Medical Students

Lord Winston Excerpts

Wednesday 26th October 2016 Lords Chamber

[Lord Winston (Lab)]

My Lords, is the Minister aware that, although there may be enough people wanting to apply to medical school, many of the brightest and the best are now completely turned off doing medicine because of the relationship with the Secretary of State for Health? This is a very serious mistrust and, whether they are male or female, the brightest and best are often not applying. There is increasing evidence for this in most medical schools, and indeed in schools as well.

[Lord Prior of Brampton]

I respect the views of the noble Lord but I have looked very carefully at the number of applications coming into medical schools in 2016 compared with the previous year. In 2016, there were 20,100 applications for all medical schools, including in Scotland. The previous year the figure was 20,390, so there is no firm evidence to support the view that the noble Lord expresses. There were some rumours that St George’s was having trouble filling its places. I have investigated that and understand that it was a result not of any lack of demand but of the fact that it wanted to wait until A-level results had come through so that it could choose the best candidates based on those results. So I do not think there is any evidence to substantiate the noble Lord’s point.

Public Health England: Alcohol

Lord Winston Excerpts

Tuesday 5th July 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, the CMO’s guidelines are 14 units of alcohol per week, which is based on 67 different independent systematic reviews of what constitutes low-risk drinking. That is the best advice that we have available to us and it is entirely up to people whether they take it or not.

[Lord Winston (Lab)]

My Lords, the Chief Medical Officer famously said recently, “When I reach for a glass of wine, I think of cancer”. Does the Minister seriously think that exaggerations of that kind actually help the public perception of alcohol or mean that as a consequence our experts are completely ignored?

[Lord Prior of Brampton]

My Lords, as I said earlier, I think that the CMO’s guidelines are based on independent scientific advice. How that advice is communicated to the public is a different issue and the CMO is currently consulting on how we should express that scientific advice in ways that will have the maximum impact so that the public will take due notice of it.

NHS: New Junior Doctor Contract

Lord Winston Excerpts

Monday 18th April 2016 Lords Chamber

[Lord Prior of Brampton]

I think that all good employers recognise that having the trust and confidence of their staff is fundamental. No employer, government or private, would wish to have the outcome we have in this situation. As I said earlier, there are absolutely no winners from this dispute, and the Government regret as much as anybody that we have come to this particular pass.

[Lord Winston (Lab)]

Does the noble Lord agree—I am sure he does—that the great majority of junior hospital doctors, whatever the situation, are deeply altruistic people and remain so? They see this strike as part of that altruism, as is very clear from talking to them, and I am sure the Minister would agree about that. Does he not feel that one risk is the long-term damage not just to the health service but as regards people who are thinking of coming into the health service in the future? The young people whom I see in universities and even in schools are now asking me, “Should I actually be doing medicine?”. Does the noble Lord agree that some kind of compromise at this stage would be better, as it might well save money, rather than cause more anguish and more money to be spent in the long term?

[Lord Prior of Brampton]

My Lords, I certainly agree that some of the best and finest young people in Britain go into medicine. It is a wonderful vocation—I use the word “vocation” advisedly. We have had three years of trying to come to a compromise and there comes a point in any negotiation when you have to draw stumps, although it is very unfortunate and very sad when that happens. Over that three-year period there were opportunities for both sides to come to an agreement and it is tragic that we did not do so, but I feel that after three years the Secretary of State had little option but to accept the advice of Sir David Dalton.

NHS: Junior Doctors’ Pay

Lord Winston Excerpts

Wednesday 27th January 2016 Lords Chamber

[Baroness Brinton (LD)]

My Lords—

[Lord Winston (Lab)]

My Lords—

[The Lord Privy Seal (Baroness Stowell of Beeston) (Con)]

My Lords, I am sorry to intervene, but I know that the noble Lord cannot see that the noble Baroness, Lady Brinton, is trying to get in.

