Health Workers: Training
Baroness Hollins Excerpts(8 years ago)
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Lord O’Shaughnessy
I thank the noble Baroness for that question. We are recruiting and creating conditions for the recruitment of more nurses. Something like 37,000 applications were turned down for those wishing to take on nursing, midwifery and allied health professional degrees in 2014-15. That was one of the reasons for removing the cap and equalising the funding arrangement that goes to nurses on other courses within higher education. That will allow universities to provide more places for trainee nurses. We are still early in the cycle and are moving to a new system. I think the UCAS applications have just closed and it is certainly true that in the past when fees were introduced by whichever Government—Labour, coalition or whoever—there was sometimes a small dip in take-up in the first year. But following that, in all those cases across the system, there was a strong rebound in interest in higher education places.
The Lord Privy Seal (Baroness Evans of Bowes Park) (Con)
It is the turn of the Cross Benches, but they will have to work out who is going to speak for them—and then we will have the Labour Benches.
Baroness Hollins
My Lords, my profession of psychiatry is the medical specialty which has recruited the most specialists from outside the United Kingdom, with 41% of trainees coming from overseas. It takes something like 14 years to train a consultant psychiatrist. Can the Minister confirm whether it is the intention of Her Majesty’s Government to allow doctors, nurses and other health and social care professionals to remain in the United Kingdom after Brexit?
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.
Tobacco and Related Products Regulations 2016
Baroness Hollins Excerpts(8 years, 6 months ago)
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Lord Campbell-Savours (Lab)
My Lords, in February 1996 I found myself under the surgeon’s knife, on the slab at St Bartholomew’s Hospital in London, having a tumour on my lung removed, an operation in which I lost half of my lung capacity, making it impossible for me now to walk upstairs or walk any great distance. The reason for all this was that for 25 years I smoked cigarettes.
I only wish that these new inventions that now exist had been available to me. I tried hypnosis on Harley Street. I tried patches of different forms. I could not quite do cold turkey but I tried everything possible to stop smoking, and it was utterly impossible. Indeed, I had my last cigarette the night before they took out the tumour. That is how addicted I was to tobacco.
With that in mind and knowing of my particular difficulties, a gentleman in the north of England wrote me a letter. I want to bring the salient points of his correspondence to the attention of the House, because he manufactures the product in question. He says:
“we … have 3 Shops and 6 employees … we are manufacturing the eliquid that is used in the devices. We have sold thousands of these devices locally”—
that is to say, in the north of England—
“and helped so many people make the switch. This has been such a rewarding and positive part of the business for myself and staff who still love helping people to remove a lifelong use of tobacco and improve their health”.
If those listening to my contribution this evening can hear my heavy breathing, that is the result of the operation that took place as a result of smoking all those years ago.
In his letter, that gentleman says that the two millilitre tank size restriction is pointless and restricts future product development. I wonder if the Minister might deal with these matters in the wind-up, if he is able, because some of this is technical. Perhaps he could write to me with a greater explanation.
The manufacturer says that limiting nicotine strength to 20 milligrams per millilitre is counterproductive as it removes the 24 milligram strength which is essential to lots of new switchers. He says the restriction of bottle size to 10 millilitres is pointless as much more hazardous household products are available in much bigger sizes. The popular size for cost-effectiveness and suitability is 30 millilitres, and bottles of 100 millilitres are available too. People can average, he tells me, 10 millilitres per day liquid usage, so a restriction on supply there is again counterproductive.
There will be a restrictive cost in introducing new products to the market. Remember, this man is a manufacturer. He says he will be classed as a producer when importing goods from outside the European Union, with MHRA notification and testing costs implications to bear. Therefore, a lot of suitable and effective products will be removed from the market. He says:
“We are looking at having to find the Cost of Emissions & Toxicology data requested per flavour SKU for our own manufactured liquids. This is estimated at £5,000 each per flavour, of which we have 20, plus Notification & data submissions for any variables of strength would also be required. Our business model could be changed from a manufacturer to a retailer with loss of jobs & future investment stifled if we are unable to bear the cost of this directive’s implementation. We can already see a burgeoning black market which the TPD (Article 20) will encourage. Individuals are now making eliquid at home & selling to whoever they please, with no testing done or age restrictions adhered to or tax paid”.
