Mental Health

Lord Alderdice Excerpts

Wednesday 10th November 2010 Lords Chamber

[Earl Howe]

My Lords, yes. We know that people with severe mental illness die on average 20 years sooner than others and that the majority of these deaths are smoking related. Improving public health is at the core of the Government’s health policy, as I expect the noble Baroness is aware. We will make clear our priorities in this area when the public health White Paper is published.

[Lord Alderdice]

My Lords, we know that early years development is absolutely critical to whether adults will be vulnerable to mental illness later. What things do the Government intend to do in terms of early development, not just in health but across departments, to try to ensure less vulnerability not only in young people, although that is important, but also in adults, since these vulnerabilities develop early on?

[Earl Howe]

My Lords, my noble friend is absolutely right: this is a cross-government effort. It is not simply for the Department of Health to deal with the issue because just about every department has some sort of remit in this area. I would say that, in particular on the attainment of children at school, we will focus very much on children from disadvantaged backgrounds because there is a high correlation between mental ill health and poverty, and mental ill health and deprivation. That will be a major focus.

Health: Chronic Fatigue Syndrome

Lord Alderdice Excerpts

Monday 8th November 2010 Lords Chamber

[Earl Howe]

My Lords, this is a pragmatic decision by the advisory committee on donation. In the case of CFS/ME, which we are looking at at the moment, the committee recommended that the donation policy should be brought into line with other relapsing conditions, where the rule is that we do not take blood from people with such conditions.

[Lord Alderdice]

My Lords, given that there is no medical test that is pathognomonic for this disorder or group of disorders, how do the authorities propose to police its exclusion other than simply by hoping that people will come forward with the information themselves?

[Earl Howe]

My noble friend is right to say that there is no diagnostic test for CFS/ME other than a process of elimination and watching the symptoms. It is largely on a self-reporting basis that the blood transfusion authorities will be alerted to the condition unless, of course, a patient’s GP is involved and can report his or her opinion.

Health: NICE

Lord Alderdice Excerpts

Wednesday 3rd November 2010 Lords Chamber

[Earl Howe]

My Lords, currently the NHS is faced with the decision of whether to say in effect yes or no to a new drug at the price that is proposed by a pharmaceutical company. We want to change that so that the price of a drug to the NHS is based on an assessment of its value, rather than pharmaceutical companies being free to set whatever price they choose and expecting the NHS to pay. So value-based pricing, which is the term we have used, will ensure that licensed and effective drugs are available to NHS clinicians and patients at a price to the NHS that reflects the value that they bring. That should get rid of the postcode lottery.

[Lord Alderdice]

My Lords, of course we already have four NHSs in our United Kingdom. What discussions are there among the authorities of the four NHSs when decisions are being taken about medications of this kind?

[Earl Howe]

My noble friend is, as ever, on the case. My officials in the Department of Health are in active discussions with their counterparts in each of the devolved Administrations on the kinds of changes that we envisage to the pricing of medicines.

Healthcare

Lord Alderdice Excerpts

Thursday 28th October 2010 Lords Chamber

[Lord Alderdice]

My Lords, I declare an interest as a recently retired consultant psychiatrist who spent his life working in the NHS. I am married to a consultant pathologist in the NHS. My brother is a consultant in the NHS, as is my sister-in-law. My brother-in-law is a general practitioner in the NHS. I therefore speak not from the vantage point of academia or any glamorous speciality in central London but from that of psychiatry and general practice in the regions. From my perspective, the NHS is broken and needs fixing.

What are the problems that affected me during my work? Increasingly over the past 15 or 20 years, decisions were being made by a larger and larger bevy of managers and administrators at every level and increasingly decisions were being made, quite naturally, more for the benefit of the management process than for that of the clinical process. As a clinician, you could go to meetings—if you could get to them and if you were invited, and increasingly you were not—and find yourself being berated because your clinics were getting larger because you were going to the meetings, or you could not go to the meetings and the decisions would therefore be made in your absence and without any attention being paid to them. The increasing focus on managerialism over the period of the previous Government meant that clinicians were increasingly ignored. My generation thought increasingly of retiring from the NHS because they felt frustrated, not by terms and conditions of service, which improved, but by diminishing morale, as what they really wanted was the freedom to make clinical decisions.

