Government Vision on Prevention

Lord O'Shaughnessy Excerpts

Tuesday 6th November 2018 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, with the permission of the House, I will repeat a Statement made in another place by my right honourable friend the Secretary of State for Health and Social Care on the publication of the Government’s prevention vision document. The Statement is as follows:

“Last week, the Chancellor confirmed that the NHS budget would rise by £20.5 billion over the next five years, because we care about the NHS being there for everyone. As well as money, however, reform is crucial. Before Christmas, we will bring forward a long-term plan for the NHS. We know that so much of what contributes to good health comes not just from what happens when someone is in hospital but from what we do to stay out of hospital. Prevention is better than cure. Today, I have laid before the House our vision for the prevention of ill health. It covers what the NHS needs to do, including more funding for community and primary care and the better use of technology. The plan also outlines what we need to see more broadly; everyone has a part to play.

As well as the rights we have as citizens to access NHS services, free at the point of use, we all have responsibilities too. Individuals have responsibilities, and we want to empower people to make the right choices. For instance, smoking costs the NHS £2.5 billion each year and contributes to 4% of hospital admissions. That is despite the massive reduction in smoking over the past 30 years. The next step to a smoke-free society is targeted anti-smoking interventions, especially in hospitals.

As well as stopping smoking, we must tackle excess salt. Salt intake has fallen 11% in just under a decade, but if it fell by a third, that would prevent 8,000 premature deaths and save the NHS over £500 million annually. We are working on new solutions to tackle salt, and we will set out more details by Easter and deliver on chapter 2 of our obesity plan too.

Next, prevention can save money and eliminate waste. At the moment, it takes too long, with too many invasive tests, to diagnose some illnesses. Doctors often have to try several different treatments before they alight on what is right for a patient. However, two new technologies—artificial intelligence and genomics—have the potential to change that. I want predictive prevention to help prevent people becoming patients and to deliver more targeted interventions with better results when people do fall ill. Instead of simply broadcasting messages to the nation, technology allows us to support much more targeted advice, messages and interventions for those most at risk.

Turning to environmental factors, our health is not determined only by what happens in hospitals. In fact, only a minority of the impact on anyone’s healthy lifespan is delivered by what hospitals do. The other factors include the air we breathe, whether someone has a job and the quality of our housing. That means our GP surgeries, our hospitals and our care homes all working more closely with local authorities, schools, businesses, charities and other parts of our communities.

Of course, the record number of people in work is good news on that front, and employers have a big role in helping their staff to stay healthy and to return to health after illness. That is where we can learn from the excellent record of our brave armed services, which have an 85% return-to-work rate after serious injury, while the equivalent rate for civilians is only 35%. Building on all that, the Government will next year publish a Green Paper on prevention, which will set out the plans in greater detail. This is all part of our long-term plan for the future of the NHS.

If I may, I will now address two separate issues that I know are of interest across the House today: the treatment of those with learning difficulties and autism, and the medical use of cannabis. Since becoming Health and Social Care Secretary, I have been shocked by some of the care received by those with autism and learning difficulties. Where people deserve compassion and dignity, they have been treated like criminals, and that must stop. Like everyone across the House, I have been moved by the cases of Bethany, Stephen and so many others, whose stories have laid bare what is wrong with our system and what needs to change. I have instituted a serious incident review, but this is not just about individual cases; it is about the system.

Three years ago, the Government committed to reducing the number of people with learning disabilities or autism in secure mental health hospitals by at least a third. Currently, it is down by a fifth, but that still leaves 2,315 people with learning disabilities or autism in mental health hospitals. I want to see that number drastically reduce. I have asked the NHS to address that in the long-term plan, and I know that its leadership shares my determination to get this right. I have also instigated a Care Quality Commission review into the inappropriate use of prolonged seclusion and segregation. The long-term use of seclusion is unacceptable both medically and ethically. It must stop. The review will recommend how to protect vulnerable people better and how to ensure that everyone is cared for with the compassion, respect and dignity they deserve.

