Health: Polypill
Lord Turnberg Excerpts(10 years, 6 months ago)
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Lord Turnberg (Lab)
My Lords, I too am grateful to my noble friend Lord Hunt for introducing this debate. It is pretty obvious that he, like me, has been briefed by Sir Nick Wald—and I suspect that the noble Earl may have heard a little from him too—so if what I say sounds a little familiar, I hope he will forgive me. Heart attacks and strokes remain among the biggest killers, despite the improvements in mortality rates in recent years. We know many of the risk factors—smoking, alcohol, obesity, salt and lack of exercise—and we must not be distracted, as the noble Baroness, Lady Brinton, says, from dealing with these public health issues. They are not mutually exclusive, of course.
We know that we should do more to detect and treat high blood pressure and raised blood cholesterol levels, but there is one important risk factor that we can do little about. That is age. There is a straight-line relationship between age and the incidence of heart attacks and stroke. The older you are, the higher the risk. The most striking thing about this is that about half of those getting one of these killers do not have one or other of the conventional risk factors—they have normal cholesterol and normal blood pressure. They come as a surprise in people thought to be fit, and it is in these unsuspected and unsuspecting individuals where the polypill may play a role.
The rationale for the polypill relies on a number of basic principles and here I rely specifically on Sir Nick Wald’s briefing, so what I say, as I pointed out, may not be entirely novel. First, we know that using drugs to lower a raised serum LDL cholesterol reduces the rate of heart attacks, and lowering the raised blood pressure reduces the incidence of strokes, but the intriguing observation is that the same drugs reduce even normal levels of cholesterol or blood pressure to a similar proportion as in those with raised values.
Furthermore—and here is the nub of the argument—lowering even normal levels reduces the risk of heart attacks and stroke. For example, Nick Wald calculates that a fall in blood pressure of 10 millimetres of mercury reduces the risk of stroke by about 60% and reducing serum LDL by 1 millimole per litre lowers the risk of coronary artery disease by 40%. The fact is that there does not appear to be a lower limit below which reducing blood pressure or cholesterol is not effective in reducing risk.
The second principle is that you can achieve as good or better effect in reducing blood pressure from a combination of two or more hypotensive drugs given in half or lower doses than a single drug given in a normal dose, and in this way markedly reduce the incidence of side effects. You get the same impact on blood pressure with many fewer side effects from a combination of half doses.
Therefore, combining these pieces of evidence—risk increasing with age, lowering risk factors even when they are seemingly in the normal range, and combining low doses of drugs to reduce side effects—leads to a conclusion that points to a need to give polypills as a preventive measure to those at risk, namely all the population over the age of 55, say, regardless of their conventional risk profile. Indeed, if they have other more obvious risk factors they are likely to be treated for them by one means or another already. It is the unsuspecting population where a polypill is most likely to be effective. In these, it lowers cholesterol and blood pressure as well as risk.
Nick Wald has suggested that one in three individuals taking a polypill containing small doses of simvastatin, losartan, amlodipine and hydrochlorothiazide would live an extra eight years than they would have done without the pill. It could reasonably be concluded that we should be giving everyone over 55 a polypill of this type, and it would help those harbouring unsuspected coronary artery disease or strokes. If this were a preventive programme like vaccination, as my noble friend suggested, we probably would not hesitate, but of course it is not a one-off, single shot like a vaccine. It is to be taken life long, every day, as a prophylactic treatment, more like the contraceptive pill to prevent pregnancy, although of course for rather longer.
So many issues would have to be overcome, and a number of critics of the mass medication that such a programme would entail have to be answered. There is the question of regulation. Although all the constituents of the pill have been through all the regulators and are in fact well out of patent, the MHRA and MEA may well need convincing that the combinations do not need further appraisal and approval. There is the question of side-effects. Although doses are low, there are undoubted side-effects with all the constituents of the pill, even in the low doses used here. They may well become significant when trying to reach whole populations.
