitis. Is the Minister satisfied that that is still sufficient?

[Lord Prior of Brampton]

My Lords, the noble Lord knows far more about this than I do. I can tell him that the PCV 13 vaccination for young children provides long-term protection and, as importantly, prevents the disease spreading. The PPV—the polysaccharide vaccination provided to older people—does not have the longevity of PCV 13, but it provides wider protection against 23 of the serotypes, rather than 13. It does not provide the length of protection that PCV 13 does, but it still provides some protection.

Health: Post-polio Syndrome

Lord Walton of Detchant Excerpts

Tuesday 20th October 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Lord is right that there is no specific pathway for people suffering from post-polio syndrome. NHS England will approach this on the basis of all long-term conditions rather than segmenting them by individual disease categories. I will be very happy to meet with him outside the House to discuss this.

[Lord Walton of Detchant (CB)]

My Lords, is the Minister aware that the poliomyelitis virus attacks the nerve cells in the brain stem and spinal cord which give origin to the nerves that control the movement of the muscles, and, hence, that if these cells are killed, the result is paralysis of the relevant muscles? Several authorities believe that in an acute attack of poliomyelitis, certain nerve cells are damaged but recover, only to die prematurely some years later, thus causing the post-polio syndrome of progressive muscular weakness. Would not one important strategy be to have a graded exercise programme to try to increase the power of those muscles that retain a viable nerve supply?

[Lord Prior of Brampton]

The noble Lord is much better informed about this than I am, and of course I agree with him 110%. However, there are other aspects to treating this pernicious illness; clearly pain relief is important. It raises the issue that GP practices having a multidisciplinary team—physios and people who are experts in mobility, orthotics, pain relief and exercise—is very important.

Local Authorities: Public Health Budget

Lord Walton of Detchant Excerpts

Wednesday 15th July 2015 Lords Chamber

[Lord Prior of Brampton]

I shall give a short quote from the Prime Minister:

“when you look at the costs of obesity, smoking, alcohol and diabetes, we know we need a completely new approach to public health and preventable diseases. A real focus on healthy living. That’s why it’s at the heart of the plan”;

that is, the Five Year Forward View. We accept that prevention is extremely important. This reduction in spending is £200 million out of a grant for local authorities of £3.2 billion—a reduction of about 6%. Local authorities have demonstrated in many other areas an ability to extract savings. I am sure they will do the same in this case.

[Lord Walton of Detchant (CB)]

My Lords, I am not the only doctor to have expressed some reservations when the Health and Social Care Act decided to transfer funding for public health from the National Health Service to the local authorities. Do the Government now regret that decision in the light of the problems highlighted in the Question—particularly at a time when public health is facing enormous challenges, not least due to the obesity epidemic and the alarming increase in the incidence of type 2 diabetes?

Prisons: Mental Health

Lord Walton of Detchant Excerpts

Wednesday 24th June 2015 Lords Chamber

[Lord Prior of Brampton]

I thank the noble Lord for his two questions. On the first, about coding, it is very important that we get the tariff right and that it does not become just another measure of activity but that outcome is built into that tariff. Paul Farmer, the chief executive of Mind, is preparing a report for NHS England, which will include proposals for the tariff and payment systems. That will include health in prisons as well as outside prisons.

The second question was about the standards issued recently by the Royal College of Psychiatrists. The noble Lord, Lord Bradley, in his foreword to The Bradley Report Five Years On, referred to the importance of having a national blueprint, which of course is now possible given that NHS England is the commissioner of specialist services throughout the country. I will also draw those standards to the attention of Paul Lelliott, the chief inspector of mental health within the CQC. I am sure that the CQC will wish to incorporate those standards into its inspection regime

[Lord Walton of Detchant (CB)]

Can the Minister say what qualifications are now required of doctors who are recruited to work in prisons? Can he further say what proportion of those who are now employed to work in prisons have had formal psychiatric training?

[Lord Prior of Brampton]

I thank the noble Lord for that question. I hope he will think it acceptable if I reply to him in writing after this session.

Standardised Packaging of Tobacco Products Regulations 2015

Lord Walton of Detchant Excerpts

Monday 16th March 2015 Lords Chamber

[Lord Scriven (LD)]

My Lords, I thank the Minister for putting before us these proposals to try to protect public health. I declare an interest—not that I am part of any cigar club, not that I have shares in any tobacco company and not that I have been wined and dined by a tobacco company. In the last few years, I have seen both my parents die through being long-term smokers, and I have seen the effect that that has had on families. Towards the end of my parents’ lives, when we were talking about their addiction to smoking, they explained that they were attracted to smoking when they were young. Once smokers are addicted, it is very hard indeed to get off the drug.

