Hepatitis C

Dan Poulter Excerpts

Tuesday 12th June 2018 Westminster Hall

[Sir David Amess]

The hon. Gentleman makes an excellent point. The hon. Member for Kingston upon Hull North (Diana Johnson) has done a fantastic job in bringing this issue to the attention of the whole House, but we must not take our eye off the ball. The hon. Gentleman is certainly right to remind me how important that issue is.

This country unfortunately lags behind Australia, Brazil, Georgia, Egypt, Germany, Iceland, Japan, the Netherlands and Qatar, which are all predicted to eliminate the virus within the proposed timeframe. I have said to my hon. Friend the Minister that we cannot really compare those countries with the UK, but it would be good if we could perhaps make even more progress on eliminating hepatitis C in this country. In the words of Polaris Observatory, the UK is “working towards elimination” of hepatitis C.

The APPG’s report highlighted awareness. First of all, it noted that awareness of hepatitis C has gradually improved in recent years, which we celebrate. However, awareness is still relatively low, and the stigma of having the virus remains a hurdle to people actually getting tested, diagnosed and treated in the first place. The report also found that there is low awareness of transmission risks among at-risk groups, with many people underestimating the seriousness of the condition and the urgency of accessing treatment. Even so, there are still misgivings among those with greater knowledge of the condition. Within that group, there is still a lack of awareness of new treatments that are available, and many still have worries regarding the side effects of former treatments.

The same is true of the stigma attached to the virus. Although it has decreased over time, the report found that progress still needs to be made in this area, as that stigma often acts as a barrier to people presenting themselves for testing or seeking treatment. The APPG therefore recommended initiating local and national publicity campaigns in an attempt to increase awareness. That is why I mentioned celebrities. Although I am not big on celebrities, I suppose that people do not listen so easily to us politicians—they tend to switch off. However, a so-called celebrity who is prepared to speak out publicly attracts more attention.

The report suggests two ways to increase awareness. One is among primary care professionals, through targeted testing initiatives in primary care, together with additional resources—it is always about securing more money—and support for primary care workers. The second is to raise awareness among at-risk groups through peer-to-peer messaging programmes. During my visit to HMP Wandsworth, I witnessed a peer-led group operated within the prison by inmates. It was wonderful what they had achieved.

However, it should be said that raising awareness of hepatitis C is in fact a short-term goal. Our long-term goal of eradicating the infection should see a switch to the offensive—to preventing the disease in the first place. That is what we are really aiming for.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I congratulate my hon. Friend on securing the debate and more generally on all his work on this issue and on promoting effective liver health during the many years he has been an MP.

On prevention, given that intravenous drug use is one of the primary causes of the transmission of hepatitis C, does he agree that at the moment a lot of drugs policy is seen far too much through the prism of the criminal justice system? We need to bring that much more into the health domain. Effective working with prisons and with the Ministry of Justice is vital if we are to get on top of this issue, reduce infection rates and provide proper treatment for people who are infected.

[Sir David Amess]

My hon. Friend was a Health Minister and has real expertise in this area. I shall use the expression “joined-up government”. He is absolutely right that we need Departments to work together. That is why it was so good that we visited the prison.

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[Sir David Amess]

I am concerned by what the hon. Lady says. No doubt the Minister will eventually be passed a note from his officials and will advise us on the situation. That does not seem right if it is what is happening, and I hope that the Minister will correct me if that information is wrong. It is also vital to re-engage those who have been diagnosed and have slipped through the net to the point where they are no longer in touch with those services.

The APPG thinks that the way to combat these issues is to change how we test for the virus. We recommend routine testing in substance misuse services, sexual health clinics and prisons. We also advocate increasing testing in primary care and in settings such as hostels, day centres and police custody. I know that that will not be cheap, but if it could be done it would be wonderful. Another solution is to test for hepatitis C on occasions when people are already having blood tests, which seems like common sense to me. For example, should we not consider testing people for hepatitis C while they are being tested for HIV, or when taking blood in accident and emergency centres?