Some say that we are already an overmedicalised society and we do not need yet more pills for everyone. I am not sure that that is a terribly good argument, because we rely quite heavily for our longevity on many of the medicines we take. I am one of the few, it seems, who is on simvastatin without side-effects, out of a huge population who are similar to me. In any case, no one is forced to take drugs if they do not want to. Nevertheless, those are views that we cannot easily dismiss and are to be taken seriously.
We come to the question of whether the polypill should be available for prescription on the NHS or simply over the counter at pharmacists. It is probably very cheap, and the economic value of preventing those diseases is a strong argument for prescription. It would at least allow us to get a clear angle on the number and incidence of side-effects, which free availability would not. It would allow doctors the opportunity to assess their patients for other preventable risk factors at the same time, which we have to do something about. On the other hand, an approach in which people simply decide whether to buy the pill over the counter is certainly more libertarian, but would probably not make a great impact on the epidemiology of those diseases, nor on the health of the nation.
There are certainly interesting debates to be had, and I am very grateful to the noble Lord, Lord Hunt, for starting us off on this topic.
Lord Willis of Knaresborough (LD)
I am grateful to the noble Lord for giving way. One issue raised earlier was about the dosage and combining those dosages in relation to particular side-effects. It was only 12 months ago, I think, that NICE advised against giving particular doses of simvastatin together with a modifier. When doses are given separately, you can take the evidence and change them. When they are combined in a polypill, that goes out of the window and you are left with all the elements at the dosages that have been agreed. Is that not an argument for retaining the current position of giving separate dosages rather than combining them all?
Lord Turnberg
Those are very good points. The doses used in polypills are very low, in fact—20 milligrams of simvastatin, when the normal dose is 40 to 80 milligrams. The other drugs in the polypill are half doses. The point is that, if you have raised LDL cholesterol or raised blood pressure, you should certainly be on the treatments; they have been shown to be effective. It is people who do not have raised cholesterol or raised blood pressure who we are aiming to treat—or to prevent their diseases—so it is a different situation. The point about safety is important. It is clear that we need and should have proper clinical trials of those doses, but the impact of such doses, from what we know about them in this combination, is that they are likely to be safe in the vast majority of cases. What we do not know is the number who will get side-effects.
Lord Hunt of Kings Heath (Lab)
My noble friend, and other noble Lords, mentioned the importance of clinical trials, which I am sure is absolutely right. Is not the problem here that in fact no pharmaceutical company will conduct a clinical trial because all the drugs used in combination in the polypill are off-patent, so there can be no protection of that research by any company taking it forward? So there is, if you like, a block here, although people can see the potential benefits. Rightly, noble Lords are asking for clinical research, but there is no possibility of that happening unless the Government take a hand themselves, which is why the debate on antibiotics is interesting. They are completely separate subjects, but the Government had to step in there because, at the moment, the market simply cannot respond to the issue.
Lord Turnberg
I agree entirely. I think that it will be difficult for the drug firms themselves to conduct trials because these are generics and they are manufactured by a number of companies. The only way forward, I suspect, if we are to have a clinical trial, is through NHS funding—that sort of trial. My final remark is that I very much look forward to the noble Earl’s response.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I thank the noble Lord, Lord Hunt, for giving us the opportunity to debate a particularly interesting subject and for having elicited a number of very well informed speeches. In calling for this debate, he has done the House a considerable service by enabling noble Lords, including myself, to bring ourselves up to date on what progress has been made in the development of the polypill concept. As has been said, heart attacks and strokes are major health issues in the western world and a growing issue in the developing world. Reducing mortality for people with cardiovascular disease and improving their outcomes is a key priority for the Government. We have made it clear, through the NHS and public health outcome frameworks and the Government’s mandate to NHS England, that we want to see action taken across the health system to reduce avoidable premature mortality from cardiovascular disease.