I want to follow the noble Baroness and the right reverend Prelate by spending a few minutes talking about why I think tobacco companies spend billions of pounds on marketing and packaging. It has become the fifth “P” in the marketing mix. For these companies, it is no longer just about price, promotion, product and placement; now, the package is the most important part in targeting young people. Research by RW Pollay shows that only 10% of people per annum change cigarette or tobacco brands.

On the history of packaging, the law suits, emails, memoranda and notes passed between Philip Morris and its marketing agency make it very clear that the company carries out research through focus groups on the colour, shape and design of its packaging, particularly for young people. Why does it do that? It does so because, if it can attract young people between the ages of 16 and 20—these are not my words but those of the tobacco industry—there is a high probability that the young people will not only start smoking but stay with the brand. That is what packaging is about: it is about addicting the young and keeping them with the brand; it is not about moving market share between brands.

Maybe my language is a bit harsh, but the packaging of cigarettes is about the marketing of death. Out of every two long-term smokers, one will die of smoking-related illness. I do not make that comment for effect or for headlines—the statistics show it to be the case. The evidence from Wakefield and Morley, who carried out research in Australia in the early 2000s, long before standardised packaging came in there, made it very clear that companies do a couple of things to try to ensure that people take up their brands. Companies can no longer advertise on TV, can no longer sponsor sport et cetera and can no longer have big billboards, so they look at the shape of their packaging. They experiment with colour—the lighter the colour, the more it is perceived that that brand is somehow safer, of milder tar. They use colour and shape for young people. They talk about the masculinity of colour and of shape. They go for women and say that certain colours and shapes can actually attract women.

Let us be very clear what this is about. This is not about waiting for evidence from Australia: there has been evidence since the 1950s, when Philip Morris used to spend $150,000—equivalent to $1 million today—on the shape and colour of its packaging to get people to take its product at a young age and to addict them for as long as possible. That is why I welcome what the Government and the Minister are doing.

We have been on a journey to try to deal with the harm. In answer to the noble Viscount, Lord Falkland, the reason that, as a former leader of Sheffield City Council, I would not have accepted this kind of approach for restaurants and licensing is because with this product, which is addictive, there is also a harm principle—harm not just to the individual concerned but to others in families and to others around people who smoke. The role of government is to balance that harm principle. I would never do that for people making a choice over a restaurant, but there is a difference with cigarettes and tobacco.

I conclude by saying that I sat with both my parents as they died. I have seen others who tried to get off this addictive drug, and have seen and read about the tactics of the tobacco industry. I understand that the small thing called a packet is now so powerful in getting people on to this drug that it is important that, as a Government and as legislators of this country, we do all we can to prevent those young children from starting on that journey of the marketing of death. It is for that reason that this is not just a sensible step but an essential one to save lives. We need to make sure that people do not use marketing to addict people to something that is both dangerous and effectively means that one out of every two smokers will die in the long run.

[Lord Walton of Detchant (CB)]

As a small boy in a mining village in County Durham, where my father was a schoolteacher, I was introduced to Woodbines at the age of 11 and started to smoke intermittently but frequently. When I went to medical school, I am horrified to tell your Lordships that we were advised by our teachers to smoke in the dissecting room to remove the smell of the carcasses which we were dissecting. The professor of physiology said that he could not live without smoking and that we were therefore fully entitled to smoke all the way through his lectures. Practically every medical student in those days did.

After graduation, when I eventually became second in command of a hospital ship sailing through the Mediterranean to Palestine and various other places, I could buy a 50-can of Senior Service cigarettes for one shilling and eight pence and that can would last me two days—25 a day I was smoking. None of us at that time knew the dangers of smoking. When I came back out of the Army and started to work in a hospital in Newcastle and then in the National Health Service, slowly but surely the work of Richard Doll and his colleagues on the desperate effects of smoking began to emerge. Eventually, thank goodness, I had the strength to give up smoking—with difficulty—in my late 30s. It was a struggle but I made that sensible decision and thank goodness I did; otherwise, I probably would not be here now.

Smoking tobacco is one of the most appalling health hazards of the age—there is no question at all about that. Not only does it cause cancer of the lung and of other organs such as the bowel and bladder, it has a very powerful effect on the cardiovascular system in causing coronary artery disease and stroke; it also has a desperate effect on the respiratory system in causing chronic obstructive pulmonary disease. It has a devastating effect on all kinds of illness. For that reason, I have been delighted to participate in debates in your Lordships’ House over the years leading to bans on advertising and on smoking in public places— bans that have all been introduced by Parliament in good sense. Any effort of any kind that can prevent young people taking up this appalling habit is well worth while.