On the prescription of medicinal cannabis, I pay tribute to my right honourable friend the Member for Hemel Hempstead, my honourable friend the Member for Dover and the honourable Member for Inverclyde for their campaigning on this issue. We have changed the law to make it possible to prescribe medicinal cannabis where clinically appropriate. Urgent cases have been brought to my attention, including concerns that those who have received treatment on an exceptional basis are now being denied that treatment. There is no reason for that to happen. The treatment of each individual patient is, and must be, down to the decision of the specialist doctor, working with patients and their family to determine the best course of treatment for them.

I met the head of the NHS on that this morning, and I have immediately instigated a system of second opinions. We have put out a call for research to develop the evidence, and we have also commissioned the National Institute for Health and Care Excellence to produce further clinical guidance on this issue. No one who currently gets medicinal cannabis should be denied it, and there is a system in place now for those who need to get it in future.

We want to deliver the best possible care to the most vulnerable, and we want to help build a more sustainable health and care system for all. Today’s announcements will help to do that, and I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Baroness Walmsley (LD)]

My Lords, at last we have a Secretary of State who has been listening to my speeches over the years, or perhaps, more realistically, he has come to the same conclusion all by himself that the NHS is unsustainable with the changing demographics and higher demand unless we do something to prevent the 40% of illnesses that are preventable. I am therefore delighted to welcome the Secretary of State’s new focus on prevention.

However, he said in his speech yesterday that it is difficult to divert money into prevention unless funding is rising, because otherwise you will be taking money from treatment. Well, funding is rising. The Minister spoke about diverting part of the extra £20 billion for the NHS into prevention, but that is only part of the answer. This a whole-government problem. People do not live in hospitals or GP surgeries. They live in cities with polluted air, often in overcrowded and damp homes, in areas with too many fast-food outlets and too few fruit and vegetable shops where the local sports centre or swimming pool has closed. They are stressed about paying the bills on low wages or benefits.

Then there are lifestyle decisions. Often when people are in their own homes or the local pub, they smoke or send out for a high-fat and high-salt takeaway or drink too much alcohol. Many do not take enough exercise. They are subjected to large amounts of TV advertising for the wrong kind of food and drink, and far too many ads encourage them to gamble. None of this is good for their physical or mental health.

My point is that the organisations that can help them with this are often not the NHS or wider national government, although both can do a lot. I am speaking about local authorities, whose overall funding, particularly for public health services, has been cut since July 2015 and is projected to carry on being cut. Does the Minister think that this is in line with the Secretary of State’s vision? There is evidence that sexual health services, sports centres and weight management services have closed. Smoking, alcohol and drugs prevention and treatment services have been discontinued. Does the Minister not agree that some of the new funding should be diverted from the NHS into local authorities and ring-fenced to allow them to reinstate and widen these services? Of course, NHS professionals must be involved, but this should come under the public health responsibility of local authorities, where it correctly lies.

Councils run as many of these good services as they can but they cannot afford as many as are needed to stall the national epidemic of obesity and other preventable health problems. According to a systematic review of the available evidence, published online in the Journal of Epidemiology and Community Health, every £1 spent on public health saves £14 on average, as referred to by the noble Baroness, Lady Thornton. In some cases, significantly more than that is saved. We should listen to such a meaty piece of research. Local directors of public health claim that they can spend money more efficiently than the NHS to prevent ill health. Why not fund them to do so?

Turning to two other matters, I applaud the Secretary of State’s initiatives for people with learning difficulties; I strongly wish them well. However, the Minister will understand from my background in cannabis-based medicines that I am still very concerned about the too-restrictive guidance that has been published on prescribing pharmaceutical-grade cannabis-based medicines. It seems that there is still a bureaucratic nightmare for patients who thought that the Government’s recent relaxation of regulations meant that their troubles were over. I fear we do not have time now to go into this in detail, but I welcome the intention expressed in the Statement to get it right. What further reassurance can the Minister give me that clinicians will be given the information from patients and other countries to enable them to make sensible prescribing decisions—not just for Sativex and Epidiolex? Can he assure me that it will not have to be done as a last resort when a lot of licensed drugs with nasty side-effects have already been tried unsuccessfully?

