NHS: Health and Social Care Act 2012
Lord Rea Excerpts(9 years, 5 months ago)
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Lord Rea (Lab)
My Lords, I thank my noble friend Lord Hanworth for bringing this important topic forward.
Before the 2010 election David Cameron specifically ruled out “a disruptive top-down reorganisation”, but this is what the Act has proved to be. It was also largely unnecessary: many of the changes brought about by the Act, particularly the beneficial ones—and, yes, there are quite a few—could have been achieved without new primary legislation. In my seven minutes, I will concentrate on public health and prevention, which is where my current involvement with health lies.
Twenty-three years after retiring from NHS clinical practice, I declare an interest as honorary president of the UK Health Forum, an independent but publicly funded body representing some 60 national organisations with an interest in “upstream” prevention of non-communicable disease—the “causes of the causes”. The Government have repeatedly emphasised the importance of prevention as the way to approach our current increasing load of chronic non-communicable disease. The Five Year Forward View, whose findings have been accepted by the Government, referred to the work of Derek Wanless, who warned some 15 years ago that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. The Five Year Forward View points out that that warning has not been heeded and that the NHS is,
“on the hook for the consequences”,
with an increasing burden of largely preventable chronic illness that can be expensively treated or cared for but mostly not cured. So I will concentrate on the sections of the 2012 Act which concern public health and the reduction of social inequalities which are at the heart of any policy to improve the health of the population.
Theresa May pointed out, in her first speech as Prime Minister, the “burning injustices” of the wide gap in health between the highest and the lowest socioeconomic groups of the population. As the noble Lord, Lord Prior, knows very well, this gap has been extensively studied by Sir Michael Marmot and his colleagues at UCL. They have shown that the mortality rates and incidence of most diseases—particularly those which form the main burden on health services today—are consistently related to social status across the board. The concept of the social determinants of health, first described in detail by Michael Marmot, is now recognised worldwide as basic to public health thinking. The 2012 Act includes changes in the provision of public health services that are potentially beneficial. Among measures that were given a guarded welcome by public health professionals in local government was the transfer of many public health functions from PCTs to local authorities. This change was logical, since local authorities have always been involved in some important public health activities. I could list other desirable changes related to the wider determinants of health, but it would take too long in a time-limited debate.
The concern of public health professionals about the move to local authorities was twofold: would the rearranged services be properly funded and would the status and independence of public health professionals within local authorities be assured? As noble Lords know, these concerns have been more than justified. The House of Commons Select Committee on Health’s report Public Health Post-2013, published just a week ago, states:
“There is a growing mismatch between spending on public health”,
which is set to reduce,
“and the significance attached to prevention in the NHS 5 Year Forward View”.
In fact the ring-fenced levels of local authority funding for public health were cut by £200 million last year, a move that was questioned in the House at the time by my noble friend Lord Hunt. This funding is on a steady downward trend until 2020, and will then have fallen in real terms by 25% since 2013. In addition, overall central government funding allocations for local authorities have been cut drastically since 2012, as everyone knows, affecting many local authority services which have a public health component. The Commons Select Committee on Health’s report concludes:
“Cuts to public health are a false economy. The Government must commit to protecting funding for public health. Not to do so will have negative consequences for current and future generations and risks widening health inequalities”.
These are strong words for a Select Committee.
The committee reports many other concerns about the functioning of the new arrangements and makes useful suggestions about how difficulties can be overcome, often using verbatim reports from witnesses describing both good and bad practices. I commend its excellent report—it should have a green cover but in the Printed Paper Office it has a white one—to the Minister and hope he will be able to say that the Government will accept its recommendations and enact them in full.
National Health Service
Lord Rea Excerpts(10 years ago)
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Lord Rea (Lab)
My Lords, in my three minutes I will concentrate on one section of the NHS Five Year Forward View, published 18 months ago, headed “Getting serious about prevention”. It makes the point that we are reaping the consequences of failure to prevent chronic diseases that would be largely avoidable if only suitable changes in behaviour could be made. The former Chief Medical Officer exhorted people to change their so-called “lifestyles” and live more healthy lives—I think we know the list.
The five-year view does not emphasise sufficiently that these diseases are all strongly related to social conditions. As Sir Michael Marmot has shown, there is a gradient in both mental and physical health through all socioeconomic groups from the top to the bottom. Health education messages to change behaviour are, however, less effective in the lower part of the spectrum. Poverty and inadequate housing may make it more difficult to give up harmful habits such as smoking, drinking or comfort eating, which can give momentary relief from economic and social pressures. Changing behaviour where it matters most is therefore the most difficult; powerful underlying pressures, some from the tobacco industry and parts of the food industry, are pulling in the opposite direction.
Professor David Gordon and his colleagues at Bristol University have drawn up an alternative list of desirable health behaviours to those advocated by the CMO. They take a rather different approach, which goes like this: “1. Don’t be poor. If you can, stop; if you can’t, try not to be poor for long. 2. Don’t live in a deprived area. If you do, move. 3. Don’t work in a low-paid, stressful manual job. 4. Don’t live in damp, low-quality housing”. There are six others, which I am afraid time precludes me from listing.
Those suggestions all have a direct bearing on health and longevity, but they lie outside the remit of the NHS and are mostly the responsibility of local authorities and other departments of state. If they were adequately funded, a great load could be lifted from the NHS, which at present is carrying a burden for which it is not really designed. I suggest that the continuing financial crisis of the NHS will not be solved until it is properly funded and other departments of state whose responsibilities have a bearing on health are enabled to carry their full share of maintaining the nation’s health and well-being.