Diagnosis is one thing, but accessing care is another. It is therefore essential that people who are diagnosed are referred for treatment as soon as possible, without delay. There should be a direct link between diagnosis and care. The time between diagnosis and the commencement of treatment should be minimised, to prevent patients from dropping out of the care pathway altogether. One way to achieve that would be to make treatment available immediately following diagnosis. That may be ambitious, but it is, ideally, what our APPG wants. Another way would be to streamline the referrals process. As it stands, some secondary care services will only accept referrals for treatments from general practitioners. Allowing referrals from any service at which someone might be tested and diagnosed, as the APPG recommends, would go some way to solving the problem.

[Dr Poulter]

I agree entirely with my hon. Friend. One challenge that we face is the fragmentation of the commissioning of substance misuse services and sexual health services. Those are commissioned by local authorities under the Health and Social Care Act 2012, which I think we have to reflect on as a mistake in this context, as opposed to many secondary care services, which are commissioned by the NHS through clinical commissioning groups. Until we sort out that fundamental issue of commissioning, we will not be able to put in place the improvements that he suggests.

[Sir David Amess]

Oh dear! I say to my hon. Friend—I and, indeed, you, Mr Streeter, were in this place when we were dealing with all these issues—that the fragmentation is very worrying. My hon. Friend is right to point out that more work needs to be done on the issue.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Streeter. Hepatitis C was identified about 25 years ago. When I was a young doctor, it was simply known as non-A, non-B hepatitis, because no one had any idea what it was. As the hon. Member for Southend West (Sir David Amess) said, we are talking about something that many people simply do not know they have. That is a key, underlying problem. Patients may only be aware that they have hepatitis C when they start to have liver symptoms, which is the start of cirrhosis or malignancy.

With any condition, we first want to prevent it. As was mentioned, at needle exchanges we already have blood screening to ensure that it is not coming from transfusion. We have to remember those in this country who previously suffered from contaminated blood that was iatrogenic—caused by doctors and the health service.

I agree with the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) that we need a more medical approach to the issue of drugs. If we drive problems underground, there is no possibility of detecting and treating people, to achieve the elimination that the World Health Organisation is aspiring to.

In Scotland we are recognised as world leaders, in the sense that we had a strategy in 2005, 2008, 2011 and then our elimination strategy, which was introduced in 2015. The 2011 strategy fed into what became the World Health Organisation strategy, as one of our senior leaders was seconded to it. The big change is sofosbuvir and ledipasvir—the new antivirals that are well tolerated and able to clear the viral load in 90% of all patients. Of course we would prefer a vaccine, as the hon. Member for Strangford (Jim Shannon) mentioned; that is how we eliminated smallpox and how we are trying to eliminate polio. However, the problem with hepatitis C is that, as he said, there are six genotypes, but 50 subtypes, and it mutates regularly. It is one of those viruses with a coating that is very hard to get a handle on with the immune system and therefore to develop a vaccine for, so we need to use the drugs until a vaccine is available.

The Scottish Medicines Consortium passed sofosbuvir in 2014 and NICE passed it in 2015. Unfortunately, NHS England took the approach of trying to slow things down because the drugs are very expensive. However, dealing with liver failure and having to consider liver transplantation is even more expensive. A cap of 10,000 patients with cirrhosis and the most severe conditions from hepatitis C was set.

In Scotland in 2015, we took the opposite approach—a public health approach—to try to reduce the virus in the community and prevent it from occurring.

[Dr Poulter]

The hon. Lady is making very good points. I am sure she will correct me if I am wrong, but the other point to make is that in Scotland there has been a much more joined-up approach in tackling heroin addiction. Scotland is much further forward than England in addressing such issues, in having a co-ordinated strategy and in recognising how addiction leads to prisons and the criminal justice system. Indeed, there is not the fragmented commissioning of services that we see in this country. Does she agree with me that that is something that England can learn from in addressing the lack of joined-up working and commissioning?

[Dr Whitford]

I thank the hon. Gentleman for his comments. As NHS Scotland is still a single public body, we do not have the issue around commissioning. We are also trying to take a much more health-based approach to addiction. As happens in England as well, we have multiple needle exchange programmes. This place has held us back from trying to introduce safe injection in Glasgow, which has one of our highest drug-addicted populations and highest incidence of drug-related deaths. However, that initiative comes under the Home Office and we have not been granted permission to try to take it forward. Always taking a criminal justice approach gets in the way of achieving the medical outcomes that we want.