The 2013 call to action on premature mortality set out the Government’s ambition for England to be among the best in Europe in tackling the leading causes of early death, including cardiovascular disease. In April this year, we published Living Well for Longer, which brings together what the health and care system will do to meet this challenge.
There has been a great deal of interest in the polypill and its potential for reducing the risk of heart disease over the years. It may surprise some noble Lords that the concept was first introduced into the scientific and public domain as far back as 2003. It was proposed in an article in the British Medical Journal by two people whose names have been mentioned already, Professors Nicholas Wald and Malcolm Law of the Wolfson Institute of Preventive Medicine. Using mathematical modelling, they estimated that a polypill comprising a statin, aspirin, a combination of three blood pressure lowering drugs and folic acid, could reduce heart disease events by 88% and stroke by 80%. Their article concluded that their proposed polypill could,
“largely prevent heart attacks and stroke if taken by everyone aged 55 and older and everyone with existing cardiovascular disease.”
Although the effectiveness of the combined drug and any possible side-effects had yet to be evidenced though patient trials, this captured the imagination of the public health research community, particularly for the prevention of non-communicable diseases such as cardiovascular disease.
Essentially, the polypill is a combination of multiple medicines which aims to prevent or reduce the risk of cardiovascular disease: that is, strokes and heart attacks. Each of the constituent medicines is either at the current recommended dose or at lower doses. The premise is that these combinations should be used in preference to using the same medicines separately. In practice, the polypill can refer to either the fixed-dose combination medicine to reduce cardiovascular risk, patented as the polypill, or any other fixed-dose combination medicine, such as the red heart pill. However, any discussion of polypills is complicated by the huge range of drugs which might be included in any combination.
Polypill active ingredients are licensed separately as medicines and well established in their own right; their use together in fixed combination is what is novel. Just like any other medicine, any application for a marketing authorisation for a polypill needs to be supported by data demonstrating that its quality, safety and efficacy are satisfactory and that the risk-to-benefit profile is favourable for the proposed treatment before such an authorisation or licence can be granted.
My noble friend Lady Brinton drew attention to the side-effects of polypills and statins. She was absolutely right to do so. My information is that the evidence is not yet there on the side-effects of the polypill. Patient safety must of course be paramount in that context.
No polypills are currently licensed for use in the UK for the prevention of heart attack or stroke. I understand that the Medicines and Healthcare products Regulatory Agency has provided scientific advice to a number of sponsors and companies for combination products of this type. However, no application has yet been made to the licensing authorities. In the event that a marketing authorisation proposal is submitted, the data supporting any claims for benefit in the stated patient population, together with any evidence of adverse events, will be carefully reviewed. Only if the overall balance of benefits versus risks is favourable will a marketing authorisation be granted.
Without a marketing authorisation, as the noble Lord will know, doctors can prescribe an unlicensed medicine under their own professional responsibility. That addresses one question raised by the noble Lord, Lord Turnberg, as to whether it is in theory available on the NHS. The answer would be yes, in those circumstances, but any national action to promote the use of a drug that is not licensed is out of the question, as I am sure he is aware. I understand that there are several clinical trials of polypill products in progress in various countries and it will be interesting to see the results.
The noble Lord, Lord Hunt, questioned whether it was the fear of additional workload that was deterring doctors in the context of the polypill. My information is that the evidence on that front is as yet unavailable one way or the other, as regards the primary prevention setting, but that clinical studies are now under way. Indeed, I have in front of me the details of three polypill phase 3 clinical trials which had either completed or were close to completion as of May 2014. I can let the noble Lord have details of those trials if he would like me to do so.
The noble Lord, Lord Turnberg, raised the possibility that the polypill could be prescribed to those people who do not fall into the risk group. That is, of course, the primary prevention group. I am advised, though, that as age advances, the risk of side-effects also increases proportionally. I suggest that before embarking on a course of this nature, we would need evidence that the polypill influences benefit more than risk. We therefore come back to the issue of clinical trials in order to demonstrate that.
