Hepatitis C

Philippa Whitford Excerpts

Tuesday 12th June 2018 Westminster Hall

[Sir David Amess]

That is excellent news. I thank my hon. Friend for that positive response to looking at this issue.

The testing and treatments initiatives in place will lead to a decline in the prevalence of the disease. However, prevention will come from identifying and educating at-risk groups. To do that, we need the help of substance misuse services, sexual health clinics and peer programmes that can educate those most vulnerable sections of society on the transmission of the virus. I am advised that these services are at risk of closure without sufficient increases in their funding. Perhaps the Minister will have some news on that when he replies.

Harm reduction is another paramount mode of prevention. If we can reduce the harm to at-risk groups, we can combat one way in which the disease is transmitted. That can be achieved by providing clean and sterilised injecting equipment. Our report also emphasises the treatment-as-prevention approach towards tackling newer infections. That approach has been successful in treating drug users and other users engaging in riskier behaviours to prevent the spread of hepatitis C.

As I said earlier, between 40% and 50% of people living with hepatitis C in England are undiagnosed, which is shocking. It is therefore vital that we continue to increase testing and diagnosis levels. It is generally believed that the vast majority of those who have been diagnosed and put in touch with support services have now been treated, which I welcome. The challenge is therefore to locate those people who remain undiagnosed. That is a tricky one; it will be a real challenge.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

The hon. Gentleman talks about all of those people who have hepatitis C who have been diagnosed being treated, but my understanding is that these new antivirals are given to those with the most severe disease and have cirrhosis, rather than to everyone who is diagnosed with hepatitis C on a preventive basis. Can he clarify that?

[Sir David Amess]

I am concerned by what the hon. Lady says. No doubt the Minister will eventually be passed a note from his officials and will advise us on the situation. That does not seem right if it is what is happening, and I hope that the Minister will correct me if that information is wrong. It is also vital to re-engage those who have been diagnosed and have slipped through the net to the point where they are no longer in touch with those services.

The APPG thinks that the way to combat these issues is to change how we test for the virus. We recommend routine testing in substance misuse services, sexual health clinics and prisons. We also advocate increasing testing in primary care and in settings such as hostels, day centres and police custody. I know that that will not be cheap, but if it could be done it would be wonderful. Another solution is to test for hepatitis C on occasions when people are already having blood tests, which seems like common sense to me. For example, should we not consider testing people for hepatitis C while they are being tested for HIV, or when taking blood in accident and emergency centres?

Diagnosis is one thing, but accessing care is another. It is therefore essential that people who are diagnosed are referred for treatment as soon as possible, without delay. There should be a direct link between diagnosis and care. The time between diagnosis and the commencement of treatment should be minimised, to prevent patients from dropping out of the care pathway altogether. One way to achieve that would be to make treatment available immediately following diagnosis. That may be ambitious, but it is, ideally, what our APPG wants. Another way would be to streamline the referrals process. As it stands, some secondary care services will only accept referrals for treatments from general practitioners. Allowing referrals from any service at which someone might be tested and diagnosed, as the APPG recommends, would go some way to solving the problem.

[Sir David Amess]

Oh dear! I say to my hon. Friend—I and, indeed, you, Mr Streeter, were in this place when we were dealing with all these issues—that the fragmentation is very worrying. My hon. Friend is right to point out that more work needs to be done on the issue.

[Dr Whitford]

I am not sure whether the hon. Gentleman is aware that there is a cap on the number of patients who are allowed to receive drugs such as sofosbuvir; certainly, hepatologists I have met in recent years report having to ration it to the most severe cases. The limit was set at about 10,000 patients a year. This year, it has been increased to 15,000, but that is not a target; it is a cap. It means that despite it having been stated that 160,000 patients in England suffer from hepatitis C, it would literally take 10 to 16 years to treat them all, so this is a matter not of referral but of access to the drugs.

[Sir David Amess]

I said at the start that I was totally the wrong person to lead this debate. I put my hands up: I was not aware of the cap. It, too, is a little worrying, but perhaps the Minister will have an answer. I am the first to admit that money is not always available for these things, but it is worrying that we are talking about another 16 years. That is not what our all-party group wants.