[Lord O’Shaughnessy]

I am very grateful to the noble Baronesses, Lady Walmsley and Lady Thornton, for their questions. I concur completely with their point that the NHS is not sustainable if it is a national hospital service, which the Secretary of State was trying to get across yesterday. He used the stark figures of £97 billion being spent each year on treating illness and only £8 billion on preventing it. Clearly, we need a shift there. Investing more money makes that shift easier; I am glad that the House recognises that we are doing that.

Before I get on to the specifics of responsibility for health, I concur with the idea that this is a whole-government challenge. It is also a societal challenge; it is not just for government to make this happen. It is about people as well, as the Secretary of State said in his point about personal and family responsibilities. We all have a role to play in making it easier for people to do the right thing. That is quite different from a finger-wagging approach; it is about making sure that it is easy to make healthy rather than difficult choices. When you talk to people about that, they feel it is a sensible approach.

On the funding question that both noble Baronesses asked about, it is worth pointing out that local authorities received £16 billion over this SR period. That obviously involves a reduction, as they pointed out. The recent Budget did not change the funding. It has been suggested that it reduced it, which it did not. Clearly, any new budget for public health specifically and for the role of local authorities will be decided at the spending review next year. I hope the noble Baronesses will forgive me if I cannot say more about that, other than that I absolutely concur that local authorities have a critical role working with the third sector, industry and others. So does technology. Noble Lords will know that we have a real technophile in the Secretary of State. He is absolutely right that, while technology will not necessarily change everything, it gives us the possibility to change behaviours much more cheaply and more cost-effectively than in the past, which I hope means that we can do more with our money. That is the promise of new technology if we get it right.

On the specific questions on the prevention strategy, the noble Baroness, Lady Thornton, asked about junk food advertising. The consultation on that is due to be published before Christmas. We are trying to train more staff on children’s health. We are working with Health Education England on a health and care workforce plan as part of the long-term plan. She also mentioned health inequalities. The Prime Minister had been very clear that she wants people to enjoy five more years of healthy life. At the moment, on average, children being born today will live to the age of 81 but might have 18 years of unhealthy life and there is a great discrepancy in that depending on one’s demographic. The greatest gains from that will therefore be for the least advantaged. That is something we are focused on. It is part of the NHS mandate today and it will be part of the plan.

We have debated GP numbers in this House. There are record numbers of GPs in training and that flow will continue over the coming years. We are also determined to make sure that there is much better treatment for mental health, not only because people with mental illness die earlier—sometimes dramatically earlier—but because, as we have discussed and as is being discussed now in the other place, there is too much unacceptable use of in-patient facilities for people with mental illness, learning disabilities and autism. I am glad that the Secretary of State’s strong words on this have been well received. He is absolutely determined, as we all are, to ensure that we deal with this. We have made some progress but we have not got as far as we needed.

As to whether such facilities will be needed in the future, I think that they will. I visited Springfield University Hospital in south London recently. It is being redeveloped from a classic Victorian institution to something being designed with patients to be much more suitable for their needs, with better access to light and to communal areas where appropriate. These facilities have a role to play when properly modernised, but they ought to be used for only a short time. They ought to be close to home and there ought to be a discharge plan in place before they are used. Clearly, in some cases none of those things is happening and unacceptable care takes place, which we need to stop.

On the various Green Papers and so on, the Secretary of State has set out vision documents in areas he has identified as early priorities. A lot of this stuff will be wrapped up in the long-term plan that we will publish before Christmas. As we move ahead there will be Green Papers on key areas. Social care will be one, for not just older adults but working-age adults; there will be a prevention Green Paper on that in the new year. There will be many more for us to discuss, to the great delight of the House, I am sure.

The noble Baroness, Lady Walmsley, asked about cannabis medicine. We are treading a fine line in difficult territory. We know the great benefits that these medicines can bring and are bringing, particularly to children with some horrendous epilepsies and other illnesses. At the same time, we know that there are risks associated with the active ingredient THC. It is about trying to move forward in a way that is compassionate to patients but does not put them at undue risk while evidence is still being gathered.

