Health: Liver Disease

Lord Ribeiro Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, as part of the responsibility deal, a financial contribution was made by some of the alcohol companies. I accept that it was a small contribution. I shall have to take this under advisement as I am not sure how much the industry does contribute to the victims of alcohol disease. I agree with the noble Lord’s premise that the damage done to many people through excessive alcohol consumption is a cause of great concern.

[Lord Ribeiro (Con)]

My Lords, does my noble friend agree with recommendation 3 in the report, which requires the establishment of liver units in district general hospitals, acting in a hub-and-spoke network with specialist hospitals? This is important to provide access to people, particularly in the north-west, where, sadly, there is very little access to specialist hepatology units.

[Lord Prior of Brampton]

My Lords, the recommendations in the report about a hub-and-spoke approach, to which my noble friend refers, with district general hospitals having some hepatology services but being linked into a specialist centre are absolutely right. It is the right model; I have no doubt about that. We have established 22 operational networks for hepatitis C treatment, which are all linked into specialist treatment centres. We believe that that may be a model for the future.

Junior Doctors Contract

Lord Ribeiro Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Prior of Brampton]

I completely agree with the noble Baroness. I am not going to stand here and be sycophantic about the Secretary of State for Health, but the one thing he has prioritised above all else since he has been there is patient safety and patient quality.

[Lord Ribeiro (Con)]

My Lords, Sir Terrence English in his excellent article in the Telegraph made the point that medicine is a vocation and doctors who enter the profession should recognise that patients always come first. The Armed Forces do not go on strike and neither, I believe, should doctors. On the issue of preconditions, in response to a question from Sarah Wollaston in the other place, the Secretary of State made it clear that there are no preconditions. I have looked at Hansard, and that is what he said. There are no preconditions and the BMA should recognise that and go back to the table.

[Lord Prior of Brampton]

My Lords, the threshold for strike should be very high because of the vocational and professional dedication of doctors. Certainly, the threshold should be higher than it usually is for pay and conditions issues such as the one before us today.

Mesothelioma (Amendment) Bill [HL]

Lord Ribeiro Excerpts

Friday 20th November 2015 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I too thank the noble Lord, Lord Alton, for introducing the Bill, and my erudite medical colleagues for their lectures and exposition on the research which supports work on mesothelioma. I confess to being a bit of a cowboy movie fan. One of my idols was Steve McQueen, whom noble Lords may remember in “Bullitt”, “The Great Escape” and “The Magnificent Seven”. The noble Lord mentioned Navy workers and the involvement of the noble Lord, Lord West, and others in this. Steve McQueen enlisted in the United States Marine Corps in 1947. In those days, warships coming out of the war were covered in asbestos. It was in every single compartment: the roofs, eating messes, everywhere. He was also required to strip out asbestos from the old ships. He died, at the height of his acting career, at the age of 50 of abdominal mesothelioma. We do not know exactly when he contracted the disease—it could have been at any time, but it was presumably between 1947 and 1950 when he was in the Navy. He was also very interested in racing cars and in those days they had asbestos masks in case of fire. It is most likely that it took 30 years before the disease was diagnosed in December 1979. He died less than a year later, in 1980, aged 50. He had malignant mesothelioma of the peritoneum, to which the noble Lord, Lord Winston, referred earlier. He tried desperately to find a cure, going to Mexico and other countries to do so, but sadly he died. His death was a huge shock to those of us who admired his acting skills, and it raised the profile of the disease of mesothelioma. It is a shame that you need such icons to bring people to understand how deadly such a condition is.

As a surgeon, I had very little experience of mesothelioma. I did a cardiothoracic job in which most of the time would be spent draining fluid from around the lungs, because this condition would compress the lungs as it spread around the pleural cavity and cause all sorts of problems. Unlike pleural problems due to tuberculosis, where we would strip off the pleura and try to stop any further fluid collecting, with mesothelioma, whatever you did made very little difference. All we could do was effectively to palliate. So my experience of the disease was very limited.

