Social Care Funding

John Pugh Excerpts

Monday 11th February 2013 Commons Chamber

[Mr Hunt]

This is a devolved matter, as the hon. Gentleman knows, but different approaches are being tried in all four constituent parts of the United Kingdom and we must look at what is happening in the different parts and all learn from each other.

[John Pugh (Southport) (LD)]

I welcome the statement. Regardless of the details and figures announced today, does this overall approach not promise certainty and predictability where previously there was anxiety and uncertainty? Is that not the big gain?

[Mr Hunt]

That is the main point of what is being announced today. We are not able, with the public finances as they are, to offer a huge amount of support, but what we can do is give the certainty that means that for the first time people will be able to plan and make provision for their social care costs. We will be one of the first countries in the world that does that, which is why this is a very encouraging and very important day for people who care about the tremendous uncertainties associated with growing old.

Terminal Illness (Access to Medicines)

John Pugh Excerpts

Wednesday 23rd January 2013 Westminster Hall

[John Pugh (Southport) (LD)]

I thank the hon. Member for The Cotswolds (Geoffrey Clifton-Brown) for introducing the debate and explaining this important issue so well. I also pay tribute to Les Halpin, whom I had the privilege to meet. I use the word “privilege” exactly, because it was a privilege to meet someone who is so afflicted and yet so thoroughly constructive.

I once had the opportunity to attend a session with the National Institute for Health and Clinical Excellence when it was investigating a particular drug for a complaint called ankylosing spondylitis—I have not written that in my notes, so Hansard is on its own. The session was robustly and impressively chaired, and the drug and issues concerning it were thoroughly examined. During my period in Parliament, NICE has come up again and again, and various complaints have been raised by Members of Parliament, the pharmaceutical industry and patient groups. One complaint is about the inordinate time it often takes to develop a drug, which certainly appears to be the case; the other complaint, made by big pharma, is the cost that NICE adds to the development of drugs.

The example of India has been cited, but I am not sure that that is a good parallel. I have been to India and spoken to pharmaceutical companies out there, and they seem to specialise not in developing the more esoteric lines of drugs but in developing and marketing lines of generic drugs or taking up drugs that are out of patent and producing them at less cost than their western counterparts.

NICE would genuinely acknowledge that it adds to the cost of development, but there is also a question about its rigorous but circumscribed methodology. There were many debates in this place a few years ago about Alzheimer’s drugs, and the issue appeared to be not that the drugs do not work, but that they do not work for everyone in a sufficiently predictable way for NICE to approve them; although I have met constituents who can genuinely testify to the benefit of a drug that NICE is not prepared to go with. Of course, there are similar cases in which people genuinely disagree with NICE’s decisions. Most Members of Parliament will, at some time during their career, write a letter on behalf of a constituent who simply cannot get a drug because a primary care trust is sheltering behind the mantra that NICE does not approve. All that set aside, NICE represents a model that has been emulated worldwide, because with NICE we end up with cost-effective, efficacious and safe drugs.

To go back to the case I witnessed in NICE headquarters many years ago, I was surprised that sufferers with that particular complaint were in the room and thoroughly involved in the process. As the process went on, however, I discovered that one of the people—the reference point, as it were, for the piece of research—had died during the project. That, perforce, will happen many times if one enlists people already diagnosed with a terminal illness; some people’s needs are more urgent, some have less to lose and in the case of terminally ill people, some are not classified in that way unless there is no available cure.

A reasonable case can be made for relaxing the rules, to have more trials and to get more innovation in such circumstances; patients, science, medicine and future patients would all benefit, provided, of course, that the patient was genuinely a volunteer and properly advised of the risks. Another proviso I have just thought of, as India was mentioned, is that the volunteer was afflicted with the particular complaint, because in no way would we be happy with a world where people were trialling drugs for reasons other than their own benefit.

The question is, should we have a more flexible system than the orthodox one that we have put in place through NICE? I was at a breakfast this morning about NHS research, and I was pleased to learn that over the past decade or so, the number of NHS patients featuring in research has increased appreciably. Apparently, a decade or so ago, only about 2% of cancer patients featured in a clinical trial or piece of research, whereas now the figure is some 20%, which is a significant improvement, so we must not kid ourselves that even in the orthodox setting of the NHS valuable pieces of research are not being conducted.

As I see it, there are still arguments against what Les is suggesting, and he must be acutely aware of the force of some of those arguments. The Minister is a lawyer and, even with a disclaimer in advance, it is difficult to avoid the spectre of litigation if a drug that has not been thoroughly stress-tested is in use; it is hard to assure oneself that it is not at least a possibility. Cost might still be an issue, if the drug is very expensive, and the NHS has to consider carefully whether to spend a lot of money, perhaps to no effect. There is always the possibility of an unsafe medicine or of one that has not been thoroughly tested having catastrophic effects and worsening someone’s decline. That can happen even when the drug is tested; everyone can recall that thalidomide was tested, quite thoroughly in some respects, but not to the nth degree, with disastrous consequences.

Such entirely valid considerations are not a case against a different regime in principle, they are a case against what might be regarded as a gung-ho approach. After all, as the hon. Gentleman said, all medicines have side effects. The worst thing someone can do when prescribed a medicine is to take out of its box the long sheet listing all the possible side effects; if they read it, they simply would not take the medicine, regarding themselves as safer by not taking it. Where a drug has no known side effects and there are genuine grounds for belief in its potential benefits, some sort of pre-approval system is genuinely arguable for terminally ill patients, rather than having to wait for full NICE approval—the full works. Flexibility is not a non-legitimate demand in any context. We have to bear in mind that although there are general rules, there will always have to be sensible provisos, exceptions and caveats about an application.

