Health: Stroke Care

Lord Winston Excerpts

Monday 4th July 2011 Lords Chamber

[Lord Clinton-Davis]

My Lords—

[Lord Winston]

My Lords, various reports show that the mortality for stroke can be as high as 30 per cent. Sadly, in the United Kingdom mortality is higher than almost anywhere else in Europe, although there is great geographical variation all over the world. One of the issues that Professor Peter Rothwell, of the University of Oxford, has pointed out is that speed is the essence of success. Therefore, it is not merely a question of informing patients, but of making certain that the right availability is present in our hospitals. If we do that we can reduce the risk of a further stroke by 80 per cent and probably, as he says, reduce the cost to the National Health Service in primary care by somewhere between £100 million and £200 million annually. Would the Minister be kind enough to explain how that will work in the future of the health service?

[Earl Howe]

My Lords, the noble Lord is quite right in all that he says. I would just point out that the official statistics are rather historic and it is important that we take stock when the revised figures are before us in some months’ time. As regards how best practice will be driven when the health service reforms are in place, I would repeat my earlier comments about the ability of the NHS commissioning board to drive forward higher quality, informed by the new quality standard produced by NICE. More particularly I think we can do a lot through the tariff. At the moment, best practice tariffs are starting to play a role in encouraging and driving best practice at hospital level.

NHS: Health Improvements

Lord Winston Excerpts

Wednesday 29th June 2011 Lords Chamber

[Earl Howe]

My Lords, my noble friend will know that an independent inquiry into children’s heart services is under way at the moment. It would be inappropriate for me to comment. I have not been involved at all but it would be inappropriate for Ministers to become involved. As regards ambulance and A&E services, we envisage that clinical commissioning groups will commission the great majority of NHS services for their patients, including urgent and emergency care and ambulance services. Prior to that, PCT clusters, which are being formed from the primary care trusts, will be responsible for commissioning ambulance services until 1 April 2013.

[Lord Winston]

My Lords, does the Minister agree that we are facing one of the greatest revolutions in medicine—that is, genomic medicine? It will make medical treatment more effective and efficient and will reduce the national drug bill. Therefore, does he not agree that one of the most urgent needs of a large population is for increased computing power and proper information technology?

[Earl Howe]

I absolutely agree with the noble Lord. The information agenda, which should run in parallel with our plans, is essential for delivering the improvement in outcomes that we all want to see. Part of that will involve new technology. As the noble Lord knows, work is under way on genomic medicine, which is extremely exciting. We have included in the amendments tabled to the Health and Social Care Bill in another place a duty on both the Secretary of State and clinical commissioning groups to promote research in the health service.

Public Bodies Bill [HL]

Lord Winston Excerpts

Monday 9th May 2011 Lords Chamber

[Lord Willis of Knaresborough]

I rise to speak specifically in support of Amendment 9, to which I have added my name. However, I want first to record my thanks to the noble Earl, Lord Howe, on the Front Bench for the very courteous way in which he has tried to respond to these issues throughout the passage of the Bill. The reality is that we should not be at this particular juncture now. If we had had proper consultation before these proposals came to light, we would have been able to argue the issues out sensibly and carefully. I recall the way the last Government treated the draft tissue and embryo Bill. They created a committee of both Houses that looked carefully at the issues and prepared a report. It was accepted by them and actually changed the legislation that was going through the House. With hindsight, we can always do things differently, as we learnt last Thursday.

I think that Amendment 9 is crucial. The Academy of Medical Sciences made a proposal to create a health research agency that was not just supported by the medical and research professions, but by all the political aspects of all the parties in both Houses of Parliament. It is rare for that to occur. I have argued with the Minister that the real crux of this Bill is not knowing what you are actually going to move to. I think that the concerns about the CQC are a little unfair. The reality of the situation is that the CQC already regulates and inspects a significant number of premises and establishments that deal with the use of embryos, embryo research and the clinical application of techniques using embryos. There is already significant duplication, so to argue that a new body would either increase or decrease duplication would depend on how you finally decide which functions will go to which organisation.

Health research is also crucial. The report of the noble Baroness, Lady Warnock, has rightly been mentioned often today. She established firmly back in the 1980s the fundamental issue of the special nature of the embryo, particularly when dealing with research. The noble Baroness, Lady Deech, is absolutely right that the founding of the HFEA has enabled research using the embryo, particularly when we started to look at stem cells and admixed hybrid embryos, to go through. That is because there has been a regulatory authority for which there has been public as well as clinical and academic support. We throw that away at our peril.

I put it to the Minister in Committee that we could not move to an interim authority for health regulatory research and believe that we could maintain continuity and credibility within the research communities both here and abroad. Unless we establish the health research agency, we will lose ground. It is too important an area for us simply to say, “Well, we'll wait and see’. In his incredibly helpful letter to the noble Baroness, Lady Thornton, the Minister referred to setting up an interim authority. However, in Committee, I proposed to my noble friend that a new clause be inserted in the Health and Social Care Bill to set up the paving legislation for the new regulatory research agency. My noble friend makes it clear in his letter to the noble Baroness that that Bill is now on hold for a while for a variety of reasons. Surely this is an excellent opportunity for the draftsmen to put into that Bill a clause which enables the agency to be set up. At one fell swoop, an early place in the legislative timetable—literally within the next six months could be given to an agency that all of us agree needs to be in place. Amendment 9 offers the Minister the opportunity to respond positively today and we could go ahead with those proposals.

The second part of Amendment 9 deals with the incredibly important business of an ethics committee. Many people who are not involved in the ethical consideration of these issues believe that this is somehow a sop or an add-on. It is not; it is fundamental to maintaining confidence in the research frameworks and the regulatory authorities. I hope that when my noble friend the Minister responds to the amendment he will give us clear direction on how the new agency will have an ethics organisation which meets the aspirations not only of this House but of the research and clinical communities.

[Lord Winston]

My Lords, I have not decided whether I shall vote for or against the amendment if it is pressed. I shall listen very carefully to the Minister’s response.