Curiously enough, we still see advertisements featuring Steve McQueen, with him advertising watches or driving a Ford Mustang. His image is still there. But the condition that he died from is not as well known as it should be. I would hate people to think that, just because this was something that happened before restrictions came into being, we will not see more of this condition. A projected figure of 60,000 deaths has been given but, as the years go by, although there may be a slight fall, I predict that there will be many more. It is also important to remember that it is not just in this country that the deaths will occur. Many countries do not have the regulations or restrictions on the use of asbestos that we have. It is important that we take a lead in trying to discover the causes of mesothelioma and getting to the bottom of how to treat it in order to benefit not only us but many people overseas.

I do not know how many noble Lords have accepted the offer of a tour of the basement of the House. If they have not, I suggest that they do, as they will find evidence of asbestos in this building that they will not believe. We are all likely to be exposed to it. The noble Baroness, Lady Finlay, mentioned her time as a medical student. When I was a medical student, I worked in a hospital where we would walk through underground tunnels with asbestos pipes along the sides. The hospital porters would push the patients on trolleys down those tunnels, bang into the asbestos and bits would fly off. As medical students, we often had a game of rugby as we went flying through the tunnels and, again, chunks of asbestos would come off. To my knowledge, one medical student who never worked in the industry subsequently died of mesothelioma. I can only assume that that was associated with exposure to the asbestos. We have it right beneath us in this building and we should all be very aware of it.

Noble Lords will remember the valiant attempt by the noble Lord, Lord Alton, to introduce his amendment the last time round. On that occasion, the Government suggested that a more voluntary approach was the way forward, with contributions being made on a voluntary basis, but the noble Lord demonstrated clearly that that has not come about. At that time, four insurance companies were bearing the burden of providing payments to sufferers of the disease. That number is now down to two—Aviva and Zurich, which have both contributed £1 million towards research, but only for two years. There are 150 other insurance firms actively involved in employers’ liability which have yet to step forward. It should not be the responsibility of two insurance companies to shoulder the burden of this condition, and it is extremely important that we find a way through this.

I know that charities are able to raise huge amounts of money towards the treatment of cancer. We are all well aware of breast cancer—it is visible and we all know of people who have been affected by it. Hundreds of millions of pounds are spent on research into breast cancer and other cancers. Mesothelioma is an insidious condition that has a sinister outcome, yet very little research has been done into it. Perhaps it is not a very sexy area for researchers to go into. I am afraid that most people do medical research because they wish to explore a particular area for which they have a passion. If we are to generate the necessary funding for this disease, it is important that we stimulate more people to take an interest in it.

There are questions to be asked. Why does a wife who launders the clothing of her husband, who works in an area with asbestos, contract and die of mesothelioma whereas her husband does not? Why can some people survive for up to 20 years? The current longest survivor is a man who contracted the disease 18 years ago and is still going strong. Why is that? Clearly the answer lies in the genes, and we need to do genetic research. Testa et al in Nature Genetics reported in 2012 research suggesting that people with a germline mutation on their BAP1 gene are at a high risk of developing mesothelioma. We need to follow through such areas of research to try to get the answers. My erudite medical colleagues have explained to the House some of the stages that need to be gone through.

I wish to mention the British Lung Foundation, which I worked very closely with when I took through my Private Member’s Bill on banning smoking in cars with children present. It has done a huge amount in supporting the battle against mesothelioma, and it needs to be recognised, acknowledged and supported. As was mentioned, one of its researchers, Dr Peter Campbell, receives a grant for work on identifying the important genes to target for mutations in mesothelioma. Notwithstanding what the noble Lord, Lord Winston, said about the need not just to target one area but to recognise that high-level research may benefit many other conditions and not just mesothelioma, this area needs far more support than we have seen hitherto.

On the previous occasion when this matter was debated, the noble Lord, Lord Alton, missed taking through the proposed levy by just seven votes. It was a very narrow vote and he had a lot of support in the House but, unfortunately, it did not go through on that occasion. At that time, the Government assured us that it would be possible to achieve the ends we wanted through a more voluntary approach. To date, those 150 insurance companies have not stepped up to the plate and we need to do slightly more than rely on that approach. A levy is the missing piece of the puzzle. It is key to essential research into this killer disease, which, as we all know, affects tens of thousands of people. It is important to discover its exact causes and how we can benefit patients in the future.