Having said that, to answer another of the noble Lord’s questions, I accept that the polypill could be more convenient for some patients and could help them to adhere to their medicines. Whether it would prove cost-effective is something that NICE might in due course consider.
I know that not everyone is convinced by the polypill. There are, for instance, concerns about the medicalisation of otherwise healthy people. Even by its proponents it is seen as secondary to other forms of prevention. Professor Wald himself is quoted as saying:
“This is not the solution for primary prevention … Primary prevention requires education of the public. As a priority this is much more important than any polypill”.
There is a range of population-based interventions that could be put in place to reduce the risk of cardiovascular disease. Each has its pros and cons and may be suitable for some patients and in different circumstances. We know that many premature deaths and illnesses could be avoided by improving lifestyles. The Government’s public health programme includes national ambitions to reduce smoking, obesity, physical inactivity and the harmful use of alcohol—all with appropriate metrics included in the public health outcomes framework.
In addition, through the NHS Health Check programme people between the ages of 40 and 74 are offered a range of tests that include measuring their cholesterol and blood pressure levels. The check has been designed primarily to help healthcare professionals identify cardiovascular risk in the adult population earlier so that steps can be taken to reduce it, but it is worth emphasising that it is also targeted at a range of other conditions.
All 152 local authorities are now offering the NHS Health Check programme, which is a significant milestone in the programme’s evolution. In 2013-14 a total of 2.8 million people—almost 20% of the eligible population—were offered an NHS health check, and just over 1.4 million of them received one, giving a take-up rate of 50%. This is the greatest number of NHS health checks offered and accepted in one year since the programme began.
Lord Turnberg
That is all extremely credible. However, the polypill is aimed at those who have passed the health check with flying colours—that is, they have normal cholesterol and blood pressure, do not smoke and are not overweight. It is with this group of individuals, who are not suspected of having the liability to develop a heart attack or stroke, where it seems to have its place.
Earl Howe
Again, that is the primary prevention group, and the point that I was seeking to convey earlier was that we would need evidence that the benefit-to-risk ratio was sufficiently positive before proceeding down that course. That is not to say that it is not, but there is work to be done to prove it.
In March 2013 the Cardiovascular Disease Outcomes Strategy was published. This set out possible actions within the current legislative framework, systems architecture and financial settlement to deliver improved outcomes for people with CVD. It set out a framework for 10 actions that would make a real difference in improving outcomes for patients and their families. While I could expatiate on that subject, I am told that my time is drawing to a close, so suffice it to say that I hope that noble Lords have found today’s debate as interesting as I have.
The polypill is certainly an interesting concept. It may be that this type of approach would be more suitable in developing countries, where the real epidemics of cardiovascular disease are building up and where clinical trials are taking place, rather than in a more sophisticated healthcare system such as ours, where prevention and tailored therapy are more the norm. Time will tell.
On the issue of market failure, which was introduced by the noble Lord, Lord Hunt, I am not convinced that the same arguments apply to the polypill as apply to antimicrobials. For one thing, there are a number of clinical trials of polypills in progress, as I mentioned, and the MHRA has provided scientific advice to a number of companies, so clearly there is commercial interest out there. We do, however, welcome any technologies that contribute to providing the best treatment for people with cardiovascular disease.
In answer to the main question of the noble Lord, Lord Hunt, of whether the Government will consider playing a more active role in this debate, I would certainly be interested in looking at the noble Lord’s proposals in more detail and would be happy to discuss the matter with him at a suitable moment. With that, I thank him once again for introducing this extremely interesting topic for our consideration.