One of the greatest ethical issues involved in this treatment is its lack of accessibility. It is a highly privileged treatment, because it is mostly in the private sector. It is true that the NHS provides some, but many health authorities have based their fees to some extent on the private sector. Therefore, the hard-pressed PCTs have not been able to offer as many treatments as many people recommend.

When I left practice running a large IVF clinic some five or six years ago, we were charging very much less than is currently charged by clinics. We were still able to turn more than £1 million a year over to research and provide the Hammersmith Hospital with a great deal of surplus income, which was then used to treat other patients.

One of the key issues with which the HFEA has not dealt is the high cost of IVF treatment. In my view, it is a scandal. There are clinics that treat patients for around £3,400 a cycle. It is only when you look at their websites that you see that they are charging up to £1,100 to £3,200 for drugs that should be obtained on contracts at around £500 to £700 per cycle. Embryo freezing will be increasingly required if we are to limit the number of pregnancies that result in multiple births by transferring just one embryo each time. One clinic in London charges £915 for embryo freezing. That is for a mechanised treatment that is extremely easy to do in the laboratory. If that were not enough, the storage fees are £325 a year. Given that liquid nitrogen, which is what the embryos are stored in, costs a few pence a litre, that seems somewhat excessive, even allowing for the costs of regulation. I am afraid that the HFEA has shown itself to be completely unable to deal with this issue at all. This privileged treatment is a shocking issue.

Secondly, one thing that the HFEA claims to be doing is giving accurate information to patients. This morning, I trawled a few IVF clinic websites. A prominent clinic in London—which I can name but will not—argues on the front page of its website a 69 per cent IVF success rate. That figure is repeated twice on the website. It is only when you delve into the small print that you realise that it is nowhere near that. That is the cumulative success rate over several cycles of treatment. Another clinic argues that it has a 30 per cent success rate in women over 40 or 42. That is a biological impossibility given that the implantation rate alone of a patient under 40 is something around 18 per cent per embryo—at best 25 per cent. What the site does not say is that this is for pregnancy but not delivery of a live baby. It does not take into account the vast number of miscarriages that presumably these patients are going through. This kind of misinformation occurs again and again.

The Bridge fertility clinic offers a 71 per cent pregnancy rate per blastocyst treatment and 67 per cent success rate for pre-implantation genetic diagnosis. As someone who has been intimately involved with pregenetic screening of this kind, I find those figures, frankly, quite incredible. Perhaps they depend on very few patients being treated and a good deal of luck. But that is highly misleading. These treatments have not been validated by the HFEA. Presumably, that is why it has allowed advertising to continue.

Then we come to the ways of promoting treatments that are not acceptable in this country. There are several clinics in London alone that offer their services in, for example, Mauritius—that is one of the Harley Street clinics—the USA, India and Spain. There they can display all sorts of unvalidated success rates on their websites and in addition can offer treatments that are not acceptable in the United Kingdom, such as multiple embryo transfer. Why has the HFEA not withdrawn the licences of those clinics? Why has it not argued that this is dishonest and dangerous?

Then, of course, we have the question of the database, which has been referred to already. The database ought to be very valuable but, sadly, in practice it is useless because we cannot follow up patients in the long term. That is a very serious issue. As the Minister knows, epigenetic issues—early experiences in development from fertilisation onwards—may have a profound effect on our health when we become adults. IVF in this country is not followed up in this way, so we have no way of knowing whether some of the treatments or exposures of the human embryo may be more likely to cause damage at a later date.

Then we have the question of another issue, which the HFEA seems to have been totally powerless to deal with. That is the issue of treatments without any evidence base that they work. Let us take the example of immune therapy, which is charged at anything from £1,000 to £3,000 a time, in addition to the already high fees of IVF. Where is the evidence that immune therapy actually improves the success rate of pregnancies? I do not know of that evidence—and, indeed, the treatment may even be damaging or harmful to the patient’s residual immune system.

Then we have preimplantation genetic testing, which is testing of embryos genetically when IVF has previously failed. I accept that preimplantation genetic diagnosis works, as the noble Lord, Lord Walton, has said, and it is a valuable technique in a few patients. However, there is actually no evidence base showing that preimplantation genetic testing in people who do not have a genetic defect, as widely used by many clinics, provides a helpful and improved chance of a pregnancy afterwards. The control trials and the control evidence are not there, and this treatment—if it is done at all—should be done on a research basis. However, the HFEA has failed to license it on that basis. The same applies to the treatment of assisted hatching. These are not small treatments; preimplantation genetic testing is charged in one clinic at £2,690 in addition to the £3,000 or so charged for the IVF and the £800 to £1,000 for the drugs that the patient pays for. At this stage, patients who are desperate will do anything to ignore the avarice of the people who might be treating them. This is a massive issue, as it is with another treatment, widely offered, of assisted hatching, in which a little piece of damage is done to the zona pellucida around the embryo or egg in the hope that it might improve the pregnancy rate. Over many years it has not been shown to be really effective, but it is still widely sold without any proper regulation.

We have heard from a number of speakers in this debate that the HFEA is the envy of the world. If it is the envy of the world, why has no other jurisdiction accepted this method of regulation? It is not used in Singapore, the USA, France, Israel or Australia, the countries that are most successful at reproductive treatments. I am not suggesting for a moment that we should not have a proper culture of regulation or a proper ethical standard in how we deliver medicine, but the current workings of the Act of Parliament are now not suitable for the original purpose. We have outgrown it. With the burgeoning private practice that has occurred with this treatment as a result of the failure to fund it in the health service, we have an increasing problem, which is very far-reaching.

It is true that there are virtually no good academic units in the United Kingdom that really produce cutting-edge research in the field of reproductive biology where it applies to humans. That was not true 30 or 40 years ago, when we led the world, in places such as Cambridge, London, Edinburgh and many other centres in Scotland. Now we cannot find people to appoint to chairs in reproductive medicine. The chair at Hammersmith was left vacant for three years after my retirement, and eventually they decided not to seek anyone to fill it. They could not find somebody who was a suitable academic because people are being attracted to the highly lucrative business that IVF provides. In my view, this is a very serious problem.