I would have thought that that is particularly relevant in this debate. He says:
“This is not a tobacco product and should not be classed as such. Doing so is disingenuous & misleading with implications for people’s health. We hope you can recognize the huge potential to save millions of lives & the health revolution this presents … to governments the world over”.
I hope the Government will find a way of re-examining these regulations. Potentially, we could do a lot of damage to a lot of people.
Baroness Hollins (CB)
My Lords, I refer to my interests in the register, perhaps particularly that until last month I was chair of the board of science for the British Medical Association.
The Motion from the noble Lord, Lord Callanan, states that the regulations,
“run counter to advice from the Royal College of Physicians to promote vaping and … that they could force vapers back to smoking”.
Noble Lords should be aware that the Royal College of Physicians does not support the Motion. The Royal College of Physicians, together with ASH, the BMA, Cancer UK, the Royal Society for Public Health and the UK Centre for Tobacco and Alcohol Studies all support the TRPR, including the regulation of e-cigarettes. Yes, medical organisations such as the RCP and the BMA recognise the substantial harm reduction offered by e-cigarettes, but they also conclude that they are not harmless—both identify the need for regulation of e-cigarettes to protect the public.
Noble Lords may have received some very inaccurate briefings, making some assertions that are just not substantiated by the evidence. For example, “nicotine itself is not dangerous”. It is just not true. It is both toxic and addictive. Although vaping using electronic cigarettes is much less harmful than smoking, nicotine is toxic. It is also not helpful if you are going to have surgery. It is not helpful when it is swallowed. It is harmful when it is in contact with the skin, and its addictive properties, for me as a psychiatrist, are particularly of concern.
It is just not true that the limits of 20 milligrams per millilitre will force many vapers to return to smoking. Use of high-strength nicotine is not the norm, and vapers who need more nicotine can get it by vaping more frequently.
It is not true that the regulations mean no advertising. Substantial forms of advertising would still be permitted under the regulations—at point of sale, on billboards, on buses, as inserts in printed media and as product information on websites. Furthermore, the ASH/YouGov results show that more than 90% of smokers are now aware of e-cigarettes, so existing smokers already know about vaping. It is the non-smokers, whom we do not want to become addicted to nicotine, who are not so aware.
Lord Forsyth of Drumlean
Can the noble Baroness explain why it is okay to advertise on the side of a bus but not in a newspaper?
Baroness Hollins
I do not have an explanation for the kinds of advertising that have been approved, but some advertising is still permitted. The information that is being put out is that no advertising is allowed.
There are particular concerns for people with serious mental illness, given that about one-third of all tobacco consumption is by people with current mental health problems. I could go into some of the complications of smoking and the relationship between nicotine and some of the psychotropic medications that are used. The Royal College of Psychiatrists states that e-cigarettes,
“seem to be fairly effective in helping smokers stop or control their smoking”,
but it goes on to say:
“Although they seem to be safe, we aren’t yet clear about longer-term health risks”.
Any benefits or disadvantages to public health are not yet well established. This reflects concerns over e-cigarettes’ effectiveness as a smoking cessation aid, the variability of the components of e-cigarette vapour and the absence of the significant health benefit associated with the dual use of e-cigarettes and tobacco cigarettes. The BMA strongly believes that a regulatory framework is essential. I hope that noble Lords will agree with the medical experts who have supported these regulations.
Baroness O'Cathain (Con)
My Lords, this has been a very interesting debate so far; it has been good-humoured and full of humour. I was glad to hear the noble Lord, Lord Campbell-Savours, and the noble Baroness, Lady Hollins, talk about the seriousness of this situation.
I and at least two other people whom I see in the Chamber at the moment fought like tigers to make sure that smoking was banned in public places. We did it because all the evidence suggested that it was a terrible scourge on people who were addicted to tobacco and smoking and just could not break the link. From a personal point of view, I come from a family of five, of whom four died prematurely from either smoking or the effects of tobacco. I know of friends who have similarly died and those have not been very pleasant deaths either. I am not saying that vaping will cause that problem, but why do we need it? They say, “Okay, it’s part of a smoking cessation thing”. I really do not believe it; I think that e-cigarettes should be banned totally and more money put into helping smoking cessation programmes. Such programmes have worked, so why not carry on with them?
