Arts: Contribution to Education, Health and Emotional Well-being
Lord Rea Excerpts(11 years, 4 months ago)
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Lord Rea
My Lords, I, too, thank my noble friend for bringing this important area before the House. I feel somewhat diffident speaking with those of such calibre. Previous speakers have shown that a good story well told can have a very big impact, which probably should be a rule for my future speeches. As a former medical practitioner, I will speak today on the effect that the arts, in the broadest sense, can have on health. Here, I am using the long WHO definition of health, which considers it to be not only the “absence of disease” but also,
“complete physical, mental and social well-being”—
a condition we aspire to but seldom achieve individually and probably never as a whole society.
This definition is useful because it recognises that health is not only physical but includes emotional and social components, factors which have tended until recently to be neglected in healthcare. Sir David Weatherall, when the regius professor of medicine at Oxford University more than a decade ago, explained how scientific medicine, which dominated the last century, changed the emphasis in healthcare from the whole patient and whole organs to diseases of molecules and cells. This caused many to feel that medicine had become reductionist and dehumanising. Although himself a molecular scientist, Professor Weatherall said that,
“we will now start putting the bits … together again … The old skills of clinical practice, the ability to interact with people, will be as vital … as they have been in the past”.
Since then the need for this is becoming more widely accepted but dehumanised healthcare is still the experience of some patients. The events in Mid Staffs, although not the rule, unfortunately are not unique. But, despite increasing pressures, most patients in the National Health Service receive expert, considerate and friendly care.
Where do the arts fit into this health story? The three components of health—physical, mental and social—are not separate entities. We all know the much quoted phrase created by the Roman poet Lucullus 2,000 years ago:
“Mens sana in corpore sano”.
The relationship between mental and physical health has now been demonstrated in a number of studies. Cheerful or normal people live longer and recover from illness more quickly than depressed people, who place a very heavy load on the National Health Service. The immune response of non-depressed people is better. My noble friend Lady Jones cited a number of other instances where mental health and social care can have a big impact on people’s physical health.
The relationship between social deprivation, even relative deprivation in prosperous societies, and physical and mental health and longevity is well known and is being increasingly better understood through the world-wide studies of the social determinants of health being led by Professor Michael Marmot of University College London. That is as relevant to the UK today, when our health problems are largely due to long-term, non-communicable diseases, as it was 100 years ago, before the era of antibiotics. Living conditions, nutrition and lifestyles are among the most important of these determinants. Here it should be emphasised that lifestyles are not simply a matter of individual choice, they are a product of economic and social pressures. It is only the exceptional individual from a deprived background who can battle their way to overcoming these commercial and social pressures and live an optimally healthy life.
I hope that this brief description of the factors underlying health will show why the arts are so relevant. As my noble friend said, is not the purpose of art to lift the spirits, open one’s eyes, educate and inspire? The emotional impact of music, so well described by my noble friend Lord Winston and the noble Lord, Lord Cormack, and works of art and sculpture as well as the written word, is often enormous. I would add high-quality media presentations on the radio and television, and let us not forget film as well. I could recite a long list of all the arts which are important. To say that the arts entertain us and cheer us up is only part of the picture. By helping to lift depression, the arts can improve our mental health and this can, in the ways I have suggested, lead to better physical health.
I have not mentioned one important aspect of our culture: the built environment. The noble Lord, Lord Cormack, talked about the majesty of Lincoln Cathedral, and of course there are other inspiring buildings all over the country. Good and imaginative design of neighbourhoods and individual buildings, apart from pleasing the eye, can have important effects on physical health. We have too many boring, or at the worst ugly, housing developments, while thoughtless redevelopment has plucked the heart out of many towns and cities. The result has been a loss of cohesive community support which can have effects on social well-being. The building of arts and cultural centres in many towns and cities has been a positive move that partly compensates for the destruction of city centres, and the evidence is that they have a sizable positive impact on the morale of their communities. However, they cannot replace the need for much more well-designed housing which, as all noble Lords know, would also act as a kick-start for the economy and have a beneficial effect on mental and social well-being. Well-designed housing, apart from being more carbon efficient, can improve mental, physical and social health through aesthetically pleasing design, good spacing, convenience and social facilities. It should also be ergonomically pleasing and more sustainable through well thought-out heating and ventilation. There are examples of excellent projects of this kind in many places throughout the country.
I do not have any specific questions for the noble Baroness, but I hope that she can reassure us that funding for the Arts Council at least will not be cut and hopefully be increased in the next spending round. I hope also that she can say that local authority support for community and other arts projects will be protected in the next round of cuts, which we are told will shortly arrive.
Health: Neglected Tropical Diseases
Lord Rea Excerpts(11 years, 10 months ago)
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Lord Rea
My Lords, I thank the noble Baroness, Lady Hayman, for bringing this important subject before the House. I was stimulated to take part because half a lifetime ago I worked with children in Lagos, Nigeria, for two and a half years and met with some of these diseases. They can have a debilitating effect by causing anaemia, malnutrition, impairment of immunity or renal failure. Most of them have a secondary host, or vector, which spreads the infection. These include a number of insects and other organisms which have been referred to and described by other speakers. I think noble Lords would agree that nobody living in the Western world would tolerate being exposed to any of these pests. However, people living in poor housing with no clean water or sanitation cannot guard against them. In this context, I would echo the noble Baroness, Lady Hayman, in asking the Minister how far vector control for NTDs other than malaria is being addressed by any of the programmes supported by DfID.