Decisions were increasingly centralised. Targets and decisions were made in Whitehall and, with the best will in the world, what looks to be the right thing from a Whitehall perspective does not feel like the right thing when you are operating at another level. It is quite true that devolution has helped. For some time, we have had four national health services in the United Kingdom, which has certainly improved things, but the possibility for that improvement through devolution in Scotland, Wales and Northern Ireland happening in England is minimal because of the sheer size of the country. If the benefits of devolution in Scotland, Northern Ireland and Wales were to be achieved in England, it would require further devolution to local government level. Here, there is evidence of the possibility of benefit.

In Northern Ireland, because of devolution, we had proper, full integration of health and social care, which meant that it was possible for me to co-operate with social workers, that in-patient was not divorced from out-patient, that hospital care and community care were seamless and that the hospital did not soak in all the money and resources from the community whenever there were inevitable pressures. There are benefits to be had, but England needs to learn the benefits that Scotland and Northern Ireland, in particular, and, to some extent, Wales have already achieved.

The most important thing was the recognition of the importance of engaged and informed patients. Why? It does not matter how clever a doctor is, even if he can afford to make the right prescription; if the patient does not comply with the treatment, it does not improve the situation and we know that, when the research is done, patient compliance is massively lower than most doctors think. However, it goes wider than that. In my own work, it is quite clear that the fundamental difference is not the prescription of medication but the change in the culture and lifestyle of the patient. That happens only when you have a fully engaged patient—an active citizen—who is taking responsibility. Those are the principles that I see reflected in the Government’s policy and that is why I am so enthusiastic about it as a doctor.

--- Later in debate ---

[Lord Brooke of Alverthorpe]

I am grateful to the noble Lord, Lord Hunt of Wirral, for promoting the debate and express my gratitude to the several professional organisations that have provided me with briefings. I make a contribution today simply as an NHS patient who has no private medical care or back-up whatever. I am also a former cancer patient; I hope that that continues to be so, but I have been waiting nearly three months for an appointment to deal with a spot on my hip. I finally managed to get one this week at the Chelsea and Westminster Hospital, where, within seven days, staff will do a local operation on it. They hope that it will not be the start of skin cancer.

I was spitting blood the other day when I listened to the Minister defending the Government’s position on cancer timetabling and how treatment was taking place. In my case, it had nothing whatever to do with commissioning or the hospital. The problem arose with what has been happening within my GP practice. I know that people in GP practices in many areas are under a great deal of stress and strain and I greatly sympathise with them, but it is extraordinarily difficult when so many patients cannot get through on the phone to their GPs and so cannot get an early appointment with a GP of their choice. They cannot get a meeting with their GP out of hours—it must be at the convenience of the doctors—and certainly cannot get GPs to come out at the weekend or at night. These are issues that my Government were responsible for; they tried to put them right and did not get them put right, so the new Government should be putting them right and not moving on into other areas.

As far as I can ascertain from how things are moving at the moment, there will be little change on these fronts, or indeed on many other issues that have been raised on the Government’s side of the House when there have been complaints. The White Paper and the programme in front of us will not address those problems. I speak with a degree of anger when I see that we are now moving into an entirely new arena, which was not forecast in the run-up to the general election. There was no debate on it and it was barely mentioned. It was not in the Conservative Party manifesto or the coalition agreement, which just said that nothing was going on. I am sorry that we do not have many Lib Dem contributions today because, in the past when we have had debates on the NHS, we have been chased all over the place by them. Today they are missing and they should be ashamed that they are not standing up and taking a firm stand on these issues.

[Lord Alderdice]

I am grateful to the noble Lord for giving way, but I have to point out to him that he is incorrect on almost everything that he has said in the last few minutes about those speaking from the Lib Dem Benches, as well as about the coalition agreement and the manifestos.