I am reminded of the forthcoming ban on the use of opiates when driving. I am obviously keen that people under the influence of methadone or heroin do not take those drugs and then get in a car. Some people, however, have long-term, chronic conditions and are taking an opiate, but they are well used to the symptoms provoked and could or should be safely allowed to drive a car. I am sure that they would drive the car with no difficulty at all. Whatever rules we have need to be flexible for such cases. Likewise, whatever rules we have about the safety of medicines need to recognise that for some people, the environment in which they are taking the medicines, their circumstances and the risks they face are quite different. We need flexibility, where the risks are limited and where the benefits to science and the individual are potentially massive. There has to be an intelligible response of some sort to the sincere request made by the hon. Gentleman and by Les Halpin.

Furthermore, I agree with the hon. Gentleman on another extremely important issue—I did not expect him to raise it, but he did. If we are looking at a more innovative, research-based NHS, it would help enormously if pharmaceutical companies signposted the dead ends they have been down, indicating where things had not worked. That would save enormous sums of money, possibly for their competitors but certainly for the health of the nation and the NHS. I congratulate the hon. Gentleman and reiterate my sincere tribute to Les Halpin. I hope that he is in good shape today and listening to the debate, and that we can get a result for him.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 15th January 2013 Commons Chamber

[John Pugh (Southport) (LD)]

Can the Minister update the House on the roll-out of the 111 service and its effect on A and E admissions and 999 calls?

[Dr Poulter]

As my hon. Friend knows, we are developing the 111 service further to improve triage and take pressure off accident and emergency services when that is appropriate. I am sure all Members agree that when patients do not need to go to A and E, it is best for them to be treated in the community or properly triaged.

Dementia

John Pugh Excerpts

Thursday 10th January 2013 Commons Chamber

[Paul Burstow (Sutton and Cheam) (LD)]

I thank the Backbench Business Committee for the timely opportunity to debate on the Floor of the House this most important of issues. I also thank my hon. Friend the Member for Chatham and Aylesford (Tracey Crouch) for her commitment to, and interest in, these issues and her determination to ensure this debate took place today, and the right hon. Member for Salford and Eccles (Hazel Blears), who chairs the all-party group on dementia. Together, the three of us argued the case for this debate to come to the House, and I look forward to their contributions. They are both passionate about this issue.

Earlier this week, I was at an event at which the daughter of an 86-year-old woman with dementia said some things that spoke to what this debate is all about. She talked about being a full-time carer for her mother and about the agonising decision to move her mother into a care home. She said that although death and moving house were probably the two most traumatic events in our lives, dementia was a never-ending bereavement and that the daily trauma had robbed her and her mother of life. Such true-life experiences, many more of which I hope will come out in today’s debate, make it plain why dementia is now the disease most feared by the over-55s.

My interest in the issue goes back well over a decade and was started by a report that I read into the inappropriate and, in some cases almost abusive, use of anti-psychotic medication. Even then, the side effects were beginning to be well documented and understood, so it is no wonder that at the time these anti-psychotics were labelled as a chemical cosh. As the evidence has mounted over the last decade or so of the increased risk of stroke as a result of these drugs and of the fact that they can shorten lives, I was prompted to ask endless parliamentary questions to Ministers about the matter and to produce a series of reports. At times, it felt a bit like banging my head against a brick wall.

I am pleased to say that the wall has started to tumble and that things have begun to change, and, in the last two and a half years, we have seen a 52% reduction in the prescription of these drugs to individuals receiving them for inappropriate reasons. As a result, lives have been saved and lives have been changed. But—and it is an important but—the Prime Minister’s progress report on his dementia challenge made it clear that there is no room for complacency and that there is still too much regional variation in the use of these drugs to manage people with dementia and too much prescribing. I hope that the Minister will tell us what the next steps will be, when the next audit, which has been committed to, will take place and be published and what other steps he thinks will be necessary to ensure that we achieve the goal of a two-thirds reduction in prescribing.

I pay tribute to Clare Gerada, president of the Royal College of General Practitioners, who was instrumental in getting the co-operation of GPs for the necessary surveys to understand prescribing practice and who has led some of the change in culture and behaviour in this area. I also pay tribute to the last Labour Government—not something I always do—for producing the first national dementia strategy. It was one of the first in the world, in fact, and should be recognised as an important contribution.

When I became care services Minister in May 2010, I had to make a judgment: did we carry on the road laid out in that strategy, or did we start again? I took the view that we should use the strategy as the foundation for future action, and I am pleased to say that, as a result, the Government have done a lot to deliver on the strategy and go beyond it, through the creation of a dementia action alliance, bringing many different organisations together in a common cause, through clearer commissioning guidance, through collaboration with the Design Council and through funding the Life Story Network to run training courses. The latter is a small thing, but it makes a big, big difference: by telling our stories and understanding who we are, we start to look beyond the diagnosis of dementia, and, as a result, we start to treat the person, not just the disease.

Furthermore, the audit of dementia services has given us a handle on where different parts of the country have reached in developing their services and has led to new incentives in hospitals to support best practice and the much-valued—I hope—analytical tools that will help to drive up diagnosis rates, which are still far too low. Following the research call made just over a year ago, I was delighted to see just last week that £20 million of funding has now gone to new dementia research projects. That far exceeds what I expected at the time as a Minister and certainly what many officials in the Department expected. It really is fantastic news.

The Prime Minister’s dementia challenge has put dementia centre stage, promoting dementia-friendly communities and raising the bar for early diagnosis and quality of care, along with ensuring vital dementia research too. There is a lot happening and it can happen back in our constituencies as well. All of us have an opportunity—and, I believe, a responsibility—to challenge our local services to do more to become more dementia-friendly and ensure that they learn the lessons from best practice. However, there are some questions that the Minister needs to answer about what comes next. The current dementia strategy runs its course in 2014. What comes next? In my view, there has to be a successor strategy—one that is perhaps different from the current strategy in a number of ways, building on the work being done as a result of the Prime Minister’s dementia challenge.