One of the most respected academics in this field is Professor Alison Murdoch, in Newcastle, who has pointed out something really quite interesting. I take her view very seriously as I believe that hers is an example of a really well-run, ethical practice. She points out that regulation of in vitro fertilisation is now far greater than regulation of, for example, abortion. That does not seem to make sense. I listened very carefully to the right reverend prelate the Bishop of Guildford. However, does he really believe that the protection of the embryo is more important than the protection of the foetus or the protection of research on the newborn child, the patient who is pregnant or the elderly patient who may be about to die from various diseases? Surely the notion of centralising our research under one body makes good sense, because we can then have a rational basis for important ethical decisions. I shall listen with great intent to how the Minister responds to this debate. However, I am not convinced that, even if we vote for this amendment, it would be a good idea to vote for the preservation of the HFEA as it stands.

[Lord Patel]

My Lords, I shall be brief as we have been debating this for a long time. I spoke to this issue in Committee and, apart from the noble Lord, Lord Winston, and the noble and learned Lord, Lord Mackay of Clashfern, who is not in his seat, I was the only one to argue against preserving the HFEA’s current status and role, particularly on the clinical side.

I start by agreeing with the noble Lord, Lord Willis of Knaresborough, about the medical research authority. I totally agree with him that the Academy of Medical Sciences report has been widely accepted and backs the establishment of such an authority. It will also have an ethics committee because, according to the report, it will take over the national ethics service, which is currently run separately. It will therefore have an ethical body to assess the ethical issues related to all medical research. There cannot be any doubt about that. Last time, the noble and learned Lord, Lord Mackay of Clashfern, asked—and I have his permission to repeat the question—whether, in the interim, the Minister will find a way of establishing such an authority before the legislation is put in place.

I turn to the HFEA and its other role. Yes, it is true that we should all feel a glow when we mention the HFEA. When it was established, soon after the birth of Louise Brown, a voluntary licensing authority established by the Royal College of Obstetricians and Gynaecologists and the Medical Research Council had been operating for two years. Its creation gave both clinicians and the public the confidence that the newspaper headlines of the time—that monsters would be created in Petri dishes—would not be realised. It is true that in its formative years the HFEA did a fantastic and useful job in establishing and licensing premises for delivering good care to those requiring IVF treatment. Yet the world has moved on. More than 1 million children the world over have been born following IVF treatment.

There is no reason to think that the clinical care provided for patients requiring infertility treatment, including IVF, is any different, or should be any different, from the care provided for children with cardiac anomalies. Both treatments are properly regulated by the CQC and the professional organisations. We hear of units being shut down because of poor outcomes; so let us consider the recent performance of the HFEA. How should we measure it? We should measure it against the success rate for IVF. As the noble Lord, Lord Winston, mentioned, apart from spurious claims, there is no evidence that our outcome for patients requiring IVF treatment is any better than anywhere else in the world; in fact, it is poorer than in some other countries. Measured against promoting better outcomes for the patients, the HFEA has not delivered.

NHS: Standards of Care and Commissioning

Lord Winston Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Turnberg]

My Lords, I am delighted to have this opportunity of opening this debate. I am pleased that so many noble Lords are remaining in the Chamber and are going to contribute. I look forward to hearing what they have to say.

I shall focus my remarks on recent reports of failures in standards of care, particularly for the elderly, but this is also a good opportunity to examine whether the commissioning arrangements proposed in the new Bill will have a positive or a negative effect on standards of care. Perhaps, too, we should look at how the Bill might be used to make things better.

I am someone who has spent most of his life working in the NHS and I bow to no one in my support and admiration of what it achieves. I see enormous advances being made every year, and patients who would no doubt have died are now cured and surviving into old age. Medicine has been transformed out of all recognition during my working life.

It is because I have this pride and huge admiration of the NHS and the people who work in it that I now feel a deep sense of shame. Despite these wonderful advances, in too many places we have been ignoring the common decency needed to care for the vulnerable, the sick and the elderly—and it is the elderly who are often the most vulnerable. As Ann Abraham, the Health Service Ombudsman, said in her report, there is a,

“gulf between the principles and values of the NHS Constitution and the felt reality of being an older person in the care of the NHS in England”.

That is why I am going to focus on the elderly, but they are not the only group where standards have slipped. I suspect that other noble Lords may speak about the mentally ill, and only the other day we had a report about failures in maternity services.

Of course, the media are quick to pick up the seemingly occasional horror stories of neglect in a hospital. You might want to hide behind the idea that these are rare incidents against a background in which 1 million people are looked after perfectly well in our hospitals and nursing homes every 36 hours, and that is absolutely true. But it turns out that it is not a rare or unusual event. It seems to be happening far too often, and stories of neglect are just too common for comfort: patients, usually in a geriatric ward, unable to eat the food left out of reach at the end of the bed and collected by staff seemingly unaware that it has not been touched, and too busy to notice that a thirsty patient is unable to even drink without help—or, worse, too busy to notice that a helpless patient, unable to get out of bed and incontinent, is sitting in damp sheets for hours or, the final degradation, soiled by faeces and unwashed for days.

Noble Lords might ask whether I exaggerate. Where is the evidence that this picture is not just a rare, occasional lapse in an otherwise acceptable system of care? Well, quite apart from the rather common anecdotes of many with elderly relatives, there is now the report of the ombudsman in which she describes 10 examples of the complaints she receives that emphasise just how bad it can get.

We cannot say that we have not been warned. In 1997 we had the report from Age Concern in its “Dignity on the Ward” campaign, describing failing standards of care. When it followed that up 10 years later, in 2007, it found that little or nothing had changed. The Commission for Health Improvement in 2003, the Healthcare Commission in 2007 and the Care Quality Commission in 2010, despite regularly changing their names, came up with the same message. Now there is the book that has just been published, Michael Mandelstam’s How We Treat the Sick, which brings all this together in a devastating way.

The scandal at the Mid Staffordshire hospital of a year or so ago turns out not to be an isolated example. Every time we have a disastrous fall in standards we have another report or inquiry. I will not list all the hospitals or nursing homes that have been the subject of criticism but they range from Cornwall to Rotherham, from Tameside to Southampton and from Oxford to Bolton. There are just too many, and it is clearly not a new phenomenon. It went on under the past Government and the one before that, so I do not want to make any political points here. But how can we have tolerated this neglect of our most vulnerable citizens for so long? No one can afford to be sanguine—not the doctors, not the nurses, not the managers and not the Government. I want to say a few words about why and how this is happening and suggest what we might do about it, because we certainly cannot allow it to go on.