If services share data more effectively, the number of patients lost to follow-up will certainly be reduced. That will minimise cases such as prisoners who have been diagnosed being released before being referred to a service that provides the treatment that they so desperately need. Another example is where general practitioners have records of people who have been diagnosed but never received treatment.

On the subject of treatment, pioneering treatments have been in place since 2014. I am advised that they are shorter in duration and have higher cure rates and fewer side effects. They have thus been instrumental in making progress in the way we treat hepatitis C, and many people have been cured thanks to the drugs available since 2014. Notwithstanding that, we should continue to maintain targets for the number of people treated and to maintain universal access to treatment for those who have been reinfected. Those targets should be local, regional and national.

There is even an argument for making the targets more aspirational. Currently, there is a target to treat 12,500 people in England per year, and the all-party group would like that to increase to 20,000 new treatment initiations. If the target is not raised, there is little chance of achieving NHS England’s target of eradicating hepatitis C by 2025. It might be more pragmatic to have initially an even greater target, which would progressively be lowered in the future. That approach would reflect the assumption that, as overall prevalence falls and approaches minimal levels, those still living with the virus will be harder to locate within the population.

Treatment should be focused in the community. That will ensure that access is not hindered for those who have difficulty accessing secondary care services. The all-party group recommends making treatment more readily available in GP clinics and pharmacies, homeless shelters, substance misuse centres, sexual health clinics and prisons.

Funding is where the crunch comes, and we have quite a bit to say on it in our report. Although new curative treatments have considerably decreased in cost, pioneering new treatments for hepatitis C are not immune to concerns. The way in which the new treatments were initially rolled out by NHS England drew criticism at the time. For example, restrictions were placed on the number of patients able to access them each year in England. Of course, the hon. Member for Central Ayrshire (Dr Whitford) has reminded the House of that. I am sure that the Minister is aware of recent negotiations between NHS England and the industry to develop a new funding model in this area and one that does not restrict access for patients. Without such dialogue, elimination in England would be severely compromised.

The all-party group has gone further, however. We recommend that any future deal should prioritise equitable availability throughout the country—I suppose we are thinking here of the postcode lottery—that does not discriminate against patient populations. On the subject of the all-party group’s recommendations, we believe that we should continue to monitor elimination progress with reference to progressive targets. The report calls for more diverse data on the virus to be collected and shared. It is the group’s belief that that would additionally allow for improved allocation of testing and treatment resources.

As the all-party group’s report makes clear, we believe that the eradication of hepatitis C in the foreseeable future is an extremely achievable goal—we really think we can do this. It is a goal to which our international partners are committed, which is very good. Some of them are making greater progress towards achieving it than we are, for whatever reason. For the target to be met, we must change our approach to hepatitis. It is my belief that the recommendations that I have summarised today must be implemented, and as soon as possible. Failure to do so will only prolong the existence of hepatitis C in this country. We have at our disposal the means to eliminate it. Let us do that.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

It is a pleasure to serve under your chairmanship, Mr Streeter. Hepatitis C was identified about 25 years ago. When I was a young doctor, it was simply known as non-A, non-B hepatitis, because no one had any idea what it was. As the hon. Member for Southend West (Sir David Amess) said, we are talking about something that many people simply do not know they have. That is a key, underlying problem. Patients may only be aware that they have hepatitis C when they start to have liver symptoms, which is the start of cirrhosis or malignancy.

With any condition, we first want to prevent it. As was mentioned, at needle exchanges we already have blood screening to ensure that it is not coming from transfusion. We have to remember those in this country who previously suffered from contaminated blood that was iatrogenic—caused by doctors and the health service.

I agree with the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) that we need a more medical approach to the issue of drugs. If we drive problems underground, there is no possibility of detecting and treating people, to achieve the elimination that the World Health Organisation is aspiring to.

In Scotland we are recognised as world leaders, in the sense that we had a strategy in 2005, 2008, 2011 and then our elimination strategy, which was introduced in 2015. The 2011 strategy fed into what became the World Health Organisation strategy, as one of our senior leaders was seconded to it. The big change is sofosbuvir and ledipasvir—the new antivirals that are well tolerated and able to clear the viral load in 90% of all patients. Of course we would prefer a vaccine, as the hon. Member for Strangford (Jim Shannon) mentioned; that is how we eliminated smallpox and how we are trying to eliminate polio. However, the problem with hepatitis C is that, as he said, there are six genotypes, but 50 subtypes, and it mutates regularly. It is one of those viruses with a coating that is very hard to get a handle on with the immune system and therefore to develop a vaccine for, so we need to use the drugs until a vaccine is available.

