NHS: Preventive Medicine

Lord Howarth of Newport Excerpts

Wednesday 20th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, if the noble Baroness reads the Five Year Forward View, she will see that prevention is a very critical part of that. But, of course, prevention goes much wider than healthcare in the NHS; it goes to employment, housing, education and a whole range of other things. Having a strong and vibrant economy with high levels of employment is vital.

[Lord Howarth of Newport (Lab)]

My Lords, in their preventive strategy what will the Government do to attend to the social determinants of ill health, including inequality, deprivation in early childhood and deteriorating public services?

[Lord Prior of Brampton]

My Lords, it is a very serious issue that over 40 years, and probably for longer, the difference between the life expectancy of the rich and the poor has always remained at about 10 years: and for healthy living it is more like 25 years. I think it is fully understood from Sir Michael Marmot’s report and thereafter that the social determinants are more important in closing that gap than anything we can do in healthcare directly, so what the noble Lord says is absolutely true.

Mesothelioma (Amendment) Bill [HL]

Lord Howarth of Newport Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Howarth of Newport (Lab)]

My Lords, I admire the passionate commitment of the noble Lord, Lord Alton, and his tenacity, to use the word that the noble Lord, Lord McNally, used about him in his own moving speech. I will only say of the noble Lord, Lord Alton, that he is a highly experienced and effective politician. I also applaud and thank the British Lung Foundation for the essential work that it continues to do and I thank noble Lords, particularly my noble friends Lord Giddens and Lord Wills, who have worked alongside the noble Lord, Lord Alton, to try to ensure that we get a better disposition of forces in the field of mesothelioma research.

Like other noble Lords, I am scandalised by how little funding has been made available for research into mesothelioma. The noble Lord, Lord Alton, described it as a paltry amount. My noble friend Lord Winston suggested that it might have been rather more than some of us have hitherto understood. Whatever the case, there has been a lamentable failure to make the progress that we would all have wished to see towards better understanding of the essential nature of this disease, its prevention and diagnosis, its cure, ideally, but otherwise mitigation of the horrible suffering that it causes.

As we have been told, the prospect on the best estimates is for not fewer than 60,000 deaths from mesothelioma in this country over the next 30 years and of very many more deaths globally in newly industrialising countries, where health and safety standards are not what they ought to be. I would have thought that this would be an interesting challenge for researchers and that they would have seen important opportunities in this field. But for whatever reasons, it appears that mesothelioma research remains a relatively unfashionable area of research for people to go into.

On Report of the Mesothelioma Bill on 7 July 2013, the noble Earl, Lord Howe, the predecessor of the noble Lord, Lord Prior, responding to an amendment moved by the noble Lord, Lord Alton, to the same effect as his Bill today, pinpointed the issue as being the problem of encouraging sufficient high-quality research applications. I made the same case in that debate and I continue to believe that that is at the heart of the problem. The noble Earl outlined four initiatives that have been rehearsed for us by my noble friend Lord McKenzie of Luton, to whom we owe so much—without his preliminary work, we might not have had the Mesothelioma Act 2014—and the noble Lord, Lord Kakkar. Those were the priority-setting partnership, the highlight notice, the availability of the Research Design Service and the convening by the National Institute for Health Research, the Medical Research Council, and Cancer Research UK of researchers to gather new ideas about how to go forward in this field. As the noble Lord, Lord Kakkar, said, it will be extremely interesting if, when the Minister replies to this debate, he is able to tell us about any progress there may have been in consequence of the initiatives promised by his predecessor and how effective they look like being.

I continue to think that the problem is not essentially one of lack of publicly provided funding for research. Admittedly, Professor Dame Sally Davies acknowledged to the All-Party Parliamentary Group on Medical Research, in a rather confessional moment quite recently, that following the decision by your Lordships’ House to advise the elected Chamber to think again about the appropriateness of cuts to tax credits, she was having nightmares that the Chancellor might turn and rend the budget for medical research. If he were to do so, that would be a grotesque non sequitur, and I do not expect it to happen.

I understand why the noble Lord, Lord Alton, charges the Government with inadequate commitment in this area and why he has tabled his Bill, which would impose a supplementary levy on the industry. But we should think very carefully before rushing to legislation. It is still relatively early days. The 2014 Act has been on the statute book for only 18 months and we should proceed in this area with caution. The typical structures that we have for mobilising funding for research in this country are broadly the right ones—the arm’s-length principle, peer review, and quality of proposed research being the criterion for funding. It is true that they do not guarantee perpetuity of funding, but they do produce high-quality research. I continue to think that the issue is how to attract the right applications for funding for research into mesothelioma.

That brings us to the role of the employers’ liability insurers. I have no hesitation in saying that they have a very strong moral duty in this area. It is one of the great business scandals of the past 50 years that the contracts that should have secured compensation for people who were exposed to asbestos and developed mesothelioma in consequence—contracts written by the employers’ liability insurers—in so many cases somehow evaporated. The documentation could not be found when it became time for people to make their claims. The insurers did not want to face their long-tail obligations, so it was right that the levy was introduced.