I will say three things. First, we are trying to fund more research so we understand the real world impact of these kinds of medicines. Secondly, by rescheduling them to Schedule 2, THC-based medicines can be procured through an unlicensed medicines route, which was not something that was there before. That goes beyond the Sativex and Epidiolex question, in terms of licensed drugs at the moment, although again that will be done with care and caution by specialist doctors. NICE is working on a clinical guideline to supersede those currently in place, which are temporary guidelines. It will be gathering evidence as broadly as possible internationally from patient groups, clinicians, families, industry and elsewhere. I am confident that, while we have clearly not perfected the system yet, there is a genuine attempt to get a much better, more compassionate system that ensures that drugs such as this can get to people who will benefit from them when they need them. I am confident that we will get to the right position eventually.

[Lord Ribeiro (Con)]

My Lords, the Statement makes reference to the use of predictive prevention to deliver more targeted interventions. At the recent meeting of the American College of Surgeons in Boston two weeks ago, the director of the National Institutes of Health—he likes to call them the national institutes of hope—said on targeted interventions that they are taking a new approach to disease prevention through the All of Us research programme and that, by taking account of individual differences in lifestyle, environment and biology, researchers will uncover paths towards delivering precision medicine. To date, since May this year, 100,000 people have signed up. What plans does the department have in the UK for a similar programme, and to use genomics for the benefit of all?

[Lord O’Shaughnessy]

I am very grateful to my noble friend for that question: he speaks with great wisdom and insight on this. The great promise of technology is to take all the information we hold about people—their health and care records, their genomic data, their lifestyle data—and use artificial intelligence to tailor health advice to them. There will be not just broadcast public health messages that everyone sees, but specific messages that will change my behaviour or your behaviour, to make sure that we live the kind of lifestyles we actually aspire to live, even if we do not always fulfil that.

I highlight three things we are doing. The first is our commitment to sequence up to 5 million genomes over the next five years. Secondly, we will try to make sure that AI is used in the right way to support healthcare and that relationships are entered into by the NHS and tech companies on a proper basis to bring the maximum possible benefit to the NHS and patients. Thirdly, we will try to take advantage of the enormous opportunity we have with the data that is available in a single-payer comprehensive health system by reassuring people that it is being kept and used safely and legally, but then utilising it so that it is joined up as a single integrated health and care data record, available for direct care and—critically—for research. Then we can start to tailor the medicine we deliver and move to a truly personalised NHS.

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[Baroness Uddin]

With respect, my Lords, I state my objection at being shouted at to move on; many Members would simply carry on.

[Lord O'Shaughnessy]

I am grateful to the noble Baroness for the question. On learning disabilities and autism, I know that the Secretary of State has been very moved by some of the cases that he has become aware of since taking the job in the summer. He has instigated not only serious incident reviews into individual cases but a thematic review by the CQC, with contributions from NHS England, on how to improve the system and ensure that we move more services out of in-patient facilities and into the community. I am absolutely confident—I will confirm this to the noble Baroness—that the best providers, from wherever they are, will be able to contribute to that review.

[Lord Kakkar (CB)]

My Lords, I declare my interests as chairman of UCLPartners and business ambassador for healthcare and life sciences. In repeating the Statement, the Minister focused on the important opportunities provided by genomics and the application of artificial intelligence to transform the landscape for prevention. In answer to a previous question, he identified the importance of trust for the ability to marshal this vast amount of deeply personal data and ensure that it can be appropriately applied for individual benefit and, more broadly, population benefit. In that regard, I make two points to the Minister.

First, what progress has been made towards achieving that social licence which will ensure broad trust with regard to the mechanisms available and the security of the structures, not only for data collected in hospital but now in the community and the prevention setting, so that it may be shared and applied for individual as well as population benefit? Secondly, there will need to be a substantial investment in skills to ensure that not only professionals who work in healthcare for the delivery of health services but those who will have to engage more broadly in the prevention agenda are able to respond to this vast amount of data, and help individual citizens and patients apply it for maximum benefit.