Health
Lord Rea Excerpts(10 years, 2 months ago)
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Lord Rea (Lab)
My Lords, I thank the noble Lord, Lord Crisp, for introducing this important debate and his excellent speech. I declare an interest as a long-time trustee and now honorary president of the UK Health Forum, the public health think tank co-ordinating some 80 national organisations interested in upstream or primary prevention of non-communicable disease. The noble Lord has drawn attention to the wide spread of social and environmental factors behind our current burden of disease, and shown that many causes of those diseases lie outside the remit of the National Health Service. To prevent or delay their onset requires political and economic engagement rather than traditional public health solutions, important though they still are.
Historically, public health measures have been regarded as an imposition on individuals and industry, because they require changes in behaviour or the products of industry. They are regarded pejoratively by some as the “nanny state”—a term particularly favoured by some who may be financially affected by the changes needed to protect public health.
To divert from the general to the particular, the marketing of harmful food products could be curtailed and their composition improved by regulation and taxation—for example, of their sugar content. Here, I echo other noble Lords. The voluntary approach, the responsibility deal, has not worked, although it has been in place for five years. If all sections of society enjoyed the health status of the best off and best educated in the population, the health status of the whole nation would be greatly improved. To achieve the noble Lord’s health-creating society, we should logically consider the factors that favour the upper layer and bring them, as far as possible, to all sections of the population, to bring the bottom section closer to the top.
Most of us know the most common risk factors for heart disease, stroke, obesity, diabetes and some kinds of cancer. These are, of course, cigarette smoking, physical inactivity, poor diet and so on. It is true that the least well off have higher risk scores and that these show a gradation from the poorest to the most favoured groups of the population. A number of studies, particularly those by Sir Michael Marmot—who seems to be the father of this debate—and colleagues, have shown that when all the known risk factors are taken into account, the social gradient of health remains. The NHS can affect only a small part of these health inequalities, which have their roots in the social fabric and economy of the country.
From conception onwards, the odds are stacked against the less privileged in diet, housing, working conditions and social status. Low income is the dominant feature of the lives of the underprivileged. The environment in which children are brought up is particularly important, especially the early years from conception onwards, as other noble Lords have pointed out. Poor nutrition and social deprivation may lead to chronic disease in later life. To protect children from the effects of poverty and deprivation should be number one on the list of any policy to promote health.
In this connection, I ask the Minister about the present status and funding of Sure Start centres. They were beginning to have some effect, but some of them have had to close and others are struggling because of local government cuts. Has the Minister any news for us on Sure Start centres?
To build a resilient society, a wide range of improvements need to be made, and many or most of them have already been mentioned. Nearly every government policy has a health dimension. This should be assessed. I suggest that the Cabinet-level committee looking at the health impact of all government policy should be restored. Here I very much agree with the suggestion of my noble friend Lady Jay that a Cabinet-level Minister should look after public health.
Welfare benefits have been developed over the past century for good reason: to protect the vulnerable. To cut them further, as is still planned despite the Chancellor’s decision to listen to your Lordships’ House on tax credits, will diminish the health and resilience of the population.
Atrial Fibrillation
Lord Rea Excerpts(10 years, 3 months ago)
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Lord Rea (Lab)
My Lords, I congratulate the noble Lord, Lord Black: he has done us all a service by bringing atrial fibrillation before us. It is not the first time it has been debated in the House, but it is very relevant. Like him, I suffer from the condition of paroxysmal atrial fibrillation. What he and many other people have said more or less follows what I have prepared; I agree with nearly everything that has been said so far. Atrial fibrillation is on the increase and is a really serious problem, in that it can cause a stroke.
It is also relevant that I am a former GP who has treated a number of people with atrial fibrillation, but that was some years ago and we did not have the tools and medications—the drugs—that we have now. Some of my information, therefore, has been gained through reading rather than practice.
Atrial fibrillation increases with age, so it is not surprising that a number of your Lordships suffer from it. Some of us may not even be aware of it, as has been said, since it gives rise to quite mild symptoms and sometimes none. Sometimes it is continuous, but sometimes it is episodic or paroxysmal. Treatment consists of measures to detect and, as far as possible, correct any conditions that might underlie the atrial fibrillation—and there are quite a few—and then to restore normal rhythm, if possible, with drugs, electrical cardioversion, or surgical ablation, as has been mentioned. Most important is the prescription of suitable anticoagulants to minimise the formation in the left atrium of clots, which can be carried around the body, block an artery and deprive an area of the brain of its blood supply, leading to an ischaemic stroke. A stroke caused by atrial fibrillation is often more serious than one from other causes, so it is particularly important to detect it as soon as possible and start treatment with effective anticoagulation. Until recently, this was not emphasised adequately by clinicians and the standard drug used was inadequate—low-dose aspirin.
Trials have shown that more powerful anticoagulants have a measurably better effect than aspirin in reducing embolic stroke. The first of these, as has been said, is Warfarin—rat poison—which inhibits vitamin k action, an essential part of the clotting process. It is remarkably cheap, and its cost is amply repaid by the savings incurred by the National Health Service that it gives rise to through stopping atrial fibrillation-related stroke. I take warfarin, like the noble Baroness, Lady Gardner. My condition is under control, but having to be tested from time to time is a nuisance. I thoroughly agree with the suggestion that self-monitoring should be made available. The instruments cost about £200.
The main trouble with warfarin is that it takes some time for its effects to cease, and it can cause internal bleeding. If such bleeding occurs and cannot be brought down quickly, that is a worry. Despite what the noble Baroness, Lady Masham, said, NOACs allow the clotting time to increase quite rapidly after stopping taking them, so they are safer than warfarin.
On detection, it is very important, as has been said, to find the cases that do not have much in the way of symptoms. I will say a few words on that. Sadly, detection has been woefully inadequate up to now. That may be simply because the doctor or nurse has failed to take the patient’s pulse.