I would like to see the employers’ liability insurers take upon themselves the responsibility of funding the process, which noble Lords have talked about, of attracting high-quality researchers into this area to develop the strategy initiated by the noble Earl, Lord Howe. They should not make their contribution conditional on the Government matching what they have to put in. They should willingly provide funding to supplement what the publicly funded research councils and the national institute find themselves able to provide for research in this field. They should supplement and, indeed, be willing to surpass what publicly provided funding is made available, just as the medical charities do.

Charitable money has been lacking in this area. My noble friend Lord Winston pointed out that some of the major cancer research charities are funding generic, high-level research that will have a very important relevance to mesothelioma. Where more specific disease-related funding is concerned, it has been notably lacking. The noble Lord, Lord Alton, gave us the comparative statistics. Why this should be one can only speculate, but I suspect that it has to do with class. Mesothelioma is perceived as a blue-collar, working-class disease. Its incidence is mostly found in the old industrial areas. Regrettably, it is apparently very much harder to raise charitable money for research in this kind of area. It is one more instance of what has been called the hideous injuries of class. Of course, the National Health Service and publicly funded research exist to overcome these kinds of imbalances and disparities.

I want to see the employers’ liability insurers voluntarily create a charitable endowment, but we appear to be very far from a situation in which that is imminently to happen. We have been told that out of 150 employers’ liability insurers, the number willing to make a voluntary contribution has declined from four to two. We are now left with only Aviva and Zurich taking that responsibility. We should certainly congratulate and thank them, and recognise what they are doing.

I hope that it will not be futile to appeal to the better nature of others in this area of the insurance business. They ought to be good citizens and decent human beings. They ought also to be mindful of their own business interest. If they fail to make a decent contribution to research, they will have to pick up the cost of compensation—unless, somehow, the contracts go missing again in the future; we should be vigilant to make sure that that does not happen. They ought to be concerned about their reputation. They have an opportunity to rehabilitate their reputation and they can certainly afford to do so. I hope that they will be willing to make a major contribution to the cost of establishing the national mesothelioma research centre that other noble Lords have spoken about and which they are trying to establish. We therefore need the whole sector to rise to the moral responsibility that they have and continue to do so. The situation as it is is profoundly unacceptable.

There will also need to be continuing determination on the part of the department. There is an imperative for more research and the department must do all it can strategically to encourage the channelling of funds towards research applications and research proposals of the quality needed. However, whether there should be legislation seems to me, as I have said, doubtful. It is relatively early days, but if the insurance sector now fails to rise to this responsibility I put it to the Minister that he and his ministerial colleagues in government really must respond to the challenge that the noble Lord, Lord Alton, has set. I would regret the necessity of it because it would be anomalous. It could be argued that it is invidious for government to accept that Parliament should legislate to provide funding for one particular disease. There are so many terrible diseases and areas where research is urgently needed. It would be inconsistent with the way research is, I believe, rightly funded in this country.

The challenge is there for the insurers. It is still not too late for them to act voluntarily to provide funding to stimulate the passion among researchers of which the noble Lord, Lord Ribeiro, spoke, to encourage them to work in this field and to maintain that support, challenge, stimulus and effort over the years to come. Early action is needed. I hope that the industry will respond. If not, I will add my support to the measure proposed by the noble Lord, Lord Alton.

Access to Palliative Care Bill [HL]

Lord Howarth of Newport Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Howarth of Newport (Lab)]

My Lords, it is a pleasure to follow the noble Lord, Lord Howard of Lympne, whose work on behalf of hospices I admire just as I admire the hospices themselves. I add my congratulations and thanks to those offered to the noble Baroness, Lady Finlay of Llandaff, for tabling this Bill, which I fully support.

I shall start by talking about the needs of children in palliative care, responding to the urging by the noble Lord, Lord Crisp. I am sure that all noble Lords have received the briefing from the admirable charity, Together for Short Lives, which tells us that, in the United Kingdom, some 40,000 children live with life-threatening or life-limiting conditions.

Children’s palliative care is different and needs to be different, if only for one important reason: because it may well, sadly, be needed for the whole of a child’s life. Yet the availability of resources for children’s palliative care is even more inadequate than it is for adult palliative care. Clinical commissioning groups contribute on average 10% of the cost of children’s hospices compared to 30% of the cost of adult hospices. Thirty-five per cent of children’s hospices had their funds frozen between 2013 and 2015 and 23% had their funding cut. Some families in remote rural areas have no access to specialist children’s palliative care. There is a dearth of people with the skills and knowledge to care for children who suffer from complex and life-threatening conditions.

