Neuromuscular Care (North-West)

Gregory Campbell Excerpts

Wednesday 9th February 2011 Westminster Hall

[Graham Evans (Weaver Vale) (Con)]

I thank Mr Speaker for allocating time for this important subject. I pay tribute to the excellent Muscular Dystrophy Campaign, which does such brilliant work in this field and has assisted me in preparing for the debate. This morning, I will bring to the attention of the Minister the significant gaps in specialist neuromuscular care services in the north-west region that many people living with muscular dystrophy and related neuromuscular conditions currently experience. Vital review work undertaken by the NHS North West specialised commissioning group in the past six months is encouraging, but families need to see it translated into real improvements to services. It also provides an opportunity to improve patient outcomes and to reduce the amount of money spent on unplanned emergency admissions to hospital for people in the north-west with neuromuscular conditions.

Let me briefly outline my personal connection to muscular dystrophy. I am 47 years old, and I had a cousin, Stephen Payne, who, if he was still alive today, would be of the same age. He was diagnosed with Duchenne muscular dystrophy at the age of six, and I remember the devastating effects that it had on our family. This was in the late 1960s, when not a lot was known about the condition. I remember my uncle, Mr Barrie Payne, taking his son to Harley street for a diagnosis. I am afraid to say that it was not good. None the less, Mr Barrie Payne is a fighter and a campaigner and he threw all his energies into fundraising to see if a cure could be found for Duchenne.

My very earliest memories, therefore, are of a family fighting and campaigning for a cure for that dreadful disease. I also have very early memories of politicians getting involved in this vital subject. I pay tribute to Lord Alf Morris of Manchester, who, at the time, was the MP for Wythenshawe. Coincidentally, Lord Morris’s sister lived on my council estate, and I remember him driving to our estate in his Wolseley car. At the time, those cars were for very special people. He came to see my family when he visited his sister and I remember thinking at the time what a special man he was. In those days, in the ’60s and ’70s, it was thought that politicians could help ordinary people from working-class backgrounds such as mine. I remember so well the work that my family and Mr Morris did to get a change in legislation. I am pleased to say that Alf Morris was behind the Chronically Sick and Disabled Persons Act 1970, which was the first Act in the world to give rights to people with disabilities.

I did my best to raise money for the muscular dystrophy charity. I used to sell pens, pencils, rulers and pencil cases in my school yard at primary school. Imagine a head teacher allowing a child to go into school with a bag full of goods to sell for cash in these politically correct times. Coincidentally, my head teacher lived next door to my cousin, Stephen Payne, and at school fairs he used every opportunity to raise money for muscular dystrophy.

My uncle continued to campaign to raise money and awareness. People in wheelchairs were often not allowed access to places such as airports and museums, which led to considerable arguments. My uncle rightly felt that people with disabilities should be allowed in. I am glad to say that in the 21st century, things are a lot different.

Stephen was a bright and articulate individual, and he was always forthright in his opinions. He was a Manchester City fan, while I was a Manchester United fan. When Manchester United got relegated in 1973, he certainly let it be known how pleased he was about that. Stephen died in California when he was 21. His peers died when they were in their very early teens, which just goes to show that palliative care and hydrotherapy can extend the lives of people with Duchenne.

The Muscular Dystrophy Campaign is the leading UK charity and focuses on all neuromuscular conditions. It is dedicated to improving the lives of all people with such conditions. Founded in 1959, the Muscular Dystrophy Campaign funds vital research, provides and supports care services and gives information, advice and direct help to individuals living with neuromuscular conditions. I am honoured to be a member of the all-party parliamentary group for muscular dystrophy, which has highlighted shocking gaps in service across the UK and continues to call for improvements in access to specialist neuromuscular care to follow up recommendations in the Walton report.

There are more than 60 types of muscular dystrophy and related neuromuscular conditions. It is estimated that more than 1,000 children and adults in every million of the population are affected by muscle-wasting neuromuscular diseases—in the north-west around 8,000 people in total. Such disorders can be genetic or acquired. A number of conditions, such as Duchenne muscular dystrophy, are particularly aggressive. They cause progressive muscle wasting, weakness, orthopaedic deformity and cardiac and respiratory compromise, and result in premature death. Many young boys in the UK with Duchenne muscular dystrophy are dying before they get beyond their teens; that is unacceptable.