People suffering from these tropical diseases are also subject to the full panoply of other universal infections, such as pneumonia and diarrhoea, which are more likely to be severe because of lowered immunity, caused by one or other NTDs, and associated malnutrition. While welcoming the international initiatives that have been praised by everybody, I have a slight caveat, as did the noble Earl, Lord Sandwich. Anthropologists Tim Allen of LSE and Melissa Parker of Brunel point out in the Lancet that, welcome though treatment of NTDs is, the mass administration of drugs gives rise to a danger that these vertical programmes can undermine already fragile and overstretched healthcare systems. However, I think that with care, co-ordination and collaboration this can be avoided. In fact, if properly managed, these programmes can actually strengthen primary care.
Populations receiving mass medication often do not understand why tablets are being given to everyone, including those with no symptoms, and may not understand or accept scientific explanations of the causes of NTDs. The two anthropologists I mentioned write:
“The availability of tablets is not enough ... dealing with NTDs in a sustainable way will involve a range of factors including behavioural change. Imagining that mass drug administration ‘will make poverty history’ is unrealistic”.
I think that the leaders of the current interest in conquering NTDs are fully aware of this, and I certainly feel that this was given evidence by the excellent research papers that were given at the School of Hygiene and Tropical Medicine this afternoon. As someone who has worked at the grass roots, the observations of the two anthropologists need to be taken into account; they have the ring of truth.
I would like the noble Baroness to reassure me if she can that the generous funding going to mass treatment of NTDs is not diverting DfID researchers away from the longer-term, but ultimately much more sustainable, objective of relieving poverty and improving health by strengthening health systems, improving nutrition, ending illiteracy and providing clean water and sanitation. Mass administration of drugs can set the ball rolling, but only through these wider means can NTDs be sustainably controlled and eventually eliminated.
Treatment of Homosexual Men and Women in the Developing World
Lord Rea Excerpts(12 years, 1 month ago)
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Lord Rea
My Lords, many people in the developing world will be grateful to the noble Lord, Lord Lexden, for raising so cogently this important and disturbing issue. Although we may condemn the draconian laws and practices he has described, we should not forget that it is only quite recently in historical terms that this country and other industrialised democracies have repealed laws which prohibited same-sex relationships. Although the law has been liberalised in the UK and other countries in the north, and many prominent people, including MPs and Ministers, are now able openly to declare their sexual orientation, powerful prejudice is still there among a substantial minority of the population. A well-known example of that is the problem that the most reverend Primate has had with some of his bishops both here and abroad. The noble Lord, Lord Lexden, has pointed out that the intolerant and puritanical attitudes to gay sex that prevail in many developing countries may be a relic of colonialism, and that before the colonial era there was a much more permissive attitude.
How does this social and legal condemnation of homosexual people affect their health, particularly in terms of HIV infection? I was privileged to serve last year on the House of Lords Select Committee that looked into HIV and AIDS in the UK, which was chaired very ably by the noble Lord, Lord Fowler. Although sexual orientation and HIV infection are different entities, there are parallels, particularly regarding stigma and social rejection. To quote from the Select Committee’s report, we found that:
“Stigma and lack of understanding can undermine HIV prevention efforts … and can also impact upon adherence to treatment”.
The double prejudice that gay people with HIV suffer from makes it even more difficult for them to get access to treatment and the follow-up which is necessary. In many countries they are thwarted in obtaining treatment by laws and attitudes that criminalise or shun them.
HIV infection was of course first discovered 30 years ago among gay men, so the disease is associated with gay sexual behaviour. However, heterosexual transmission in Africans is now more common than homosexual transmission both at home and among the diaspora. HIV infection itself is nevertheless still much more common in gay men than heterosexuals both here and in Africa; 19 times more common, in one study quoted in the recent excellent report of the Global Commission on HIV and the Law. Stigma and discrimination play a significant role in causing and maintaining these high rates. In Caribbean countries where homosexuality is criminalised, such as Jamaica and Guyana, which are both Commonwealth countries, the prevalence of HIV is around one in four gay men, while in countries that do not criminalise same-sex sexual activity, such as Cuba and the Bahamas, it is only around one in 15. Can the Minister who is to reply outline the response of DfID to this unacceptable situation? I am aware that the Government are concerned about the issue and that they have played an important role in bringing it on to the international stage.
However, there is still a long way to go, with discriminatory legislation being passed or debated in Uganda and several other countries in the Commonwealth and elsewhere; I mention particularly eastern Europe. A fundamental step should be to encourage and support citizens and civil society who oppose these outdated and misguided laws in those countries. We should encourage them to put pressure on their Governments to repeal them as soon as possible.
This is not an impossible task. For example, the UN Secretary-General, Ban Ki-Moon, the Independent Commission on AIDS in Asia and the UN special rapporteur on the right to health, as well as a meeting of Commonwealth Foreign Affairs Ministers, have all recommended repealing laws that prohibit sex between consenting adults of the same sex, as have courts in Hong Kong and Fiji, as was mentioned by the noble Lord, Lord Lexden.