--- Later in debate ---

[Lord Prior of Brampton]

The noble Baroness raises a very important point that we are highly dependent in a whole range of medical specialties on overseas doctors and of course overseas nurses as well. Health Education England is expanding the number of training places, in particular for GPs; we hope to have an extra 5,000 GPs in place by the end of this Parliament.

[Lord Winston]

My Lords, I apologise for interrupting the noble Baroness. The Government’s stated objective is essentially to cover NHS hospitals 24/7—that is, with weekend working. Many hospital managers—for example, those in Birmingham—have pointed out that they are perfectly able to staff their hospitals fully under the existing contract. Can the Minister tell us how many NHS hospitals in the United Kingdom have closed as a result of inadequate staffing at weekends?

[Lord Prior of Brampton]

My Lords, it is not a question of hospitals closing at weekends because of inadequate staffing; it is a question of whether hospitals are able to offer high-quality care throughout the weekend. Some hospitals can but some cannot. We have seen, for example, the reorganisation of stroke care in London. Providing high-quality seven-day services for stroke care can have a significant impact on the quality of patient care. This seven-day issue is not just about junior doctors by any means; it is a question of having diagnostics, senior doctors and a whole range of other specialties on duty over the weekend.

Health: Hormone Pregnancy Tests

Lord Winston Excerpts

Thursday 21st January 2016 Lords Chamber

[Lord Prior of Brampton]

I understand that all the relevant documents are being made available to the expert working group. The chair of the association looking after the children who have been damaged by these pregnancies is an observer on that committee.

[Lord Winston (Lab)]

My Lords, with deference to my noble friend’s Question, is it not a fact that 40 years on—it is actually more than 40 years because the last letter in the British Medical Journal was in 1977 on things that had happened previously—it is now really impossible to decide the precise nature of what happened after the dosage of Primodos? While an inquiry might be helpful to some people, it is very unlikely that we will uncover anything that will be really useful in the future. Is not the message to pregnant women that they are not advised to take any kind of drug during pregnancy?

[Lord Prior of Brampton]

My Lords, the noble Lord is clearly an expert in this field. If the advice is that pregnant women should not take any kind of drug during pregnancy, that must be the right advice. I agree with him that many of these documents go right back to the early 1950s and many are in German rather than English. The quantity of documentation is enormous. That is one reason why this review has taken so long. However, the people on the expert working group are very distinguished clinicians and are doing the best they can in very difficult circumstances.

National Health Service

Lord Winston Excerpts

Thursday 14th January 2016 Lords Chamber

[Lord Winston (Lab)]

My Lords—

[The Lord Bishop of Leeds]

My Lords, I am very grateful for the opportunity to speak in this debate. Much of what I was going to say has been said and I do not intend to repeat it. I have surveyed some of the National Health Service foundation trusts in my diocese and there are common threads, both of opportunity and concern: financial, operational and clinical. Yet it ought to be said that some of the administrations of these health services are doing heroic work at a time of enormous complexity and constraint. Again, as has been said about the need to raise morale among staff, we should at least thank and congratulate those who are making the system work despite the challenges.

As demands rise, constraints are harder to deal with. I will throw into this that questions around PFI will have to be addressed at some point because of the deficits that some of our trusts are facing. One obvious issue here is that collaboration across key organisations at a system or place level is made difficult when each is bound by an independent regulatory regime and independent internal governance arrangements.

The relationship between health and social care was raised earlier. Social care is means tested. If you want to shift people out of acute beds in hospitals and into social care, there has to be a smoother route for doing it; obstacles should be handled or dismantled.

Finally, in relation to questions about the future, I will raise the question of chaplaincy—not as a bit of special pleading but because chaplaincy recognises the holistic nature of the care of people. In a debate such as this, we very easily talk about money, finance constraints and administration systems, but looking at the whole needs of people, so that they cease to be just medical cases or numbers or bed throughput, will be increasingly important.

[Lord Winston]

My Lords, I hope that the right reverend Prelate the Bishop of Leeds will forgive me for my intemperance. Normally, I do not interfere with the bishops, except when I am playing chess. I also apologise, if I may, to the Minister, the noble Lord, Lord Prior. I feel very deeply about what I am going to say, and it will be uncomfortable. I want to assure him of my respect for him and my recognition of his commitment to the National Health Service. However, what I have to say is important.