That challenge is a challenge to the whole of Whitehall, not just the Department of Health. Every Department should be a catalyst for action on dementia within its sphere of responsibilities. Indeed, just before Christmas I tabled a series of parliamentary questions to try to establish what each Department was doing to support the dementia challenge. The answers I received were highly variable. Not all Departments seem to have clocked the fact that they could materially do something to make a difference in their sphere of responsibilities. I hope we can pick up on what the Prime Minister said about this being a challenge that cuts right across society, as well as ensuring that it is picked up and understood right across government. Any new strategy needs to embed dementia-friendly thinking right across Whitehall.

We cannot have a debate such as this and not talk about carers. It is important to stress and value the role that family carers play. That is why I was pleased to see recently that the National Institute for Health and Clinical Excellence has launched a consultation on new indicators in the quality and outcomes framework for identifying carers of people with dementia. That is fantastic, but what about all the carers who do not happen to be caring for someone with dementia? On this occasion I think it is wrong to single out one disease. I hope that others will make that comment in the consultation too. The most recent research by the Carers Trust into the NHS and carers’ breaks continues to make depressing reading, however. Too much of the NHS is still ignoring carers and not doing enough to passport the money that this Government have committed to carers’ breaks and make them a reality. As the NHS increasingly wakes up to the big challenge of supporting people with dementia and other long-term health conditions, it needs to wake up to its role in supporting carers too.

I have already mentioned that I was pleased to see the increased research funding that is coming through. I was delighted in 2010 when the coalition programme included a commitment to dementia research. That is a commitment that I lobbied the then Liberal Democrat health spokesman—now the Minister on the Front Bench—to include in our manifesto. Although there has been progress—with a road map now setting the direction of travel, a challenge group bringing various players together and a commitment to double research spending—I found myself becoming increasingly frustrated as a Minister by what I felt to be a poverty of ambition when measured against the burden of disease that dementia represents. We are not yet doing enough—we do not yet have the critical mass—to reach the scale and pace necessary to gain the understanding and insights that we need to make the breakthroughs. The £20 million from the research call is fantastic and I hope it will make a difference, but we still have lessons to learn from the journey made by the cancer research movement. I believe the dementia research challenge group itself needs to be challenged more. We need a long-term plan for dementia research and a sustained increase in funding for at least the next decade. This is about a common endeavour—a collaboration, as it were—between the research funders and the research community, so that we make a concerted effort to expand our knowledge of this disease, to diagnose and treat it and, ultimately, to understand and defeat it.

[John Pugh (Southport) (LD)]

I am listening carefully to my right hon. Friend, but dementia is clearly not an English disease; rather, it is an international threat. Is there not scope for massive international collaboration on what is an issue confronting all nations?

[Paul Burstow]

My hon. Friend makes an important point. Yes, there is scope for that; indeed, many research organisations in this field are already collaborating internationally. However, as a country with a very reputable research tradition, it is important that we should be in the vanguard of that research and put in place the necessary infrastructure to drive it forward.

Diabetes

John Pugh Excerpts

Wednesday 9th January 2013 Westminster Hall

[Mr Sanders]

I am grateful to the hon. Gentleman for making that point. When one puts together speeches, they sometimes go on too long, and I had cut out that bit, so I am glad that he has raised it. The big issue is that the cause of death is sometimes recorded as stroke or heart disease when the underlying problem is diabetes. We have targets for cancer, heart disease and stroke. We really ought to look at diabetes as the root cause of other conditions for which there are targets.

The variation in care across the country is probably the largest worry for patients now, and the new implementation plan should focus on that. Failings in diabetes care cause an estimated 24,000 premature deaths each year. In 2001, the Department of Health published the national service framework for diabetes, which set out clear minimum standards for good diabetes care. Those standards include nine basic care processes that aim to end preventable complications by looking for early warning signs. Despite those targets, much of the country has seen little progress towards improving detection of type 2 diabetes and reducing the number of preventable diabetes complications. In 2009-10, results from the national diabetes audit showed wild variations in inputs and outcomes for both type 1 and type 2, including the astounding figure that the proportion of type 1s receiving the recommended nine care processes ranged from as low as 5% to 50%, with an average of 32% in England. The figures were only marginally better for type 2s. It really is not good enough.

The point about the condition is that people treat themselves 364 days a year and see a practice nurse or sometimes a general practitioner—more rarely, these days, a consultant—only once a year, although they should receive the nine care processes. The chance of developing diabetic complications can be reduced by keeping blood pressure, blood glucose levels and cholesterol levels low. Regular monitoring, backed up by periodic checks, is the key. The results from the national diabetes audit demonstrate that more needs to be done to end the postcode lottery of care for people with the condition. When as few as 5% of people with type 1 diabetes are receiving all nine care processes in some areas, there is a definite failure of care. If all health care trusts followed the national service framework, such complications as blindness and kidney disease—as well as stroke, heart and other diseases—could be prevented.

I hope that we will explore a range of best practices, but I want to highlight a couple that have scope to bring immediate improvement at very little cost. An acute issue is the provision of insulin pumps for type 1s. That is an example of where the UK should look abroad for best practice. Type 1s in other developed countries, such as France, Germany or the US, can expect to benefit from a pump if that is required for their diabetes management. Somewhere between 15% and 35% of type 1s in those countries have pumps, which enables them to lead normal lives, but in the UK the figure is less than 4%. That is clearly a failure of the commissioning structure as it is now. Will the Minister address how that is likely to improve? The Work Foundation has estimated that, if pump usage reached 12%, the NHS would save about £60 million a year.

Another example of where best practice is needed is surprisingly simple: good local leadership. Good leadership, as I have been fortunate enough to experience in my own area of Torbay, is essential to promoting effective and integrated services. Integration is key to reducing costs in the long term and, more importantly, to improving patient outcomes, which all too often get lost in the debate over health care services.

The move to clinical commissioning groups, with the potential for better scrutiny and criticism from patient groups, local authorities and health care staff could, in theory, lead something of a revolution in spurring innovation and creativity and in the striving to find best practice.