Let me apologise for starting with the nurses, for whom I have the greatest admiration and to whom I owe a great deal of personal gratitude. However, at the end of the day, it is the nurses who patients look to first for their personal care and empathy. It is always tempting to look back to a golden age that never was, but one thing that is clearly fixed in my mind is how high the standards of nursing care were on the medical wards where I worked in the 1950s and 1960s. Those were the days when the sister in charge of her ward really was in charge. She was usually a mature woman in a career job who made absolutely certain that everything ran efficiently and well. I admit to running scared of her; as, indeed, did the patients.

However, those were the days before the revolutions in nurse management and nursing education. One of the unintended consequences of the upward drive to better educated nurses with university degrees has been the development of a generation whose aspirations are set high. They quite reasonably expect to have a career in which they can practise their skills to a high standard. Who can blame them? They do a great job with all the caring attitudes you can wish for. However, that has left a gap at the more basic and, to many, less attractive level of the general and geriatric ward where there is greater emphasis on the basic needs of patients: feeding, washing, help with movement, going to the toilet and so on.

Those are the wards where staffing levels are often lower per patient in the belief that they do not need the more intensive, one-to-one care of the specialist units. So they are often understaffed and sometimes come to rely on temporary, or “bank”, staff, who constantly change. Continuity of care is damaged as patients, already a little disorientated by being removed from their familiar environment, are faced with a bewildering series of new faces.

It is not only the nurses who are constantly changing. Confusion is compounded by the way the rotas for the ward doctors are arranged to fit in with the European working time directive or as they rotate through yet another experience to chalk up on their training programme. So there are new faces at every turn. These wards do not have the champions that the specialised departments have, who can put pressure on management to protect them from cuts. Not much wonder that nurses in training pass through those experiences quickly on their way to higher things. Nursing sisters in charge may not stay long enough to be able to stamp their authority and, in any case, are distracted by paperwork or, nowadays, putting stuff into their computers—care plans and the like.

I fear that these changes have created a situation in which we have two starkly different standards of care. On the one hand we have highly trained, highly professional and caring nurses in well staffed specialised units—intensive care, coronary care, chemotherapy units and the like—and, on the other hand, poorly staffed wards, rushed nurses, falling morale, falling standards and poor supervision. These are the staff who are struggling to cope with patients whose vulnerability makes enormous demands for the care and attention that the nurses have neither the time nor the patience for.

Of course, this picture is not true everywhere and many, probably most, wards and hospitals are very good indeed. It is just that this picture is too common for us to take any comfort from it.

So what is to be done? Here it is clear that there is a need for a multifocused set of actions which no one profession or body can shirk. First, we must have someone at ward level who takes full responsibility for ensuring that patients are properly looked after with the respect and dignity that they deserve. That is absolutely key. I hope that my nursing friends will forgive me for saying that we should be making this job, the ward sister or charge nurse, a career post and rewarding those who do it accordingly.

[Lord Winston]

Hear, hear!

[Lord Turnberg]

My Lords, there has to be some continuity in that post to make it an attractive alternative to the lofty pastures of the specialised departments.

Then there is the issue of too few carers on the wards. What happened to all those state-enrolled nurses—SENs—whose roles were predominantly in the caring world and who did not aspire to higher degrees? They disappeared in project 2000. Is it possible for us to resurrect the SEN grade and make it attractive again? I hope that some thought can be given to that.

That leads me to the medical profession, who cannot absolve themselves—ourselves—from responsibility for the neglect we are now discussing. They, after all, must see the way their patients are being cared for and, I am afraid, have not raised their voices loud enough. They should be leading the charge for proper staffing levels on their wards. They should be pressing hard on the managers of their hospitals. Of course, they really must do something about these disruptive rotas that are destroying the continuity of care that patients need and deserve.

The managers must make themselves much more aware of their responsibility to ensure that there are sufficient staff on these wards to cope with what is one of the most demanding areas of a hospital. They should know that these wards cannot be among the first, for example, to take cuts. Then there are the responsibilities of the trust boards. Board members have to be rather more hands-on and need to know what is going on in their wards. Many obviously do, but it seems that there are too many who do not.

Finally, I come to those bodies who will be commissioning services in the bright new tomorrow, the GP consortia, and the responsibilities that we should be placing on them for standards of care in the NHS, under the Health and Social Care Bill coming through the House—in whatever form that Bill survives. To paraphrase Aneurin Bevan, there are bed pans clanging on the floor all over the country and, in the rush to devolution to the local level, important though that is, devolved responsibility must also mean some central accountability.

As these services are commissioned, we must make sure that the Bill places a duty on the GP consortia to make sure that high standards of care for the elderly, at least, are a contractual obligation on the providers. Furthermore, we must have a robust system of monitoring so that we can have some confidence that this care is actually being provided. Perhaps the proposed commissioning board can take this on, but only if it has the capacity to monitor what is going on in hospitals and nursing homes, and has a mechanism for action when standards slip.

We have been through too many years in which we have seen indifference punctuated by intermittent reports and wringing of hands. It has to stop. The time for action is now.

--- Later in debate ---

[Lord Winston]

My Lords, the points that I shall make are no criticism of the Government; indeed, they are not faults induced by them. If there have been faults, they have been those of healthcare professionals and the management of the health service. I hope that the noble Earl will be able to respond by saying how we can build in these suggestions. This is a strong echo of what the noble Lord, Lord Turnberg, said. He spoke with nobility, dignity and humanity and his points were very well made.

Some weeks ago, I brought to the attention of the House my experience at a leading hospital, where I was faced with a woman in her postnatal period, four days after delivery, with a dangerously high, life-threatening blood pressure, which no one was dealing with—she had not seen a doctor in four days. There was no continuity of care on the ward. When I tried to speak to the nurses, they were busy at their computers and with their paperwork.

