Health: Liver Disease
Baroness Finlay of Llandaff Excerpts(10 years, 2 months ago)
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Baroness Finlay of Llandaff
To ask Her Majesty’s Government what progress has been made to implement the recommendations of the Lancet Commission on liver disease, to address the incidence of liver disease in the United Kingdom.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
Since the publication of the report of the Lancet commission, the Government have continued to address the incidence of liver disease through a number of measures which focus on both the prevention of liver disease, and improved care for those with liver disease. Public Health England has a programme of public health action to tackle liver disease and is working with key stakeholders, including the Lancet commission, to produce a framework for liver disease next year.
Baroness Finlay of Llandaff (CB)
As we enter the festive binge drinking season, do the Government recognise that 28% of deaths in 16 to 24 year-old males are alcohol-related and that 85% to 90% of the cost of in-patient liver disease is due to alcohol? By raising the floor cost of alcohol by 10%, we may be able to reproduce the Canadian evidence of a 30% fall in deaths attributable to alcohol. Do the Government also recognise that we have a responsibility to the next generation because in pregnant women hepatitis, obesity and alcohol are each risk factors, each compounding the other? If we implement a six-in-one vaccine programme for hepatitis B in neonates, we may prevent the next generation suffering from hepatitis B as well as decrease the incidence of foetal alcohol syndrome by tackling alcohol abuse in pregnancy.
Lord Prior of Brampton
My Lords, there was quite a lot in that question. Some 6,000 babies suffer from foetal alcohol syndrome and it is a shocking and appalling by-product of alcohol. Canada has increased the floor price of alcohol and I understand it has seen some reduction in alcohol-driven disease as a result of that. We are watching what happens in Canada carefully. Of course, Scotland is considering a similar move although it is awaiting the outcome of a court case in the European Union. I gather that Wales will possibly follow suit if that court case goes accordingly. We will watch what happens in those other countries, study it and then make up our minds accordingly.
Mesothelioma (Amendment) Bill [HL]
Baroness Finlay of Llandaff Excerpts(10 years, 2 months ago)
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Baroness Finlay of Llandaff (CB)
My Lords, like others, I congratulate my noble friend Lord Alton on his tireless work in this area and on his perseverance in trying to improve the outlook for the future. I shall concentrate on mesothelioma not as an epidemic of today but as one that is looming because of the problem in our schools. The need for research is ever more pressing as time goes on.
It has been estimated that more than three-quarters of our schools—my noble friend Lord Alton referred to 87% of schools—have asbestos in place. We know that deaths from workplace exposure are more common among healthcare workers, teachers, telephone engineers, shop workers, finance workers and so on. It is estimated that about 20 deaths a year occur among teachers. In healthcare, we are not sure of the exact number of deaths. When I was a junior doctor the lagging was hanging off the pipes in the basement of Westminster Hospital, just across the road from here, and in other hospitals in London in which I worked. To go to cardiac arrests, we would literally run through the dust and sometimes hit our heads on bits of lagging that were hanging down. Everyone was oblivious to the dangers.
The problem is that we have asbestos in our schools and that means children are being exposed. Other countries have decided to have a phased removal—for example, Australia has already implemented that—and the European Parliament has called for the removal of asbestos from all public buildings by 2028. The Committee on Carcinogenicity of Chemicals in Food, Consumer Products and the Environment reported that,
“it is not possible to say whether children are intrinsically more susceptible to asbestos-related injury. However, it is well recognised … that, due to the increased life expectancy of children compared to adults, there is an increased lifetime risk of mesothelioma as a result of the long latency period of the disease … for a given dose of asbestos the lifetime risk of developing mesothelioma is predicted to be about 3.5 times greater for a child first exposed at age 5 compared to an adult first exposed at age 25 and about 5 times greater when compared to an adult first exposed at age 30 … we conclude that exposure of children to asbestos is likely to render them more vulnerable to developing mesothelioma than exposure of adults to an equivalent asbestos dose”.
The current advice with regard to asbestos is that it should remain undisturbed, and indeed that seems sensible. However, there does not seem to have been a comprehensive assessment of what happens in our schools when children’s chairs and desks scrape along the walls and a little shower of asbestos dust comes into the classroom; or when windows or doors are slammed, not because of children behaving badly but simply because the school is a building with lots of boisterous children in it. Assessments have been done when buildings have been empty.
There is an urgent need for research into why some people develop mesothelioma and others do not, and for long-term epidemiological studies, which take money and investment, to understand what is going on in the long term so that we can plan for it if the numbers are going to go up hugely. In my own field, I have made a plea for us to undertake some research into why mesothelioma causes so much pain, and why it appears to be relatively difficult to manage with straightforward analgesics. In my own hospital, the Velindre Cancer Centre, Dr Jason Lester is doing some innovative research on tumour-associated antigens and their expression on the surface of tumour cells, but that research is not cheap—it cannot be done on a shoestring—and needs dedicated cell lines.
The Asbestos in Schools Steering Group was set up by the Department for Education in 2012. What is its position with regard to academies and free schools in relation to their responsibilities for managing asbestos, and where are the levers that the Department for Education has for managing it? I understand that the Health and Safety Executive produces guidelines for how asbestos should be managed, but the responsibility seems to lie with those who are running the schools themselves.
For us in Wales, this has revealed what you could call the “devolution crack” because no one seems to be taking clear responsibility for schools in Wales. In the Senedd on 28 January this year, the First Minister said:
“The responsibility lies with the Health and Safety Executive; that is quite clear”.
He went on to say that,
“in terms of ensuring that the responsibilities are progressed, that is also a responsibility of the environmental health officers”.