Specialist multidisciplinary care has been developed by leading clinicians as the best model for delivering effective care for such complex multi-system diseases. The provision of expert orthopaedics and early cardiac monitoring and intervention has been shown to improve muscle function and maintain independent mobility. People with neuromuscular conditions, therefore, need specialist multidisciplinary care, support and intervention from a range of professionals and specialists. That was recognised as part of the specialised services national definitions set. Leading neuromuscular clinicians fought hard to get those services recognised as specialist by the Department of Health.

Specialised services are defined in law as services with a planning population of more than 1 million people, which means that a specialised service is not provided by every hospital in England. The SSNDS describes the services in more detail. The definitions provide a helpful basis for service reviews and strategic planning, which enables commissioners to make comparisons of activity levels and spend. They help with the identification of activity that should be regarded as specialised and therefore subject to collaborative commissioning arrangements. The 10 specialised commissioning groups, acting on behalf of the members of primary care trusts, are responsible for the commissioning arrangements for specialised services.

Neuromuscular conditions come under the auspices of a number of specialities; they are genetic conditions, so geneticists sometimes deal with patients. The conditions sometimes affect children, so paediatricians are involved. A number of the adult forms come under the heading of neurology. Some of the conditions require respiratory care, which is provided by a respiratory practitioner, and some are metabolic conditions such as Pompe, and patients are treated by specialists for metabolic disorders. Therefore, health care for people is quite fragmented, and that clouds professional responsibility. “Neuromuscular” must be recognised as a speciality along with neurology.

Dr Ros Quinlivan, a leading consultant in paediatrics and neuromuscular disorders, has outlined the effects of neuromuscular conditions and how they need to be managed:

“Neuromuscular conditions are rare and include: Muscular dystrophies, metabolic myopathies, congenital myopathies, inflammatory myopathies, Spinal Muscular Atrophies. Many of these conditions affect only skeletal muscle and thus cannot be considered to be neurological disorders, in fact skeletal muscle can be considered to be the largest organ in the body. Most neuromuscular disorders are genetic in origin and affect families, but the inflammatory myopathies are acquired and require specific treatment. Affected patients range from newborn infants to elderly people. The effect of many of these conditions is on the skeleton causing skeletal deformities due to muscle contractures and on the heart and lungs causing respiratory or cardiac failure which can significantly limit life expectancy.

The physical management of these disorders is quite distinct compared with conditions affecting either the nervous system or the musculo-skeletal system (bone and joints). Proximal and axial muscle weakness caused specific functional difficulties not seen in patients attending clinics in other specialist areas. The progressive nature of these conditions means that a multi-disciplinary approach to care, with experienced clinicians specialising in neuromuscular disorders, is essential to achieve the best outcomes.”

It is now felt by the clinical community that it is time to make a neuromuscular curriculum part of the medical career, to establish the neuromuscular field in its own right. The conditions have a lot in common, so it makes sense that they are treated by the same person. For example, some forms of limb-girdle muscular dystrophy exhibit similar symptoms to some forms of spinal muscular atrophy, but one is a muscle disease and the other more a neurological disease. They are long-term rare conditions, which makes them quite different from neurological diseases such as Alzheimer’s and Parkinson’s.

Neuromuscular services need to be commissioned on a regional basis. Currently they are commissioned by the 10 regional NHS specialised commissioning groups, with top-slicing of PCTs. That method of commissioning services for these rare and very rare conditions has been endorsed by a new body of experts, the British Myology Society. It makes no sense for one PCT to commission specialised services. Unlike conditions such as Parkinson’s or multiple sclerosis, there are no guidelines from the National Institute for Health and Clinical Excellence for these neuromuscular conditions, which presents real difficulties when trying to set standards of care across the country.