However, action on the ground is less evident than declarations of intent. The clear evidence that punitive discriminatory laws encourage the spread of HIV infection should act as a stimulus to repeal them. I hope that the noble Baroness can outline the moves the Government are taking to encourage international action as well as words.
A further line of attack should surely be to encourage treatment centres for HIV and AIDS to be freely open to people of any sexual orientation. DfID devotes a substantial proportion of its budget to the prevention and treatment of HIV. I hope the noble Baroness can assure the House that the special problems encountered by gay and other sexual minority groups in getting access to medical help are taken fully into account.
Global Fund: AIDS, Tuberculosis and Malaria
Lord Rea Excerpts(12 years, 5 months ago)
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Lord Rea
My Lords, the noble Lord, Lord Fowler, has, as usual, chosen a topic which urgently needs to be addressed. In three minutes I shall try to cut to the quick.
The Global Fund has been an overall success, as everyone has said. DfID has played a major part in this, recognising its transparency and accountability. In fact, the Global Fund itself recently detected and put right a minor accountability problem within its organisation. It was a small fraudulent diversion of funds, I believe, but that was seen to.
The Global Fund is a very focused organisation which funds vertical targeted programmes. However, subsidiary aims are to assist and strengthen national healthcare systems and support civil society. Many, like the noble Lord, Lord Parekh, feel that this should have greater emphasis, as only then will the programme initiated by the Global Fund be sustainable. These aims need to be integrated into the general healthcare provision of the countries concerned. HIV, TB and malaria are a heavy burden but they are only part of the whole infectious diseases picture, let alone the increasing role in the developing world of non-communicable diseases.
In April, the Secretary of State for International Development, Andrew Mitchell, said that, following up its already substantial grant to the transitional funding arrangements to take the place of the missing funds from the cancelled round 11, the UK could increase its contribution to the Global Fund very substantially, as the noble Lord said, in 2013, 2014 and 2015 by up to double the current £384 million pledge. Can the noble Baroness give us some indication of how much it will be and when the amount will be announced? What occasion will the Secretary of State choose to make that statement? The money is urgently needed, as already several programmes have had to be either contracted or postponed. I am worried in particular by the postponement of plans to address emerging threats such as resistance to artemisinin combination therapy, in Myanmar—Burma. That of course is the main, if not the only, weapon against the malaria parasite. I hope that, if a donation is made, other countries will be encouraged to contribute to the fund, as the noble Lord suggested will be the case.
Health and Social Care Bill
Lord Rea Excerpts(13 years ago)
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Lord Walton of Detchant
My Lords, I should like to ask the Minister to clarify a point of some importance. Many years ago, in the early stages of my neurological career, I was involved in interpreting electroence- phalograms. Subsequently, I was heavily involved in the pursuit of electromyography—a technique for measuring the electrical activity of the muscles in health and disease—and in measuring nerve conduction velocity. I also looked at evoked nerve potentials. A group of individuals grew up in that field originally; it was called the EEG Society. Then there was the Electrophysiological Technologists’ Association—the EPTA—of which I was briefly president. Eventually they came together to form the association of clinical neurophysiologists.
The Health Professions Council regulates 15 health professions, including biomedical scientists and clinical scientists. My understanding is that clinical neurophysiologists, like other clinical physiologists, are not included in or embraced by the term “clinical scientist”. However, I wish to know whether they are covered by the Health Professions Council. If they are not, it is important that they should be regulated. For that reason, if they are not included at present under the terms of the Health Professions Council, I strongly support this amendment.
Lord Rea
My Lords, in supporting this amendment I declare an interest. Not only my former patients but I, as a patient, have received skilled help from clinical physiologists. The pacing unit at St Mary’s Hospital, which is run by clinical physiologists, has monitored my pacemaker since it was fitted four and a half years ago. My life has literally been in their hands while they periodically adjust my heartbeat to get the best setting.
The Registration Council for Clinical Physiologists, which has been described, has been trying to persuade the Department of Health to include the profession in the mandatory regulatory framework for health professionals for the best part of a decade. The Health Professions Council recommended in 2004 that clinical physiologists should be included in its regulatory regime, as well as other clinical scientists whose work involves a potential impact on patient safety. The then Secretary of State accepted this recommendation but still no action was taken and has since not been taken despite frequent reminders from me, among others. On my count, 30 parliamentary Questions have been tabled on this issue. It has also been raised in your Lordships' House in a debate on an order to do with the Health Professions Council. I hope that this amendment will serve to speed up the process by focusing the Government’s attention on an overdue step that we feel needs to be taken.
Baroness Finlay of Llandaff
My Lords, this group of amendments is very interesting as it reveals the enormous number of people involved in healthcare who literally hold the lives of others in their hands and are not subject to any statutory regulation but are voluntarily registered. I have an amendment in this group which seeks to establish,
“a statutory register of Physicians’ Assistants (Anaesthesia)”
and of other healthcare professionals. I will speak about that in a moment in relation to clinical perfusion scientists.