However, that appears to be at odds with Answers that have been given in this House. When the noble Baroness, Lady Randerson, was Parliamentary Under-Secretary of State at the Wales Office, she answered a Written Question last year from my noble friend Lord Wigley about responsibility in Wales by saying:
“The Health and Safety Executive has responsibility for regulations and guidance as it applies to the management and control of asbestos in all workplaces in Great Britain, including schools. However, within this framework, the development of policies for the management and control of asbestos in schools is a matter for the Welsh Government”.—[Official Report, 14/1/14, col. WA 11.]
Your Lordships might think that that would be the end of it and it should all sit with Wales, but I suggest that in the long term the devolution crack that has been demonstrated will affect NHS England just as much as NHS Wales. Wales is a net exporter of young people, particularly into the professions, and a net importer of older people. We have a lot of older people coming to spend their last years in nursing homes, particularly in north Wales and along the coastal strips. So Wales may have a problem today but unless there is joint working between those responsible, and unless Wales is invited to join in and share expertise on these committees, we are not going to solve the problem in the long term for the next generation. I also suggest that the confusion over this has been evident in the complaint that was taken to the Parliamentary Ombudsman by Annette Brooke on behalf of the Asbestos in Schools group regarding the conduct of the Health and Safety Executive following the closure of Cwmcarn High School in 2012, the outcome of which is awaited.
This Bill is very important for the future, not only for the health of the whole of our nation—England and Wales joined together—but because it is important to plan expenditure and demand, and to plan how we are going to manage what may be a looming epidemic among our schoolchildren that we have not even begun to take notice of yet.
Lord Prior of Brampton
If there is a shortfall—and there may be a shortfall—given that that levy is raised from the industry on an equitable basis rather than relying upon two or three insurers to do it on a voluntary basis, that strikes me as a better approach. The point has been made that compensation payments are somehow different from funding research, but it strikes me that the two are very closely related. I am just putting it out there for further discussion, and I would like to pursue that discussion with my noble friend Lord Freud, who is probably the expert on our side of the House on this matter and was intimately involved with the Bill which came through the House in 2014. I would like to have that discussion with him and perhaps with the noble Lord, Lord Alton.
I have not dealt with the veterans issue or the schools issue. I shall deal with them by letter, if that is all right. They are both extremely important. The situation with the veterans and the MoD is under active consideration by my noble friend Lord Howe. I will write to the noble Baroness, Lady Finlay, if she is happy with that, setting out the situation on schools in Wales.
The instinct of the Government is not to support the Bill, for the reasons I have given, but there may be a way through this which we are able to explore over the next month or two.
Baroness Finlay of Llandaff
When he writes to me, will the Minister include in the correspondence the noble Lord, Lord Wigley, who has done a lot of work on schools in Wales? He might want to meet him. Will the Minister clarify who has responsibility for free schools and academies? They are in a different position from maintained schools, yet they often occupy buildings which contain asbestos.
Lord Prior of Brampton
I think the answer to that question is that the Health and Safety Executive would have prime responsibility for them. I think the point that the noble Baroness is making is that the local authority no longer has the responsibility it would have over local authority schools. I will look into that issue and write to the noble Baroness.
Junior Doctors Contract
Baroness Finlay of Llandaff Excerpts(10 years, 2 months ago)
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Lord Prior of Brampton
I agree entirely that industrial action is the last thing that any of us want. I have worked with trade unions of one kind or another off and on since 1980—for 35 years. I think that the Junior Doctors Committee of the BMA is behaving in an extraordinary fashion.
Baroness Finlay of Llandaff (CB)
My Lords, can the Minister say how sincerely the Government are considering going to ACAS, which, as far as I understand it, is acceptable to the BMA Junior Doctors Committee, and can he explain why there is resistance to doing that? Given the threat of terrorism that we now face, have the Government assessed the impact and the security that would be needed on the strike days both in the event of a terrorist attack on the population at large, when those who are well versed in managing it will not be working, and in the event of a terrorist attack specifically targeted at demonstrations by junior doctors, when they will be injured and the hospitals will be empty?
Lord Prior of Brampton
The Secretary of State has said that he is open to conciliation. Frankly, it would be so much better if we could sort this out ourselves rather than go to conciliation, but he has said that he is open to it. If there is a terrorist attack, speed will be of the essence if people are severely injured. Junior doctors care hugely about their patients, so I think we have to rely on junior doctors to be available in hospitals in the event of some awful terrorist outrage, even if they are on strike. I will certainly draw to the attention of COBRA and the relevant authorities the question of the impact of terrorism on a demonstration by junior doctors.
Access to Palliative Care Bill [HL]
Baroness Finlay of Llandaff Excerpts(10 years, 3 months ago)
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Baroness Finlay of Llandaff (CB)
My Lords, I declare my interests as palliative care lead for Wales, chair of the National Council for Palliative Care and chair of the National Mental Capacity Forum.
The only certainty is that every one of us will die. Nothing else in healthcare in the UK applies to 100% of our population. About three-quarters of us will need palliative care input at some level when we are dying. The UK seems to be a good place to die. It was ranked top of 80 countries in the recent Economist Intelligence Unit report. We can be unashamedly proud of our hospices and palliative care services. I am grateful to them all for their support of my Bill.
Let me explain why my Bill is needed, what it will do and why it will not incur costs but will free up resources in the system. The Parliamentary and Health Service Ombudsman’s report, discussed yesterday in the excellent debate of the noble Lord, Lord Farmer, shows all too clearly that provision of palliative care in England is unacceptably patchy. The Minister spoke of our transparency, and although he cited that many report good or excellent care, he admitted that a quarter of bereaved relatives reported that end-of-life care was not good enough. The memory of that experience remains in the minds of bereaved relatives and can blight their lives, particularly if they are children.