I should not say this, but I am going to: nobody knows just how manipulative the tobacco industry was during the period when we were fighting it. It was quite disgraceful—I see my fellow in arms, the noble Lord, Lord Faulkner, looking at me and agreeing. I am concerned that, with our having gone through all this and now reducing the amount of money spent on smoking cessation programmes, we will find in another 20 or 30 years—well, I will not be around—that we are doing it all again and people will be smoking. So I just say: please take care.
Learning Disabilities: Transforming Care
Baroness Hollins Excerpts(8 years, 7 months ago)
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Baroness Hollins
To ask Her Majesty’s Government what progress has been made by the Transforming Care programme in supporting people with learning disabilities to leave in-patient settings and live with enhanced support in the community.
Baroness Hollins (CB)
My Lords, I beg leave to ask the Question standing in my name on the Order Paper and to draw attention to my interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, the data show a small but sustained reduction in in-patient numbers over the last year. Some 2,565 patients were recorded in hospital at the end of April 2016, compared with 2,800 at the end of March 2015. Forty-eight local transforming care partnerships have mobilised to deliver the three-year service transformation detailed in Building the Right Support, which was published in October 2015, with a national ambition of closing 35% to 50% of in-patient capacity and building community-based support.
Baroness Hollins
My Lords, I thank the Minister for his reply. Does he agree that this programme will succeed only if robust community support helps people to live in their own homes and prevents new admissions? Is the Minister confident that enough money is being provided to local areas to develop and commission the right support and services, as outlined in the NHS England service model, in particular to develop a trained and supervised social care workforce, which is currently seriously underdeveloped?
Health: Alcohol
Baroness Hollins Excerpts(8 years, 8 months ago)
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Lord Prior of Brampton
My Lords, the new guidelines published by the CMO are very clear about how much alcohol should be drunk and the implications it has for health. I do not know whether the noble Lord has been on to the One You website or has downloaded the drink tracker app. The information is out there. A campaign is being conducted by Public Health England, and we are making some progress.
Baroness Hollins (CB)
My Lords, does the Minister agree that introducing the evidence-based minimum unit price for alcohol would send a strong message from the Government about their concerns about the health dangers of alcohol? I should draw the attention of the House to my interests shown in the register.
Lord Prior of Brampton
Public Health England is conducting an evidence review of the harm done by alcohol, and minimum unit pricing will be an aspect that is addressed. To express a personal view, if we are going to address alcohol consumption by increasing the price, is it best that the benefit of that should go to the drinks companies through charging higher prices, or is it better that it should go to the Government through taxation? That is a question that the House might want to ponder.
NHS: Mental Health Services
Baroness Hollins Excerpts(8 years, 10 months ago)
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Lord Prior of Brampton
My Lords, I can give the noble Lord the assurance he wants. There are no plans to change the way in which funding for the training of psychotherapists is done at the moment.
Baroness Hollins (CB)
My Lords, given that people with learning disabilities and autism are at high risk of mental health problems, what specific support, and clarification of that support, will the Government commit to giving to address their needs?
Lord Prior of Brampton
My Lords, our strategy for this area was set out in Transforming Care, a paper produced by NHS England some six weeks ago. It shows that we are absolutely committed to treating more and more of these people outside institutional settings and back in the community.
National Health Service: In-Patients with Learning Disabilities
Baroness Hollins Excerpts(9 years ago)
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Lord Prior of Brampton
My Lords, this is a very important question. The fact that so many people with learning difficulties die much younger than people without them is of concern to everybody in this House. The review being conducted by Sir Bruce Keogh, to which the noble Lord referred, is a self-assessment tool. It is due to report quickly—by April—so is a short-term attempt to get the bottom of this. It is not a long-term effort, which would be much more comprehensive. We have two forms of looking at avoidable or excess deaths. One is the standardised system, which is a statistical basis for looking at the number of excess deaths. The other looks at avoidable deaths and is done by looking comprehensively at a wide sample of case reviews to give us a much more accurate picture of what is really happening.
Baroness Hollins (CB)
My Lords, as the noble Lord says, we know a great deal about why people with learning disabilities die sooner than they should. What has been missing so far is a mechanism for taking that learning forward into practice. Such feedback mechanisms, and the fact that their reviews are mandatory, are the strengths of the other confidential enquiries. Will the Minister explain why the new national learning disability mortality review has not been established on the same footing as, for example, the national child death review?