Physicians’ assistants in anaesthesia already have a voluntary register in place and they applied to the Health Professions Council for registration and had their application accepted. However, that all went on hold with the emergence of this Bill. The Royal College of Anaesthetists does not allow physicians’ assistants in anaesthesia to become associates as they are not registered with the General Medical Council, but it permits them to have affiliate membership. However, the college does not have a regulatory role as such; it is tied up with education and standards.
Physicians’ assistants in anaesthesia urgently need statutory regulation, given the range of invasive, and potentially life-threatening, procedures that they perform and the knowledge and autonomy of practice required in the roles that they carry out. These practitioners perform tasks that, in the UK, were previously carried out only by doctors. They cannot get indemnity insurance for their practice or apply for prescribing rights, even though they sometimes have to be able to respond in a matter of seconds, not minutes, if something goes catastrophically wrong with an anaesthetised patient while the anaesthetist is outside the theatre for whatever reason. They are on a voluntary register, which provides some reassurance for patients and employers, but that cannot realistically be seen as an alternative to statutory regulation. I think that in 2009 they were identified by the Department of Health as being urgently in need of registration. The Health Professions Council felt that these assistants fulfilled sufficient of its criteria to warrant the recommendation for statutory regulation being accepted.
Irrespective of whether Members of this House have undergone a procedure requiring anaesthesia, would they consent to being rendered unconscious by an individual who was neither bound by a stringent professional code of conduct nor properly registered to practise? After all, we would not get into an aeroplane if we did not know that both the pilot and the co-pilot were appropriately qualified to a very high degree, with ongoing continuing professional registration. We trust them just as we trust these physicians’ assistants, but if something goes wrong in theatre it does so with catastrophic rapidity. When I did my training in anaesthesia, on more than one occasion I saw these physicians’ assistants recognise problems arising before the trainee anaesthetists had done so. They carry enormous responsibility during complex procedures.
I have included other healthcare professionals in my amendment as I am well aware that the Government do not like to have enormous lists in a Bill. My amendment would therefore leave the door open to include clinical perfusion scientists—the other group involved in theatre—whose role is primarily to maintain a patient’s circulation during open-heart surgery, during a period of surgical repair when the heart has been stopped. They were recommended in 2003 for statutory regulation.
There have been two high-profile cases involving clinical perfusion scientists. The first fatality, in 1999, led the Southwark coroner to recommend the immediate statutory regulation of clinical perfusion scientists. The second fatality, in 2005, was attributed to inappropriate drug administration by a clinical perfusion scientist during an operation on a five-month-old baby at Bristol Royal Infirmary. That led to the publication of the Gritten report, which concluded that:
“The incident occurred because of latent weakness that lay dormant for years hidden by healthcare professionals compensating for inadequacies within national and local systems”.
The report recommended that action at national level should include,
“regulation and guidance on perfusion practice in cardiopulmonary bypass”.
More recently, there have been fatalities that have led to clinical perfusion scientists’ actions being questioned by coroners—the most recent of these incidents occurring in 2010 at Nottingham City Hospital.
I do not want to scare people from going in for surgery and I do not want to scare Members of this House who may be going in for surgery, but in the current climate people need to know that these very critical roles are being undertaken by people who are on a voluntary register but do not enjoy indemnity, as they would if they were on a statutory register and subject to the rigours of being statutorily regulated.
Health and Social Care Bill
Lord Rea Excerpts(13 years ago)
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Lord Rea
My Lords, I oppose Clause 31 which concerns the abolition of primary care trusts. My noble friend has talked about the strategic health authorities and, although not in detail, about the problem of getting rid of PCTs. This is intended to give the Minister an opportunity to give us some information about the implementation of this rather stark clause. For example, what about the actual handover of responsibility from PCTs to CCGs? Will all staff of PCTs be made redundant, thus giving rise to considerable redundancy costs? How many and which staff will be retained and transferred? Will those transferred continue their employment without interruption or will they have to reapply for their new post, which in fact is likely to involve the same or very similar work because the provider trusts providing the healthcare will be the same under the CCGs as they are now? Perhaps my noble friend Lord Hunt will amplify this. He has already said a considerable amount about the abolition of the strategic health authorities. Although the work of PCTs has been criticised, it has been improving all the time over the past nine years and much valuable experience in commissioning has been gained. It would seem logical to transfer as much of it as possible to avoid the expense of bringing in outside advisers and consultants or to make sure that such expense is minimised as far as possible.
Very relevant to the commissioning role of PCTs is a document that was published by the Department of Health just last month, Developing Commissioning Support. It includes former PCT staff among those who will be given a role in providing this support. There are many people in PCTs who have considerable expertise. The report’s emphasis is on a business model in which outside organisations, including the independent sector, play a major role. Can the noble Earl tell us how this will be monitored and how transparent the contracting and subsequent work of these outside organisations will be? On the whole, how long will their contracts be for, and will it be possible to terminate them when necessary?
Expressing a view very sympathetic to mine is a quotation that I have found from a speech that was made five years ago in your Lordships’ House regarding private sector commissioning. It reads:
“I want to sound a note of warning. I am worried that if that really is the way that we are going, it could represent a very serious wrong turning, not least in the context of the future development of effective practice-based commissioning”.