Just as educating the commissioners is crucial, so, for diabetes, is patient education, which has the happy side effect of making patients far more aware of whether they are receiving a good service and enabling them to become better advocates for their condition. I have no doubt that the great knowledge possessed by volunteers for Diabetes UK, the Juvenile Diabetes Research Foundation, INPUT and the many other groups involved in diabetes will be a considerable asset in shaping good services at a local level now that we have better scope for patient scrutiny and involvement.

In the wider sense, patient education is the core to preventing complications, which diminish the quality of life for patients and which, all too often, reduce life expectancy and increase the costs to the NHS in the long term. Good patient education programmes may require some investment, but they would pay for themselves many times over.

On a broader level, work needs to be done on detection and prevention. The number of people suffering from type 2 diabetes is set to reach a staggering 5 million by 2025. However, what many people do not know is that type 2 diabetes is a largely preventable disease. At the very least, its onset can be delayed and complications reduced.

NHS checks are vital to the detection and prevention of diabetes. In theory, such checks are available to all 40 to 74-year-olds who are seen to be at risk of developing diabetes. Shockingly, a number of primary care trusts in the UK failed to offer a single person an NHS health check last year, which demonstrates the dangerous variations in provision in the NHS. The Government can look to rectify that if they create a new national implementation plan for diabetes. Indeed they may even take up the suggestion by the hon. Member for Gillingham and Rainham (Rehman Chishti) to set targets for diabetes.

This year, the current national framework for diabetes comes to an end. It is important that we build on the successes of the framework, that we focus on reducing discrepancies in diabetes care and that the new framework emphasises the importance of health checks and prevention of the disease through simple means such as diet management. Indeed, it is essential for the Government to spell out to commissioners and to patients what services can be expected and to provide a road map to show where we want to be in a few years’ time and how to get there.

[John Pugh (Southport) (LD)]

My hon. Friend analyses the fair degree of regional variation that exists and talks about a postcode lottery. Does he think that that is primarily down to a lack of leadership at PCT level, or to the qualitative variations that we get anyway in primary care practice among GPs across the country?

[Mr Sanders]

It is a combination of both. We cannot prescribe from the centre precisely what must happen in every area. Of course local areas must reflect their own demographics and their own health picture and be able to apply priorities accordingly. However, there is something to be said for ensuring that local areas have the tools that they need, which is where NHS Diabetes did such a good job on the back of the NHS framework for diabetes.

It is equally important that health checks are used to detect diabetes in its earliest stages, as early detection and appropriate treatment can prevent the severity of the condition and the risks associated with complications such as amputations.

--- Later in debate ---

[Rosie Cooper (West Lancashire) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Crausby, for this debate.

I congratulate the hon. Member for Torbay (Mr Sanders) on securing the debate on such an important issue, which affects a growing proportion of our population. Indeed, having listened to the contributions that have already been made, it is very clear that there are many facets of diabetes that could be covered during this debate, but I think that we will all probably concentrate on amputation. I will spend a few minutes focusing on the importance of podiatry services, which can reduce preventable amputations for those with diabetes.

Currently, 4% of the population live with diabetes, and a fifth of those people will develop a foot ulcer at some point. At any one time, there are 61,000 diabetics in England who have foot ulcers. A foot ulcer may not sound like a very serious condition, but for a diabetic the consequences of foot ulcers can be severe, and even fatal if the appropriate treatment is not given. Statistics for England alone show that, of those diabetics with foot ulcers, 6,000 people—that is 10% of the total number—had leg, toe or foot amputations in 2009-10. Based on current trends, that figure is projected to rise to 7,000 people by 2014-15. An amputation is devastating. If any individual loses a limb, it will have a far-reaching impact on their life. For many diabetics, an amputation can increase the likelihood of premature death.

Let me put those figures for diabetes in context. The five-year survival rate for those with breast cancer is just over 80%, but for those with a diabetic foot ulcer the five-year survival rate falls to just under 60%. For those people who have a lower limb amputation, their survival rate worsens after five years. The consequences are even more horrific when we consider that 80% of those amputations are preventable. In 2012, that is simply incredible. We are not doing everything we can to rectify that and to ensure that people have the information and services that will help them protect their limbs.

It is scandalous that with our 21st-century health care we are allowing people to go through the completely unnecessary, torturous and miserable experience of amputation. Prevention is supposed to be the watchword of the modern national health service; through prevention, people can enjoy a better quality of life and the NHS can save itself millions.

It is therefore hard to understand why better prevention is not deployed with diabetes and amputations. Why is more effective use of podiatry services not a priority for the health service? At a time when the number of diabetics is growing, and with it the costs of treatment, podiatry could be a means of improving a diabetic’s quality of life and saving the NHS money. Amputations cost the NHS considerable sums, which are estimated to be in the region of £600 million to £700 million each year.

Results from pilot projects can demonstrate the positive impact of investing in good podiatry services. A multidisciplinary foot care team for in-patients with diabetes in Southampton led to a reduction in the length of in-patient stays from 50 days to 18 days. Not only were patient outcomes improved but annual savings to the NHS of £900,000 were generated from an investment of £180,000. That savings ratio of £5 saved for every £1 invested was bettered in another example. In James Cook hospital in Middlesbrough, a multidisciplinary foot care team generated annual savings of some £250,000 at a cost of £30,000, which is a ratio of £8 saved for every £1 invested. Those figures show how it would be not only the Government and the NHS that reaped great rewards from a small investment, but diabetics and those who need podiatry care. Based on the pilot evidence, logic would suggest that even in these straitened times we should be investing in podiatry services, because that could save even more money and improve health.

There is evidence, however, that the opposite is happening and that services are not improving. The danger of the new arrangements is that important issues fall between the cracks, are left to local decision making and do not get the prioritisation they deserve. More than half of hospitals do not have a multidisciplinary foot care team. In fact, 31% of hospitals do not even have an in-patient podiatry service, according to data from the national diabetes in-patient audit in 2011. That reflects a worsening service, because in 2010 only 27% of sites had no provision. The amount of provision has dropped, and nearly a third of hospitals no longer have that service.

