Hepatitis C

Steve Brine Excerpts

Tuesday 12th June 2018 Westminster Hall

[Sir David Amess]

My hon. Friend was a Health Minister and has real expertise in this area. I shall use the expression “joined-up government”. He is absolutely right that we need Departments to work together. That is why it was so good that we visited the prison.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

I may be able to help my hon. Friend here. As he knows, the drug strategy board is a cross-government committee. It met yesterday, chaired by the Home Secretary, and its members include the Justice Secretary, Health Ministers, Home Office Ministers, Housing, Communities and Local Government Ministers and representatives from the Department for Work and Pensions, as well as senior police officers, representatives from the National Crime Agency and a representative of the police and crime commissioners. That board takes that cross-government look, and hepatitis C is certainly an issue I would like to see it look at.

[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.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

It is genuinely a pleasure to serve under your chairmanship, Mr Streeter, and to be back in Westminster Hall on such a quiet day in Westminster. The hon. Member for Ealing, Southall (Mr Sharma) is sadly not in his place today, but I thank my hon. Friend the Member for Southend West (Sir David Amess) for securing and leading this debate. Although he said that he was not the best person to introduce the debate, he could have fooled us because he did it very well.

Hepatitis C is a significant health issue in our country, and for too long it has been overshadowed by other public health concerns that, despite the superstars involved, have had higher public profiles. I pay tribute to the Hepatitis C Trust and the wonderful Charles Gore, whom I have got to know in this job. He is a colossus in this area, and has become a friend. I also thank the Hepatitis C Coalition—this issue has been central to both those organisations.

My hon. Friend mentioned lots of local services for Southend residents, and a lot is going on in his constituency. Few MPs champion their constituency more than he does, so for his press release I will mention that screening and onward referral services are provided by the Southend Treatment and Recovery Service, known as STARS. For primary care, GP practices refer people to the specialist treatment services in my hon. Friend’s much-loved Southend Hospital. Local drug and alcohol treatment services in Southend hold outreach screening sessions for hepatitis, and all positive cases are referred for onward treatment. Big local successes that I noted in my papers included last year’s hepatitis C roadshow, which took place in my hon. Friend’s area, and there is the hepatitis C operational delivery network educational event 2018—he can see me after class for more details if he would like.

It is always good to see the hon. Member for Strangford (Jim Shannon) in his place, speaking so knowledgably and passionately about this issue, as well as the hon. Member for Central Ayrshire (Dr Whitford), and my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter).

The World Health Organisation has set ambitious targets to reduce the burden of chronic hepatitis C over the coming years, with a pledge to eliminate it as a major public health threat by 2030. The UK Government are committed to meeting and beating that target, as has rightly been said.

A few years ago, hepatitis C-related mortality was predicted to increase in our country, but through the measures that we have in place and the hard work and dedication of so many unsung heroes in the field, 9,440 treatments were delivered nationally against a target of 10,000 in 2016-17; the number of deaths fell for the first time in more than a decade, and that has been sustained for another year; and between 2014 and 2016, there was a 3% fall in deaths from hepatitis C-related end-stage liver disease. That is good news.

However, hepatitis C continues to make a significant contribution to current rates of end-stage liver disease. I welcomed the recommendations to tackle that in the report, “Eliminating Hepatitis C in England”, which was published in March by the all-party parliamentary group on liver health, of which my hon. Friend the Member for Southend West is co-chair. I often produce a recommendation-by-recommendation response to Select Committee reports in my area, but when I checked with my officials during the debate, I found that I did not do it for that report—I was not asked to by the group—but I offer to do so. In fact, I will go further than that—I will go crazy and do it. The group will get that from me as a written response to its report.

This is a timely debate, because NHS England recently launched its procurement exercise for the new generation of hepatitis C antivirals. If that exercise delivers successfully, the ambition is to eliminate hepatitis C as a public health threat earlier than the WHO goal of 2030, and to get to 2025.

[Dr Poulter]

Given the experience that we had with NHS England on HIV PrEP medication and its argument that that was a public health responsibility, which I believe was wrong and which was legally found wanting, will the Minister ensure that he holds its feet to the fire on hepatitis C so it recognises that although it is a public health issue, it has a responsibility for the effective procurement of antivirals and for making them available to all people with hepatitis C?

[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.

[Dr Poulter]

The fundamental issue is that there is no greater evidence of fragmentation—I speak from my own clinical experience—and failure of joined-up working than the fact that local authorities commission substance misuse services but that the NHS commissions mental health services for the same patients and secondary care services for hepatitis C patients. People are falling through the gaps. Many people who have hepatitis C do not present to GPs, and are not even routinely on their lists, so the issue has to be looked at in a much more effective way if we are to make a difference.

[Steve Brine]

I hear my hon. Friend’s experience of the frontline and I would not disagree that in some areas there is unhelpful fragmentation. If I remember rightly back to those happy early days of the election of my hon. Friend and I to this place, we sat on the Health and Social Care Bill Committee. That piece of legislation, controversial as it was, enacted the decision to pass that responsibility to local authorities and, of course, all local authorities are now, in effect, public health bodies. All of them—well, top-tier authorities in England—have directors of public health.

Just because there are challenges and fragmentation, that is not a reason to redraw the system. I do not think there is any desire within the system for a top-down or bottom-up reorganisation—I suspect that, as a doctor, my hon. Friend would agree with that—but there is a challenge to the system to come up with a much better whole-system approach, to make sure that people do not fall between those cracks.

My hon. Friend and I could debate at length—I am sure we will—whether those cracks can ever be filled, and whether there will ever be Polyfilla that is big enough or strong enough to fill those holes, but I do not think that it is a reason to break open the system.

[Dr Poulter]

rose—

[Steve Brine]

I give way to my hon. Friend for the last time.

[Dr Poulter]

This fragmentation of commissioning is a really important point and it comes up in so many debates in Westminster Hall and, indeed, in the main Chamber. I urge my hon. Friend and indeed the rest of the health team—we have got to put right the things that we got wrong. If we want to get this issue right, and get it right for people with hepatitis C, and for people with mental health conditions who are not getting access to services because of this fragmentation, then we have to revisit it.

I urge my hon. Friend to go and spend some time out on the frontline with some professionals and to get them to talk to him candidly—not on a ministerial visit. He should get them to talk to him candidly about these problems, because we have to recognise that this situation needs to change for the benefit of the people we care about, who are the patients.

[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.