Sugar Tax
Baroness Hollins Excerpts(9 years ago)
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Lord Prior of Brampton
My Lords, I think the Prime Minister’s position is that he will want to think long and hard before imposing a tax that would fall by and large on those least able to afford it. On the other hand, the Prime Minister and the Secretary of State for Health recognise that obesity is a scourge in this country, affecting young people in particular, and will want to implement a comprehensive range of measures to tackle it.
The Lord Privy Seal (Baroness Stowell of Beeston) (Con)
My Lords, I was just going to say that perhaps the House itself would like to indicate who it would like to ask a question because we are at that point in the cycle when it is not anybody’s turn next. However, I think the House has indicated that it would like to hear from the noble Baroness, Lady Hollins.
Baroness Hollins
My Lords, what assessment have Her Majesty’s Government made of evidence provided by the BMA—I should declare an interest here as chair of the BMA’s Board of Science—Public Health England and others on the anticipated positive impact of implementing a sugar tax? Does the Minister agree that we need a range of regulatory and educational measures to reduce the intake of added sugars, particularly among children and young people, but also adults with learning disabilities who are vulnerable to some of the same market pressures?
Lord Prior of Brampton
My Lords, the Government have taken into account a range of evidence from Public Health England, the McKinsey institute, the SACN and others in coming to their strategy. The noble Baroness is absolutely right that the response will need to take into account issues such as reformulation, portion size, availability and a whole range of other issues that affect sugar intake.
Down’s Syndrome: Do Not Resuscitate Orders
Baroness Hollins Excerpts(9 years, 1 month ago)
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Lord Prior of Brampton
My Lords, the right reverend Prelate makes a number of very important points. This is a society issue as much as a medical issue. Before coming into the Chamber today I discussed with the noble Baroness, Lady Hollins, the importance of teaching students at medical school how to value people with learning difficulties, and the important role that people with learning disabilities might play by going to medical schools and directly telling medical students about their lives and concerns.
Baroness Hollins (CB)
The assumption that pregnant women who are expecting a baby with Down’s syndrome will abort that child affects public and medical attitudes. As one woman with Down’s syndrome put it when speaking at a conference on prenatal diagnosis, “You want to kill us”, which is a hard perspective for an adult with Down’s syndrome to hear. I am grateful to the Minister for picking up the point that medical nursing students need to learn from people with learning disabilities, so that their attitudes change. That familiarity with and being comfortable with people with learning disabilities will change things. Will the noble Lord commit to asking the General Medical Council, the Nursing and Midwifery Council and the Medical Schools Council to make this a priority and to teach not just knowledge and skills but practical attitudes to people with learning disabilities?
Lord Prior of Brampton
My Lords, the noble Baroness makes a profound point—that medical education and training is not just about passing exams and the technicalities of medicine but about attitudes and how you work and deal with people, particularly people such as those who suffer from learning difficulties. I will certainly do what I can to encourage medical schools and nursing schools to adopt the noble Baroness’s suggestion.
Alcohol
Baroness Hollins Excerpts(9 years, 1 month ago)
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Lord Prior of Brampton
My Lords, we have asked the London School of Hygiene and Tropical Medicine to review the impact of the responsibility deal, which it will do later in 2016. There have been, however, some benefits from it on alcohol, to which the noble Lord referred particularly. The number of units not sold as a result of it is 1.3 billion and the package labelling on alcohol products has improved substantially.
Baroness Hollins (CB)
My Lords, does the Minister agree that it would be better named the “irresponsibility deal” and that it is time for effective policies to be introduced, including a minimum unit price; zero tolerance for drinking and driving; and clear and unequivocal advice for pregnant women not to drink?
Access to Palliative Care Bill [HL]
Baroness Hollins Excerpts(9 years, 3 months ago)
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Baroness Hollins (CB)
My Lords, I congratulate my noble friend on introducing this very important and timely Bill.