I say to the noble Lord, Lord Naseby, that my friend Sir Cyril Chantler is not a master of the kind of market research that he talked about but he is an expert in epidemiology and in statistics, and his research clearly demonstrated that standardised packaging is,

“likely to lead to a modest but important reduction over time on the uptake and prevalence of smoking”.

Any measure that has that effect and prevents young people taking up smoking is well worth while, and for that reason I regard standardised packaging as another essential regulatory measure in addition to the ones that have been passed by your Lordships’ House and by Parliament in general in having the effect of preventing youngsters from taking up this appalling habit.

I therefore strongly support the regulations, I strongly support the excellent introduction by the noble Earl, and I am afraid that I regard this Amendment as having another devastating effect, which is without question not necessarily sponsored but supported by the tobacco industry, which has done so much to delay the development of these important public health measures, which have made such a great contribution to public health.

[Lord Geddes (Con)]

My Lords, like my noble friend Lord Blencathra, I declare an interest as a member of the Lords and Commons Cigar and Pipe Smokers’ Club—and proud of it. Also like my noble friend Lord Blencathra, I commend and congratulate my noble friend the Minister, who could not be a nicer man, on leading the debates on this subject and indeed on tobacco-related products in general so courteously over many years.

However, I am glad to support my noble friend Lord Naseby. I may be the only Member of your Lordships’ House who has experience of plain packaging in this country; I am trying to see whether anybody is going to disagree with me. That was when I first joined the Navy as a national serviceman aged just 18, when I was offered what were called “Blue Liners”. They came in totally plain packets and all there was on the cigarette was a minute blue line running along it—no name of the manufacturer, nothing of the sort. It certainly did not deter me from taking up smoking, nor did it deter any of my colleagues. I just do not believe that plain packaging will deter the young—who ought to be deterred; I could not agree more—from taking up smoking.

NHS: Cancer Drugs Fund

Lord Walton of Detchant Excerpts

Monday 16th March 2015 Lords Chamber

[Earl Howe]

The noble Lord is right that NHS England has just gone through a reprioritisation process. There are three important things to observe in that process. NHS England has assured the department that no patient whose treatment is currently being funded through the fund will have funding withdrawn, as long as it is clinically appropriate that they continue to receive that treatment. In addition, no drug will be removed from the fund where it is the only therapy for that condition. Clinicians will still be able to apply for individual patients to receive a drug not on the national list on an exceptional basis. We have seen through experience that many of those applications succeed.

[Lord Walton of Detchant (CB)]

Would the Minister accept that NICE is faced with an extremely difficult problem in continually having to consider the efficacy and affordability of new cancer drugs as they emerge in a National Health Service under financial constraint? Would he also accept that another major problem is emerging in relation to the orphan and ultra-orphan drugs now coming on stream for the treatment of rare diseases, which are equally deserving in many respects? How does he feel that the next Government—however they are constituted—will be able to consider this increasingly serious problem?

Health: Rare Diseases

Lord Walton of Detchant Excerpts

Tuesday 3rd March 2015 Lords Chamber

[Lord Walton of Detchant (CB)]

My Lords, last week I had the privilege of attending a symposium, or reception, for what was called Rare Disease Day, sponsored by the International Rare Diseases Research Consortium and various other bodies. The Minister made a useful and helpful contribution, as indeed did a member of the staff of NHS England.

As the noble Lord, Lord Turnberg, to whom I am very grateful for introducing this debate, said, several thousand rare diseases have now been identified. These are of varying degrees in that some are fatal, some are progressive and some very much less so, but there is clear evidence that new forms of treatment are beginning to emerge for many of them, not least for the many inherited rare diseases, many of which are due to single genes. The gene has been located, the missing or abnormal gene product has been isolated, and effective drugs are now coming on stream to overcome the problems. The drugs for the very rare conditions are called ultra-orphan drugs, whereas drugs for conditions affecting 1,000 or more patients are called orphan drugs. It is clear that, although some of them are life-saving, others have produced an improvement but not, as yet, a cure. I pay tribute to the industry for the excellent work that has been carried out to develop these drugs, which is continuing to expand at a very important and interesting rate. I have often said that today’s discovery in basic medical science brings tomorrow’s practical development in patient care, and there is no more obvious example than the case of many rare diseases.

Many of the drugs are extremely costly, because the benefit to patients is relatively small and the number of patients who benefit is, again, very small—hence in many instances they are not commercially viable. Quite a few of these drugs have been licensed. Examples come particularly from the Cancer Drugs Fund, but that fund of £360 million is now running out of money and under threat of being closed. When, a couple of months ago, I said to the Government how important it was that they should create a rare disease drugs fund, this was not looked upon with any great favour because the Cancer Drugs Fund is not now managing to handle the needs of many patients with cancer.