Why does the UK have the unenviable record of the highest mesothelioma mortality rates in the world, and what are we doing wrong that we could do better? I believe that only research can answer these questions. As I said, it cannot be left to charitable organisations to raise the money for such research, and it is important that we find a way of achieving the necessary funding. Winston Churchill once said, “Action this day”. I think we have reached the point where we need to move towards “action this day”, and I hope the Minister, having listened to the debate and the comments that have been made, will be more inclined to take a harder line on this and to consider finding a way of introducing a levy on the insurance companies.

NHS: Costs of Operations

Lord Ribeiro Excerpts

Monday 9th November 2015 Lords Chamber

[Lord Prior of Brampton]

The reference costs try to pick up all the costs attributable to certain procedures. As I was saying earlier, a patient-level costing system would probably be more accurate. I did not catch the first part of the noble Baroness’s question, so perhaps we could deal with this outside the Chamber. Hospitals are incredibly complex and picking up all the costs, particularly allocating overhead costs to individual procedures, is difficult. Compared to any other hospital costing system I have seen in the world, though, the NHS reference-cost system is pretty comprehensive.

[Lord Ribeiro (Con)]

My Lords, one category not included in the list is the independent sector treatment centres. Are these proving as cost-effective as we would like? If so, is it not time that NHS consultants have greater access to them to deal with their elective cases, many of which are often cancelled because of the need to bring in emergencies?

[Lord Prior of Brampton]

My noble friend raises an interesting question about independent treatment centres, which are for elective cases, not emergencies. They are able to plan their case mix more accurately, and are much choosier about the case mix they take. They can be extremely efficient, and if they have the volumes coming through, they are. Because of the case mix they take, they ought to be able to deliver significant cost advantages over providing such surgical care in a normal NHS hospital. The argument for ring-fencing orthopaedic procedures, for example, is overwhelming in terms both of cost and the quality of care delivered.

Access to Palliative Care Bill [HL]

Lord Ribeiro Excerpts

Friday 23rd October 2015 Lords Chamber

[Lord Ribeiro (Con)]

My Lords, I too thank the noble Baroness, Lady Finlay, for introducing this important Bill. I shall address Clause 3, on education and training. In the debate proposed by the noble Lord, Lord Farmer, on palliative care yesterday, we noted the many harrowing accounts of treatments delayed, patients’ wishes to die at home denied and junior doctors unable to provide timely device and treatment. As a house surgeon in 1968—a long time ago—I felt well supported, not only by my medical colleagues but by the wise ward sister who provided immediate care and support for me. It is best to remember that nurses are much closer to patients and their advice on treatment should never be ignored.

However, times have changed. We no longer work an average of 100 hours a week or are resident on call. We now require junior doctors to work shifts of an average of 48 hours a week. Continuity of care has become a big problem, and handovers of the care of patients mean that some are occasionally overlooked. This is not the sort of care terminally ill patients require. The Parliamentary and Health Service Ombudsman’s report makes the need for education and training in palliative care mandatory, yet a report in the BMJ in 2013 found that 63% of doctors felt that they required specific training in palliative care. A national audit on care of the dying found that mandatory training for doctors occurred in 19% of trusts and for nurses in 28% of trusts. Given that only 21% of the sites audited had access to face-to-face palliative care services seven days a week, it is clear that we have a long way to go, and I hope that this Bill will help to accelerate the process.

A review of the Liverpool care pathway in 2014 found that medical training in palliative care was inconsistent and often inadequate and left many junior doctors ill prepared to care for dying patients. Breaking bad news and managing dying patients are difficult to learn and often require trainees observing how more senior staff or consultants do it. Part of learning is to reject practices which lack compassion and sensitivity. I agree with the noble Baroness, Lady Finlay, that end-of-life care should be part of all medical school curricula, as it is in the Intercollegiate Surgical Curriculum Programme—ISCP—for surgical trainees. The MRCS exam tests candidates’ ability to manage patients in need of palliative care. It uses actors in examination bays to play of the role of patient and challenge candidates to manage them not just correctly but with compassion and care.

My hospital—Basildon University Hospital—employs a care pathway for terminally ill patients which has an escalating treatment plan. It is established on admission. If there is an expectation of deteriorating health, agreement is reached on whether the intensive care unit is to be used or a programme of palliative care is to be introduced. The end-of life pathway should be consistently applied across all trusts, and I believe that the purpose of this Bill is that that should be the case.