I want to talk about the loss of continuity of patient care in the hospital service. The noble Lord, Lord Turnberg, talked about halcyon days. Although we may not want to return to those days, the old-fashioned firm system in medical practice was very good: the idea of consultants working in tandem, usually two at a time with the same secretarial support, followed by a senior registrar, a registrar, house physicians and house surgeons, was a good way to ensure continuity. Nowadays, we do not even have the privilege of interviewing the staff who come on to the team. Because of political correctness, they are often appointed. That means that we lose a valuable kernel within the health service.

There used to be flexibility about time off. We did not go off when a patient was really sick. We had a detailed handover when we went off, if we had to. We would make sure that the person to whom we were handing over understood what was going on. We were still responsible, as junior doctors, when we were off, and would expect to be informed if critical decisions were being made about those whom we regarded as our patients. That ethos and that culture have been lost, partly because of the European working time directive, although that is not the only reason. The restrictions on working time, which we have previously encouraged the Government to think about, have had a massive negative effect not only on training and experience but on morale and continuity. A “watch the clock” attitude has been engendered.

There used to be general ward rounds for the whole team, at which the ward sister would be an important person, together with the general practitioners. Often, general practitioners came to the wards, which meant continuity in society afterwards. Nowadays, we do not have the same attitude towards the hospital in which we work. We have no hospital nurse, no medical porters and no dedicated bedrooms. There is no staff dining room. That may seem a ridiculous point, but the disadvantage is that, in terms of morale, we cannot replace the staff dining room, where we used to discuss individual patients with other consultants in order to learn. In science units, restaurants and coffee facilities are in every research lab, but they are no longer in hospitals. We should think about that. I have to say that I learnt my haute cuisine of Indian cooking in such messes. We felt valued members of an institution in a way that we do not now.

As the noble Lord, Lord Turnberg, said, there is no leadership on the ward. Without ward sisters, individual nurses do not feel responsible for all the patients in their care on the ward. Doctors now normally do ward rounds without the sister present; indeed, it is difficult to find a nurse who is free.

I make one final point. Basic nursing has been lost: cleaning patients, caring for them, listening to them, trying to feed them occasionally. Yesterday, I met a paediatric nurse at one of the best nursing schools in the country. She said: “I got an A in hospital management and NHS management in my essays, but I cannot change a paediatric colostomy bag, and that really worries me”.

Public Bodies Bill [HL]

Lord Winston Excerpts

Wednesday 9th March 2011 Lords Chamber

[Lord Mackay of Clashfern]

My Lords, I declare an interest as an honorary fellow of the Royal College of Obstetricians and Gynaecologists and as the person who had the privilege of introducing to this House the Bill that ultimately became the Act which has been referred to more than once. As a parent of such a body, it would be strange if I wanted to see it dissolved altogether. On the other hand, a parent who is interested in his child is glad to see him or her develop and possibly make unions with others who seem to be suitable for them. I had the honour of serving on the Joint Committee looking at the recent Bill in this area under the distinguished chairmanship of the noble Lord, Lord Willis of Knaresborough. I strongly supported the decision taken by that committee to recommend against the proposed union between the Human Fertilisation and Embryology Authority and the Human Tissue Authority. I think I am right in saying that the noble Lord, Lord Willis, may have done a slight injustice to the noble Lord, Lord Warner, because I think the noble Lord, Lord Warner, said that he had recommended against it to the Minister. I do not know whether the Minister accepted it immediately, but eventually it was accepted by the corresponding Minister.

The matters that were the subject of the Bill which I had the privilege of introducing are certainly among the most important areas of modern scientific and medical work. But science and medicine have moved on very fast and far since that Bill was introduced and the developments dealt with in the most recent Act show that. That Act moves out of pure human embryology to the transition towards hybrids and, at the extreme end, towards the animal end of embryology. It shows that science has developed in such a way that the distinct field carved out in the original Bill has been altered by progress, if you like to think of it in that way, and I hope that that is what it is. There is a great deal to be said for the view that modern scientific and medical research is very difficult to split up. The embryo is important, but there are other important aspects of that research. I can therefore see a very strong argument for having a research body which has overall responsibility in this area.

There are of course other functions in HFEA which are important, particularly the control of IVF. When the body was originally set up, the practice of IVF was exceptional and a complete novelty, but a lot of water has gone under the bridge since then and it has become much more of a standard clinical procedure. It is true that developments have taken place there, but they have taken place also in other branches of medicine. It is not only embryology or IVF that have moved forward; fortunately, a great number of developments have taken place in the practice and application of medicine and surgery. It strikes me as extremely logical to have a body that would have overall responsibility for that.

If that be right, there is a good deal to be said for the view that the time has come to review the position in regard to the two health bodies that we are discussing and see whether a more integrated approach to research on the one hand and clinical practice on the other could be furthered by having bodies responsible for the whole of the first and the whole of the second. I agree that a good deal of detail needs to be filled in, but I remind myself that we are not deciding today whether this should happen. We are talking about a power for a Minister to decide what to do in the light of the further consultation provided for in the amendments moved by the Government since the Bill has been in Committee. It is a valuable opportunity for these matters to be considered. I can understand a lot of what has been said on the other side of this argument, but I should like to see retained in the Bill the power to deal with these issues in a way that reflects the developments that have taken place in the research and practice of medicine since the original Act came into force.

[Lord Winston]

My Lords, my noble friend Lord Warner has declared support for the Minister sitting on the Front Bench; I suspect that I might in the next few minutes give him even greater support.

We have to understand that research in these areas has now gone way beyond embryology. There was a time when people were very concerned about the status of the embryo, when embryo research was relatively novel. I should like to correct a remark made by the noble Lord, Lord Walton, who very kindly referred to work on pre-implantation diagnosis. That work produced pregnancies before the establishment of the Human Fertilisation and Embryology Authority, and people like me were greatly exercised to establish regulation. In spite of what has been said in this Chamber, we were very much in favour of regulation. Since there was no government regulation, we started a voluntary licensing authority which became a model in time—obviously, a very imperfect model—for the body set up under the splendid Bill introduced by the noble and learned Lord, Lord Mackay of Clashfern.