This was five years ago, when practice-based commissioning was the order of the day. The speech went on:
“One has to question whether the ethos and values of a private sector organisation will make it fit for purpose as a commissioner. PCTs have public service values and they are accountable. Private commissioners are differently motivated and they are not in the same sense accountable to the public. The way in which private companies operate is too often hidden by considerations of commercial confidentiality, and it is questionable whether they will be susceptible to judicial review. If the Government want to go down the road of private sector commissioning, we need, at the very least, an open debate about it and about what it will mean for the NHS and for patients”.—[Official Report, 3/11/06; col. 581.]
That exactly expresses my views. It will be interesting to know what the noble Earl thinks of it because they are his very own words, spoken when he was winding up for the Opposition in November 2006 on an Unstarred Question that I asked about the role of the private sector in the National Health Service.
Earl Howe
It is accountable for its decisions at a regional or sub-national level in a real sense. If it was not interacting with the boards, the noble Lord, Lord Hunt, might have a point; but it will be. I think that that is accountability in a meaningful sense. The noble Lord, Lord Warner, talks about budgetary accountability, and I understand that that is a real issue. Of course there will be no budgetary accountability, but there will be accountability for the decisions and actions taken by the field forces.
I was saying that the structure means that all too often neither of the roles that PCTs perform is performed well. GPs, who actually make the clinical decisions, are not properly involved in PCT commissioning; and PCTs do not have the detailed understanding of their communities or the link to other local public services. The result is an unsatisfactory compromise, with commissioning that fails to deliver improvements in health outcomes and local services that are fragmented and not integrated.
It has been suggested by some noble Lords that one could have kept PCTs and parachuted in a whole lot of doctors, perhaps filtering out some of the administrators. Anyone who has visited any pathfinder CCG and put that question to the doctors and other clinicians involved will know the answers to why that would not have been a valid and sensible idea. The way in which services are commissioned has to depend on the judgment of clinicians and the wisdom of establishing geographic areas for commissioning groups that make sense in terms of patient flows and in terms of links with local authorities, social services and public health. It does not make sense to retain structures that, frankly, are administrative constructs that do not necessarily bear any relation to patient flows or relationships with local authorities. These clinical commissioning groups are being created from the bottom up by those who know what is in the best interests of patients, and it is to patients that we must always return in our thinking. We currently spend £3.6 billion a year on the commissioning costs of PCTs. PCT and SHA management costs have increased by £1 billion since 2002-03. That is a rise of over 120 per cent. We cannot make savings on the scale that we need to while retaining the administrative superstructure of the NHS.
The noble Lord, Lord Hunt, suggested that the pathfinder CCGs were being built on nothing at all. They are not being created from nowhere. They are building on, and are indeed a logical development of, practice-based commissioning groups, of which there were a very significant number. There are currently 266 pathfinder clinical commissioning groups covering 95 per cent of GP practices in England. As I have indicated before, I cannot say how many we will eventually end up with, but that will give noble Lords a rough indication of the order of magnitude.
The noble Lord, Lord Rea, quoted some words of mine from a debate of several years ago. I would simply say to him that I was speaking then of something completely different from the Government’s current proposals, and I am grateful to the noble Baroness, Lady Murphy, for pointing that out. These reforms place leadership of commissioning firmly with clinicians. I completely agree that giving leadership to a non-statutory, private-sector firm would be a bad idea. That is why there are very clear safeguards against this happening. With PCTs, I feel that there was a genuine question over where commissioning leadership really lay, and this is very firmly no longer the case.
On Amendment 236A, I must clarify one point. It is not the case that a clause stand part debate on Clause 30 would be consequential if a Division was to be called on Amendment 236A and won. It would simply amend this clause and not entail that it needs to be removed.
I hope that I have sufficiently covered the issues raised by noble Lords. I do not suppose that I have satisfied everyone, but I hope that I have at least indicated the direction of government policy in a coherent way.
Lord Rea
The staff of PCTs below management level are going to be rather disappointed that the Minister did not answer my question regarding their employment and the possibility of their being moved over to the CCGs, where many of their functions are going to be precisely similar. Are they going to be made redundant? Is it going to be possible to move staff over smoothly without a break in their employment status?
Earl Howe
My Lords, the rules apply on transfer of employment, and we anticipate that around 60 per cent of PCT staff will transfer to clinical commissioning groups, local authorities or the NHS Commissioning Board. It has been necessary to institute a programme of managed accelerated retirement for those for whom there will be no posts. However, this is being done in as friendly and generous a way as possible and the process is working well. But on the noble Lord’s main concern, yes, the terms and conditions of employment should not alter for those who stay.
HIV and AIDS in the UK
Lord Rea Excerpts(13 years ago)
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Lord Rea
I thank the noble Lord, Lord Lexden, for his contribution and congratulate him on it. It was very refreshing to have someone who was not on the committee bring us some fresh insights and information from a part of the world which we did not visit.