NHS: Better Care Fund
Lord Turnberg Excerpts(10 years, 7 months ago)
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Lord Turnberg (Lab)
My Lords, there is no doubt that care in the community is grossly underfunded. There are too many elderly people living alone and in need of care that they are being denied. We know that social services are now only able to provide care for urgent cases and then often only a quite inadequate 10-minute visit to help those people get dressed, bathed or fed. We know, too, that GP services are extremely stretched in many parts of the country. I do not think the BMA was simply crying wolf in its recent pronouncements when it said that it is having great difficulty coping with its growing workload. On top of that I hear it is having problems recruiting in general practice, especially in the north.
Now we hear from the Local Government Association that its budgets will have been cut by 15.5% by next year and that it is looking at a black hole of a £5.8 billion deficit by then. It is against this background that we see this inexorable rise in demand for both acute and longer-term care. On the one hand, the increase in numbers of those aged over 80 is heartening and is a tribute, at least in part, to modern medicine, but equally it is troubling that we have to cope with them accumulating multiple illnesses and disabilities. The prospect of dealing with more than 1 million people with dementia by 2030 is not exactly comforting either.
It is irrefutable that social care services need more funding and the Government’s response has been to rob Peter to pay Paul by taking this £3.5 billion out of the NHS and handing it across. Social services certainly need it and the rationale for doing so might seem reasonable on the face of it. After all, the budget for the NHS is so much bigger at more than £100 billion a year and, of course, we know that our hospitals are full of patients who would be much better off at home if care could be provided there. Some 30% of beds are said to be blocked in this way. So let us shift money across. However, that ignores the extreme financial stress that already exists in the NHS, where talk of a looming financial cliff edge in 2015 is commonplace. The impact of the Nicholson challenge with £20 billion savings already made, largely by short-term measures such as wage restraints and redundancies, and predictions of even more stringent savings of some £30 billion by 2020, is sending shivers down the spine of many a trust chief executive when 40% of them are already said to be running a deficit.
I hope the noble Earl will forgive me for introducing a note of aggression in my talk. He knows my normal benign nature does not allow for much aggression but I feel quite strongly about this. There are those who say that we should close some beds or whole hospitals and money will be freed up. That may be true—money will be saved, but at what cost to patient care? We have already heard of the stresses placed on hospitals by rising demands for acute care—that is acute care, not the care of longer-term patients within hospitals. It is the rising tide of acute emergency cases that is taking its toll now on hospital services that is so difficult. These demands are being made now, in the summer, when we have approaching 88% bed occupancy rates. Incidentally, we have the lowest number of beds per head of population in Europe and the shortest length of stay, so we are already pretty efficient.
Of course we should do more to improve efficiency. We should continue the process of focusing specialised services in fewer major centres; we should merge services between small, relatively inefficient hospitals; and of course we should be looking at better models of integrated care across the health and social care divide—that is essential. Today’s publication by the NHS Confederation and the Local Government Association is a step in that direction.
There could be more efficiencies, too, in the bureaucratic machinery that we have set up to run the service. I am struck by the fact that we removed two layers of administration, the SHAs and PCTs, and replaced them with four. We have NHS England with its large staff, the 40 outposts, 27 area teams and of course the 211 CCGs. That says nothing about the clinical senates, of which we hear so little, and the complex network of clinical reference groups. Instead of the promised bonfire of bureaucracy, we have had an explosion of bureaucrats. We could save money here with a closer look at all this superstructure but that is not going to happen any time soon.
Meanwhile, the cash-strapped NHS is being taxed again by the better care fund. To expect to be able to run an acceptable level of integrated care between hospital and community by shifting limited resources from one to the other may be expecting just too much. Yet we are a wealthy country: the fourth wealthiest in the world, according to the ONS, and with more billionaires than anywhere else. In spite of that, we have cut the proportion of GDP that we spend on this from around 8.2% in 2009 to about 7% now, and we are predicted to cut that proportion to about 6% by the end of the decade. I can well understand the Treasury wanting our services to be more efficient, but I cannot see what justification there can be to cut the share of the national cake for the care of our population to just 6%, which is so clearly well behind other OECD countries. The contrast between reports of a country said to be doing so well economically with those that show that at the same time it is starving our vital services is, I find, just too much.