There is also evidence that there is a problem with GPs having no incentive to refer their patients on to a foot protection team for education or follow-up. Why is that? Why is this woeful situation tolerated? If more referrals were made, we would see a beneficial reduction in ulcer and amputation rates.

[John Pugh]

Will the hon. Lady explain why a GP would need an incentive to do what is clinically desirable in the first place?

[Rosie Cooper]

I absolutely share that concern, which is why I cannot understand the current view that doctors do only what they get paid for and if there is no money attached to something, it may not be the first thing they do. As I pointed out in Westminster Hall yesterday, when we had a debate on the Liverpool care pathway, financial rewards to clinicians should not be the driver of what happens or the pathways that are followed. That is good clinical practice. Surely to goodness, if a referral to podiatry is required, that is what should happen. It could also be said that if the services are not there or are being reduced, the GP has less incentive to refer, knowing that it will take so long to get an appointment.

The College of Podiatry is

“fearful that public expenditure constraints mean that rather than being prioritised through the QIPP”—

quality, innovation, productivity and prevention—

“agenda, current podiatric services are at best, being frozen and in some cases being reduced, with patient services including the diabetic foot service deteriorating as a consequence”.

That has massive implications for the NHS budget and for the patients themselves. During a debate in the other place on 29 November 2012, the Under-Secretary of State, Earl Howe, accepted that

“rapid access to multidisciplinary foot care teams can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team.”—[Official Report, House of Lords, 29 November 2012; Vol. 741, c. 336.]

My question for the Minister is whether the NHS, which is in the throes of a reorganisation and being more localised through clinical commissioning groups, as well as being put under increasing financial pressure, will move towards or away from having more multi- disciplinary foot care teams, given that fewer than half of hospitals currently have such a team. Investment in more podiatry services would result in improved foot screening, appropriate follow-up services, enhanced care when required, better outcomes—including fewer amputations—reduced length of stay in hospitals, increased quality adjusted life years and reduced morbidity. We would all win; we would have a healthier nation and significant financial savings.

--- Later in debate ---

[Jim Shannon]

That is an excellent point, and I am sure that the Minister will address it in her response. There are groups in the whole of the United Kingdom in which diabetes is more prevalent, and we need to look at those target areas.

There are 3.7 million people in the UK diagnosed with type 2 diabetes. I was diagnosed four years ago. With me, it was down to bad eating habits, stress and the fact that there were no set hours to my job. I ate whatever was quickest, and that was Chinese, usually with two bottles of coke, five nights a week. That was why I was 17 stone. I am now down to 14 and a half stone because I no longer do that. The issue is eating and living styles—eating what is quickest rather than what is best.

Edwin Poots, the Minister at the Department of Health, Social Services and Public Safety in Northern Ireland, is very aware of the ticking time bomb that is diabetes. I am aware of the key initiatives in operation in Northern Ireland, and I know that the Minister here today has had discussions with the Minister in Northern Ireland. They are doing a great job, including setting aside funding to employ additional diabetic staff—specialists, nurses, dieticians and podiatrists. That is providing all the help that a diabetic needs, but it is still not enough.

We need a concerted effort across the United Kingdom, through the media, and even perhaps through the TV soaps. I am not a soap watcher. I could not tell anyone what happens in “Emmerdale” or “Coronation Street”, but my wife could. She knows everyone in them—what they are doing this week and what will happen to them next week. Could we not perhaps use the soaps to make people more aware of the issue? I understand that plenty of issues are brought up in them regularly, so perhaps we should try this one.

It is great that our children are taught about diabetes in school. It is surprising what a five or 10-year-old knows about food that their mum and dad do not. Who is educating the mums and dads at home who are making the dinner and buying the shopping? The hon. Member for Blaenau Gwent (Nick Smith) made a point about how the food coming into the house is controlled by the parents. Diabetes UK Northern Ireland is taking part in an organisation-wide campaign entitled “Putting Feet First” to raise awareness of amputations among people living with diabetes and to work to prevent unnecessary amputations.

The Minister might want to comment on the new medications that are available. In the press this week, there was talk about a new diabetic medication in tablet form that could replace—not totally but partially—type 1 injections. The figure used was a cost of £35 per month. It would be good if we could get some feedback about whether the new medications will be available across the United Kingdom and whether everyone will be able to take advantage of them.

In Northern Ireland last year, 199 diabetes-related amputations took place, and the “Putting Feet First” campaign highlights that an estimated 80% of lower- limb amputations are preventable. There must be a UK strategy to reduce diabetes-related amputations by 50% over the next five years. What can we put in place in this Chamber to highlight and support the campaign? How can we use our influence to see the number of cases of type 2 diabetes dropping, instead of this steady rise?

The links between type 2 diabetes and obesity are firmly established, and it is clear that, without appropriate intervention, obesity can develop into diabetes over a relatively short time. For instance, the risk of developing type 2 diabetes is about 20 times more likely in obese, compared to lean, people. A newspaper recently stated that academic sources have estimated that the predicted rise in obesity rates over the next 20 years will result in more than 1 million extra cases of type 2 diabetes, and that is really worrying. Can that go unchallenged, when it is within our power, as parliamentarians, to do something about it, at least by putting a strategy in place or by beefing up the ones that we already have? When the current UK-wide strategy ends, it will perhaps be time to do something more.

I live the life, as do many others, of testing my blood every day, of feeling unwell when my blood sugar is out of control and of worrying that the next visit to the doctor will bring worse news, which can be the case if we do not discipline ourselves and ensure that we do things right. That is not the life that I want to have, or the life that I want my family, friends or constituents to have. The way to take on the issue is to continue with the UK-wide strategy, with dedicated funding and with all the regions working together, which will save money in the long run and, more importantly, improve the quality of lives across the United Kingdom.

I urge the Minister to take the initiative. I believe that she will and that her response will be very positive, because she understands the issues. I urge her to work with the devolved bodies, in coming together to disarm the ticking time bomb of diabetes—the cost of which some people indicate will be £10 billion—before it explodes. Type 2 diabetes is preventable, and we must do all that we can to prevent it. Education, with attention paid by everyone in this Parliament and the regional assemblies, is the way to do that.