[Lord O'Shaughnessy]

On the question of trust and social licence, which is a very good expression, KPMG published a report in September which found that the NHS was the most trusted organisation in the country when it came to looking after people’s data. That is a very precious thing and we must not lose it, so a number of steps are being taken to try to reinforce that degree of trust. We have introduced a national data opt-out and very recently had the national data guardian Bill, which puts the National Data Guardian on a statutory footing to provide that security and statutory guidance to government, so that we can ensure we build on that trust. On investment in skills, we have commissioned Eric Topol to carry out a review of the skills needed in the workforce to adopt new technology, which will report soon. We also have to recruit new professions: it turns out that bioinformatics is one of the most important things to have in taking advantage of that. We do not currently train enough people in that field but we need to ensure that we do, so that every patient and every clinician can take advantage.

[Lord Robathan (Con)]

My Lords, in commending this Statement may I pick up on what the noble Baroness, Lady Walmsley, said about the obesity epidemic? I think that she used that word. Does my noble friend agree that all of us, be it in Parliament or as health professionals or teachers, have a role in setting examples to others? Does he also agree that young people and others look to us to see what we do? If we eat or drink too much, or if we smoke, they may follow. Does he also think that health professionals should perhaps be less understanding when people are grossly obese and tell them that, if they do not lose weight, they will die early and cost the NHS a huge amount through diabetes and other diseases?

[Lord O'Shaughnessy]

My noble friend brings to mind the quote—I forget who it was by—saying that children never listen to their parents but have never failed to imitate them. There is a point about setting an example, which I agree with. I do not quite agree with the force of his opinion about how health professionals should speak to people suffering weight problems of that kind. These things can be genetic or epigenetic; there can be all sorts of causes. The most important thing is to get people on board with losing weight and motivate them to do so. We have lots of good understanding about how to do that, which is at the heart of the obesity strategy.

[Lord Sherbourne of Didsbury (Con)]

My Lords, on the question of obesity, will the Minister look carefully at the two successful public health campaigns which helped to change behaviour? One was the campaign on AIDS many years ago and the other was the campaign over many years against smoking. Both had beneficial effects on behaviour.

[Lord O’Shaughnessy]

My noble friend is quite right. The campaigns took quite different approaches. One used tax and regulation and the other used destigmatisation and the provision of services, but they were highly successful and I reassure him that the knowledge and learning from those campaigns influence our current prevention strategy.

[Lord Framlingham (Con)]

Given how unhelpful much of the advertising is nowadays, how brave are the Government prepared to be in curtailing it?

[Lord O’Shaughnessy]

We have said that we will clamp down on junk food advertising. Clearly we have cut down on the advertising of alcohol, smoking and many other things over successive Governments. This country has led the way in dealing with this sort of issue, so I am confident that we will have the necessary approach.

[Baroness Masham of Ilton (CB)]

My Lords, will the Minister assure us that some of the most important things that are not in the Statement are not downgraded? They are antibiotic resistance, vaccination and immunisation, drug misuse, the prevention of hepatitis C in prisons and sexually transmitted diseases which are becoming resistant.

[Lord O’Shaughnessy]

I can provide the noble Baroness with that reassurance. This is a vision document, not a plan. It does not go into detail in every area, but merely tries to set out an ambition for the kind of health service that we want. All the issues that the noble Baroness raises are incredibly important, and I promise her that they form a big part of the department’s agenda.

[Baroness Barran (Con)]

My Lords, I join other noble Lords in welcoming the focus on prevention. A key point in prevention is early childhood, the so-called first 1,000 days of a child’s life. I looked at the paper from the department and found several references to this, but they were nearly all in relation to the impact on adult mental health as opposed to physical health. The evidence on the impact on physical health, including obesity, cardiovascular disease, diabetes and cancer is overwhelming from the research done by some of the big health insurers in the States and from the Harvard Center on the Developing Child. Will my noble friend reassure me and other noble Lords that greater prominence will be given to the prevention of the so-called adverse childhood experience, the toxic stress that very young children experience, which impacts on their mental and, crucially, physical health as adults?