According to independent international observation, we have the best National Health Service in the world, often funded at a lower level than almost any other equivalent in Europe. However, I am not sure that it can remain so after the 2012 Act, which of course was introduced by the noble Lord, Lord Lansley, whose idea it was.

The one thing that makes our National Health Service as good as it is, is the quality of academic medicine and research that goes on in our universities. Jeremy Farrar has pointed out that the reason he became such a good doctor is that he did research. In spite of the ludicrous boasts that we are doing more research in the NHS and that every patient will be part of research, sadly, this is really not happening. As Professor Geraint Rees, the notable neuroscientist at UCL has said, the culture of the NHS has become increasingly inflexible and actively hostile to clinical academic training. Why do I say that? It is because it is inflexible in allowing research-oriented doctors to move to different regions to get experience. The system makes it difficult for research-oriented doctors to return to clinical training, and the career that I had would now be impossible. Doctors wanting to do research find it extremely difficult to persuade seniors and managers that they should spend time doing this, and the current problems doctors face are a shocking example of what is happening.

The fact is that research takes time: it takes time to read, to reflect, to discuss, to think, to write, to publish and to talk to patients to explain why the research is so important. I see prospective medical students in schools all over the country and they show one thing: they cannot get into a university to do medicine unless they demonstrate their altruism and an understanding that they will need to be ethical, their commitment to justice, and the notion that they are going to have to be extremely diligent. As you see, they go through medical school with all those principles—the notion of justice, public service and, above all, diligence—drummed into them at every stage in every university.

But what have the Government done? I congratulate the current Secretary of State on one thing. He has certainly united the most diligent, altruistic, committed, intelligent and well-trained workforce in the country; they have gone on strike almost unanimously. The fact is that the attitudes that are being pushed on to the doctors are, ultimately, extraordinarily destructive, and the Government have a major responsibility for that. The future of our NHS is imperilled by this change of attitudes.

Children: Obesity

Lord Winston Excerpts

Tuesday 12th January 2016 Lords Chamber

[Baroness Walmsley]

My Lords—

[Lord Winston (Lab)]

My Lords, given that homo sapiens is a species that is programmed to eat carbohydrate and fat, what estimate have the Government made of how much childhood obesity is due to epigenetic factors rather than simply eating sugar and carbohydrate later on in life? Might this not be programming earlier in the generation perhaps as the result of previous generations’ environment? This is an essential point in understanding obesity.

[Lord Prior of Brampton]

The noble Lord makes an interesting point to which I cannot give an answer from the Dispatch Box. It is clear that epigenetic factors are important. It is not just about behaviour: rather, it is also the genes that we have inherited from our forebears and the fact that we have entirely different nutrition and an entirely different way of life today from that of 70,000 years ago. Would it be all right if I write to the noble Lord and explain that more fully?

Mesothelioma (Amendment) Bill [HL]

Lord Winston Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Winston (Lab)]

My Lords, it is a pleasure to congratulate the noble Lord, Lord Alton, on introducing the Bill. I agree completely that this is a terrible condition that causes massive injury to a number of people.

I want to take a slightly different tack during this debate; I would like to put the disease into some focus. I was first aware of mesothelioma in the 1960s as a medical student. I worked with a very great physician, the late Donald Hunter, who was probably the first person really to identify industrial diseases as a major issue in medicine. He was very prominent in the field of lung disease—pneumoconiosis in miners, for example. He also had further interests in a whole range of things; he even changed the way that diamond drills were used in South Africa to reduce the dust that would cause lung disease in miners.