That situation has been a contributing factor to the postcode lottery that has arisen, and which was highlighted in the all-party group on muscular dystrophy’s Walton report, published in August 2009. That followed reports by the Muscular Dystrophy Campaign, as part of the charity’s “Building on the Foundations” campaign, which revealed the shocking lack of specialist care in many parts of the country. The lack of knowledge, training and skills in the sector is a significant concern. For example, there is no specific training or curriculum for neuromuscular services in the neurological field.

I am sure that hon. Members will share my concerns and the frustrations of people living with neuromuscular conditions in the north-west, as expressed in the Muscular Dystrophy Campaign’s patient survey in 2010. Deborah Hurst from Liverpool is affected by facioscapulohumeral—FSH—muscular dystrophy. However, she was not diagnosed with it until she was in her late thirties. She is now 47. Her two daughters were born before she was correctly diagnosed and one of them, who is now aged 25, has inherited the condition. Deborah says:

“I have two daughters and I knew one was affected, but the doctor told me I was fussing and silly. When I finally got them tested, he congratulated me on my actions, which I was very mad about as my daughter took her diagnosis very badly at the time and ‘congratulations’ was not what we wanted to hear.”

Mrs H from Lancashire has a son affected by a neuromuscular condition. She says that in her experience, GPs do not understand such conditions:

“My GP is very good but says, ‘We have about two hours of tutorial on muscular dystrophy in the whole medical training.’ So therefore they have no in-depth knowledge.”

Elaine Sands from Stockport is also affected by FSH muscular dystrophy. She does not receive any specialist care, but she would value the support of a neuromuscular care adviser. She says:

“As I am housebound, it would be nice to have someone give me physiotherapy and also some kind of visitor who knows about my condition, as I live alone and I would appreciate being able to talk to someone who understands the disease.”

However, the situation is different for Joanne Ashton. She has a five-year-old son, Liam, who has Duchenne muscular dystrophy. Through the specialist neuromuscular service at Alder Hey hospital, Joanne and her family have access to a specialist consultant, Dr Stefan Spinty, and to a full multidisciplinary service, including a neuromuscular care adviser. Joanne says:

“Shirley, our Care advisor, is fantastic. We only have to ask and she’s there. Liam had his wish granted, through the “Make A Wish Foundation”, because he was nominated by Shirley. So we are all impressed with the care advisors.”

The Muscular Dystrophy Campaign’s clinician-led report, “Building on the Foundations in the North West”, which was published in June 2009, made a number of findings about neuromuscular services in the north-west.

[Mr Gregory Campbell (East Londonderry) (DUP)]

I thank the hon. Gentleman for giving way and I congratulate him on securing this debate. He has rightly referred to the issue of care advisers. Obviously I understand that the north-west of England is his particular concern, but does he agree that if more emphasis were put on having excellent care advisers right across the UK, like the adviser who he has just referred to, that would help those who suffer from this condition immensely in trying to come to terms with it?

[Graham Evans]

I thank the hon. Gentleman for that intervention. I wholeheartedly agree. When someone is suffering from a condition, there is nothing quite like having people trying to help who understand what they are going through, both physically and mentally. So I wholeheartedly agree.

As I was saying, the “Building on the Foundations in the North West” report found that three out of four neuromuscular patients and their families have no access to a key worker or a care co-ordinator. About 6.5 regional care advisers are needed to serve the estimated 8,000 people —which is up from an earlier estimate of 6,500 people—in the north-west area who have a neuromuscular condition. Many of those people are simply not known to providers of health services.

The report also found that neuromuscular patients have very limited access to treatment, in particular to ongoing physiotherapy. Specialist physiotherapists are required to support outreach clinics and to provide training and professional development for community physiotherapists. In the north-west, two fifths of neuromuscular patients said that they do not receive enough physiotherapy.

Another finding of the report was that there is no dedicated physiological service for neuromuscular patients, despite the importance of such a service as part of multidisciplinary care for that patient group, who have rare and very progressive conditions. Those conditions are often genetic, there are no known cures and there are only limited treatments available. Greater support at the transition from paediatric services to adult services is needed, given the evidence that services are removed or greatly reduced when patients leave paediatric services, even though their needs may well increase given the progressive nature of many of these conditions.