The ombudsman reported that in its casework:
“End of life care is, sadly, a recurring and consistent theme”.
Inadequate care is not a few isolated incidents. National audits by the Royal College of Physicians and Marie Curie, and the recent House of Commons Health Committee report on end-of-life care, and many others, all say the same: many places provide excellent care but provision is patchy and varies in quality, accessibility and reliability.
In response to the report More Care, Less Pathway, the Leadership Alliance for the Care of Dying People set five priorities of care in its report One Chance to Get it Right. The Bill is a chance to finally get it right for all. It meets the recommendations that appear consistently in reports, in particular the Health Committee report, What’s Important to Me: a Review of Choice in End of Life Care, which is awaiting the Government’s response, Ambitions for Palliative Care and End of Life Care, from a wide coalition of 27 lead providers and charities, published just this month, and the ombudsman’s report. It would narrow the widening gap in hospice provision between affluent and poorer areas. It would ensure access to hospice care for those with non-cancer diagnoses.
The NHS Confederation describes the NHS as “at a cliff edge” and points out the need to transform the way that the health service provides care. David Behan, reporting on the state of health and social care in England, points to the need for more collaboration between organisations and services; to evidence that person-centred care is better for the individual and can be more economical for service providers; and that safe services require the right staff and skills mix.
We all know what to do—we have strategies, working parties and reports galore—but we are just not doing it all the time, everywhere. Why not? The demands on clinical commissioning groups are great. They are well intentioned, but drowning. They need a clear, simple template to bring up the standard of services. Importantly, patients and their families, faced with all the fears and uncertainties of discovering that this is likely to be their final illness, need and deserve the assurance that their care will be good and that they will not be abandoned or failed in their hour of need, wherever they are, whatever the time or day of the week.
In 2008 we had the End of Life Care Strategy for England and a similar national strategy in Wales that we implemented pan-Wales. Both were reinforced by the NICE guidance on what high-quality palliative care should look like, including that patients’ physical and psychological needs are safely, effectively and appropriately met at any time of the day or night, including access to medication and equipment, and that those whose needs may benefit from specialist palliative care are also offered it at any time of the day or night.
In Wales, we developed a funding formula for palliative care services in 2008 to correct the wide variation in availability. We developed seven-day services, with specialist advice to any healthcare professional at any time of the day or night. We set a benchmark of provision of one actual bed, or a virtual hospice-at-home bed, per 15,000 population; a standard of responding rapidly to urgent referrals; out-of-hours “just in case” boxes for medication for patients at home; a single core palliative care IT record; and staff education initiatives. I am not claiming that we are perfect, but we know that patients consistently rate their experience of care from palliative care providers in Wales as over 9.5 out of 10 across domains of dignity, being listened to, having their concerns addressed and timely care. Indeed, scores of seven out of 10 or below set an alert.
In preparing for today I sent a freedom of information request to all 209 clinical commissioning groups. One hundred and twelve gave information about the number of beds they commission. Benchmarking against Wales on a population basis, 49 have fewer dedicated palliative care beds than Wales and 66 have more. The beds are probably there already, overall. Subject to data validation, clinical commissioning groups’ spend ranged between £15 and £10,504 per patient with palliative care needs, with an average spend of £886 per patient.
Regarding levels of services commissioned, there was wide variation—a true postcode lottery. Some 78% commission 24/7 specialist palliative care advice, but what happens to patients in other areas when staff get stuck and do not know what to do? Only 29 clinical commissioning groups knew how many people they had with palliative care needs, although the Palliative Care Funding Review showed that 0.75% of the population have palliative care needs at any one time.
Narrative from the bereaved and professionals, reported in Every Moment Counts, highlights failures in co-ordinating and personalising end-of-life care, particularly pain relief. Such care is, and should be, delivered by and large by generalists, but often they lack training and confidence to open up difficult conversations, to know how to respond appropriately to distress, or to manage pain urgently.
Actions for End of Life Care set policy aims for 2014 to 2016. It is packed with words such as “promoting”, “supporting”, “facilitating partnership” and “working together”. Its aims are laudable and it would deliver better care if they were all fully implemented. But we do not live in an NHS of plenty; we hear daily of cash-strapped services, of deficits, of failing to meet priorities. There are 15 million people living with one or more long-term conditions. Their admission to hospital is often avoidable.
Cicely Saunders Institute research showed that early integrated specialist palliative care significantly improved quality of life for patients with severe respiratory disease at no additional cost. Sue Ryder’s Bedfordshire partnership provides out-of-hours support, resulting in lower emergency hospital admission rates.
Cancer patients receiving palliative care are half as likely to attend the emergency department in the last month of life. Those with pain and poor care are more likely to have multiple emergency department visits in the last two weeks of life. The Nuffield Trust estimates that over that last three months of life the cost of end-of-life care in a hospice is around £550 per person, compared with £4,500 per person in a hospital—an increase largely due to emergency admissions that could have been avoided.
A new palliative care service for people with severe multiple sclerosis improved pain and care-giver burden, at a total cost saving of almost £2,000 per patient over three months. Coordinate My Care, developed by the Royal Marsden, has ensured that three-quarters of those who died while on the programme did so in the place of their choice, with an average saving of more than £2,000 per person.