[John Pugh]

rose—

[Keith Vaz]

rose—

--- Later in debate ---

[John Pugh (Southport) (LD)]

I am happy to give way to the right hon. Member for Leicester East (Keith Vaz)—in any case, I will make just a few remarks. I pay tribute to his efforts in the House of Commons in this area, as well as those of my hon. Friend the Member for Torbay (Mr Sanders).

I am provoked to make a few remarks by things that other hon. Members have said. I think that we all recognise that diabetes is a major problem. Rates are increasing—it is almost a worldwide epidemic—and it is a killer, linked to a series of other sorts of organ failure. We all recognise and it has been clearly stated that type 2 diabetes is rampant in our society and is lifestyle-related. Diagnosis is important, but I got the sense that that is fundamentally not the problem. We can get diagnosis right. There are clearly failures in general practice, in not picking up the condition early enough, but we do tend to find out who has it and who does not.

The issue appears to be treatment, as has been phrased by most Members. From events that I have attended from time to time in the House, I am aware that the treatment of diabetes is becoming increasingly sophisticated. A series of technology is attached to that nowadays, and we also have the advent of telehealth. All the major practitioners of telehealth are keen to provide better services for diabetics.

Additionally, there is the expert patient initiative, about which I was slightly sceptical when it was launched. The initiative is becoming very effective in connection to diabetes. The charities are playing along with that, too. A lot of good things are going on, but we are recording a variation in practice. There is something of a postcode lottery. I wonder what will prevent that. In which direction will we go?

My hon. Friend the Member for Torbay voiced concerns about the future of NHS Diabetes, but, like the hon. Member for West Lancashire (Rosie Cooper), I wonder how that will play into the new system. There seem to be two ways in which things could go. Without the local primary care trust, there may be, temporarily at any rate, an absence of leadership, because one of the PCTs’ jobs was to manage GPs, to keep them up to the mark and to assess how well they were performing. Clearly, part of the problem that we are addressing today is the failure of GPs, first, to diagnose diabetes early enough and, secondly, to treat it as effectively as they might. It is a fact that, although they are slow to admit it, GP practices in this country can be something of a lottery; they are extraordinarily variable in quality and character. Such features may be more manifest in the new structure.

My hon. Friend the Member for Torbay sketched a more optimistic scenario, however, in which the health and wellbeing boards will become ever more vigilant and keep GPs up to the mark. GPs themselves have suggested to me that one of the best ways to produce good and more standardised practice is peer review, with every GP knowing what other GPs are doing.

I am not sure which of those two outcomes is more likely, but there is great concern that the Department of Health ensures that the right one results.

I am uncomfortable with the thought, as raised by several Members today, that we could simply impose targets and that that would somehow get things right. The hon. Member for West Lancashire and I attended a debate not 24 hours ago on the Liverpool care pathway, in which we considered the corrosive and dysfunctional effects of targets. Once targets are set, we do not always get the results that we want. What, for example, would a target to reduce amputations do? Would it mean people do not do amputations in circumstances where an amputation might be desirable for the patient?

We come back to the perennial dilemma of many of our debates, particularly on specialist conditions, in that we can identify good practice—we can see it, and we miss it when it does not occur—but the national health service has never successfully found the secret of spreading good practice fast enough, which is happening again with diabetes.

Liverpool Care Pathway

John Pugh Excerpts

Tuesday 8th January 2013 Westminster Hall

[John Pugh (Southport) (LD)]

I also congratulate the hon. Member for Montgomeryshire (Glyn Davies) on introducing this important debate in such a measured and sympathetic way. It was effective indeed.

I do not like the term “Liverpool care pathway”; I prefer talking about guidelines for palliative care. That is probably a less contentious way of discussing it. The Liverpool care pathway was developed in Broadgreen, and I was born in Broadgreen. More importantly, my grandmother died there, having been readmitted several times. The last time she was admitted she had declined somewhat at home and I can remember the expression of horror on her face indicating that that was not the right way to treat her. She knew that she was going to die and she wanted to die at home, and she was being admitted unnecessarily to hospital. I regret that we arranged for that to happen. It is very important to get the last years, months and weeks of people’s lives correct and we certainly did not; hence there is a need for things such as the Liverpool care pathway and a more understanding, measured and sensible approach to affairs.

There is a need for the hospice movement, but the reality is that most people do not die in hospices; they die in the NHS and there is a need for the NHS to have some clinical guidelines to follow. That is particularly the case for those in their last hours, day, weeks and months, whose death is imminent and who cannot have that death prevented or, realistically, postponed. That is quite a high threshold to be met, and finance should in no way come into meeting that threshold. When finance does come into it, it can only corrupt the process. The Liverpool care pathway guidelines imply constant review and no one wants that coloured by financial incentives. After all, there is always the remote possibility of people getting the diagnosis wrong.

That is not a case against having guidelines at all or against thinking that we sometimes need to opt for a palliative choice rather than a remedial one, if there is no realistic remedial choice available. If that choice has to be made, there is no in-principle case for involving relatives and the patient in it, with the important caveat that what is done should be in the patient’s interest. I am not always sure there is an obligation to clarify the situation for the patient or their relatives, if they prefer to die in hope or expectation of recovery and find the thought of their inevitable demise insupportable, particularly if it will not change clinical behaviour and the only option is palliative care for that person. That is a difficult issue, which every clinician needs to face and be guided on in facing it.

There is certainly a need to inform the patient and/or relatives if expectations about care are starting to differ, or if the nature of the palliative care offered is unclear. That might be the case if a patient is wrongly categorised, or if there is a debate about the palliative care itself, and it is seen as substandard. Some of the episodes of dehydration that have been described in the national newspapers have seemed to me to be substandard palliative care. The bottom line is that palliative care should not worsen the condition or augment the suffering of somebody who inevitably will die, unless the patient chooses it. In certain circumstances, I can imagine somebody trading pain for more life.