It is also important to remember that not all patients who enter hospices go there to die. My wife, a physiotherapist, worked in a hospice for 10 years. She saw many patients come in and go out again having had their pain controlled, their anxieties, which have been referred to, alleviated and relieved and having been helped to mobilise, if they had previously been unable to do so.

We need to shift the balance from dying in hospitals to dying in hospices and at home in the community, as the noble Baroness, Lady Byford, so clearly explained. Providing access to palliative care seven days a week, 24 hours a day, will encourage more GPs to use those services rather than relying on acute hospitals for their dying patients. In doing so, we can reduce the cost in hospital because caring for patients in hospital is expensive and most terminal patients spend an average of 30 days in the acute hospital sector, which we should seek to avoid.

Palliative Care

Lord Ribeiro Excerpts

Thursday 22nd October 2015 Grand Committee

[Lord Ribeiro (Con)]

My Lords, sadly, the ombudsman’s report documents many instances of poor care, poor communication, a lack of active review of cases and inappropriate discharge from hospital. However, I take issue with a statement in the conclusion:

“How we die is part of the core business of the NHS”.

As one who practises medicine and surgery I do not recognise this, as the core business for me was to save lives and prevent death. Death and dying should ideally take place in quiet surroundings with people we love and care for around us. That is at home or in a hospice, as has already been mentioned. We should do more to increase financial support for the nation’s hospices. What are the finances? In 2010-11 we spent £460 million on adult palliative care and end of life care, but there are wide variations with some areas spending £186 per death on specialist care and others £6,213 per death—a wide variation, as I have said. Some 61% of the PCTs at that time spent less than £1,000 per death. Will the Minister say what the latest costs are and whether the variations have been ironed out?

Another issue is that of training for all healthcare workers—doctors, nurses, care assistants and even porters—in dealing with patients who are terminally ill. For doctors, breaking bad news can be a challenge for many. The Royal College of Surgeons in its MRCS examination has a communications bay marked, “Breaking bad news”, where we use actors to simulate patients or relatives so that we can put the trainees through a process where they have to break bad news to patients and react when the patients react adversely. It is important that this is not limited to examinations but is refreshed as part of continuing professional development.

Finally, all of this care must be delivered on a seven-day basis, and preferably with access to specialist palliative advice 24/7. The challenge is how to achieve this without the introduction of a seven-day service, and we know the deliberations that are going on at the moment vis-à-vis the junior doctors’ contract. It was a common occurrence to have dying patients referred by their GPs for admission on a Friday. I recognise that many of the people who were admitted on a Friday would subsequently die. So when we are considering mortality at the weekends, it is important that we bear this in mind. As has been said, one of the drivers for seven-day working is to try to reduce mortality at weekends. Hospital admissions in the last year of life cost the NHS £1.3 billion for adults and £18.2 million for children. Transferring some of these costs to the community and commissioning more hospice care may not only generate savings, but provide for the kind of death that 74% of patients desire. But as the right reverend Prelate said, 58% find that they end up in hospital. I therefore support the words of the noble Lord, Lord Farmer.

Health: Detection Dogs

Lord Ribeiro Excerpts

Thursday 17th September 2015 Lords Chamber

[Lord Prior of Brampton]

I agree with the noble Lord. Dogs—indeed, all pets—can provide companionship to many people who are lonely, particularly elderly people who have lost many of their relations. I congratulate Pets as Therapy.

[Lord Ribeiro (Con)]

My Lords, the Minister is absolutely right in referring to the research in Milton Keynes. As far as prostate cancer is concerned, a man’s best friend probably is his dog. However, there is no doubt that the molecular markers can be detected in urine, and this may be the way to go in future research. It needs to be directed in that way because just a simple dipstick might well be able to detect the markers. If it is possible to detect prostate cancers using dogs, will the Government be prepared to fund such research and carry out a proper controlled clinical trial?

[Lord Prior of Brampton]

Clearly, molecular diagnostics is a growing field and will have a hugely important role to play in diagnosing many cancers. This was certainly a recommendation of the cancer task force led by Harpal Kumar. We are not by any means saying that we should pursue dogs at the expense of molecular diagnostics, just that we should try every opportunity. There seems to be some evidence regarding the number of false positives—for example, the use of dogs to sniff urine is considerably more accurate than more conventional forms of detecting cancer. We would not therefore want to rule out the use of dogs by pursuing solely molecular diagnostics.