I have a number of questions for the Minister. How is it intended that the money from the NHS will be used for care in the community? Is it to be ring-fenced? Will there be true integration between the NHS trusts and social services in the way that it is spent? Have the Government any plans to encourage recruitment into general practice, particularly in the north, and for A&E consultant posts, two key services at the interface between community and hospital?
Have they given any thought to their predictions for the future funding of health and social care beyond 2015? I know that the Minister will say that future spending plans will have to wait for the next spending review but I fear that the crunch will come rather sooner than that, and probably far sooner than the election. The department must be making contingency plans now about how the service will cope over the winter; I would be surprised if it was not. I wonder if the Minister would be willing to share some of that with us. I look forward to his response.
Health: Multiple Sclerosis
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Earl Howe
My Lords, I am pleased to say that the number of specialist nurses for multiple sclerosis in the UK has risen from 80 in 2002 to 245 currently. I hope that my noble friend will agree with our view that local healthcare organisations, given their knowledge of the healthcare needs of their local populations, are the people best placed to determine the workforce needed to deliver safe and effective patient care within the available resources. However, it is of interest that NHS England’s service specification for specialised neurology does specify that nurse specialists should be involved in the care of people with multiple sclerosis.
Lord Turnberg (Lab)
My Lords, 11 drugs are now available for remitting and relapsing multiple sclerosis, three or four of which have been approved only in the past two or three months, which is great news. Is there any chance that these new drugs will be included in the risk-sharing initiative with industry?
Earl Howe
My Lords, I think that the answer is almost certainly no because the risk-sharing scheme initiated under the previous Government is quite complex to administer and we would need to be persuaded that the administrative burdens associated with it were worth while. Now that we have the NICE process, it is probably best that NICE should look at these drugs in the context of its new clinical guideline, which is what the stakeholder groups thought was preferable.
Health: Rheumatoid Arthritis
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Earl Howe
My Lords, I pay tribute to the National Rheumatoid Arthritis Society, which is organising Rheumatoid Arthritis Awareness Week this week, between 16 and 22 June. I am aware that Public Health England has run early diagnosis campaigns, which up to now have focused largely on cancer. However, I understand that a broader focus on earlier diagnosis is currently being considered. What might be done to tackle other conditions or symptoms has yet to be decided, but I will keep the noble Baroness informed of developments.
Lord Turnberg (Lab)
My Lords, one of the problems is that there are still far too many single-handed general practices, which have great difficulty providing a full range of services. Are the Government doing anything to try to bring them into bigger groupings?
Earl Howe
My Lords, we are encouraging single-handed practices not to disband but to federate themselves—if that is a good word—with other practices in the area, and certainly to seek the support of their clinical commissioning group. That would ensure that the range of professional training available is utilised and that there is peer support where appropriate. Therefore, while many single-handed practices do a very fine job, there is scope for them to collaborate with their colleagues in the local area.
National Health Service: Hospital Beds
Lord Turnberg Excerpts(10 years, 7 months ago)
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Lord Turnberg (Lab)
My Lords, is the noble Earl aware that we have one of the highest rates of bed occupancy in the EU, approaching 90%, and yet we have the lowest average length of stay? All this makes it extremely difficult to think about reducing bed numbers still further.
Earl Howe
In fact, average annual bed occupancy rates have been stable at around 84% to 87% since 2000. Of course, that rate goes up and down. We know that winter sees greater pressure on bed occupancy, but the NHS has long experience in managing peaks in demand, particularly over the winter. We do not set optimum bed occupancy requirements on the NHS. As the noble Lord knows well, that is a matter for the local NHS to manage.