Care can be worsened in two quite different ways: it can be worsened by disruptive, painful, pointless, futile interventions, and it can equally be worsened by neglect, and indifference to people’s symptoms and the manner of their decline. My aunt recently died in the Royal Liverpool, which has taken over Broadgreen. I remember going to her bedside and seeing the signs that said, “Nil by mouth”, and wondering whether we should offer her a drink while we sat there and talked. We never managed to get round to having a sensible conversation about that with the medical staff. I was never sure what I was confronted with. It might have been wise care; there may have been a genuine risk of choking, which I believe is one of the reasons why people are not given liquids at that stage. It might just have been neglect or absence of thought. What did not happen—and should have—was a discussion about treatment: a sort of negotiation.

If palliative care is the path chosen—it should only be chosen when it is, in a sense, the only path—there needs to be a negotiation. It is the trick of getting that negotiation right that is the difficult thing. We need to respect the rights of all people concerned, and the patient’s rights sometimes differ slightly from the family’s rights. The family fearing bereavement can only wish the patient to live at all costs. That may not always be the patient’s aspiration in that circumstance. The hon. Member for Montgomeryshire has started us along the path of having a measured discussion and review of these matters and I hope it continues.

[Mr David Burrowes (Enfield, Southgate) (Con)]

I respect what my hon. Friend says on communication with the patient, but I would like to clarify something. A survey by the Marie Curie Palliative Care Institute Liverpool and the Royal College of Physicians said that half of those on the LCP are never told that they are on such a pathway. Also, the LCP is not just a framework of good practice but a pathway, taking the patient towards the presumed outcome of death. Surely, therefore, it is important to make it clear that there should be communication with the patient; it should not be only the best half who know.

[John Pugh]

That in part is the dilemma. I know that the saying is “No treatment about me, without me”, but there are certain circumstances that we will all be aware of where the patient is dying and the clinician is in an acute moral dilemma over whether to inform them that that is the case—that there is no hope and that they will be given purely palliative treatment. I am fairly confident that a good number of people will die in our hospitals for years to come, despite the Liverpool care pathway or any other guidelines that we put in place, who will, until the moment of their decease, expect recovery.

[Mr Mike Weir (in the Chair)]

We have just under 12 minutes left and two speakers to go. I ask that they bear that in mind.

NHS Funding

John Pugh Excerpts

Wednesday 12th December 2012 Commons Chamber

[John Pugh (Southport) (LD)]

While you were not in the Chair, Mr Speaker, you missed a lively and interesting but predictably arid debate. We have reached a kind of stalemate. Those who understand the dark art of political messaging tell me that it is important to say the same things again and again, and psychologists tell me that those who do that are more likely to be believed. Prior to the election, the Tories were unique in having as an important part of their messaging the wish to ring-fence and preserve NHS spending.

That message was then embodied in the coalition agreement and has influenced subsequent spending decisions. We all recognise that there are good reasons for that—the NHS is a demand-led service. It is therefore perfectly sensible, in the Westminster bubble, for the Opposition to make an issue of it. Members have come to the debate with predictable information from the Whips-SpAd axis about the private finance initiative, the misdemeanours of Wales, evidence of unexpected service rationing, reconfiguration trouble, positive and negative variations in waiting lists and ambiguous data on productivity. We have all been given that stuff, and we can use it as we wish.

Meanwhile, the public have clocked that we have a real problem. The demands on and expectations of the NHS will continue to rise, resources are tight and there will potentially be a huge problem. They know that politicians cannot be seen to reduce the NHS offer—they simply would not tolerate that. They do not know quite how all the sums will ultimately stack up, and nor do we. That is the big question.

[Andy Sawford]

Will the hon. Gentleman accept, though, in the interests of being transparent with the public, last week’s letter from Andrew Dilnot, the chair of the UK Statistics Authority?

[Andy Sawford]

The letter stated unequivocally that

“we would conclude that expenditure on the NHS in real terms was lower in 2011-12 than it was in 2009-10.”

Until both Government parties acknowledge that truth, which independent experts have told us about, they will not have any credibility in health debates.

[John Pugh]

I think I will take the advice of my hon. Friend the Member for Beverley and Holderness (Mr Stuart) and move on.

I think we all agree that the only acceptable answer to the problem is to spend public money wisely. Currently, the NHS is holding up—sort of—by making economies and savings, largely off the back of a wage freeze, which is not sustainable. However, I am starting to be alarmed by the disagreement about what else we can do and what strategies we should follow. I will run briefly through the suggested options.

It has been suggested that we should keep people out of hospital, but we already have fewer hospital beds than almost anywhere else in Europe, and according to the NHS Confederation there is no clear evidence that treating people outside hospital would necessarily be cheaper.

Some people recommend personalisation and personal budgets, but it can be argued that that would not lead to better use of scarce resources, despite the fact that it would be more popular than some current service configurations. Telehealth has also been suggested, and I am a great enthusiast for it—it is my personal favourite suggestion, and I am chair of the all-party telehealth group. However, although there are cost-effective pilots, the Nuffield Trust has expressed some criticism of telehealth, saying that it may not save us anything like the money that we believe it will. The industry itself is concerned that if the roll-out is not efficient and effective enough, telehealth simply will not take off.

[Mr Dorrell]

I am listening carefully to my hon. Friend, and I have some sympathy with him, but will he acknowledge that the arguments for those options are partly about health economics but partly related to the need to deliver better quality to those who rely on community-based services? We do not want acute cases if they are avoidable.

[John Pugh]

I agree; none the less, we both agree that there is still a huge economic problem.

Even reducing the number of managers has mixed impacts, because asking doctors to manage services or buy in management service from elsewhere has cost implications. It uses up medical time, which needs to be replaced. Then there is the blighted history of IT and the uncertain role of technology and innovation, which can increase demand but also reduce cost. Even if we see public health as the answer, it is still not a complete answer by itself, because if we do not solve the huge problem of dementia, there is no saying that prolonging life and keeping people fit will necessarily reduce overall costs in the long run. If we look at things such as rewarding doctors through the quality and outcomes framework, and so on, we find some pretty expensive deployment of public money, albeit not always to massive effect. The point I am trying to make is that there is a whole medicine chest of remedies available, but no complete agreement on precisely how or where best to use them. None of them seems to be a cure-all, and many have undesired side effects.