The Scottish Medicines Consortium passed sofosbuvir in 2014 and NICE passed it in 2015. Unfortunately, NHS England took the approach of trying to slow things down because the drugs are very expensive. However, dealing with liver failure and having to consider liver transplantation is even more expensive. A cap of 10,000 patients with cirrhosis and the most severe conditions from hepatitis C was set.

In Scotland in 2015, we took the opposite approach—a public health approach—to try to reduce the virus in the community and prevent it from occurring.

[Dr Poulter]

The hon. Lady is making very good points. I am sure she will correct me if I am wrong, but the other point to make is that in Scotland there has been a much more joined-up approach in tackling heroin addiction. Scotland is much further forward than England in addressing such issues, in having a co-ordinated strategy and in recognising how addiction leads to prisons and the criminal justice system. Indeed, there is not the fragmented commissioning of services that we see in this country. Does she agree with me that that is something that England can learn from in addressing the lack of joined-up working and commissioning?

[Dr Whitford]

I thank the hon. Gentleman for his comments. As NHS Scotland is still a single public body, we do not have the issue around commissioning. We are also trying to take a much more health-based approach to addiction. As happens in England as well, we have multiple needle exchange programmes. This place has held us back from trying to introduce safe injection in Glasgow, which has one of our highest drug-addicted populations and highest incidence of drug-related deaths. However, that initiative comes under the Home Office and we have not been granted permission to try to take it forward. Always taking a criminal justice approach gets in the way of achieving the medical outcomes that we want.

It is really important to recognise the breakthrough of the drugs. With an eight or 12-week course, expensive as it is, more than 90% of patients will achieve a sustained virological response. That means they remain with undetectable levels of virus 12 to 24 weeks after the end of their treatment. The problem with rationing treatment to those who are actually ill is that it is the people who are not ill with hepatitis who spread it to other people, because they are out and active. If they are drug users, they are still using drugs. Someone who is so ill that they are confined to bed is not spreading it. That is why we took a public health approach to eliminating hepatitis C over the coming years. We certainly aim to achieve that before the World Health Organisation target date.

As the hon. Member for Southend West said, one of the key issues is people not knowing that they have the virus, so, in Scotland, part of our approach has been to create opt-out screening at various points of blood being taken. That will be from general practice in areas of high prevalence. It already includes bloods taken in accident and emergency. It includes screening at other times such as when we screen for HIV. Obviously, we screen for HIV when a woman has her booking appointment at the time of her pregnancy. We need to use all the opportunities that we can. Of course a patient always has a right to opt out, but when we make something the norm it becomes easier for people to agree.

The prison population obviously has a big problem with drugs, including IV drugs—either in the present or the past, before the prisoners were incarcerated. It is important that we get the tests taken up by such populations.

We also offer testing in more social settings, where there have been education events around hepatitis and HIV and where peer-to-peer work has been done. It is important that we raise awareness and try to reduce the stigma. There is a problem with always talking about HIV drug users, as opposed to recognising that someone might have been contaminated by blood in this country, while undergoing maternity care or surgery overseas, or, as was mentioned, in a tattoo parlour: it means that people do not care. We end up with, “Well, it’s their own fault”, which maintains the risk to everyone else and hampers elimination. As well as raising awareness, we absolutely have to reduce the stigma.

It is important to take a public health approach, as we have done in Scotland. I commend that to NHS England, which should remove the cap and do as we are doing: try to set a minimum target for new people to be found and treated as soon as possible. We have seen the new cases reduce from 1,500 in 2007 to 700 in 2013, but it is the chronic cases that have been out there for years that we have to find because they still carry the virus and can spread it to other people.

Of course, NHS England should try to get the price down. There is no right for drug companies to profiteer as opposed to having a fair return, but the issue must be taken in the round. We must recognise that eliminating the virus by using drug treatments while we wait for a vaccine will overall be an huge benefit to society.