It is really important to recognise the breakthrough of the drugs. With an eight or 12-week course, expensive as it is, more than 90% of patients will achieve a sustained virological response. That means they remain with undetectable levels of virus 12 to 24 weeks after the end of their treatment. The problem with rationing treatment to those who are actually ill is that it is the people who are not ill with hepatitis who spread it to other people, because they are out and active. If they are drug users, they are still using drugs. Someone who is so ill that they are confined to bed is not spreading it. That is why we took a public health approach to eliminating hepatitis C over the coming years. We certainly aim to achieve that before the World Health Organisation target date.

As the hon. Member for Southend West said, one of the key issues is people not knowing that they have the virus, so, in Scotland, part of our approach has been to create opt-out screening at various points of blood being taken. That will be from general practice in areas of high prevalence. It already includes bloods taken in accident and emergency. It includes screening at other times such as when we screen for HIV. Obviously, we screen for HIV when a woman has her booking appointment at the time of her pregnancy. We need to use all the opportunities that we can. Of course a patient always has a right to opt out, but when we make something the norm it becomes easier for people to agree.

The prison population obviously has a big problem with drugs, including IV drugs—either in the present or the past, before the prisoners were incarcerated. It is important that we get the tests taken up by such populations.

We also offer testing in more social settings, where there have been education events around hepatitis and HIV and where peer-to-peer work has been done. It is important that we raise awareness and try to reduce the stigma. There is a problem with always talking about HIV drug users, as opposed to recognising that someone might have been contaminated by blood in this country, while undergoing maternity care or surgery overseas, or, as was mentioned, in a tattoo parlour: it means that people do not care. We end up with, “Well, it’s their own fault”, which maintains the risk to everyone else and hampers elimination. As well as raising awareness, we absolutely have to reduce the stigma.

It is important to take a public health approach, as we have done in Scotland. I commend that to NHS England, which should remove the cap and do as we are doing: try to set a minimum target for new people to be found and treated as soon as possible. We have seen the new cases reduce from 1,500 in 2007 to 700 in 2013, but it is the chronic cases that have been out there for years that we have to find because they still carry the virus and can spread it to other people.

Of course, NHS England should try to get the price down. There is no right for drug companies to profiteer as opposed to having a fair return, but the issue must be taken in the round. We must recognise that eliminating the virus by using drug treatments while we wait for a vaccine will overall be an huge benefit to society.

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[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is genuinely a pleasure to serve under your chairmanship, Mr Streeter, and to be back in Westminster Hall on such a quiet day in Westminster. The hon. Member for Ealing, Southall (Mr Sharma) is sadly not in his place today, but I thank my hon. Friend the Member for Southend West (Sir David Amess) for securing and leading this debate. Although he said that he was not the best person to introduce the debate, he could have fooled us because he did it very well.

Hepatitis C is a significant health issue in our country, and for too long it has been overshadowed by other public health concerns that, despite the superstars involved, have had higher public profiles. I pay tribute to the Hepatitis C Trust and the wonderful Charles Gore, whom I have got to know in this job. He is a colossus in this area, and has become a friend. I also thank the Hepatitis C Coalition—this issue has been central to both those organisations.

My hon. Friend mentioned lots of local services for Southend residents, and a lot is going on in his constituency. Few MPs champion their constituency more than he does, so for his press release I will mention that screening and onward referral services are provided by the Southend Treatment and Recovery Service, known as STARS. For primary care, GP practices refer people to the specialist treatment services in my hon. Friend’s much-loved Southend Hospital. Local drug and alcohol treatment services in Southend hold outreach screening sessions for hepatitis, and all positive cases are referred for onward treatment. Big local successes that I noted in my papers included last year’s hepatitis C roadshow, which took place in my hon. Friend’s area, and there is the hepatitis C operational delivery network educational event 2018—he can see me after class for more details if he would like.