Elderly People: Abuse
Lord Turnberg Excerpts(10 years, 8 months ago)
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Lord Turnberg (Lab)
My Lords, I, too, am grateful to the noble Baroness, Lady Cumberlege, for raising this important issue. We cannot say we have not been warned about abuse of the elderly. Numerous detailed reports have been published over many years, and we have not neglected to talk about it in your Lordships’ House either. The Government’s response to the Francis report on the Mid Staffs affair was well meant and the Care Bill we passed last week is very helpful, but to my mind, neither of them is aimed at the right targets, nor are they sufficient. They both place far too much emphasis on inspection and punishment for wrongdoing, which of course is essential, and far too little emphasis on measures to prevent bad behaviour happening in the first place.
It is possible that we do not recognise often enough how difficult and taxing, both physically and mentally, the job of caring for elderly people really is. Quite apart from the nature of the job of feeding, toileting and cleaning physically disabled people, many of whom may be mentally disturbed and sometimes resistant or even aggressive, we have to face the fact that these jobs are spectacularly underpaid and underappreciated. They are not appealing jobs and they attract only very specific types of people: those who are dedicated to caring, angelic individuals who are devoted to looking after others. We are fortunate that there are many who fit into that category, but we should not take advantage of these remarkable people by giving them such poor recognition and little to bolster their self-esteem. No wonder there is a high turnover and absentee rate. Job satisfaction depends on being appreciated and there is no doubt that, where carers are appreciated, those who they are caring for gain the benefit. So what can we do to attract carers, and having done so, give them a sense of esteem and job satisfaction?
First, we must pay them better. Jobs in care homes are among the lowest paid anywhere. I fear that the profit motive of some care home operators may be just too strong and the low wages on offer will put off many whom we want to bring in. Also, local authorities are so cash-strapped now that, after a 30% drop in their funding, their services are clearly failing to keep up with rising demand. Poorly funded and understaffed services, leading to rushed overworked carers, are hardly conducive to the sort of care we aspire to.
Secondly, there is then the problem of a lack of professional training and qualification for care workers. We have gone some way along that route, with the help of the noble Earl and with a recognition that training should be an essential part of these posts. However, we are still some way off offering registration to allow care workers that self-satisfaction that comes with belonging to a qualified profession. We have been trying for some time in this House to correct this anomaly and I have no doubt that we will hear more about this topic.
Thirdly, there is the big problem of poor supervision in care homes and hospital wards. There seems little doubt to my mind that a well qualified, competent and active person supervising care at that level is of enormous benefit. These people are the key element in the mix leading to high-quality care. However, here again, recruitment to these posts and retention of people in them is dependent on making them attractive. Nursing sisters in charge of hospital wards should be recognised as having career-grade posts, so that these nurses are not attracted by the prospect of promotion off the ward after a year or so. They should be rewarded appropriately.
Finally, it is good to see in the Care Bill a duty on local authorities to investigate accusations of abuse. However, again, this is after any abuse has occurred and it is rather more important for those commissioning services to take greater care in ensuring that standards for the care that they commission are up to scratch. I look forward to the noble Earl’s response.
National Health Service: Nursing Staff
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Earl Howe
My Lords, as regards specialist nurses, the Government have supported the development of a range of specialist roles within the profession. In the end it is for local NHS organisations, with their knowledge of the needs of the local population, to invest in training for specialist skills and to deploy specialist nurses. We recognise that more could be done by some local healthcare organisations in this area, and Health Education England is able to support employers with continuing personal and professional development—but within clear limits. The planning process has created an opportunity for employers, through the LETBs—local education and training boards—to prioritise investment in this area.
Lord Turnberg (Lab)
My Lords, the number of nurses may have gone up a little, but the main problem is the marked reduction in the number of senior nurses on wards. These are the women and men who are in charge of a ward and make sure that care is properly delivered at the ward level. Does the noble Earl consider that this particular loss is because we do not reward and value these key individuals well enough to recruit or retain them?
Earl Howe
My Lords, as the noble Lord will be aware, finances in the NHS are tight. However, as I said earlier, there are now 5,100 more nurses on our wards than there were in May 2010. That must indicate that nursing is still an attractive profession for the brightest and the best of our young men and women.