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[Steve Brine]

Point taken; feet will be held to said fire. I do not think that NHS England is found wanting in this area, and I will go on to say why, but I take my hon. Friend’s point and will follow it through, because I want this to work.

The new industry deal may allow for longer contract terms that cover a number of years, but whether a long-term deal can be reached and what its duration is will be contingent on the quality and value of the bids submitted by industry. I expect the outcome of that in the autumn.

On local delivery networks, NHS England has established 22 operational delivery networks across our country to ensure national access to the antiviral therapy. I will touch on the issue of the cap in a minute. Those clinically led operational networks are given a share of the national annual treatment run rates based on estimated local need.

That local operational delivery network model ensures better equity of access. Many patients with chronic hepatitis C infections come from marginalised groups that do not engage well with healthcare, as has already been said. Through the development of networks, it has been possible to deliver outreach and engagement with patients outside traditional healthcare settings, such as offering testing through drug and alcohol services and community pharmacies.

As hon. Members know, I have a great soft spot for community pharmacies, and I think that they can and do play an important role in this space. In April, I hopped along to Portmans Pharmacy, which is just up the road in Pimlico, to see the pharmacy testing pilot of the London joint working group on substance use and hepatitis C that is going on there. I saw the testing and the referral to treatment that takes place in pharmacies that offer needle and syringe programmes across six boroughs in London.

Portmans Pharmacy has provided a needle and syringe programme and the supervised consumption of methadone for a number of years. Those points of contact with people who inject, or previously injected—a key distinction—drugs provide an ideal opportunity for us to make every contact count and to test for hepatitis C, as we think that about half of people who inject drugs in London have the virus.

The approach of Portmans Pharmacy and the London joint working group is innovative. It aims to provide quick and easy access to testing and a clear pathway into assessment and treatment in specialist care, which is obviously critical. I pay great tribute to the work that the group has done. It has rightly received a lot of coverage and a lot of plaudits. I am anxious and impatient—as my officials know, I am impatient about everything—to see the peer-reviewed results of that work and where we can scale it out more.

The hon. Member for Central Ayrshire mentioned treatment in respect of the cap. It is different north of the border, but NHS England offers treatment as per the NICE recommendations. The drugs that she mentioned are expensive, which limits the number of people who can be treated each year, but treatment has been prioritised for those most severely affected. The NHS then provides treatment to others who are less severely affected. So far, 25,000 people in England have been treated with the new drugs and a further 13,000 will be treated this year. The NHS procurement exercise should allow for even larger numbers to be treated each year. Of course, nothing is perfect in life. Resources in a publicly funded health system are finite, which is why we have to target them at the most challenged group. That is one of the reasons why making every contact count through primary care and pre-primary care, as I call community pharmacies, is so important.

[Dr Whitford]

Does the Minister accept, though, that the people who are likely to continue to spread the condition are those who are less ill? The old concoctions tend not to be so effective or well tolerated. That is a big difference from the new antivirals, which are very effective and very well tolerated. It strikes me that in England, we may be letting more people become more ill before they qualify for the better drug.

[Steve Brine]

Of course, the hon. Lady states a fact not an opinion, and I accept that, which is why I speak of the importance of primary care and of making every contact count. The people who Portmans Pharmacy interacts with are not all sick. People who have a hepatitis C infection or a drug-use issue have other issues—they get flu too—so they interact with that pharmacy, and the pharmacy makes every contact count by grabbing people earlier. That is one reason why I am so passionate about the way that that underused network can help us to reach the ambitious targets that we have set.

Everyone has rightly talked about prevention—in many ways, I am the Minister with responsibility for prevention and it is the thing that I am most passionate about in our health service. As well as testing and treating those already infected, an essential part of tackling hepatitis C must be the prevention of infection in the first place, or the prevention of reinfection of those successfully treated, which would not be a smart use of public resources.

NHS England and Public Health England, which I have direct ministerial responsibility for, are actively engaged in programmes at a local level to prevent the spread of infection. As people who inject drugs or share needles are at the greatest risk of acquiring hepatitis C, prevention services, particularly those provided by drug treatment centres, are key components of hepatitis C control strategies. Clearly, the key to breaking the cycle of hepatitis C is to prevent infection happening in the first place.