Let me explain what my Bill would do. It would ensure that wherever a dying person is, whatever the time of day or night, whatever day of the week, they can receive high-standard care. How would it do this? It would do so by ensuring that commissioners commission a level of service for their populations to meet need. If you are a patient with complex needs and things become difficult, you cannot access a specialist service if it is just not there. You cannot expect staff to meet your needs if they do not know what to do and have no one to ask for help. You cannot access medication at home if your needs change, if there is no local way to get that medication urgently, and if the out-of-hours provider does not carry even the basics because they will not pay £4,504 to be licensed to hold an emergency stock. If you need equipment, you cannot wait days or weeks for it. Electronic palliative care communication systems promote better co-ordinated timely care, avoiding inefficiency and duplication. They need to be everywhere. My Bill would ensure co-ordination so that help is accessible, efficient and can meet needs. It is often said that good care costs less than bad care. Sensitive attitudes and caring behaviours by staff cost nothing, but they transform the quality of the patient and family experience.
Health Education England has indicated that it would welcome this Bill to ensure core education and training everywhere. Currently, only one-fifth of trusts have mandatory training in care of the dying. And research is essential to drive forward improvements; it is not a bolt-on.
There are around 500,000 deaths a year in England. Although three-quarters of people have an expected death, the way the deaths of the other quarter are managed can be improved by lessons from palliative care being applied to ways that family members are informed and supported, and how the critically ill and rapidly dying patient is managed.
The stories of people dying at home in distress through failures of commissioning have to stop. We know what to do but we are just not always doing it. At the end of the day, no amount of nice words will make commissioners ensure that they have in place the services to meet their population’s needs.
Why legislate for this and not for other services? It is simply because everyone will die. No other area of healthcare has 100% certainty, so this will not set a precedent. This is the time to make the good care of everyone who is dying a given. I beg to move.
Baroness Finlay of Llandaff
My Lords, I am most grateful to everyone who has spoken in this debate. They prepared for it carefully and highlighted the inequities in provision. I thank all those who support the Bill. I believe that patients and relatives out there, hearing that the Government do not support legislation that would drive up standards of palliative care provision, will be horrified. This has not been plucked out of the air. In Wales we have been doing this for seven years. It is a template as the result of a natural experiment between England and Wales. Through the Bill, we are trying to share best practice.
The Bill is indeed only skeletal. Since coming to this House, I have learnt that you do not put into a Bill what can go in guidance. The issues that have been raised by Peers over possible amendments I would certainly expect to see set out in guidance because that is the right place for them. The reason is that systems change over time, healthcare professional responsibilities change, and you do not want to be locked into something that becomes archaic.
This is not the Liverpool care pathway in another guise. In fact, I have to say publicly that we did not adopt the Liverpool care pathway in Wales because we predicted that it would run into trouble. We developed a slightly different, modified system of our own.
The principles of the Health and Social Care Act 2012 have to work out, and over time they will, but this Bill will not stifle innovation. In fact, it will make sure that there is innovation because research has set out in the Bill. It will make sure that those who provide specialist care have to keep up to date with what is going on and participate in research. No longer will they be able to duck out of it using all kinds of weasel words and excuses about wanting to protect patients from people who want to find better ways of care and thus improve it. Those people are called researchers who, like those at the Cicely Saunders Institute, have delivered most of the data to provide the transparency the Government want. I am greatly indebted, particularly to Dr Felicity Murtagh, Professor Irene Higginson and other colleagues there, who have provided me with an enormous catalogue of evidence to check out what is in my Bill.
As for consent and control, we already have the framework in place. No one should be treated against their wishes, so we have a framework that enables people to make advance refusals and statements of wishes. They can do it now, when they are well and long before disease strikes, and they can make changes if they change their mind. That is what the Mental Capacity Act 2005 is all about. It ensures that no one is treated against their will. I know that I now have an uphill struggle in trying to get it properly implemented, but it is a challenge that I take on willingly and I am humbled at being given the chance.
I am also alarmed at the thought of care being discriminatory against people on the basis of age and so on. As for people wanting to be cared for at home, I am cautious about anything that tries to put into legislation specific pathways of care because people change their mind. I have had patients change their mind about what they want and where they want to be in their dying moments—not about the place of care, but even about trying chemotherapy or asking for a second opinion about surgery. We have to be flexible all the time with our patients until they are dead because they may change their mind about what they want in the last few minutes. It may be a minor issue, such as whether the family is in the room or out of it, but those wishes need to be respected.
I am saddened that some have tried to link this Bill with the debate on the Assisted Dying Bill. The House of Commons looked at the proposal for physician-assisted suicide very comprehensively and has spoken very clearly. That Bill is unsafe and should not be brought back into either House of Parliament. It is actually an abuse of the House even to think about doing so. If people want assisted suicide, then go away and write a Bill that is safe, but do not saddle doctors in palliative care with it. They are the group that wants to provide better care and do not want to be involved in such a process. Those doctors also have the right to behave ethically and to do what they want for their patients; they do not want just to give in to demands.
I am also saddened that the Government have been so blunt; they will not even look at ways to improve the situation. We will watch the position over time. I hope that the Bill will have a Committee stage because I want to debate some of these issues further, and I also want transparency. But above all, I want every person dying in this country to be secure in the knowledge that they will get the care they need, but I am afraid that the response I have had today from the Government does not give me that assurance.
Child Health: Play
Baroness Finlay of Llandaff Excerpts(10 years, 4 months ago)
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The Lord Privy Seal (Baroness Stowell of Beeston) (Con)
My Lords, we have not heard from the Cross Benches on this Question yet.
Baroness Finlay of Llandaff
Do the Government recognise that there is another group of children who must be considered—those who have illnesses limiting their mobility for a variety of reasons, some acquired and some congenital? The role of physiotherapy in paediatric departments is essential to ensuring that they can grow and develop and become as independent as possible. I declare my interest as president of the Chartered Society of Physiotherapy.
Lord Prior of Brampton
The noble Baroness makes a powerful and strong point. All I can do is agree with her 100%.