It is always good to see the hon. Member for Strangford (Jim Shannon) in his place, speaking so knowledgably and passionately about this issue, as well as the hon. Member for Central Ayrshire (Dr Whitford), and my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter).

The World Health Organisation has set ambitious targets to reduce the burden of chronic hepatitis C over the coming years, with a pledge to eliminate it as a major public health threat by 2030. The UK Government are committed to meeting and beating that target, as has rightly been said.

A few years ago, hepatitis C-related mortality was predicted to increase in our country, but through the measures that we have in place and the hard work and dedication of so many unsung heroes in the field, 9,440 treatments were delivered nationally against a target of 10,000 in 2016-17; the number of deaths fell for the first time in more than a decade, and that has been sustained for another year; and between 2014 and 2016, there was a 3% fall in deaths from hepatitis C-related end-stage liver disease. That is good news.

However, hepatitis C continues to make a significant contribution to current rates of end-stage liver disease. I welcomed the recommendations to tackle that in the report, “Eliminating Hepatitis C in England”, which was published in March by the all-party parliamentary group on liver health, of which my hon. Friend the Member for Southend West is co-chair. I often produce a recommendation-by-recommendation response to Select Committee reports in my area, but when I checked with my officials during the debate, I found that I did not do it for that report—I was not asked to by the group—but I offer to do so. In fact, I will go further than that—I will go crazy and do it. The group will get that from me as a written response to its report.

This is a timely debate, because NHS England recently launched its procurement exercise for the new generation of hepatitis C antivirals. If that exercise delivers successfully, the ambition is to eliminate hepatitis C as a public health threat earlier than the WHO goal of 2030, and to get to 2025.

[Dr Poulter]

Given the experience that we had with NHS England on HIV PrEP medication and its argument that that was a public health responsibility, which I believe was wrong and which was legally found wanting, will the Minister ensure that he holds its feet to the fire on hepatitis C so it recognises that although it is a public health issue, it has a responsibility for the effective procurement of antivirals and for making them available to all people with hepatitis C?

[Steve Brine]

Point taken; feet will be held to said fire. I do not think that NHS England is found wanting in this area, and I will go on to say why, but I take my hon. Friend’s point and will follow it through, because I want this to work.

The new industry deal may allow for longer contract terms that cover a number of years, but whether a long-term deal can be reached and what its duration is will be contingent on the quality and value of the bids submitted by industry. I expect the outcome of that in the autumn.

On local delivery networks, NHS England has established 22 operational delivery networks across our country to ensure national access to the antiviral therapy. I will touch on the issue of the cap in a minute. Those clinically led operational networks are given a share of the national annual treatment run rates based on estimated local need.

That local operational delivery network model ensures better equity of access. Many patients with chronic hepatitis C infections come from marginalised groups that do not engage well with healthcare, as has already been said. Through the development of networks, it has been possible to deliver outreach and engagement with patients outside traditional healthcare settings, such as offering testing through drug and alcohol services and community pharmacies.

As hon. Members know, I have a great soft spot for community pharmacies, and I think that they can and do play an important role in this space. In April, I hopped along to Portmans Pharmacy, which is just up the road in Pimlico, to see the pharmacy testing pilot of the London joint working group on substance use and hepatitis C that is going on there. I saw the testing and the referral to treatment that takes place in pharmacies that offer needle and syringe programmes across six boroughs in London.

Portmans Pharmacy has provided a needle and syringe programme and the supervised consumption of methadone for a number of years. Those points of contact with people who inject, or previously injected—a key distinction—drugs provide an ideal opportunity for us to make every contact count and to test for hepatitis C, as we think that about half of people who inject drugs in London have the virus.

The approach of Portmans Pharmacy and the London joint working group is innovative. It aims to provide quick and easy access to testing and a clear pathway into assessment and treatment in specialist care, which is obviously critical. I pay great tribute to the work that the group has done. It has rightly received a lot of coverage and a lot of plaudits. I am anxious and impatient—as my officials know, I am impatient about everything—to see the peer-reviewed results of that work and where we can scale it out more.