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[Steve Brine]

I will not prolong this discussion, Mr Streeter, but I take my hon. Friend’s point and I think it is a subject that will receive further airing, to put it mildly.

[Dr Whitford]

Will the Minister give way one last time?

[Steve Brine]

One last time and then I must conclude, because I want to touch on prisons.

[Dr Whitford]

Obviously, this debate has emphasised the importance of diagnosing people and getting people to undergo testing. However, does the Minister see that it is much easier to encourage people to undergo a test when they can be promised that they will get effective, tolerable treatment that will be successful, as opposed to their perhaps being left languishing on what is now relatively old-fashioned treatment that is full of side effects?

[Steve Brine]

Yes, of course, and that is why I have talked about the local networks, and about early detection and prevention. What the hon. Lady says is self-evident.

The Hepatitis C Trust, which has rightly received many plaudits today, has played an important role for us in recent years in piloting pretty innovative ways of increasing testing rates, through mobile testing vans—for example, in the constituency of my hon. Friend the Member for Southend West—and the pharmacy-based testing work that I mentioned, as well as the introduction of peer educators in prisons, which a number of people have mentioned today. My hon. Friend mentioned his visit to Wandsworth Prison, which he was right to say is a very good example of peer educators working.

The subject of prisons is one the House knows is of great interest to me. Given the number of people who, sadly, actively inject drugs across the criminal justice system and the custodial system today, it is obviously likely that a significant proportion of those in the infected but undiagnosed population will have spent some period at Her Majesty’s pleasure.

As part of the health services commissioned for those in detained settings, an opt-out testing programme for blood-borne viruses, including hepatitis C, in adult prisoners was fully implemented across the English secure estate last year, 2017-18. Because of the expected higher rates of prevalence, opt-out testing for blood-borne viruses is offered in 100% of the prison estate in England, as part of the healthcare reception process, although, it has to be said, with differential success and outcomes. We are currently addressing that through a range of initiatives that have been put in place to improve the delivery of testing and the provision of successful treatment in prisons. So, in some areas the whole-system changes are being piloted.

My shadow, the hon. Member for Washington and Sunderland West (Mrs Hodgson), made the very good point that we’ve started, so we must finish. Absolutely; as I said earlier, it would be a very inefficient use of public resources to start treatment inside the secure estate. That is why, when we talk about through-the-gate treatment, that treatment must include health treatment. That is something—I cannot believe that my hon. Friend the Member for Bracknell (Dr Lee) is getting a second mention in this debate; I see that he is on his feet in the main Chamber—that I look forward to talking to the new Minister with responsibility for prison healthcare about, whenever he or she takes up that lucky role in future hours or days.

Let me take the opportunity once again to congratulate the all-party parliamentary group on liver health. It is not the first time that I have said this and it will not be the last: so much good work in this place goes on in all-party parliamentary groups, including so much informed debate. As a Minister—I am sure that others in the Chamber who have been Ministers would concur—I think that those groups are incredibly valuable to us and to the work that we do.

That is why I spend so much time listening to all-party parliamentary groups, helping them, including helping them to launch their reports, and then writing back with line-by-line responses to their reports, because their work is so vital to us. It is critical on a public health issue such as this, which, as I said at the start, is often overlooked and sometimes brushed under the carpet as being a little bit, “We don’t want to discuss this.” That is because, exactly as the hon. Member for Central Ayrshire said, there may even—God forbid—be an unspoken feeling that, “Well, with their behaviour they had it coming.” She is very brave to say it and I have no qualms in repeating it, but I think that feeling does exist.

The measures that I have spoken about today are not a panacea; the target is an incredibly challenging one for us. However, the Government, Lord O’Shaughnessy—who speaks for us in the other place on this subject and shares an office with me—and I are all passionate about this issue. We passionately believe that it is something that we can and will beat. We are taking it seriously, and we are in a good position to push forward and significantly reduce the burden of hepatitis C, in line with our commitment on it.

This debate shows us that improvement in hepatitis C testing and delivery of treatment are best delivered where there have been whole-system improvements. The Government, together with the wider health and social care system, have got to take all the opportunities available to us to address this key, but sometimes overlooked, public health challenge.