As we choose to use those remedies, they need to be employed with skill, judgment and the benefits of experience, because we are dealing with an almost insurmountable problem. We have to approach the problem—almost like good medicine—using the right remedy, at the right time, in the right way and with skill, judgment and experience. However, that will not result simply from using market forces or creating some sort of ersatz market—that is just another tool we might choose to use. What we want—I am sure the Minister agrees—is integrated services, which would avoid expensive duplication, cost-shunting and piecemeal provision. It would be really nice if we could exploit better economies of scale in procurement, for example, or make better use of the NHS estate. It would be nice if we could discover good practice and roll it out across the piece quickly. It would be really nice if the NHS was a well oiled and efficient machine—a truly integrated system with proper clinical networks that were properly protected. It would be nice if we got what the Minister describes as integration, which is a kind of holy grail at the moment.

However, I have a problem—I am sure the Minister has a response to it—in that we have just abolished what I think would be the best agency for integration. The strategic health authority, unloved as it was—a bit obese, misunderstood, and so on—was a vehicle that could perform that role, applying the right remedies in the right place. I must own up: we decided in the Lib Dem manifesto that we wanted to get rid of the SHA. However, perhaps over the fullness of time the NHS Commissioning Board will create something like that—quietly, privately—because to some extent, I think we all agree, it is needed. Meanwhile, there are key things we need to get on with. We can certainly improve procurement without any difficulty. We can try to release ourselves from the pointless grip of the EU working time directive, which adds appreciably to salary costs. We can also work hard to move data around the system better. There is an enormous amount to do and it is not obvious who is going to do it.

Winterbourne View

John Pugh Excerpts

Monday 10th December 2012 Commons Chamber

[Norman Lamb]

I thank the right hon. Gentleman for his welcome for the broad thrust of my proposals, and for his questions. On standards of business in the sector, it strikes me that the levels of corporate accountability seem to be significantly lower in this sector than in many others. How bizarre is that, in a sector in which the protection of individuals is absolutely vital? In our response to Southern Cross and to this case, we will require owners to adopt a much more transparent approach and to disclose details of their financing arrangements. We are introducing that level of engagement and transparency as well as addressing the need for accountability. The right hon. Gentleman also asked about restraint, and we will certainly look at the appropriate methods of restraint. It should really be used only for the protection and safety of an individual or of others. It should not be used for chastisement or punishment, as appears to have been the case in some locations. That is completely unacceptable.

[John Pugh (Southport) (LD)]

One of the big problems is the fact that many local authorities house vulnerable people at a considerable distance from their families. What element of the proposals will constrain that unfortunate practice?

[Norman Lamb]

I thank my hon. Friend for that question. He is absolutely right that one thing uncovered, both at Winterbourne View and in the Care Quality Commission survey of similar institutions, was that people were sometimes placed hundreds of miles away from their families. That still continues; that is what we have to address. My hon. Friend asks about what in the proposals will address that and ensure that it does not happen. Every part of the system is signed up through the concordat to changing what has been an unacceptable practice. People will be held to account. I said in my statement that I will chair a programme board throughout this period of change, and we will publish regular updates so we can, in a sense, hold to account every primary care trust or clinical commissioning group and every local authority that fails to change in the way expected.

Oral Answers to Questions

John Pugh Excerpts

Tuesday 27th November 2012 Commons Chamber

[Dr Poulter]

It is worth reminding the hon. Gentleman that, as I outlined in my first answer, it was the previous Government who gave foundation trusts additional freedoms to set their own pay terms and conditions outside national frameworks. This Government are working closely with NHS employers and the trade unions to make sure that we maintain “Agenda for Change” and national pay frameworks as fit for purpose, and we are very pleased with that. If the hon. Gentleman wants to ask why there is regional pay and freedoms for employers to set regional pay, he should ask those on his own Front Bench, some of whom were Ministers when these freedoms were set.

[John Pugh (Southport) (LD)]

Does the Minister recognise that the recent progress in national negotiations over greater flexibility is very encouraging and makes the efforts of the south west consortium and others both disruptive and pointless, in context?

[Dr Poulter]

We have had encouraging results from national pay negotiations at the recent NHS Staff Council, and unions are to consult their members on those results. There is general agreement that we need to maintain national pay frameworks, provided they are fit for purpose. I hope my hon. Friend will find that the south west pay consortium, which has been somewhat heavy-handed in the way that it has conducted its affairs, also sees the benefit of maintaining national pay frameworks. That is why we would like to see a quick resolution of the matter at a national level.

NHS Commissioning Board (Mandate)

John Pugh Excerpts

Tuesday 13th November 2012 Commons Chamber

[Mr Hunt]

Let me remind the hon. Gentleman, as I reminded the right hon. Member for Leigh, that for the four years that preceded this Government, there were underspends, including when the right hon. Gentleman was Health Secretary, and in three of those four years the underspend was higher than it was in our first year in office. But we do want innovative cancer treatments to be available. That is why we introduced, among other things, the cancer drugs fund, which was not introduced by his Government and which has transformed the lives of thousands of cancer sufferers.

[John Pugh (Southport) (LD)]

I welcome the statement, particularly the use of IT and online resources, but how will we avoid the previous errors of Connecting for Health and its huge costs?

[Mr Hunt]

That is a very important question. We are going to avoid that because I will not be signing any big national IT contracts. The initiative will be locally led and locally driven. Guidelines will be laid down to make sure that all the systems developed in different parts of the country are inter-operable. That is very important, but we will not have any grand plans nor will there be a big single database, so we can thereby avoid some of the problems. We must none the less be prepared to grasp what technology changes can mean for the NHS, just as they do for the rest of society.