The hon. Member for Central Ayrshire mentioned treatment in respect of the cap. It is different north of the border, but NHS England offers treatment as per the NICE recommendations. The drugs that she mentioned are expensive, which limits the number of people who can be treated each year, but treatment has been prioritised for those most severely affected. The NHS then provides treatment to others who are less severely affected. So far, 25,000 people in England have been treated with the new drugs and a further 13,000 will be treated this year. The NHS procurement exercise should allow for even larger numbers to be treated each year. Of course, nothing is perfect in life. Resources in a publicly funded health system are finite, which is why we have to target them at the most challenged group. That is one of the reasons why making every contact count through primary care and pre-primary care, as I call community pharmacies, is so important.

[Steve Brine]

Of course, the hon. Lady states a fact not an opinion, and I accept that, which is why I speak of the importance of primary care and of making every contact count. The people who Portmans Pharmacy interacts with are not all sick. People who have a hepatitis C infection or a drug-use issue have other issues—they get flu too—so they interact with that pharmacy, and the pharmacy makes every contact count by grabbing people earlier. That is one reason why I am so passionate about the way that that underused network can help us to reach the ambitious targets that we have set.

Everyone has rightly talked about prevention—in many ways, I am the Minister with responsibility for prevention and it is the thing that I am most passionate about in our health service. As well as testing and treating those already infected, an essential part of tackling hepatitis C must be the prevention of infection in the first place, or the prevention of reinfection of those successfully treated, which would not be a smart use of public resources.

NHS England and Public Health England, which I have direct ministerial responsibility for, are actively engaged in programmes at a local level to prevent the spread of infection. As people who inject drugs or share needles are at the greatest risk of acquiring hepatitis C, prevention services, particularly those provided by drug treatment centres, are key components of hepatitis C control strategies. Clearly, the key to breaking the cycle of hepatitis C is to prevent infection happening in the first place.

[Dr Poulter]

The fundamental issue is that there is no greater evidence of fragmentation—I speak from my own clinical experience—and failure of joined-up working than the fact that local authorities commission substance misuse services but that the NHS commissions mental health services for the same patients and secondary care services for hepatitis C patients. People are falling through the gaps. Many people who have hepatitis C do not present to GPs, and are not even routinely on their lists, so the issue has to be looked at in a much more effective way if we are to make a difference.

[Steve Brine]

I hear my hon. Friend’s experience of the frontline and I would not disagree that in some areas there is unhelpful fragmentation. If I remember rightly back to those happy early days of the election of my hon. Friend and I to this place, we sat on the Health and Social Care Bill Committee. That piece of legislation, controversial as it was, enacted the decision to pass that responsibility to local authorities and, of course, all local authorities are now, in effect, public health bodies. All of them—well, top-tier authorities in England—have directors of public health.

Just because there are challenges and fragmentation, that is not a reason to redraw the system. I do not think there is any desire within the system for a top-down or bottom-up reorganisation—I suspect that, as a doctor, my hon. Friend would agree with that—but there is a challenge to the system to come up with a much better whole-system approach, to make sure that people do not fall between those cracks.

My hon. Friend and I could debate at length—I am sure we will—whether those cracks can ever be filled, and whether there will ever be Polyfilla that is big enough or strong enough to fill those holes, but I do not think that it is a reason to break open the system.

[Dr Poulter]

rose—

[Steve Brine]

I give way to my hon. Friend for the last time.

[Dr Poulter]

This fragmentation of commissioning is a really important point and it comes up in so many debates in Westminster Hall and, indeed, in the main Chamber. I urge my hon. Friend and indeed the rest of the health team—we have got to put right the things that we got wrong. If we want to get this issue right, and get it right for people with hepatitis C, and for people with mental health conditions who are not getting access to services because of this fragmentation, then we have to revisit it.

I urge my hon. Friend to go and spend some time out on the frontline with some professionals and to get them to talk to him candidly—not on a ministerial visit. He should get them to talk to him candidly about these problems, because we have to recognise that this situation needs to change for the benefit of the people we care about, who are the patients.

[Steve Brine]

I will not prolong this discussion, Mr Streeter, but I take my hon. Friend’s point and I think it is a subject that will receive further airing, to put it mildly.