Like all speakers, I congratulate the noble Lord, Lord Fowler, not only on his excellent introductory speech and on securing this debate on this day, but, more than this, on his dogged persistence with this issue over the past quarter of a century and his courage and correct judgment in putting HIV/AIDS so startlingly on the map in the mid- 1980s. As my noble professional friend Lady Tonge said, he faced strong disapproval and opposition from powerful members of the establishment, despite getting all-party support. He wisely persisted with the tombstone public education campaign as well as the controversial but highly successful needle exchange scheme which he has told us about. As result, the UK became the most successful country in the world in curbing the epidemic. In the developing world and some developed countries, the epidemic has continued to spread and, in sub-Saharan Africa, has resulted in the expectation of life for the whole population being reduced by 10 to 15 years with serious socioeconomic effects. But that is another debate, although a highly important one.
It was a privilege to serve on the Select Committee. I thank not only our chairman and our specialist adviser, Professor Anne Johnson, but also our two brilliant, dedicated clerks and, last but not least, our highly efficient secretary Deborah Bonfante, who handled the mountains of printed paper which passed before our eyes smoothly and effectively. Our witnesses, whether scientists, clinicians, voluntary sector workers or patients, were always knowledgeable and helpful.
I shall concentrate on some clinical and epidemiological aspects of the epidemic, emphasising, as all speakers have done, the imperative need for better prevention. This was the common thread which drew all our witnesses together and is the theme of the report. It is often said that the persistence of HIV in the developed world is at least partly due, as the noble Baroness, Lady Tonge, said, to the availability since the mid-1990s of antiretroviral treatment that prevents HIV developing into AIDS, and that this has resulted in greater risks being taken by some sections of the sexually active population now that HIV is no longer a death sentence. Even if this was only partly true, it indicates widespread ignorance of the burden that living with HIV can cause, as several noble Lords have most vividly described, even when ARV treatment is being correctly given. Though some of them will live a full lifespan, others will not be so fortunate. There are often unpleasant side-effects, though they are now less common since combination antiretrovirals have become more refined.
The future health and lifespan of HIV-infected people receiving ARV depends very much on the stage that the infection has reached when treatment is started. Early diagnosis after infection is thus extremely important. ARV drugs are much less effective when there is a high viral load, so that full blown AIDS symptoms which are difficult and expensive to treat can develop, even when the subject is on ARV treatment. Fifty per cent of newly diagnosed cases in the UK are classified by the HPA as being at a late stage of infection, with a CD4 cell count of less than 350 per cubic millimetre, just over half of which are severely immunocompromised, with a CD4 count of less than 200. The late diagnosis rate varies from group to group, being highest among heterosexual men—63 per cent of them. It is estimated by the HPA that 22,200 people are living with HIV infection in the UK who are undiagnosed. Most of them are unaware of their condition; some of them are developing high viral loads which means that they will respond less well eventually to treatment as well as acting as a reservoir of infection.
HIV carriers who are being successfully treated, on the other hand, have a very low infectivity of 1 per cent or 2 per cent but even this low rate means that they must still use a condom or take other steps to reduce the chance of passing on their infection. So while acquiring HIV infection is no longer an automatic death sentence it is still a life sentence—it means a lifetime of medication and the other serious drawbacks I have described—a much worse fate than that of other sexually transmitted diseases which can now mostly be treated and cured.
In addition, as the noble Lord pointed out so vividly, people living with HIV are subject to a number of social consequences. We heard from several of our HIV-positive witnesses examples of stigma against people with HIV in employment and in social settings, despite successful ongoing treatment. Frequently there are psychological symptoms, sometimes very severe, including suicide. Life insurance policies and mortgages are difficult or impossible to obtain by HIV-positive people, according to the Terrence Higgins Trust. If after perseverance a policy is agreed, the premium is highly loaded and no cover will be given for illness or death from an HIV-related condition. That puts people at a huge disadvantage when attempting to live a full life, and buying a house, for instance.
The noble Lord, Lord Fowler, and others have described the increasing financial burden caused by HIV infection, particularly the cost of drugs. This cost is increased if HIV is detected late and complications have to be treated in hospital. But the main cost of HIV comes from the persistence and spread of the epidemic through sexual contact with HIV carriers who are not aware of their HIV status. As other noble Lords have pointed out, this is why one of the main messages from our witnesses and the report is the need to widen the screening net by testing in more settings than previously. In fact I suggest testing wherever a blood test is being carried out for any reason and on certain other occasions, for instance when a patient is having a health assessment or being registered at a general practice, for hospital out-patients or in-patients and in STD clinics even when a blood test was not originally planned.
The case for this policy is very well argued in the Time to Test for HIV report, mentioned by the noble Baroness, Lady Gould, published this year—or was it last year?—by the HPA. We visited a group practice in Brighton where routine HIV testing was done as well as the carrying out of general healthcare of HIV patients being followed for their HIV and treated by at the HIV unit at Royal Sussex County Hospital. When a positive test result meant that someone had a fatal disease there was a policy of only testing when suitable counselling for this eventuality was made available. Now that a positive test does not have quite such a dramatic meaning, it is acceptable for the test to be carried out by any suitably trained professional, providing of course that the consent of the patient is first obtained; an opt-out possibility must always be offered.
I have not covered our recommendations at all systematically. There are 53 of them; each has been covered by the Government’s response and many of the report’s recommendations have been accepted. I am particularly pleased that the recommendation to make home testing legal and quality controlled has been accepted. This was the suggestion of many of our witnesses. Also welcome is the lifting of the requirement for all overseas visitors to have to pay for HIV treatment. Lifting this charge makes good public health sense.