Some noble Lords might remember that around 1998 I made a television programme about an Irish individual called Herbie, whom we filmed dying. It was a unique film that was part of “The Human Body”. It was massively criticised before it was shown because it was the first time that anyone had filmed a death on television. We filmed Herbie over the best part of two years. It was an amazing experience for me. He was dying of mesothelioma. Interestingly, while of course I bow completely to what the noble Baroness, Lady Finlay, points out about the pain, the pain from his abdominal mesothelioma was quite well controlled by pretty heavy amounts of morphine-like drugs. Extraordinarily, the fact that we filmed him for so long probably extended his life. Amazingly, he lived for at least a year or two longer than was expected by his physicians. We all went to the funeral and filmed that as well, and it was a very moving moment. The value of that was partly to show someone dying from a disease of this sort but also to recognise that there is not necessarily a need to have such fear about death, a very important issue on which I think the noble Baroness will understand where we were coming from. Once the film had been shown, it did not receive any more aggressive comments in the press; it was recognised as being quite important.

Mesothelioma is an extraordinary disease. I shall try to make it understandable. Our lungs, or rather the pleural cavity in which our lungs are contained, are lined by a lining that covers the heart and the contents of the abdomen, including the bowel. The tumours arise from this lining. Unfortunately, unlike epithelial cancers—most cancers are on epithelial tissues—cancers that arise from these embryological tissues have always been much more resistant to treatment. They include tissues that grow from the bone, such as sarcoma, although I think that that is now changing a bit in its impact. None the less, there is no doubt that these conditions are recognised as being astonishingly hard to deal with.

There is no doubt that mesothelioma is primarily caused by exposure to asbestos, almost invariably in the lung and probably in the abdomen as well. It is true that about one-fifth of patients claim never to have been in contact with asbestos but, as the noble Baroness, Lady Finlay, eloquently points out, it is obvious why that might not be so. It is also interesting that the epidemic, as it has been called, that we have at the moment may be on the decrease as asbestos—particularly blue and brown asbestos, the most dangerous forms—is controlled and regulated. Sadly, however, we have not done nearly enough, so the pleas for much better understanding of what we must do in public and private places go without question.

I will declare two interests. First, I am still a research academic at Imperial College, and my most recent project grant has a cancer edge to it, although it is not on one of these cancers. It has not yet been awarded—I may not get the money—but I hope that it will be funded in due course. The other reason for declaring an interest is that many years ago I was a trustee of Cancer Research UK and before that the Imperial Cancer Research Fund. I emphasise to your Lordships that Cancer Research UK raises between £300 million and £400 million a year for cancer research. It also has a number of notable scientists; for example, there are at least two Nobel prize-winners I can think of immediately: one is Paul Nurse, and the other of course is the recent Nobel prize-winner, Tom Lindahl. They both look at cells—cell development, cell cycle, cell division, and what interrupts them. I make it very clear that that kind of research these Nobel prize-winners have done, which is typical of many people in cell biology, has a profound effect on our understanding of all cancers. Their research is not focused on mesothelioma, but it does not mean to say that it is any less relevant. It is very important to understand that an understanding of how cells work is as important as any specific, targeted approach to a particular condition.

There is always a slight risk of targeting one or two particular diseases at the expense of other diseases. We have to be aware of this, particularly when perhaps smaller charities are involved in targeting a particular disease because of an interest group. Cancer Research UK says very clearly that it is very happy to help smaller charities and help fund research where it is properly peer-reviewed, to improve and increase their impact. However, it is also very clear that Cancer Research UK, which is our main cancer research organisation in this country, has not ignored mesothelioma. On the contrary, if you look at its website, you will see very clearly that it is involved with a number of research projects. I will delineate some of the areas, because it is very relevant to this debate.

First, Cancer Research UK has been very clearly interested in the past in seeing whether there might be causes other than asbestos; for example, a viral cause. There is probably not a genetic cause either, but there may be a genetic predisposition to how you react to the tumour once it is being treated. One of the problems with mesothelioma is that it is very difficult to diagnose and often appears late. That patient, Herbie, for example, was diagnosed very late, and when I was active in surgery years ago I opened the abdomen of someone in pain to find that they had a mesothelioma, although there had been no suggestion beforehand that there would be a mesothelioma in that particular patient. Therefore one of the approaches that Cancer Research UK is trying to achieve is slightly earlier diagnosis. In particular, there are two promising compounds: one is osteopontin and the other is the serum mesothelin-related protein, both of which are secreted by these tumours. Unfortunately, one of the problems is that both these markers are secreted by other tumours as well, including, for example, ovarian cancer. Getting a specific marker is a difficulty, but research will continue.