[Lord Brooke of Alverthorpe]

I shall not go into that—I shall move on. If we are faced with this, we need greater openness and transparency and greater access to the economic factors behind it all. If I was in the private sector, all the issues that I have just complained about, with a private GP looking after me, would have been solved. I would have had access to the information and to the costs. We should move to a position where, if people are given choices, they should know what the cost is. Equally, we should be given the opportunity under the changes to know what is being paid into the GP consortia, what profits they will make and what the private sector providers will get out of it. At the moment, this area is all within the public service, but it is likely to be privatised under the coming arrangements. Those are the points that I put to the Minister—there should be greater openness on the economic side of the operation.

Health: Osteoporosis

Lord Alderdice Excerpts

Tuesday 19th October 2010 Lords Chamber

[Earl Howe]

My Lords, information is produced by the National Health Service on the risk of fragility fracture and, indeed, on how to prevent it. A number of good and authoritative sources of information exist on this topic, not simply from the NHS, but I would just say that information on osteoporosis is available on the NHS Choices website, which of course is accessible on computers, including those in libraries.

[Lord Alderdice]

My Lords, if the normal communal incidence of osteoporosis were to be applied to your Lordships House, it is likely that half or even more than half of its membership would be suffering from it, even if they were not aware of any symptoms. That tells us what a common disorder we are dealing with. Does my noble friend agree that it is important to raise public awareness not just of diagnosis and treatment, but of how lifestyle changes to diet, smoking behaviour and alcohol consumption are extremely important in making sure that these adverse consequences do not arise?

[Earl Howe]

My noble friend is right. The job of the NHS in its public health role is to provide information about healthy lifestyle choices. NHS Direct does this at the moment, and in the future we will be looking to the new national public health service to maintain the provision of high quality and authoritative health advice. Moreover, as my noble friend says, that advice includes information about the value of a diet rich in vitamin D from oily fish, liver, cereals, eggs and so forth, as well as from safe exposure—I emphasise the word “safe”—to natural daylight.

Health: Neurological Conditions

Lord Alderdice Excerpts

Monday 11th October 2010 Lords Chamber

[Lord Alderdice]

My Lords, I am grateful to my noble friend Lady Gardner of Parkes for obtaining this debate, because the conditions which we are considering are not glamorous. They are not the kinds of thing that excite public interest all the time. It is important that there are thoughtful, committed individuals like my noble friend who, from time to time, bring this back to your Lordships’ House to help us focus on this important area of medicine and health and social care.

I shall pick up from where she finished her speech: paying tribute to those allied health professions who are involved in the care of chronic neurological disorders. It is of course difficult to deal with any kind of serious illness, but particularly when you know that these conditions are chronic and are, in many cases, simply not going to go away. For those of us involved in medical care, a degree of excitement is present when you see a problem, can get involved and know what to do to bring a good outcome. You can receive great personal satisfaction from that, but there is not that excitement when the conditions are generally not of that kind. You know that a long-term, dogged commitment is necessary. I take the opportunity of paying tribute to those allied health professionals who continue on with this kind of work not just week after week, or month after month, but year after year after year. It is extremely important.

From a medical point of view, these conditions induce a certain amount of appropriate humility because the neurological conditions in general are not ones that we know very much about how to cure. We can often diagnose them, sometimes rather accurately, and do lots of tests to demonstrate all the elements of them. Yet at reversing or curing them—relieving the patient completely of the problem—we are not so good. In fact, the truth is that the amount of useful work we can do in diagnosis and treatment is much less than the value of the management that can be provided over a long term by allied health professionals.

In many ways, while is important to have some of the time and expertise of the neurologist it is often more important to have the long-term commitment of the physiotherapist, who is able to help you manage the problem—and here is one of the difficulties. While physiotherapists are vital, there is what we have come to describe as a churn or turnover of them. It is fairly inevitable to some extent, but the long-term care is difficult if you have a lot of turnover. Can my noble friend the Minister say anything about how we can encourage the long-term continuity of care in nursing—particularly community nursing care—and physiotherapy, rather than the rather fast turnover that there sometimes is?

The second thing I will say is about not just the importance of physiotherapists, but the significance of other allied healthcare professionals. It is becoming clear to us that, while it may be more scientifically and technologically interesting to do lots of complicated, high-tech, expensive scans, things like art therapy, music therapy and hydrotherapy—physiotherapy exercises in a pool—often are much more important. They make a difference to people. For example, we know from recent research that people who have had strokes and have music therapy often recover more quickly and more completely than people who do not. We do not always know why, but it seems that some of these other professions are able to help.