People with Learning Disabilities (NHS Treatment)

Gregory Campbell Excerpts

Wednesday 14th July 2010 Westminster Hall

[Chris Skidmore (Kingswood) (Con)]

As the secretary of the all-party group on disability and a member of the Select Committee on Health, I have a dual interest in this debate. I am also a member of the all-party group on learning disability. I am sorry that I could not attend yesterday’s AGM; it sounds as if it was a fascinating event.

I thank the right hon. Member for Coatbridge, Chryston and Bellshill (Mr Clarke) for calling the debate, which is clearly necessary. If I repeat any of the points that he made so eloquently, it will be only because they need to be driven home. The debate highlights some current failings in the NHS with respect to people with learning difficulties. As the right hon. Gentleman said, there have been several reports on the issue in recent years. The Disability Rights Commission’s report, “Equal Treatment: Closing the Gap”, published in 2006, showed that although people with learning difficulties were more likely to develop conditions such as obesity and respiratory diseases, they were less likely to receive adequate care, treatment and health checks.

In the following year, as the right hon. Gentleman also mentioned, came Mencap’s report “Death by indifference”. That seminal study highlighted some of the failings of the past several years and showed that six people with learning difficulties had died prematurely owing to discriminatory care. Yet after those reports were published, and despite moves towards dealing with the situation, the most recent survey by Mencap, which was released in June—again, the right hon. Gentleman referred to it—showed that half of doctors and a third of nurses had witnessed a patient with learning disabilities being treated with neglect or a lack of dignity, or receiving poor quality care. Those statistics are clearly unacceptable.

What can be done? The right hon. Gentleman has already referred to the issues that we need to address. I shall probably repeat some of what he said, and I hope that he does not mind. To my mind, the first issue is training for professionals in the NHS. There is clearly an institutional failure to make adequate provision for people with learning difficulties in the NHS, despite the fact that they receive £1.7 billion of NHS money. The Mencap survey highlighted the training issue; it found that 53% of doctors and 68% of nurses felt that they needed specific guidelines on how to care for people with learning difficulties, and how treatment should be addressed to them, to meet their needs. There is clearly a gap that we need to examine in closer detail.

I welcome the plans in the White Paper that has just been published to end the top-down managerial approach and the current centralised funding of education and training, because previously the multi-professional education and training levy was not accountable in relation to the amount of training and continuing professional development that it provided. The White Paper sets out welcome plans to give employers greater autonomy and, above all, accountability. Accountability is what we need, because training has been available but there is no way of showing that it works. We need to get back to a local level, which is what the White Paper sets out to achieve, so that there will be greater professional ownership of the quality of training. I welcome that accountability and recognise that accountability at local NHS organisational level must also ensure that people with learning difficulties are treated adequately.

The second issue that I want to mention is the broader one of communication. That is at the heart of treatment for people with learning difficulties. The question is how to cross the communication barrier between professionals—doctors and nurses—and people with learning difficulties, who often cannot express their needs, which may be very individual. One of my constituents was recently rushed to the Bristol Royal infirmary on a weekend. He had a procedure on his heart and a doctor explained his condition to him as if he were communicating with a normal member of the public. That approach was clearly inadequate for someone with learning difficulties. The nurse then presented him with some complicated leaflets, which he could not understand. There was no co-ordination with his carer at NHS level—or certainly not at the acute hospital level—and that led to a man who was already very sick being further distressed and scared.

It is in that context, to which the right hon. Member for Coatbridge, Chryston and Bellshill referred, that the role of learning disability liaison nurses is crucial, for the support of patients, families and those who support people with learning difficulties. It is not yet clear how many such posts exist. In my area of Bristol, which has the Frenchay and Southmead hospitals, there are only two. However, I was surprised to discover that that is pretty good by national standards.