[Lord O’Shaughnessy]

I agree with my noble friend. There is a strong desire for the Green Paper to be cross-government and therefore, like the vision document, take us into areas that go well beyond the remit of the Department of Health and Social Care. My noble friend Lord Farmer has published an interesting paper on the impact of family stress, marriage breakdown and other things on childhood outcomes. It is quite disturbing. Clearly making sure that we support families in all their forms is a critical part of giving children the best chance in life.

[Lord Robathan]

Since my noble friend thinks I am a bit harsh, does he not agree that the ghastly photographs on cigarette packets of people suffering from diseases caused by smoking have contributed to the reduction in disease from smoking and that therefore we should perhaps be a little bit harsher in explaining to people that they will die early if they do not take control of their own lives?

[Lord O’Shaughnessy]

I do not disagree with the content, in a sense, of what my noble friend said, but I think it is important that we communicate it in a way that will motivate people rather than terrify them into inaction. The difference with smoking is that there is no good or safe amount that you can smoke whereas there is clearly a good and safe amount that we can eat and drink and for sugar and salt intake and so on. It is about striking the right balance.

[Lord Scriven (LD)]

My Lords, while I welcome the Statement, particularly around prevention, and the use of AI, technology and data, there are two issues that come to mind. My first question is this: what regime will there be on issues related to the ethics of AI and data use? This is quite important, and there needs to be some form of regime and regulation about what the health service does there.

The second issue is on prevention. As a former health service manager, I know that hospitals are huge sunk costs, and the issue of prevention has been around for many generations. The key is how you move resources from the sunk costs in hospitals into prevention. What work and ideas do the Government have on that? It has always been the Achilles heel of prevention and dealing with hospitals.

[Lord O'Shaughnessy]

I absolutely agree with the noble Lord about ethics. In a sense, everything that we do in this area has to pass the basic fairness test that people apply to it: is this a fair use of resources and a fair distribution of benefit? A number of programmes have been set up to support our work in this area. There is the Centre for Data Ethics and Innovation set up within DCMS. I also point the noble Lord to the code of conduct for data-driven technologies in health and care that I published at the NHS Expo in September. This is our first attempt to provide some rules of engagement on how NHS trusts or other bodies can enter into relationships with technology companies in a way which brings the maximum possible benefits to the NHS. We will do more on this in due course.

[Lord Patel (CB)]

My Lords, I support what the Minister said about the importance of the national data guardian legislation. That will give the public the confidence they need that their health data will be properly used and protected. I hope that legislation will not be held back.

On the Statement, one of the factions of our society that is at higher risk of diabetes and obesity is the south Asian population. I declare my interest as a patron of the South Asian Health Foundation. Any health education programme needs to target that population in order to reduce the incidence of diabetes, which probably runs at around 40% of the population. If we are to benefit from the information that genomics will provide, we need not just bioinformatics but data scientists, with the ability to mine genomics data. My question for the Minister is: what is the plan for further education for both bioinformatics and data science?

[Lord O'Shaughnessy]

I am very grateful to the noble Lord for welcoming the NDG legislation, as he did when we dealt with it in this House. I hope that that can progress at full speed.

On the noble Lord’s point about diabetes, he is absolutely right that prevalence differs from population to population. I will send him details of the NHS Test Beds programme, which includes quite a few diabetes programmes aimed at different parts of the country, which obviously have different ethnic make-ups. We are conscious of the need to tailor messages to particular groups.

The noble Lord is also absolutely right about the workforce. That is why I mentioned the Topol review. It is critical to making sure that people who are in the service are retrained properly, and that we have enough data scientists, bioinformaticians and others.

I apologise to the noble Lord, Lord Scriven; I did not answer his second question about the sunk costs of hospitals. We are in the process of moving to a system of integrated care services, which is an attempt to integrate primary, secondary and tertiary care—we know what the goal is. These things are up and running and are showing some great benefits through the new models of care programme in moving care out of hospital, improving outcomes and reducing costs. That is clearly something that we need to take nationwide.