The Minister would be astonished if I did not raise the question of counselling and psychotherapy, and of the importance of the input of those professions to those who are suffering from chronic, long-term conditions and to their partners and families. Chronic conditions affect not just the person but everyone with whom they live, and sometimes counselling of a didactic or emotional kind is helpful and necessary to sustain the person with a chronic disorder and their family and partner or spouse.

The noble Baroness, Lady Gardner of Parkes, mentioned music therapists and other health professionals. She rightly said that a large number of them are already regulated by the Health Professions Council. As the Minister knows, that is not true of psychotherapists and counsellors. I will use this opportunity to ask him—because I never fail to use such an opportunity—how we are getting on with the question of regulation, because as we move toward more decisions being made at a local level about which services to commission, commissioners quite properly will want to see regulated professions employed. If we do not have regulation of psychotherapists and counsellors for these kinds of condition, commissioners are likely to be wary of employing them—understandably so.

The third and final area that I will touch on is what is sometimes described as multidisciplinary teamworking. It is clear that an enormous number of people are required to be involved in managing these conditions. The Motor Neurone Disease Association calculated that on average 18 healthcare professionals were involved with any patient. Some of this is terribly important and valuable. There are lots of areas of life that are adversely affected when somebody has a chronic, long-term neurological condition. However—this is a delicate matter, not particular to these disorders—we must be careful sometimes in the health service that we do not simply make yet another referral and add on yet another person who does not necessarily operate with the others as a team. When 18 people are involved, it is not a team but a lot of different professionals.

I found in my own work, until recently, that sometimes I would suggest an out-patient appointment to a patient and they would say, “I’m sorry, I’m too busy to come along that week because I have appointments every other day”. That is not terribly helpful. The Motor Neurone Disease Association rightly says that it is very important to have a key worker to whom the individual patient refers, and everything else goes through them. In medical terms, this is the general practitioner. We do not like referrals being made without the general practitioner being informed because they can act as a gatekeeper. However, it is also important for allied health professionals that one of them—preferably one who knows a good deal about the disorder concerned—acts as the key individual, and that everyone else relates to them. If not there is a temptation, when a patient comes along with a chronic condition and you desperately want to help but cannot do much, to make a referral, sometimes in the desperate hope that somebody else will be able to contribute something.

However, we must not forget that every referral is a resource taken away from another patient; so encouraging colleagues to think about whether yet another referral is necessary, or whether more collegiate teamwork is possible with those who are already being treated, is a very difficult area that I do not expect my noble friend to be able to say a great deal about. However, perhaps he will take this genuine problem back to his colleagues: the notion of multidisciplinary teamworking, which is excellent and important in all these areas, becomes a lot of different people working in a not necessarily terribly co-ordinated fashion. Maybe at a strategic level we must think about some kind of guidance as to the difference between a bunch of people on the one hand, and a multidisciplinary team on the other. Is there an optimum size for this kind of input?

I finish, as I began, with a tribute to those involved in this kind of work. It is by no means easy. It requires strength of character and a commitment to the care of people that is quite remarkable. We are profoundly fortunate in this country to have so many people who are prepared to undertake this, not for a day or a week, but over a long and committed professional career. I am honoured to pay tribute to them.

Health Protection Agency

Lord Alderdice Excerpts

Thursday 7th October 2010 Lords Chamber

[Earl Howe]

My Lords, transparency is one of the aims of our proposals. As regards independence, the Government will continue to rely on their scientific advisory committees, the members of which, as the noble Baroness knows, are drawn from the foremost experts in their respective fields. The fact that the scientific secretariat to each committee is provided by experts formerly within the department, instead of within the HPA, will not prevent the committees reporting as they judge to be appropriate.

[Lord Alderdice]

My Lords, one of the most important elements in dealing with emergencies and pandemics is the communication of accurate, concise and timely information to the community. The HPA website is a very good facility for providing information to professionals during the ordinary way of things but is not particularly good at providing emergency information to the community as a whole, nor is it adequate on its own. Will my noble friend assure me that when the public health service takes over it will concentrate on this question of emergency communication to the public as a whole?