There is no question that in the field of treatment there is a great deal of research. I have a list here, which I have written down, of the number of chemotherapeutic agents which have been looked at. In recent years I can count at least 10 or 11: raltitrexed, gemcitabine, mitomycin, vinorelbine, irinotecan, vinflunine, and there are various combinations of those therapies with other well-known mitotoxic agents. These have included trials; I do not quite understand the figures for funding which have been put round the Chamber, because of course clinical trials, which are often multi-centred, are extremely expensive to carry out, and whether those are included in the figures which are being bandied about is very questionable. The noble Lord, Lord Prior, may have something to say about that issue. We would like to see more trials, and they are expensive, but I do not know whether they are included in the total cost of the research into mesothelioma that is being quoted.

Other treatments have been researched: of course there is surgery, pleurodesis, and there are now attempts to try to reduce the tumour inside the lung membranes. However, some of the more promising therapies which are being actively looked at by Cancer Research UK are biological therapy and immunotherapy. So far, none of these drugs works particularly well. At least 12 have been looked at; there is some promise, and there is no question but that used in combination they may improve. However, these remain, like so many other of these tumours of similar embryological origin that are not mesotheliomas, quite resistant to treatment, just as they become resistant to therapy. Incidentally, photodynamic therapy has been tried.

I do not want to go on at great length about research, but I will talk about three trials that Cancer Research UK is doing at the moment to emphasise the wide range of stuff that is going on. One is some work with HSV1716, which is a virus that acts against dividing cancer cells. It comes from the herpes virus, if I remember correctly. Therefore that is a very good example of where we might make a breakthrough in treatment. Then there is a different strand of research with ADI-PEG 20, which in combination with other drugs such as cisplatin affects a particular amino acid in the chain of cell division. The amino acid that is of particular importance here is arginine. If that can be inhibited, the cancer cells do not multiply. That has been specifically targeted for the treatment of mesothelioma. A compound, GSK3052230, developed by GSK, is I think about to enter phase 3 trials very shortly. That attacks the FGFR1 gene, and therefore stops cancer cells growing.

It is therefore important to emphasise that we are doing research in this country. Whether we are doing enough remains for other people to decide. However, it is important to recognise that these cancers are very resistant to all sorts of treatment, which is one of the reasons why they are so emotionally as well as physically painful. I also suggest that we have heard so many times before about how it has been decided by Governments to put massive funding towards a particular biological project. I think President Nixon said, “We’ll put funds into conquering cancer”, and that was a total failure. We need to understand that of course there need to be targeted funds, but there also needs to be an understanding of the basic mechanisms. That is definitely going on with a wide range of cancers, some of which will affect mesothelial cancer research as well as lung cancer, bowel cancer and testicular cancer research. It is very important to understand that it is not just about simply focusing on one disease which is of terrible significance, not least because it is almost invariably fatal.

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[Lord Prior of Brampton]

It is hard to know what the right figures are. After this debate, we need to sort out exactly what the figures are.

[Lord Winston]

I hate to disagree with my noble friend, but one problem with mesothelioma research is that Cancer Research UK, for example, puts such funding partly in the box of lung cancer funding—it is a different form of lung cancer. There is a risk that we may be underestimating the amount of money being spent. That always happens when these figures are bandied about. I am not suggesting that we should not be spending more—or less—but it is very difficult to be precise about the figures sometimes cited.

[Lord Prior of Brampton]

We probably cannot today sort out the figures in the way we would like. It will be very difficult to allocate some of the more generic research expenditure. Let us move on from funding, if we can.