The Health Select Committee noted also that a wide variety of childhood conditions can cause death before adulthood. Many of them are rare and, therefore, the requirement for diversified specialist care is all the greater. A Royal College of Nursing survey in 2015 found that nearly a third of children’s nurses said that they did not have the resources to deliver adequate care in a home setting, which of course is what most families want; and 31% of nurses acknowledged that they lacked the confidence to discuss end-of-life issues with children and their families.

The RCN calls for a greatly increased number of undergraduate training places to address what it describes as,

“massive gaps in children’s nursing”.

Only 17 community children’s nurses were due to qualify in 2014-15. Many consultants in this field are approaching retirement; too many are not trained to level 4. The training of general practitioners in paediatrics and in physical and mental healthcare for children needs to be improved. There is a 15% vacancy rate among children’s social workers. The commissioning of children’s palliative care is patchy and inconsistent, insufficiently integrating the various disciplines and agencies that need to be involved. The Bill addresses this range of problems. I do not know whether the noble Baroness intends in due course to provide model guidance, but guidance would be preferable to amendments to the Bill.

As to the predicament of children who are bereaved or face bereavement, the Childhood Bereavement Network, to which the noble Baroness, Lady Hollins, referred, has again briefed us extremely helpfully. Its 158 members are supporting children before and after bereavement. The network estimates that some 30,000 children under 18 lose a parent each year and, of course, more lose a sibling or a grandparent. It is a very sensitive issue and it is very difficult for children, parents and professionals to communicate in these situations.

Gillian Chowns, writing in Bereavement Care and reporting on her research among adolescents facing the death of a parent from cancer, quotes those children. We hear their own voices describing their struggle with their isolation, their anxiety—who is going to care for them when a parent is gone? They want to know the full truth and they need the opportunity to release strong emotions. All such children should have access to well-organised support, proper information, a plan as to who is to do what, and advice and support for other family members, carers, their peers and their teachers. Only 65% of local authorities have an open-access service for bereaved children and most of those services are provided by the voluntary sector through charities such as the wonderful Winston’s Wish.

As the noble Baroness, Lady Hollins, also mentioned, children who suffer bereavement typically face worse outcomes in their future lives, including earlier mortality, mental health problems and entanglement with the criminal justice system. It is not only better but cheaper to ensure that these children come through the emotional crisis of losing a parent or someone important to them without being traumatised.

Many noble Lords will have read the beautiful book by Atul Gawande, Being Mortal, in which he argues that the role of those caring for the terminally ill is not to fight death to the ultimate but to ensure well-being—to ensure what the noble Lord, Lord Howard, called good deaths.

I will make one final point. The arts have an important contribution to make in palliative care. Music therapists, storytellers and those practising other art forms are able to help terminally ill people to prepare mentally, emotionally and spiritually for crucial transitions; to turn depression into hope; to have a sense of agency; to integrate feeling with cognition and sensation; and to gain insight and a sense of meaning and value in what would otherwise be a deeply unhappy and traumatic situation. The arts provide a safe opportunity to organise intense, confusing and contradictory thoughts and feelings; to find self-expression; to share important information that has previously been too difficult to talk about; and to mitigate isolation.

Primary Care: Targets

Lord Howarth of Newport Excerpts

Tuesday 13th October 2015 Lords Chamber

[Lord Prior of Brampton]

This raises an important point—that we ought to train our own nurses. Relying on recruitment from overseas is not a viable long-term strategy and we must increase the number of training places in the UK.

[Lord Howarth of Newport (Lab)]

My Lords, in seeking to broaden the skills base in general practice, as the Minister has just said he wishes to do, will he consider encouraging GP practices to employ artists? Is he aware of the excellent outcomes for patients in GP practices that have an artist in residence?

[Lord Prior of Brampton]

My Lords, the short answer is no. I do not think that I could stand here and promise funding for artists in GP surgeries, but I do have an open mind. If the noble Lord would like to talk to me about it outside the Chamber, I would be very happy to do so.

Health Funding

Lord Howarth of Newport Excerpts

Thursday 9th July 2015 Lords Chamber

[Lord Prior of Brampton]

My noble friend raises a very interesting point. I will certainly bring it to the attention of Public Health England and, depending on its reaction, I will be happy to come back to the House and give the noble Lord the answer to his question.

[Lord Howarth of Newport (Lab)]

My Lords, the Government are placing new duties on local authorities in terms of the anti-drugs strategy, and Public Health England, very rightly and admirably, is seeking to develop its contribution to the strategy ambitiously and appropriately. Will the Minister ask his right honourable friend the Secretary of State for Health to give a very strong moral lead, at least to urge local authorities not to reduce spending in this area, which is so crucial to the health and safety of young people in particular?

[Lord Prior of Brampton]

I will certainly have a word with my friend the Secretary of State for Health. Clearly the Government have an important role in this area; I will have a discussion with him and come back to my noble friend.