I was, however, disappointed in the Government’s response—other noble Lords have mentioned this—to paragraphs 236 and 237 of the report, which called for the integration of HIV and sexually transmitted disease services. This is particularly relevant in the light of the changes envisaged in the Health and Social Care Bill now in Committee in your Lordships’ House. I hope that the noble Baroness who is replying to this debate will be able to raise in Committee some of the issues that I am about to describe.
We heard justifiable concerns about the split between HIV treatment services to be commissioned by the National Commissioning Board, and the provision of prevention services for HIV and other STIs in genitourinary medicine clinics to be provided by local authorities—through their ring-fenced public health budgets, presumably. The proposed changes claim to enable integration between the services, but in this case it seems that the reverse is being proposed. Many PCTs have increasingly brought HIV and STI services together under the same roof, as they logically should be. In this case the opposite seems most likely to occur. Perhaps the noble Baroness can tell us the department’s latest thinking on this particular problem.
I was going to speak also about the future of the HPA, but that has been covered extremely well by the noble Baroness, Lady Masham, and, as I have now been speaking for 12 minutes, I shall end on that point.
Health and Social Care Bill
Lord Rea Excerpts(13 years, 1 month ago)
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Lord Whitty
My Lords, I will leave that question for the Minister, because it clearly raises wider issues. I totally agree with the noble Lord, Lord Greaves, that one of the most acute effects of all this will be at the district level, where the funds are less protected, and where there is already some difficulty and some serious variability in performance and resourcing.
Given the Government’s support for the establishment of a chief environmental health officer at the centre to help co-ordinate all these issues and—if you like—to punch the weight of environmental health in the other range of priorities which the Department of Health has to pursue, I would ask the Minister this. Will the assessment of public health and the ongoing process she described in trying to defend the Bill from not spelling this out in great detail, lists or no lists, be available to us before we complete the consideration of this Bill, the exact timescale of which looks ever lengthier? Nevertheless, before we reach final conclusions on this, we need to have greater clarity on the direction in which the Government are going on public health, and, I would argue, on environmental health in particular.
I shall mention one other issue that relates to this. The abolition of the HPA also has significant implications in this area. I intend to come back to this at a later stage, but some of the functions of what are currently statutory authorities are going to go to Public Health England, as I understand it, and there is some confusion there as to how that will be carried out, what authority those roles will have and what their local manifestations will be. Under the new structure we will have health protection units around the country. So that is just one more complication here. By Report we ought to have some greater clarity in the strategy of the Government. I ask the Minister to give us an indication of that.
Lord Rea
My Lords, I had not intended to intervene on this amendment, but just from memory, I can think of several areas where the presence of an environmental health officer at the centre would perhaps have speeded things up. The noble Baroness, Lady Finlay, alluded to air quality, but there are other examples as well. I am old enough to remember the smog of 1951 and the enormous benefit of the Clean Air Act which followed a few years later. I was also in your Lordships’ House when lead-free petrol was debated, and when that became law nationally. There is also the question of food safety—the noble Lord, Lord Rooker, will know all about this—particularly the BSE epidemic, when it became necessary to ban animal-sourced feed for ruminant animals. Again, that required national legislation. Local environmental health officers, who do a fantastically important job, would not have been able to deal with these things on a local basis.
Lord Northbourne
I rise to support the amendment moved by the noble Baroness, Lady Finlay. One thing that has so far not been mentioned is that it is important to think about the alternatives to alcohol and to regular alcohol use. I used to spend a certain amount of time with very disadvantaged young people, and a great deal of their problem was boredom, inferiority complexes and no belief that there was any real future for them, so let us also think about all sorts of other things that they might be doing.
Lord Rea
My Lords, as a former GP, I echo the words of my noble friend Lord MacKenzie. Screening for alcoholism should be added to the QAF measures in view of all the reasons that have been eloquently adumbrated by other people. I want to raise a fairly basic problem which is the cost of alcohol services. At the moment, a lot of these are funded as outreach programmes by PCTs, and those are going to be transferred to local authorities. They will have to be paid for out of the index-linked £4 billion-odd that is going to be given to local authorities for this purpose. Perhaps the Minister could say whether the actual cost of running these alcohol services is being taken into account when considering how that £4 billion is going to be calculated. There are also plenty of other services being transferred to local authorities.
Baroness Thornton
My Lords, I rise to comment on these excellent amendments, and to support my noble friend Lord Beecham who has his name against Amendment 71. Amendment 71 is one of those very small amendments that changes “may” to “must” but it is actually at the heart of this discussion. What we are talking about here is how national campaigns will be linked to local action, and how they will be funded.
I start by reminding the Committee of some of the key components of this Government’s health policy on the harmful use of alcohol: banning the sale of alcohol below cost price; reviewing alcohol taxation and pricing to ensure that it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries; overhauling the Licensing Act; local authorities having more powers to remove licences and refuse grants that are causing problems; allowing councils and police to shut down establishments; doubling the fines for underage alcohol sales; and local councils being able to charge more for late-night licences.