--- Later in debate ---

[Lord Prior of Brampton]

I think the answer to that question is that the Health and Safety Executive would have prime responsibility for them. I think the point that the noble Baroness is making is that the local authority no longer has the responsibility it would have over local authority schools. I will look into that issue and write to the noble Baroness.

[Lord Winston]

Before the Minister sits down, and I apologise for prolonging this debate for longer than necessary, does he agree that medical advances in every field are often very serendipitous? The classic example would be the completely unfunded discovery of penicillin when it was first produced, and it was subsequently only mediocrely funded until we had a wartime crisis.

In about an hour’s time the Minister will be answering a Question about doctors’ overtime. One of the critical issues that has not been discussed in that debate has been raised by Jeremy Farrar, the director of the Wellcome Trust, who points out that one of the real issues is the problem with young doctors being able to do research in a very generic way, which has all sorts of benefits, including clinical mesothelioma research. That is a fundamental problem. We in this country are very good at medical research and on the whole we fund it quite well, although obviously we would like to have more funding, but providing the environment for continuing research is essential for what we are discussing in this Second Reading debate.

[Lord Prior of Brampton]

I thank the noble Lord for that comment. We in this country are often highly self-critical but actually we have a remarkable record on research. We have three of the top medical academic institutions in the world in this country: Oxford, Cambridge and Imperial. We have UCLH, King’s and Manchester. We have some extraordinary research organisations in this country. There is, I guess, an issue over quality and quality control. There are an awful lot of clinicians who do research that may not be to the—

Junior Doctors Contract

Lord Winston Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the threshold for strike should be very high because of the vocational and professional dedication of doctors. Certainly, the threshold should be higher than it usually is for pay and conditions issues such as the one before us today.

[Lord Winston (Lab)]

My Lords, I deeply regret the tone of the statement. I understand that that is not the responsibility of the noble Lord, Lord Prior. I also respect very much his attitude, which is, I think, respected by the whole House. We have to say very clearly that this is an unprecedented situation. I do not think the nature of how junior doctors feel is understood. Already, there are more doctors in medical schools looking at going overseas—they are actually asking me whether they should be working in this country. The key issue is one we discussed in today’s earlier debate: the backbone of a good NHS is the good research we do. Research is massively threatened by what the Secretary of State is proposing. That has been emphasised by Jeremy Farrar, who, after all, is a very independent person as head of the Wellcome Trust. Would the Minister be kind enough to address that issue?

[Lord Prior of Brampton]

I agree. It is tragic that we are in this situation. My son is a medical student and I meet many of his friends; they do not want to be in this position. Concerns have been raised about whether junior doctors will have time to do research or will lose out on their progression if they do. That should be discussed and argued out with the BMA sitting around the table.

Mental Health Services

Lord Winston Excerpts

Monday 19th October 2015 Lords Chamber

[Lord Prior of Brampton]

It is too early. I cannot give the noble Baroness specific figures for last year’s spending, but we believe that they will show an increase of some £300 million over the year before. We have made it very clear to NHS England in the mandate that we expect spending on mental health services to increase this year and that every CCG in the country will see a real-terms increase in mental health spending compared with the previous year.

[Lord Winston (Lab)]

My Lords, we are very grateful that money is being spent on waiting times, but will the Minister be kind enough to comment on a particular situation that occurred just a few weeks ago? The husband of a colleague of mine had a severe manic episode and was in a hospital casualty department for the best part of the day and the whole night, most of the time not being seen. He waited for two days before a bed could be found, not at that hospital, nor at his local mental hospital. Eventually, a bed was found some distance away. Does the Minister feel that that is satisfactory?

[Lord Prior of Brampton]

The noble Lord makes a very good point. It is totally unsatisfactory that beds are not available for people suffering a severe mental health crisis. However, looking at the research done by the noble Lord, Lord Crisp, it is not the number of beds that is a problem, but the use of the beds we currently have. Far too many people still in in-patient beds could be treated outside. The answer is not more beds, but using the beds we have more effectively. I completely agree with the noble Lord. What he described I have seen myself. It is totally unsatisfactory.