I will speak mainly about mental health and well-being for people who are terminally ill. To achieve a comfortable death, it is imperative that psychological distress is understood and attended to as well as treating any physical symptoms. Parity of esteem for physical and mental disorders was mandated in law for the first time in the Health and Social Care Act 2012 and it applies at the end of life, too. Depression, which can be defined as pervasive low mood lasting more than two weeks, is a common co-morbid condition of pain and advanced illness. A systematic review of the evidence in 2006 found that up to 80% of people with cancer experienced clinically diagnosable depression, as did up to 70% of people with chronic lung disease. A considerable proportion of such mental illness remains undiagnosed and untreated, thus pointing to the need for an integrated psychiatric service in hospice and palliative care teams. Another study published in 2014 found that out of 444 advanced cancer patients in the study, 160 patients reported moderate or severe depression, often linked to anxiety. Of these 160 people, 56% showed a significant improvement in their anxiety or depression after just one supportive palliative care consultation.
Three barriers to excellent psychiatric care at the end of life have been described by the Academy of Psychosomatic Medicine: first, the challenge of diagnosing mental disorders in the presence of serious physical illness; secondly, confusion about the threshold of clinical significance—when is distress part of a process of normal psychological adjustment and when is it pathological?—and thirdly, the commonplace but unnecessary nihilism about the potential benefit of treatment for mental disorders at the end of life.
I suggest that psychiatric teams with a specialist understanding of mental health in palliative care have a crucial role to play in the provision of truly holistic end-of-life support. Research points to stigma as a barrier to diagnosing depression. One paper reported that,
“patients were ashamed to admit to psychological symptoms of depression because of their fear about the stigma attached to it”.
Stigma leads to both a reluctance by individual patients to seek help and a reluctance by healthcare professionals even to broach the subject. It will be through effective training in communication and in diagnosing mental illness that these barriers will be broken down, and psychiatrists need to be involved in supervision and reflective practice with the multidisciplinary team.
The Oxford Handbook of Psychiatry in Palliative Medicine, published in 2009, described the multifactorial function of the psychiatrist: first, as a clinical consultant contributing to direct patient care, liaising with other palliative care clinicians and working with families; secondly, as an educator to leverage knowledge about mental health issues and teach communication skills when difficult dynamics are involved; and, thirdly, as an investigator undertaking and supervising research about what works best at the end of life.
My noble friend’s Bill explicitly includes a clause specifying that Health Education England should ensure that health and social care providers deliver good- quality training to all healthcare professionals in four specified fields related to palliative care: pain control; communication skills; the appropriate use of the Mental Capacity Act; and how to support families and carers of people with palliative care needs. I would ask my noble friend if the Bill’s provisions adequately include a mandate for training in mental health and for the provision of specialist mental health care, and whether her intention would be to emphasise the importance of parity for mental and physical health care in guidance.
The Bill is not just about care for the dying person. The legacy of a traumatic death can have lifelong negative repercussions for those left behind. The Childhood Bereavement Network estimates that around 33,000 children under 18 are newly bereaved every year. Being open about death and allowing them to understand what is happening can reduce otherwise negative sequelae. My own research with Dr Abdelnoor found that, compared with their peers, parentally bereaved children scored an average of half a grade lower in their GCSEs. Other researchers found that bereaved children are one and a half times as likely to have a mental disorder and three times more likely to have physical health symptoms in the clinical range.
As I said in this House yesterday, access to palliative care services does not require just geographical equity but equal access for all individuals in our society. People with learning disabilities, children and individuals with severe mental illness may all need reasonable adjustments to be made to their care and treatment. My research with people with learning disabilities has shown that collaboration between services is the most effective way to ensure that they receive satisfactory palliative care. The problem is not people’s inability to communicate but our inability to understand their way of communicating. We know that in general health services, people with learning disabilities die earlier than they should and face disproportionate barriers to care. Unsurprisingly, the Confidential Inquiry into Premature Deaths of People with Learning Disabilities found problems in advance-care planning, poor adherence to the Mental Capacity Act, and carers not feeling listened to. These areas are also identified in the Bill as needing improvement in end-of-life care. If we could get it right for people with learning disabilities, we would probably get it right for everyone.
I was grateful to the Minister for his response to yesterday’s Question for Short Debate in the name of the noble Lord, Lord Farmer, and his announcement of the planned thematic review by the CQC of inequalities in end-of-life care. Such initiatives will help improve services but legislation is needed to make a significant step change in the availability of adequate palliative care services. I support the Bill wholeheartedly.