Stem cell biology covers every aspect of human disease, from cancer to brain research, from human consciousness to the replacement of organs and transplantation, and a whole range of other areas. It is really—forgive the pun—inconceivable that this could be dealt with by the Human Fertilisation and Embryology Authority properly under its present form or any future form. I would argue that with the advent of epigenetics, the recognition that now the environment in which cells are placed in culture and elsewhere is such a universal issue in medicine there has to be a much more global look at this kind of research. I feel that there is a strong case for suggesting that we have to accept that research ethics are universal and that they tend to have the same sorts of problems, whether it is patient consent, the end or beginning of life, or a whole range of other issues. In fact, the end and beginning of life have some very similar moral issues which need to be debated by ethics committees. The noble and learned Lord was right to point out that trying to look at these issues in a new form would be absolutely apposite. I for one am certainly not in favour of a free-for-all. I am not quite certain who in the medical profession is. I do not think that that is true.

The regulation of clinical treatment has been in many examples woefully inadequate. The noble and learned Baroness, Lady Butler-Sloss, pointed out that while she was sitting on the Bench she had the most terrible case of a woman who had the wrong embryo transferred. That was done, of course, under the auspices of the Human Fertilisation and Embryology Authority. No regulatory authority, no matter how perfect or how good, can regulate against every human error. We should have a set of principles in laboratories which keep those mistakes to a minimum, and the regulation of medical practice must also enforce that.

I do not think that there is any evidence from what has happened that the HFEA has done a particularly good job or a particularly bad job. In some areas it has not been very powerful. For example, many things are forbidden under regulation in this country. Patients actively seek fertility tourism in other countries where they can get, for example, donor eggs and perhaps come back pregnant. Very often clinics in this country, although it may be against regulations, refer these patients outside. Of course the HFEA, not unreasonably, is powerless to deal with that sort of problem.

It is also true that the fees charged to patients are often extremely exploitative. I have no doubt that we will come back to this when we come to the pending health Bill, because this is a much bigger issue in terms of how we finance the health service. At the moment, IVF, whether it is done in the private sector or in my view in the National Health Service, is charged on the basis not of what it costs but rather of what the market will bear. That is a very big issue which we will need to discuss, because I suspect that that may apply to a lot of medical practice. It is an issue to which I am sure this House will want to return. Costing the procedure is very important.

Someone mentioned follow-up: one sad thing about the opportunity in 1990 was that we did not—even though we had records of IVF pregnancies, and IVF successes and failures—make any attempt to follow up babies after this procedure for the long term. There have been many reasons why that was difficult, such as data protection. But this lost opportunity means that some of the procedures often in routine use may have unforeseen consequences in children when they are adults. We now know from David Barker’s work, for example, that babies who are born underweight and premature are much more likely at the age of 50 or 60, as the Minister knows, to suffer from heart disease, stroke, hypertension and possibly osteoporosis as well as diabetes and one or two other diseases as well. Of course, we may see more diseases which are likely to be epigenetic due to those early influences.

I have to say that, although it is claimed that the HFEA gives out information to patients, six years after I retired from clinical practice running a very large IVF service, I am bombarded daily with e-mails—I have had several today—from patients who want information about IVF and do not feel that they are getting the information they should from the statutory authority. That remains a problem.

The clinical regulation of non-evidence-based practices has been poor. For example, there is no evidence that the preimplantation and genetic screening of embryos designed “to improve pregnancy rate” works. Yet several clinics charge large fees for doing this under regulation even though there is not a base for justifying its use. That also applies to costly immune therapy, which is highly controversial. Again, this is used in women who sometimes fail to get pregnant, under licence from the HFEA. This is an example of how in fact regulation is really quite limited in clinical practice.

--- Later in debate ---

[Baroness Deech]

My Lords, on a factual point, may I correct the impression—it may have been a mistake— that the previous speakers have given that any number of embryos can be implanted in a patient? The HFEA brought down the number of embryos from three to two and is working towards one. That was in the face of relentless resistance from patients, who wanted the best chance of becoming pregnant, and indeed many—but not all—of the clinicians and embryologists, who said, “We know what’s best for our patients”. The impression should not be given that an unlimited number of embryos are implanted. The number is two and they are working towards one.

[Lord Winston]

Forgive me for correcting that impression. Many units limited the number of embryos well before the HFEA did. At Hammersmith Hospital, we limited the number of embryos two years before the HFEA did. We were not alone; a number of units did that because we were very concerned. The idea that medical practitioners do not feel responsible for the pregnancy that is induced is, I think, a dangerous precedent. It is just not true. Of course there is a problem when patients put you under pressure, and it is a very difficult ethical issue that needs to be resolved.

[Lord Patel]

My Lords, I think I have lost my thread, but I have said what I wanted to say.

Health: Multiple Sclerosis

Lord Winston Excerpts

Wednesday 2nd February 2011 Lords Chamber

[Earl Howe]

My Lords, I have extensive briefing on some upcoming and promising treatments that may or may not emerge in the National Health Service, but I have to say that that is not one of them. I shall go away and ask the department to inform me.

[Lord Winston]

My Lords, in addition to the important point made by the noble Lord, Lord Walton, about drugs that should be available under the National Health Service, is the Minister aware that some years ago a Select Committee for Science and Technology inquiry gave clear evidence that, in small doses, cannabis is of great benefit to some patients who have spasms and other problems with multiple sclerosis? Do the Government have any plans to allow the use of that drug in those circumstances?

[Earl Howe]

My Lords, the noble Lord will know that a drug called Sativex was recently licensed, which is derived from an extract of cannabis, as he will be aware. Having said that, I believe that NICE has issued no guidance to the NHS on the use of Sativex, so it is for local primary care trusts to make funding decisions based on an assessment of the available evidence and on the basis of the patient’s individual circumstances. As the noble Lord rightly said, Sativex treats the symptoms of severe spasticity caused by MS and is not a disease-modifying drug as such.