[Earl Howe]

My noble friend makes a good point about communications. Indeed, the idea of creating a public health service is to have in the Department of Health a joined-up means of having advice, surveillance, training and planning that will then feed out to local authorities, which will be responsible for prioritising action on the ground. An essential part of that will be to get the communications right.

Health: Addiction to Prescribed Drugs

Lord Alderdice Excerpts

Wednesday 6th October 2010 Lords Chamber

[Lord Alderdice]

My Lords, I am grateful to the noble Earl, Lord Sandwich, for the opportunity to explore this complicated issue in a larger way than with a simple question and answer.

I have never taken diazepam but it did help me sleep on one occasion. I had just qualified as a junior doctor and, on my first night on call, I got to my bed shortly after 12 o’clock. I was suddenly seized with the anxious thought that I could not think of a single medical emergency that I could treat on my own. Eventually it came to my mind that if a patient came into the casualty department with status epilepticus, I could simply inject diazepam until they stopped fitting and that would resolve the problem. It was not a dangerous procedure—in fact it was much the best way of dealing with the situation; it was not a toxic drug—and I was able to sleep with the knowledge that I could possibly treat it. My last words were a prayer that any patient who came in that night would have status epilepticus. I woke up at half-past seven the next morning but there had been no patients, with or without the condition, and so the diazepam, in my thinking, had helped me to get to sleep.

As a young doctor—particularly as a young psychiatrist and one who specialised in psychotherapy and worked in an addictions department—I became familiar with the whole question of benzodiazepines. The first thing to say is that although this is a group of drugs, they are not identical by any means. I remember that in those early days, diazepam and a number of other drugs of that kind had been used and it was beginning to become apparent that for many people they had addictive qualities, and a new drug, lorazepam, was sold under the drug name Ativan. We were recommended this drug because it was believed that it was much less addictive. As it turned out, it was much more difficult to get patients off it. It had a very unusual profile: you could reduce the dose of the medication by a half, even by three-quarters, without any terribly serious effect, but getting them off that last bit was extremely difficult.

The point is that benzodiazepines as a group are not all identical with each other—they have different components—and they are addictive because they are effective for many people in relieving them of their anxiety and helping them, for example, to get to sleep because some are used as hypnotics rather than anxiolytics. That is not to take away from the tragic stories which have been recounted in the debate, which are also absolutely true and the case. Many people suffer because they become dependent but we must remember that many people function and get on with their lives, get to sleep at night and operate the next day. They are able to manage with their anxieties and difficulties precisely because they have access to these medications. Therefore the idea that this is a kind of modified cocaine or something like that is to not understand the need for some of these medications.

The noble Baroness, Lady Meacher, referred to the medical use of marijuana. Given all the indications, it was interesting for how long we knew problems were arising with the use of marijuana that people refused to accept. It is only in the past few years that people have been prepared to point up the increase in psychosis among young people who use marijuana and the increase in suicidal behaviour. The idea that we should shove aside benzodiazepines and introduce medical marijuana would need a great deal more exploration. There are major problems with even medically-used marijuana and we need to be very careful about it.

My preference is to move to psychological methods of treatment and I wish to say two or three things about that. First, many patients do not want to adopt a psychological approach to treatment; they very much want a pill that will take away the unpleasantness of the difficulties of the moment. I suspect there may be some, not in your Lordships’ House this evening but perhaps at other times, who might use other ways of putting a problem to the side rather than confronting it—perhaps in the Bishops’ Bar, for example. Whatever the problems of benzodiazepines, they are generally less than the problems of alcohol addiction in various ways. We need to steady ourselves and realise there are many problems with these drugs but there are also certain benefits to a substantial number of people. That is what makes it difficult. If they were only problematic it would be easy; it is because they are helpful to some people that we have a big problem.

But there is a further component. We began to notice in Northern Ireland in the late 1960s and the early 1970s a major increase in the prescription of benzodiazepines in the areas around where there had been street trouble and riots. It was not in the areas where they were happening, but in the areas around—the penumbra, as it were—where people as a whole community were terrified about what might happen to them and their families. In other words, you were not dealing with a mental illness; you were not dealing with a personal problem; you were dealing with a societal problem of anxiety on a large scale. In the end, the only way to deal with that was to deal with things at a social level and to try to remove the fundamental problem.