Care Bill [HL]
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Lord Turnberg
“(b) biomedical and health research.”
Lord Turnberg
My Lords, I am grateful to the Minister for that full and helpful description of the background to this whole area of the use of confidential information. There is little doubt that public confidence in the uses to which their confidential information may be put has been badly shaken. For example, a number of recent revelations that access has been gained by one means or another by commercial organisations, insurance companies and so on has made the public—and many general practitioners—very wary and anxious.
That is why I want to put my own amendment, Amendment 45C, into the context of Amendment 45F, proposed by the noble Lord, Lord Owen, which emphasises a much stronger oversight by a statutory body: similar to, but stronger than, the Confidentiality Advisory Group chaired by Dame Fiona Caldicott, who commands such public respect and confidence. That is why I intend to support it if he moves it.
It is only against that background—of strong oversight and carefully controlled and limited access to such sensitive data—that we can even consider the very specific circumstances in which we can allow their use: not only legitimate use, but those uses which are vital for the benefit of the public and their health.
Lord Turnberg
My Lords, I was rather encouraged by the noble Earl’s initial remarks about strengthening Dame Fiona Caldicott’s committee and making clearer what role it might be able to play.
The problem I wanted to address in Amendment 45C is the uncertainty in the ways in which the words “promotion of health” may be interpreted. I know that the noble Earl has said that they cover research, for example. What about research that does not immediately seem to promote health? It is this rather vague term that I wanted to clarify. It is not about trying to unravel the legislation, as someone has suggested. It is about making it absolutely clear. I am afraid I was not very convinced by the noble Earl, and I beg leave to ask for the opinion of the House.
NHS: Bed Capacity
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Earl Howe
Yes, my Lords. As ever, the noble Baroness makes an extremely good point. It is heartening that infection rates have come dramatically down in hospitals over the past few years, but we can never be complacent and it is important that when a patient is moved the infection question is always considered.
Lord Turnberg (Lab)
My Lords, is it not the case that we have the lowest number of beds per head of population of any OECD country, bed occupancy rates of approaching 90%—a dangerously high level—and, despite all that, the shortest lengths of stay of any European country? Does the noble Earl agree that the idea of closing wards or hospitals can only worsen the situation, unless, of course, we are able to build up the community services before we do any of that?
Earl Howe
I agree with the principle that the noble Lord has articulated. Certainly, commissioners and providers of care should reduce beds only where it is clinically safe and appropriate to do so. The NHS is very experienced at flexing the number of beds it has available; it does this every year and every winter. As a principle, I would agree with the noble Lord but I come back to the point that bed occupancy rates have, in fact, remained stable over the past 10 years, fluctuating between 84% and 88% on average, and increasing slightly over the winter period.
NHS: Midwives
Lord Turnberg Excerpts(10 years, 10 months ago)
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Earl Howe
The noble Baroness is quite right. Helping commissioners to reduce unwarranted variation in service delivery is one of the key roles of the maternity and children strategic clinical networks, as I am sure she is aware, which are being established and supported by NHS England. Clinical commissioning groups are responsible for commissioning maternity services locally, but they work with local authorities and in conjunction with provider partners to give assurance that processes and service specifications are in place which ensure that midwifery staffing is appropriate for the locality.
Lord Turnberg (Lab)
My Lords, the number of births has gone up by 25% in the past 10 years. The vacancy rate among midwives is about 11%. That is the long-term vacancy rate. There seems to be a problem with recruitment and retention. Despite the figures that the noble Earl has cited, we are in some difficulty.
Earl Howe
The noble Lord is right. We recognised that issue at the outset of the Government, which is why we were determined that the number of midwives in training should be increased. It is now at a record number of 6,000. The number of trained midwives is increasing—that is, full-time equivalent midwives practising in the NHS rather than just on the register. We are heading in the right direction, but there is a long way to go.