Human Fertilisation and Embryology Authority/Human Tissue Authority

Lord Winston Excerpts

Tuesday 1st February 2011 Grand Committee

[Lord Winston]

My Lords, I most grateful to my noble friend Lady Thornton for introducing this debate. It is rather delightful for me to be able, on this rare occasion, to support the Government’s position and to support the Minister—at least, I suspect that I will be supporting him. It is a particular delight to see the noble Lord, Lord Wigley, attending this debate; it was he who, in 1985, broke the Speaker’s Chair in the debate when the Private Member’s Bill came in as part of Enoch Powell’s attempt at legislation. I, of course, can declare an interest as an ex-poacher in this area—I no longer run an IVF unit—and I note that I am followed by a noble Baroness who was a gamekeeper.

I must say that I was open-mouthed at the quality and the succinctness of the speech of the noble and learned Lord, Lord Mackay of Clashfern, when he introduced the HFE Act. It seemed like a model of what should happen. It is fair to say that at the time it was an essential piece of legislation, which has now passed its day. It is no longer necessary; the research that it regulates is not really suitable for regulation by the HFEA. I believe that other areas of medical research, such as paediatrics, obstetrics, geriatrics and assisted dying, in many ways raise much more important ethical issues on a day-to-day basis. With stem cell research, the HFEA is inadequate for the purpose. A completely different body is needed, since stem cell research is ubiquitous and affects every tissue in the body, including the brain and the liver, and will clearly be an important replacement therapy in future. If it is to be regulated, it needs a different kind of touch.

As for clinical regulation, frankly the HFEA cannot prevent accidents or errors. It has not done that and it cannot do that; no regulatory authority can do that completely, any more than any other way of inspecting laboratories can. It does not prevent exploitation of women, who pay massive fees—in my view unreasonably—and has not helped in the costing of IVF treatment. It is unable to prevent fertility tourism, which goes around British legislation on a regular basis, and has not prevented clinics from collaborating with overseas units in allowing their patients to go to places such as Spain and Russia to seek treatment that they cannot offer themselves—with what kind of relationship, I am not sure.

There is a repeated assertion that the HFEA has always assuaged public concerns about IVF. I think that that was true 20 years ago but it is not true any longer. The public are pretty mature about this area, as was shown clearly by the hybrid embryo Bill. Things have moved on and the public are rather more sophisticated.

Lastly, one of my concerns about the HFEA is that it is extremely costly for men and women who are already paying for these services. I have just checked on the cost at Hammersmith Hospital, a clinic that I used to direct. Effectively, the HFEA requires two extra salaries to be paid and individual patients will pay on average around £300 for the use of IVF licences for their treatment. That seems an unfair burden in an area of medicine that is already extremely burdensome for the patients.

NHS: Front-line and Specialised Services

Lord Winston Excerpts

Thursday 13th January 2011 Lords Chamber

[Lord Winston]

My Lords, back in November, when I had just come back from cycling around Beijing and seeing at first hand the health service in China, I spoke later that day in a similar debate when the noble Earl, Lord Howe, admonished me for being somewhat acerbic in my comments about the health service. I hope that he has forgiven me, because I think a combination of my jet lag, my passion for the health service—like his passion for the health service, which I greatly respect—and the anxiety that one sometimes feels when speaking from these Benches, and for me the unusual taste of being very briefly on the Front Bench, resulted in my being rather stronger in my remarks than perhaps I should have been. I would, however, like to ask him some questions about the third issue that the noble Lord, Lord Turnberg, has produced in his debate, and I congratulate him on introducing it. May I also say what a pleasure it is to see that the noble Baroness, Lady Jolly, has put her name down to make her maiden speech in this debate? We look forward to hearing her in just a moment.

Noble Lords must forgive me if I concentrate on hospital medicine, but that is the area I know best. I remember many years ago, from my experience in the United States—when I was a visiting professor in Baltimore and Boston, and later in Texas—that the Americans were very surprised at the massive surgical experience that we could gain in the health service in this country because of the way in which the service was run. We could centralise many specialised services and do very advanced work that was both innovative and useful for research. One issue is that, while this has been more difficult since the introduction of the internal market, there have been at least some attempts to get back to doing exactly that.

Many aspects are really important for centralisation. First of all, that kind of centralisation is best for some patients with particular needs if they can travel to a service. That often means that they are going to get the best medicine. It is a question not of patient choice but of making sure that they get the best treatment from the most qualified people. Secondly, that kind of centralisation is ideal as a pull for teaching. It is also excellent—indeed, some people would say essential—for training people to make sure that we get the best surgeons. It is a problem that the noble Earl, Lord Howe, is very conscious of, given the changes that have happened as a result not of the NHS but of European pressures, which have made things more difficult.

Centralisation is also important for innovation. The key issue is how these expected changes in the health service will affect our excellence in research. What I really want is reassurance from the noble Earl that the sorts of things that were developed in the health service hitherto will not be difficult to achieve under the current proposals in the White Paper. For example, it seems impossible to imagine that in vitro fertilisation could develop as a research procedure in the structure as proposed. Certainly, during my time at Hammersmith, I saw by-pass surgery, transplant surgery and the cancer smear test being developed, and many other examples of innovative surgery and medicine. Many of the great institutions, such as Great Ormond Street, Hammersmith, and some in Liverpool, Manchester and elsewhere have been made great and international because they have been able to function in a way that it is difficult to see will continue under the structure in this White Paper. I want to make certain that the Minister agrees—I know he does—that the jewel in our crown is the National Health Service. A very special aspect of that, which is internationally recognised, is the unique nature of academic medicine in this country. I would like him to tell us how academic medicine will be protected and will flourish in the structure of the White Paper.

Health: Influenza

Lord Winston Excerpts

Tuesday 11th January 2011 Lords Chamber

[Earl Howe]

That is precisely why we have an independent Joint Committee on Vaccination and Immunisation: to advise Ministers on these matters. Ministers are bound to take that advice. Indeed, the previous Government determined that they were legally obliged to take the committee’s advice, which is what we have done.

[Lord Winston]

My Lords, is the Minister aware that many pregnant women are particularly nervous about all kinds of vaccination during pregnancy, including the flu vaccination? I know that from first-hand experience. Does he feel that the Government are doing enough to inform pregnant women about the risks or otherwise in that instance? Could more be done?