Health: Children
Baroness Finlay of Llandaff Excerpts(10 years, 5 months ago)
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Baroness Finlay of Llandaff (CB)
Do the Government accept that intrauterine exposure to environmental toxins, psychological stress and nutritional deficiencies in the mother have long-term health effects on the child, as well as problems that arise in the immediate postnatal period? Will the Government therefore undertake to support epidemiological research in these areas, linked to their reviews of maternity services?
Lord Prior of Brampton
I am well aware of the impact on the health of children before as well as after they are born. I cannot give the undertaking that the noble Baroness would like me to give here today but I am very happy to pick it up with her outside the Chamber.
Health: Lymphoedema
Baroness Finlay of Llandaff Excerpts(10 years, 5 months ago)
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Baroness Finlay of Llandaff (CB)
My Lords, like others who have spoken, I am most grateful to the noble Lord, Lord Hunt of Kings Heath, for introducing this debate so comprehensively. He gave us a very good tutorial in the pathophysiology of lymphoedema. I declare my interests: I am president of the Chartered Society of Physiotherapy and the clinical lead for palliative care in Wales. I will be speaking about our Welsh service because we have a strategy and people can learn from it, just as the noble Lord, Lord Maginnis, outlined the one for Northern Ireland, where the advances have happened because of having a national strategy, just as we do. Unfortunately, as has been said and as personal stories have outlined, there is inequitable access in England because there is no strategy and there are no NICE guidelines.
What has been our experience in Wales? We published a national lymphoedema strategy in 2009 and invested £1 million in 2011 to focus on a clinically effective service that had to be value for money. There are now 9,300 patients with lymphoedema, which works out at 450 new referrals each month to the service. Fifty per cent are cancer-related and in 93% the lymphoedema is secondary to another cause, rather than being primary lymphoedema. Forty-three per cent of the cases are considered complex or severe and there is a direct correlation with age, 86% of the patients being more than 51 years old.
However, the waiting time has gone down since we have had our strategy. In 2011 it was 24 weeks; in 2015 it is 14 weeks, with 95% of patients being seen within 14 weeks. Palliative patients are seen within two weeks and urgent patients within four weeks of referral. Garment dispensing has radically improved. In 2011, 50% of garments were wrongly dispensed; it is now only 5%. The waiting time for garments has reduced from 42 to 10 days. With our surgeons, we have also been able to develop a unique microsurgical technique, which is a real pioneer and has shown a 96% reduction in cellulitis episodes and a 70% reduction in the need for compression garments. I do not think that investment in research would have happened without the rest of the clinical infrastructure being in place. It is estimated that there has been an overall saving, per patient each year, of more than £9,700, while the national contract for purchasing garments is saving £135,000 annually. The cost pre-service was more than £89,500,000 but post-service it has fallen to £41 million, so there is an annual saving of more than £48,500,000 from having a co-ordinated strategy in place.
Let me turn back to England. It is a myth that lymphoedema is so rare. A recent study by Moffatt and Pinnington noted that almost four in 1,000 people have lymphoedema, which is three times the current estimate. This means that somewhere between 72,000 and 227,000 people in England have it, making an average of somewhere around 700 patients per clinical commissioning group. Cancer-related lymphoedema gets the publicity but is only 25% of the workload. Breast cancer, about which most of the public-facing work in educating patients has been done, actually represents 14% of the workload in England.
One of the difficulties is obesity, which has a serious role. I know that when I was setting up the lymphoedema service in the cancer centre, we would get patients referred and, quite often, their bigger problem was obesity. The lymphoedema was very much secondary to it and almost unmanageable until the obesity was tackled. With the predictions of increasing obesity that is a major problem, as 63% of lymphoedema patients have been found to be obese and 21% severely obese. The noble Baroness, Lady Smith of Newnham, who—for those who cannot see her—is very far from obese, outlined that the patients’ experience is poor. That is borne out by all the other data. As has been said, 80% of people have had to take time off work. Half have uncontrolled pain of some sort and about a third were told that they have lymphoedema but have not received treatment.
There is a lack of a national contract for compression garments, which means that prices are inappropriately high. As the noble Baroness outlined so clearly, patients with a condition that appears to be relatively minor feel quite guilty when they are referred to a service linked to a hospice but are also quite often really scared that there is something else going on that they have not been told about.
Services are spread across numerous sectors and there is currently no audit surrounding the level of practitioners’ training or skills. There are then high knock-on costs from primary care into secondary care. This patchy service has effectively meant that there is discrimination against those with non-cancer lymphoedema, because a lot of services have been set up that are linked to cancer centres. The other problem is that there has been a 2.37% reduction in the lymphoedema workforce from 2010 to 2011. The services that are there are vulnerable as a third of them are run by single-handed practitioners. If that person goes off sick, retires or leaves, there is a tendency for that service to fold.
I suggest that there is a need for a national strategy, which should follow the lymphoedema framework and would: identify those who are at risk and their clear clinical grades; empower people who are at risk of or have lymphoedema to manage their own conditions, which frees them up from dependency on the health service; have integrated community, hospital and hospice services, with high-quality clinical care, particularly for the very early management of cellulitis and erysipelas; provide compression garments—the right ones, properly fitted by people who know what they are doing; and require multiagency health and social care. I would stress that some of the best services around the UK have been led by physiotherapists rather than by clinicians of other sorts. I want to give credit to them, because they really have been pioneers.
As for education, since the BMJ produced a learning module, more than 2,000 doctors have completed it. They have sought this out and recognised that they need to learn about it. The noble Baroness, Lady Masham, vividly described the problems when lymphoedema is not properly diagnosed and treated. The National Cancer Survivorship Initiative has shown how early diagnosis and symptom management through improved access to information and treatment would heavily reduce escalation and the need for hospital admissions, as well as reducing morbidity and complications.