Here we have a problem of the moment. The serious economic crisis that we face, the austerity that all of us experience and will experience, is going to make life more difficult for people to manage. That is just a piece of reality. So, in looking at the individual question of how we deal with the withdrawal of dependent people from drugs, there is a particular approach—a psychological approach, a medical approach and the provision of talking therapies—that we can take. However, let us not imagine that if we go down that road it will be cheaper than the prescription of medication, because it will not be. It will be more expensive to pay for the time of people. Cognitive behavioural therapy is very helpful, but it is very rarely a short-term resolution for all problems.

But one opportunity is opened up for us in the proposals of the Government for reform of the health service; that is, by devolving more control and more decision-making to a local level, particularly in relation to local councils, which also have responsibility for the provision of social care. It may, I hope, be possible for general practitioners and others in acute primary care to see the resolution of a lot of the anxieties that were raised, for example, by the noble Baroness, Lady Bottomley, whose experience as a social worker let her see how the prescription of medication was used to deal with social problems. If social services departments can co-ordinate much better with primary care, it becomes possible for general practitioners not to prescribe medications of any kind but more to relate to those whose responsibility it is to deal with social service and social care problems.

I therefore hope that the Minister will be able to tell us something about dealing with benzodiazepines, but I trust also that he will be able to fold that into the opportunities for better co-ordination between the different components of care that we need to provide for our citizens.

Health: Prostate Cancer

Lord Alderdice Excerpts

Monday 19th July 2010 Lords Chamber

[Earl Howe]

My Lords, there will be plenty of support for GP consortia in the area of cancer diagnosis and treatment, not least from the commercial support units but also from the cancer networks. However, the noble Baroness is right that we are not doing well enough in this country in picking up cases of prostate cancer. Late diagnosis is likely to be a significant contributor to that and is, in itself, the result of a number of factors, poor public awareness being one. Late presentation to primary care is another and, as the noble Baroness hinted, poor detection in primary care is a third. Therefore, supporting GPs in detecting cancer earlier will be a key part of the work that we have to do.

[Lord Alderdice]

My Lords, given that the prostate-specific antigen test is not in fact pathognomonic of cancer of the prostate but simply of disturbance of the prostate and that significantly high levels of the antigen are likely to lead to an investigative biopsy by a urological surgeon, is the Minister content that we have enough urological surgeons in the country to undertake the level of investigative biopsy that is likely to arise from the higher index of suspicion by general practitioners indicated by the noble Baroness? Entirely separate from that is the question of whether we have enough urological surgeons to carry out the treatment for prostate cancer when it is diagnosed.

[Earl Howe]

My Lords, I am not aware that there is thought to be a significant shortage of urological surgeons or expertise around the country, although the coverage varies from region to region, as the noble Lord will know. However, I shall take his concerns back with me and make suitable inquiries. If I can write to him further, I shall certainly do so.

Health: NICE

Lord Alderdice Excerpts

Wednesday 14th July 2010 Lords Chamber

[Earl Howe]

My Lords, that target of a 14-day referral period has a definite clinical underpinning. There are certainly no plans to abolish it.

[Lord Alderdice]

My Lords, the treatment of such disorders—particularly cancer, but it is also true of Alzheimer’s disease—requires not just biological but psychological and social interventions. Although the biological research is often funded by pharmaceutical companies, NICE has great difficulty in finding the funding for research for psychological and social treatments. Can my noble friend indicate whether there is any way in which NICE can be assisted to be more broad-ranging in its understanding of a bio-psychosocial approach to treatment of these disorders by facilitating more funding for research in the psychological and social areas?

[Earl Howe]

My Lords, I am sure that my noble friend will accept, as I hope I made it clear the other day, that the Government are wholly committed to improving the quality of care for people with dementia and their carers. We are standing fully behind the dementia strategy, instituted by the previous Government. That strategy contains a specific objective of improving the quality of dementia care in hospitals. I take on board what my noble friend says about the absence of adequate research in the psychosocial domain. I shall discuss that point with NICE over the next few weeks as I am aware that it is one of its concerns.