[Earl Howe]

I am sure, as I have just said, that lessons can always be learnt about what more can be done. As I mentioned, we saw a lower than desirable uptake of the vaccine in the early weeks among pregnant women. I am happy to say that that has now been rectified and a lot more pregnant women are coming forward. However, it emphasises the noble Lord’s central point that perhaps GPs have a special duty at the moment to encourage pregnant women and to reassure them that the vaccine is absolutely safe.

Healthcare

Lord Winston Excerpts

Thursday 28th October 2010 Lords Chamber

[Lord Winston]

My Lords, I congratulate the Government on a wonderful, beautifully written document—the White Paper, Liberating the NHS. Finally, the NHS is to be freed. The document’s honeyed tones and warm aspirations are sweetness and light. Its expressions of good intentions will easily deceive less well informed readers. However, to leave aside the aspirations, to which I shall return, the one thing that the NHS does not need is another reform. That is why in opposition Mr Cameron promised to halt the merry-go-round of organisational change with which the NHS had been previously inflicted. This promise was countersigned by a pledge by Mr Clegg, the Deputy Prime Minister.

I have absolutely no desire to embarrass the noble Earl, Lord Howe, for whom I, like so many of us, have genuinely a huge regard, but we have already learnt how trustworthy this Government as a whole are. So this merely minor change—no merry-go-round—means a reorganisation in which all primary care trusts are to be liquidated, all hospitals will become foundation hospitals, strategic healthcare authorities are to be abolished and the responsibility for public health will become part of the remit of local authorities. This does not seem to be so minor after all—more of an amazing big dipper. In this battle for the NHS, more than three-quarters of the £100 billion NHS budget will be devolved to general practitioners for administration.

Over the past few months, we have heard a great deal about the legacy left by the previous Government. Forgive me if I feel angry at this; it is not often that I do and seldom have I felt as angry. The negative tones have been the cornerstone of an excuse for the severest cuts in public spending in living memory. This Government’s pronouncements, on the whole, are not to be trusted. If their pledges on the NHS reforms are void, so are their promises on the ring-fencing of NHS funding. If we want to consider a legacy, perhaps we might recognise that the Labour Government left the NHS in its healthiest state for decades—a position that this Administration have inherited.

In spite of the Government’s assurances, the NHS is already being cut. Managers have been told to find £20 billion in efficiency savings if widespread closures are to be avoided. To give just one other example, in London the deaneries are threatened. Perhaps the Minister can confirm that, where so much healthcare is needed and where the cream of our young professionals is trained, junior hospital posts are facing a cut of 14 per cent next year. As I understand it, 70 key training posts in general medicine out of a total of 300 are to go—perhaps the Minister can confirm this—and another 70 posts from the other specialities are to be cut by 2014.

If the King’s Fund has calculated correctly, the reorganisation will cost the NHS between £2 billion and £3 billion, which will be taken from patient services. Consider this for a moment: the pressure of population change, the incidence of chronic illness, the rising age of our population, inflation and the rising expectations of patients mean a real cut in resources. The biggest problem will almost certainly be in chronic care. The massive cuts proposed in social care and welfare services will inevitably result in increased pressure on what we can now see is becoming an already underfunded NHS.

What about research? Here is another unbelievable sleight of hand by the Government. Some of the so-called ring-fenced NHS research budget will almost certainly come from the other research councils. I declare an interest as a member of the Engineering and Physical Sciences Research Council. We already fund a huge amount of healthcare research, as does the BBSRC. We will be asked increasingly to contribute substantially, at the risk of other research. We will be heavily pressured on our own so-called ring-fenced budgets. Meanwhile, regarding NHS R&D carried out by the NIHR, if we are talking about assessing outcomes, how is its performance to be evaluated? That will certainly not, it appears, be anything like as rigorous as the superb work of international quality, funded by the research councils, in our top research universities. Here, surely, is a case for government scrutiny.

Front-line care is already threatened. The dulcet tones of the White Paper with its emphasis on patient choice and outcomes are a smokescreen. Of course patients would like choice, whatever that means, but what they really want is competent, efficient medical care. I recently went to a maternity ward in one of the most famous maternity hospitals in the country to visit a relative of mine in her 20s, an NHS patient, who had recently given birth to a premature baby at 35 weeks. Her GP had given her the choice of three different hospitals and she had chosen this hospital. She was four days post-delivery and she had not seen a doctor. Her blood pressure had been 200 millimetres of mercury—a situation in which she might even have had a stroke or a seizure—but she said that she had not been seen by a doctor. She was sitting there trembling with worry. She was scared stiff. What she wanted was a doctor to listen to her and to talk to. Even though it is some time since I left the health service or have done any medical practice, I felt obliged to examine her. I went to see the nursing staff and asked whether I could speak to the house surgeons. None was available, so I asked to speak to the registrar. They did not know the name of the registrar. I had to phone the central switchboard to find out who the on-call registrar for obstetrics and gynaecology was. It was only when I left the hospital that there was suddenly an outpouring of care and three doctors visited my relative in about five minutes.

What about outcomes? Outcomes depend so much on social circumstances. Equity and Excellence: Liberating the NHS mentions cancer, stroke, asthma and so on, but the outcomes of treatment depend on the circumstances of the patient. What we learn more and more, certainly with epigenetics, is that what happens to us in early age also plays a part. What happens in a child aged two or three can have far-reaching effects on whether that child is more prone to diseases such as stroke in 60 years’ time. How do you measure those kinds of outcomes with the possibility that this White Paper offers?

Finally, to leave the—

[Baroness Northover]

My Lords, I think that I need to remind noble Lords, as the noble Baroness, Lady Farrington, would always remind us, that this is a time-limited debate. When the clock reaches four, noble Lords’ time is finished.

[Lord Winston]

My noble friend Lady Thornton and I have agreed to split our time, which is why I went on for the extra time. I shall finish with one sentence. If we really want to improve the health service, we should make certain that doctors have enough time to listen to patients and that nurses are not involved with so much paperwork that they cannot speak to patients, we need to improve training by better investment, we need to renegotiate the EU working time directive and we need to make certain that hospital doctors work in teams so that there is proper continuity of patient care.