The NHS could save £100 in reduced hospital admissions for every £1 spent on lymphoedema treatments that limit swelling and therefore avoid complications. I understand that England currently spends more than £178 million on admissions due to lymphoedema, with a rise in costs of £7 million from 2013 to 2014, equating to more than 22,904 additional admissions. It is predicted that the NHS, as the noble Lord, Lord Maginnis of Drumglass, said, could save £32 million a year by having a proper national strategy that provides a national service. That would mean that patients have fair access, rather than feeling discriminated against due to either the type of lymphoedema they have or where they live. It just does not make sense not to proceed with a strategy.
NHS: Reform
Baroness Finlay of Llandaff Excerpts(10 years, 6 months ago)
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Lord Prior of Brampton
I can only agree with the noble Baroness on bureaucracy. The new body that we are setting up to look at incident reporting, as recommended by the PAC, will only look at big incidents so will not be an added bureaucracy for the day-to-day running of a trust. I am always struck by the figure that nurses spend only between 70% and 80% of their time dealing directly with patients because they are dealing with bureaucracy. The bureaucracy argument falls into two parts: it is partly about the way hospitals run their affairs and partly about external regulators. We believe fundamentally in intelligent transparency. I see the CQC, for example, as less a regulator and more a means of providing intelligent information to boards of hospitals and to patients. But I take on board what the noble Baroness says. We will do everything we can to reduce the level of bureaucracy.
As far as the timetable is concerned, junior doctors will switch over much more quickly than consultants, because they turn over much more quickly. It will take time for consultants to move over to the new contract, but we hope that we can make it more attractive to consultants and that it will be more of what I would call a professional contract, so that existing consultants will switch over to it as well as new consultants. We will have to watch that very carefully.
Baroness Finlay of Llandaff (CB)
The way that the Minister has been speaking has made it sound as if the majority of consultants do not work on weekends, and I question the validity of that. The consultants who are on and on call are dealing with emergencies at the weekend and are very often in. However, without diagnostic back-up, without physiotherapy and occupational therapy, without specialist nurses and without community services to which they can discharge patients, they effectively have to function with one hand tied behind their back—sometimes both. You cannot provide modern medicine without that broader team. If you are going to free up hospital beds, you have to be able to discharge patients safely, knowing that they will have the care they need. The 24 hours post-discharge is when patients are at their most vulnerable.
I will question one thing the Minister said. He gave a six-week timeframe for the BMA. Does that also apply to the NHS Pay Review Body negotiations? What will be done to make sure that all the other staff also move on to contracts that will provide that infrastructure, right through from operating department staff to, as I said, allied healthcare professionals and so on?
The Statement referred to end-of-life care. Could the Minister inform the House when there will be a response to the report What’s Important to Me. A Review of Choice in End of Life Care, which was undertaken for the National Council for Palliative Care? I declare an interest as its incoming chairman. It has been submitted to the Department of Health, but there has still not been a response to it, even though it has been universally welcomed by both providers and patient groups.
My last question relates to digital innovation. I welcome the fact that the noble Baroness, Lady Lane-Fox, with her tremendous skills, will be brought in. What are the Government’s targets and how rapidly are they planning to roll out digital innovations? Will they undertake in the process to decrease the paper-load bureaucracy, so that staff can be freed up to deliver front-line patient care, and are not caught by risk-averse processes and procedures that force them to spend a lot of time in documenting or double-checking, when the evidence base for that improving patient care is extremely thin?
Barts Health NHS Trust
Baroness Finlay of Llandaff Excerpts(10 years, 10 months ago)
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Earl Howe
The decision to create Barts Health was taken following a report that analysed the options open to the department at that time. As the noble Lord knows, there was, effectively, a merger of several trusts to create Barts Health. The advice received by the Secretary of State at the time was that none of the three trusts subject to the merger with Barts was sustainable as a stand-alone organisation. The appraisal of the options identified the three-way merger as the most beneficial and strategic solution for the system as a whole, taking into account a wide range of clinical, financial and government issues.
Baroness Finlay of Llandaff (CB)
My Lords, in looking at the non-viability, I have been concerned that the PFI deals that Barts Health is saddled with amount to £115 million a year. I wonder whether the other trusts that went into special measures have also had this albatross of PFI deals around their necks that has pulled them down over the years. Why have the Government been unable to address the problem of the burden of previous PFI deals?
Earl Howe
Early on in the Government’s term of office, we analysed all the trusts that were subject to PFI liabilities. The worst affected trusts were singled out to be given ongoing financial support by the Department of Health. Barts has a very large PFI debt of about £1 billion, and I have asked whether it is considered that this in itself has proved to be a deciding factor in the trust’s financial stresses. The advice I have been given is that it is not seen as a particular cause of the difficulties now being experienced.
Nicotine Inhaling Products (Age of Sale and Proxy Purchasing) Regulations 2015
Baroness Finlay of Llandaff Excerpts(10 years, 10 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, these regulations restrict children’s access to electronic cigarettes. I am glad that we have the opportunity to debate these regulations, as they are the final element of the package of measures the Government introduced in the Children and Families Act aimed at protecting young people from tobacco and nicotine addiction and the serious health harms of smoked tobacco.
The provisions in the Act give Ministers regulation-making powers to introduce an age of sale requirement for electronic cigarettes and we have taken the decision to do so. The market for electronic cigarettes—which are also known as e-cigarettes—has developed rapidly in recent years. There are many different types and brands now available. Some of them are designed to look and feel like conventional cigarettes; others have a tank or reservoir which is filled and refilled with liquid nicotine. E-cigarettes can be disposable or rechargeable.