My noble friend Lord Brooke put his finger on it, as did my noble friend Lord Turnberg, when he expressed scepticism as to the efficacy of these when you link them to the responsibility deal pledges on labelling. As part of the public health responsibility deal agreed with the Government in March 2011, UK alcohol beverage companies have pledged—that is an interesting word to use in this context—to implement a health labelling scheme to better inform consumers about responsible drinking. This pledge is in line with the industry’s response to the Department of Health’s consultation in May 2010 on options for improving information on the labels of alcoholic drinks to support consumers in making healthier choices in the UK. I do not think this is going to work.
Will the Government be reviewing their national campaign on alcohol and the misuse of alcohol in the light of this Bill? We have a national policy and a campaign, presumably run and directed by the Secretary of State for Health through the public health agency within the department. We have to look at what will actually happen on the ground and indeed address the dangers or risks that are posed by this Bill. A key question is the distinction between primary prevention and secondary prevention, which is complex in relation to the prevention of alcohol misuse. It is a concern when interventions cannot be clearly delineated as primary and secondary prevention. It seems that the reforms being proposed here will make that worse, not better.
Multiple commissions across one therapy, such as alcohol misuse, may cause uncertainty over who is responsible for funding services considered for both primary and secondary prevention. The worst case scenario is that neither the directors of public health nor the GP consortia commission secondary prevention services because the directors of public health are focused on primary prevention, awareness and information, the GPs are focused on treating the physical complications and harms relating to alcohol, and the hospitals are mopping up the people who turn up needing treatment for alcohol abuse.
If we are to tackle the fact that the number of hospital admissions was over a million in the last year, and that it is estimated to cost the NHS £2.7 billion a year—almost twice the equivalent figure for 2001, with the costs to society being even greater—there has to be co-ordination between national and local, and some direction about how these programmes will be carried through at local level. On these Benches we are therefore very sympathetic to what we see as a series of rather modest and focused amendments. We hope that the Minister will be able to look upon them with some sympathy.
Population Growth
Lord Rea Excerpts(14 years ago)
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Lord Rea
My Lords, I think that the whole House will be grateful to the noble Lord, Lord Hodgson, for raising this Question and for his thoughtful and thought-provoking speech. The fact that 11 speakers have put their names down for this one-hour slot gives an indication of the importance of the issue.
I am going to talk mainly about population and economic migration but, on the way, I should like to flag up briefly the way in which rapid population growth will affect not only this country but the rest of the world through its impact on the environment by accelerating resource depletion and climate change. We are already faced with a time bomb since, although the output of greenhouse gases per head in the developing world is low at present—about one-20th of ours per head—this will inevitably increase with rising standards of living. China is already providing us with an example.
I should declare an interest in that I am a long-standing member of the All-Party Parliamentary Group on Population, Development and Reproductive Health. In January 2007, we published a report, Return of the Population Growth Factor, Its Impact upon the Millennium Development Goals. This was a distillation of a series of parliamentary hearings of experts in the fields of population and demography. Its conclusions, in brief, were that each of the first seven MDGs was adversely affected by population growth when it exceeded the rate of economic development. This applied particularly to sub-Saharan Africa, where population growth rates are the highest in the world and economic development the slowest. With regard to MDG 1, which is to,
“eradicate extreme poverty and hunger”,
the report says on page 21 under the heading “Running to stand still”:
“In sub-Saharan Africa, GDP per capita has been falling at nearly one percent a year, and those living in poverty … rose modestly from 44.6% to 46.4% between 1990 and 2001”.
Annual economic growth is expected to be 1.6 per cent between 2006 and 2015 but,
“due to the countervailing effect of rapid population growth, the World Bank predicts that by 2015, 340 million people in Africa will be living in extreme poverty, compared with 318 million in 2001”—
an increase of 22 million. The pressure to seek a better life in another country comes not so much from overcrowding and population growth per se but from lack of employment and poverty—in other words, “the economy, stupid”. Initially, employment is sought in the rapidly increasing slum cities of the developing world, but when this is not forthcoming the most enterprising citizens seek it elsewhere—perhaps in the El Dorado of the prosperous north and west. As the noble Lord said, the populations of some of those countries are in decline with a shortage of young people, so inward migration may not always be a bad thing.
Of course, there are reasons other than poverty for migration—conflict and political persecution are two. In the past, this country has benefited greatly from migrants from Europe fleeing political persecution. The largest number of immigrants, as the noble Lord pointed out, are seeking their way out of poverty.
There are two approaches to the problem, which are equally important. We must make more efforts to boost the economies of the developing world and diminish poverty. This in itself will result in fertility rates coming down. We all accept that that is a gargantuan task and inevitably slow. In the mean time, much can be done to assist mothers to have fewer children. The two most important are to aim to boost female education and to ensure that contraceptive supplies are made available to the 220 million women who wish to use them but at present cannot obtain them. There is no time to develop these themes. Suffice it to say that DfID is well aware of the needs of the developing world in reproductive health and family planning—not least because our group makes sure that they are aware. DfID devotes a greater proportion of its budget to it than most other countries. I am sure that the noble Baroness in her answer will take the opportunity to describe DfID’s work in this field.
Baroness Northover
I remind noble Lords that this is a tight time-limited debate, and when you hit four minutes you have already exceeded your time.