I understand that interesting new moves are under way towards developing the role of liaison nurses, and in particular that St. George’s healthcare trust in south London has gone further, by appointing a nurse consultant in learning difficulties. The success of that probably says something about the need to examine the NHS staffing structure in relation to people with learning difficulties. The holder of that nurse consultant post remarked:

“This job would not have had the impact it has had if it was not at consultant level.”

That shows an interesting divide, by which those with learning disabilities are often dealt with at a nursing level, when to get the impact that is needed it is necessary to go higher up the chain. Clearly, there is a need to explore the greater use of liaison nurses, the employment of a number of such nurses, and what happens at local level.

The White Paper gives us much encouragement about the personalisation of services, and, above all, the determination to put patients at the heart of the NHS. I note with interest that one of its principal aims is to ensure that shared decision making will become the norm. To use the familiar maxim that we use in the all-party group on disability, “No decision about me without me.” Sadly, we know that for some with learning difficulties that will be impossible.

We already know about the difficult ethical issues, which have been reported in the national media, in respect of those with learning difficulties having treatment forced on them. For instance, a lady with cancer was forced to undergo an operation. I do not want to touch on the ethical issues today, but such cases clearly raise questions about the relationship between patients and professionals. Given the White Paper, the greater personalisation of services and putting patients at the heart of the NHS, we must ensure that patients with learning difficulties are not left behind.

Personalised care that reflects individual health care needs is just as relevant for those with learning difficulties, if not more so. If we want to realise the promise of the White Paper—I note that it is also committed to promoting equality—we must understand the importance of health outcomes for those with learning difficulties. Moving from targets towards outcomes will benefit those with learning difficulties, as some of their problems need to be considered over a greater period, and hospitals cannot always deal with them in a single session. However, those outcomes are not being met, and that reflects on society.

Above all, it is important to ensure that the most vulnerable, particularly those with learning disabilities, receive the greatest care. In that regard, the introduction last year of incentive payments for GPs to carry out annual health care checks for those with learning difficulties was welcome. However, there is clearly a problem. Take-up has risen by about 60% between 2008-09 and 2009-10, yet still only half the money allocated for such checks by doctors is being used.

The White Paper and Government statements show that giving GPs greater control over their budgets will circumvent some of the centralised mechanisms. GPs will thus know exactly what tailored care is necessary for their patients, including those with learning difficulties. I hope that GPs will take the opportunity to expand the use of health checks within their allocated budgets. That will ensure that prevention is at the heart of treatment.

Above all, the issue is about prevention. As the right hon. Gentleman said, those with learning difficulties and disabilities are often at greater risk of illnesses that could have been prevented; they could avoid reaching the acute hospital stage, which can often be confusing and stressful, early in their treatment. Personalised care will ensure that GPs monitor patients more carefully. I hope that having annual health care checks in place will ultimately prevent people with learning difficulties from reaching the stage in the NHS that they find so disturbing—the stress of late diagnosis.

Finally, I echo the right hon. Gentleman’s comments about the national health service. We are not here to criticise the institution. We share a common cause; we wish to make it better and more effective for those with learning difficulties.

[Mr Gregory Campbell (East Londonderry) (DUP)]

I thank the hon. Gentleman for giving way. He touched on the excellence of the national health service. Does he agree that we must try to ensure best practice throughout the United Kingdom, particularly in devolved regions, and that we should not have patients in one part of the UK demanding of the health service a level of service that they see elsewhere? We should aim for equality and best practice across the UK.

[Chris Skidmore]

I agree with the hon. Gentleman. We are learning that health inequalities throughout our nation are extremely profound. Only by dealing with health inequalities can we raise the standard of public health in the nation as a whole—something that applies to many of our public services. Having a greater drive towards the localisation of services and the personalisation of care will get us to the stage where prevention is at the heart of NHS treatment. Through prevention, we will achieve greater equality; it will iron out some of the inequalities that we see in our most deprived communities.

The principles on which the NHS was founded are still relevant today, and we agree that that must remain so. However, although free health care at the point of access should be available to all, based on need, we must look harder at how to ensure that the needs of the most vulnerable are met. That includes those with learning difficulties. More clearly needs to be done, but I hope that we will be able to achieve it.