Most of the e-cigarettes on the market are flavoured and some of these flavours, such as cherry cola, bubble gum and gummy bear, may be appealing to children. The use of e-cigarettes is also increasing. Action on Smoking and Health estimates that 2.1 million adults in Britain currently use them. This is an increase on the estimated 700,000 users in 2012. Use of e-cigarettes by people under the age of 18 is not currently widespread in this country; however, international evidence suggests that this may increase. The emerging evidence suggests that awareness of e-cigarettes by British children is high. A Public Health England report found that two-thirds—66%—of 11 to 18-year olds had heard of e-cigarettes. Some 7% had tried e-cigarettes at least once and 2% reported using them sometimes or often. E-cigarettes are widely promoted through social media. They are sold in a wide range of retail outlets, including supermarkets, newsagents, specialist shops and pharmacies, and are often prominently displayed and promoted in store.
It is clear that more research is needed before we can determine whether e-cigarettes are acting as a gateway into tobacco use. While e-cigarette use by children is currently associated with existing tobacco smoking, research published by the Welsh Government provides tentative evidence that e-cigarette use may represent a new form of childhood experimentation with nicotine. The Chief Medical Officer has raised concern about e-cigarette use by children and the World Health Organization has recommended that they should not be sold to minors.
Nicotine is highly addictive; it is five to 10 times more potent than cocaine or morphine, and young people can rapidly develop nicotine addiction. Research shows that adolescents are more sensitive to the rewarding effects of nicotine and this may be a reason why many people start to smoke during adolescence. We are aware that responsible e-cigarette manufacturers and retailers do not sell e-cigarettes to children at the moment. However, we have decided to introduce an age-of-sale requirement; we consider that concerns about the increased awareness and use of these products by children make this an appropriate step to take. The age of sale requirement will also provide clarity and consistency for retailers and enforcement officers.
Proxy purchasing occurs when a person over 18 buys an age-restricted product on behalf of someone underage. Young people are known to approach strangers outside shops or ask friends, neighbours or, in some cases, parents to buy tobacco for them. That is why we introduced a new offence of proxy purchasing of tobacco in the Children and Families Act. The regulations extend this offence to cover e-cigarettes.
I shall briefly set out what the regulations will do. The first set of regulations defines a “nicotine inhaling product” as any device which is intended to enable nicotine to be inhaled through a mouthpiece. The definition encompasses e-cigarettes, including disposable and rechargeable types, and certain component parts such as nicotine refill cartridges and nicotine refill substances, often called “e-liquids”. It does not cover component parts such as batteries or charging devices. The regulations do not apply to tobacco products, because we already have age of sale laws for tobacco. The regulations include exemptions for products that are licensed as medicines and so are subject to separate regulatory rules. There are exemptions for nicotine inhaling products that are a medicine or medical device made available in accordance with a valid prescription by a pharmacist. The regulations also exempt the sale of any nicotine inhaling product licensed as a non-prescription medicine—that is to say, available for general sale—and which the licensing authority has determined is indicated for use by children under 18. In such cases, the seller need not be a pharmacist, as such medicines can be sold in other types of shops including newsagents. This means that those under 18 years trying to quit smoking would still be able to access e-cigarettes as well as products such as nicotine patches or gum.
The regulations also extend the proxy purchasing provision in the Act to make it an offence for an adult to buy, or attempt to buy, a nicotine inhaling product on behalf of a child aged under 18 years. The penalties for these offences are set out in the Act: a person making a proxy purchase may be issued with a fixed penalty notice or could be referred to court; and the adult making the purchase would be committing the offence, not the retailer. A retailer guilty of selling nicotine inhaling products to someone under the age of 18 could be fined up to £2,500 on conviction. Local authority trading standards officers would be responsible for enforcing the regulations, as they enforce much of the tobacco control laws.
The regulations bring the age of sale offence for nicotine inhaling products within the scope of primary authority. This arrangement allows businesses to form a statutory partnership with one local authority, which then provides advice for other local regulators to take into account when carrying out inspections or addressing non-compliance.
We are also debating a second set of regulations, which set the amount of the fixed penalty notice for the proxy purchase provisions at £90; this is reduced to £60 if it is paid within 15 days. This provides consistency for retailers and enforcement officers as it will bring the proxy purchase of tobacco and nicotine inhaling products in line with the equivalent offence for alcohol.
The regulations will apply to England and Wales and have been agreed by the Welsh Government. They would come into force on 1 October 2015. We have decided to use the October—rather than April—common commencement date to allow time for the training of enforcement officers and to raise retailer and public awareness.
There will also be further negative statutory instruments to complete the enforcement regime. One will set out the fixed penalty notice form for the proxy purchase of tobacco and nicotine inhaling products in England, and one will add age of sale and proxy purchasing to the list of offences for which enforcement officers can carry out directed surveillance, subject to existing safeguards; for example, to allow test purchasing operations.
The Department of Health held a six-week public consultation on the draft regulations and received 81 responses. The consultation responses confirmed that many responsible manufacturers recommend that their products are for use by adults only and responsible retailers already voluntarily restrict children from accessing e-cigarettes. Almost all respondents supported the policy aims and the specific proposals set out in the regulations. Retailers, e-cigarette manufacturers, local authorities, enforcement officers and the public health community have all been absolutely clear that they want these regulations in place.
The regulations are business-friendly and a number of retail organisations have told us that putting the age of sale in law will help those responsible retailers that already refuse to sell e-cigarettes to children, by ensuring that they are not at a competitive disadvantage by doing so. The cost of the regulations is estimated to be very small indeed and will be mainly on businesses that currently profit from selling e-cigarettes to children and young people.