There are excellent examples of drugs for rare diseases. A drug called eculizumab is a cure for haemolytic uraemic syndrome, but it has to be continued almost indefinitely, at a cost of £100,000 per patient per year. As the noble Lord, Lord Turnberg, mentioned, for other conditions such as tuberous sclerosis, which causes brain tumours, and the rare condition called lysosomal acid lipase deficiency, which causes severe liver disease, drugs are now available. But they are not at the moment becoming prescribable under the NHS.

My own field of research is muscular dystrophy, and I declare an interest as life president of Muscular Dystrophy UK. About 10% to 15% of cases of the serious progressive paralysing disease Duchenne muscular dystrophy are due to a nonsense mutation where a single letter of the DNA places a stop signal in the middle of a gene. The drug encourages cells to ignore this, and the signal therefore allows the dystrophin protein to be restored in the muscle, which produces clinical improvement. Clinical trials in Newcastle have shown significant improvement in the walking capacity of boys receiving the drug. A new generation of drugs called exon-skipping drugs are being developed that produce a molecular patch over deletions in the gene. Clinical trials were very effective in Newcastle and the results were helpful, but the drug, although licensed, is not currently prescribable under the NHS because it is going through what is called a draft clinical commissioning policy. That means that these boys, whose walking was improving, are now finding that they are again deteriorating because they are no longer in a position to receive the drug.

As the noble Lord, Lord Turnberg, made clear, the bodies in the NHS are extremely complex. NICE, the National Institute for Health and Care Excellence, has a specialised technology assessment, a single technology assessment and a multiple technology assessment. There is also specialised commissioning under NHS England and a Rare Diseases Advisory Group advising NHS England. As yet, I am finding it extremely difficult to find out what that Rare Diseases Advisory Group is doing and I cannot get hold of any of its reports. This is an extremely complex problem because the cost of these drugs will be huge. Patients’ charities and patient groups are small but are collectively becoming increasingly vocal and concerned about the problem of finding the appropriate treatment for these diseases. I have said that the patients are relatively few but, collectively, they are huge in numerical terms, and it is not possible in my opinion to assess human suffering in purely numerical terms. We need from the Government greater clarity on how the drugs for these rare diseases can be produced.

I have to express serious concern for the future. The next Government will be faced with a huge dilemma because drugs are coming on stream at such a rate that it is perfectly clear that the present mechanisms available in the NHS will not be able to fund the treatment necessary for these diseases. I wonder whether it is not time, as the noble Lord, Lord Turnberg, said, to have a major review of the funding issue. I would love to see a mechanism whereby the Association of Medical Research Charities, the Specialised Healthcare Alliance and other bodies in this field might embark on a massive fundraising programme to support the availability of these drugs.

If only we could find a donor like Bill Gates, who has given so much to the management of malaria. I was even thinking of the second wealthiest person in the United States, Christy Walton, the widow of John Walton—no relation, I am sad to say—who was at Walmart. Can we not find someone to take on board the funding of the drugs—a very major effort? It might temporarily reduce the money available for research, but the important thing is that the research will not be translated into treatment unless we have funding for the treatments that result from that research. A major new initiative along those lines will be needed.

Health: Obesity

Lord Walton of Detchant Excerpts

Thursday 26th February 2015 Lords Chamber

[Earl Howe]

My Lords, there is always scope to raise additional funding from charities and, indeed, from industry. Alongside the ring-fenced budget we have given to local authorities—it is the first time that this has been done for public health—we have a number of programmes in train which can work side by side with local authorities, such as the work going on in NHS England’s five-year forward view programme. Public Health England, in conjunction with the Local Government Association and ADASS, is commissioning work to support local authorities to take a whole-systems approach and look more widely in the way that the noble Lord has suggested. Public Health England’s Healthy Places programme is also relevant here, looking at how we can use the planning system to promote public health.

[Lord Walton of Detchant (CB)]

My Lords, in light of the alarming increase in type 2 diabetes, which is closely related to the incidence of obesity, what advice are the Government giving to the population at large about the dangers of overeating? When I was in clinical practice I used to advise my overweight patients to take a large dose of will power three times a day with meals.

[Earl Howe]

My Lords, the noble Lord very eloquently makes an important point. There is no simple answer to the problem of obesity: it is multifactorial. However, in recognising that we need to communicate our messages to health experts and, indeed, members of the public—which is his central point—my department and Public Health England are leading work with a group of experts to consider how to make the Chief Medical Officer’s guidelines easier to communicate to health professionals and the public. That work is progressing well, but we do need to progress it.