Many consultation respondents emphasised that this is a fast-moving market in terms of product development as well as patterns of consumer use, and that research evidence into the effectiveness of e-cigarettes in smoking cessation and potential long-term health harms is still emerging. I agree that these are all important aspects of this policy area and we have therefore included a duty to review the regulations within five years of them coming into force.
As I said earlier, I am very pleased to be able to present these regulations to the Committee. They represent the final stage in the implementation of the important public health measures in the Children and Families Act. In recent weeks, we have also introduced legislation to end smoking in private cars carrying children, and earlier this week noble Lords debated the regulations that will introduce standardised packaging for tobacco products. They are all part of our comprehensive approach to tobacco control and make an important contribution to our vision of a tobacco-free generation in the future. I commend the regulations to the Committee.
Baroness Finlay of Llandaff (CB)
My Lords, I thank the noble Earl for introducing these regulations and welcome the way in which they have been drafted. Clearly, a great deal of care was taken in the drafting, and they seem eminently sensible.
It is most reassuring to know that the Association of Convenience Stores welcomes these regulations and the clarity that they provide. It says:
“We support strong enforcement against proxy purchasing of tobacco. We need to see these properly enforced, something that is lacking with the same powers that are in place for alcohol proxy purchasing”,
and that the penalty for proxy purchasing on e-cigarettes puts everything consistently in line. Indeed, it has welcomed the age restriction.
I was glad, too, to hear the reference to the Welsh study because it was the data from Wales that really began to make me personally concerned about these products. There is evidence of increased use among under-18s. I know some people will say that data from ASH are biased, but ASH has been fairly neutral in its view on electronic cigarettes because of the way that they have helped people quit ordinary tobacco cigarettes. It has found that the number of 11 to 18 year-olds who have tried an electronic cigarette increased from 5% in 2013 to 8% in 2014, although it did put the caveat around those figures that the use is closely linked with smoking behaviour.
One piece of research which is really important to have on the record is the work from Counotte and colleagues, published in Developmental Cognitive Neuroscience in 2011, which found that,
“nicotine exposure during adolescence can disrupt brain development bearing long-term consequences on executive cognitive function in adulthood”.
These are new products, with high levels of nicotine in them. We know that the propensity for the developing brain in the age group up until 25 years to develop addictions of all sorts, right across the board, and addictive behaviour is greater than in the older brain. There is a concern that exposure in the young leads to a much greater propensity to develop nicotine addiction.
I have been concerned at the way that these products are marketed, especially to the young, and about their appeal almost as a fashion accessory. When I have looked at those shops which specialise in selling these products, they have made me feel as if I was probably a bit too old to go and buy one. They seem to be marketed very much to a young, vibrant population, which I find alarming. If they are shown to be as addictive as they might be, this will create a long-term market for them in the future.
I have been to several meetings about electronic cigarettes, including one held here in your Lordships’ House at which I was concerned at the almost aggressive way in which vaping was being pursued by some people present, which set alarm bells ringing a bit in my head over the process. These regulations are proportionate, timely and welcomed by those who have the responsibility for selling these products. I am glad that they appear to have universal support.
Lord Hunt of Kings Heath (Lab)
My Lords, I welcome both sets of regulations. The Opposition fully support them. Like the noble Baroness, Lady Finlay, I was very impressed by the evidence from the Association of Convenience Stores and its support for the regulations. It is very persuasive in relation to the introduction of a minimum age of sale and I commend the ACS for the responsible briefing that we were sent ahead of these regulations.
The noble Earl referred to the research, such as the Welsh data and the evidence we have received from ASH, and mentioned the CMO’s concerns. Essentially, although one can certainly see that these products can have a beneficial health impact for many adult smokers, there is this issue about whether children go to smoking through these e-products. Is the noble Earl satisfied that enough research is being undertaken at the moment, either through the traditional research areas such as the MRC and Wellcome or perhaps through Public Health England? I do not know if he has information about this, but clearly it would be good to know that his department is keeping a continuing watchful eye to ensure that enough research is being done. Particularly relating to children, there is enough uncertainty around to make us want to ensure that there is ongoing research on this.
I have another question for the Minister, raised by the evidence that ASH submitted to his department when it was consulting on the regulations. ASH says that there is real confusion about the relative risks of electronic cigarettes compared to smoking, not just among the general public but among health professionals. It quotes from newspaper articles saying that smokers have been given advice by medical people and have had the impression that it is nicotine rather than tobacco smoke that is harmful. ASH quotes a study presented at the UK National Smoking Cessation Conference; it was some years ago so the profession may be more up to date now, but in one study presented at the conference a substantial proportion of GPs incorrectly asserted that nicotine in cigarettes caused CVD, strokes and lung cancer.
The point that ASH makes is that at the same time as regulations are introduced, the Department of Health should promote better understanding of the relative harm of electronic cigarettes and other nicotine products, including those authorised as medicine and their potential benefit to smokers. I understand that with regard to children there are areas where we are uncertain, but there are areas where we are more certain as well. I would be interested to know whether any advice or guidance accompanying the regulations is to be given to medical practitioners in particular.
I welcome the proxy purchasing offence, which is something that we very much support. The Minister quoted cases of young smokers having their cigarettes bought for them by another person, and outlawing this will help to crack down on it and send a wider public message that this is wrong. The other point comes back to the issue raised by the ACS regarding the e-cigarette issue: introducing the offence will give greater power to responsible shopkeepers not to serve people who they know, or strongly suspect, are going to pass cigarettes on to children. Overall, we are glad to see these regulations and to support them.