Ageing: Public Services and Demographic Change Committee Report
Lord Crisp Excerpts(10 years, 6 months ago)
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Lord Crisp (CB)
My Lords, this is an excellent report. I very much agree with the recommendations and with the disappointment of the noble Lord, Lord Filkin, at the Government’s response. I add that I am not a member of the committee that produced the report. I also agree with many noble Lords who said that this issue cannot be avoided or just left to muddle through. I congratulate the committee on not letting it go, and on continuing life after its committee proceedings.
I speak as a former permanent secretary of the Department of Health and chief executive of the NHS, and declare that I work in health, although globally, not in the UK. This is, of course, a global issue, as the noble Lord, Lord Livingston, said in his excellent maiden speech. I agree with the analysis that the committee has made of the problem. Very simply, we are using a 20th century model of health and social care to deal with 21st century problems of health and social care. It does not work, and we see that every day in the newspapers and will continue to see it in the newspapers, in our A&E departments, in the number of elderly people who are stuck in hospital—and in everything that we all know.
As noble Lords have said, and as the report says, we still do not have a clear strategic vision for the future of health and social care, and that is fundamental. I will mention two areas where the report could go even further—and I hope that the Government will. There is a lot of agreement, as has been said already in the House, about the nature of the problem. People are all aware that we need a much more community-based system that is much more focused on prevention. We also seem to accept a lot of the implications of that, which will involve bringing together health and social care much more closely, closing some acute hospitals, and investing in technology and in the community. However, agreement falls apart when we get to some of the detail, and the issues of winners and losers. Because we do not have a strategic vision that spells out all the implications, we have too many initiatives that are piecemeal and that often tackle symptoms rather than causes. Camilla Cavendish’s review of healthcare assistants, which was mentioned in the government response, is a good case in point. It was a good review, but it would have been even better if it had been in the context of a genuine, strategic vision for the workforce. Healthcare assistants do not operate in a vacuum.
This is the biggest failure at the moment. The biggest factor to take into account is the workforce. I do not think that it is mentioned in the report or in the Government’s response. I may have got that wrong, but clearly it is not in any of the headlines. Of course, the workforce never is. If you are going to have radical change in the service that is provided, you will have to have radical change in the workforce, as well. I will give some radical examples, although I am not necessarily advocating them. Are we going to be talking about having far fewer specialist doctors and more generalists? Are we talking about nurses doing many more of the things that doctors do now, and other people doing things that nurses have done in the past? We need graduate nurses, but do all nurses need to be graduates? What about the links between health and social care and the workforce? How radical are we going to be in taking this on? I am a member of the Lancet commission on the future of professional education. That has produced some radical notions about the role of senior professionals and team leaders as agents of change who are constantly searching for quality and cost improvements. Are we going to be that radical?
Of course, this is the biggest cost in the NHS; around two-thirds of the cost is in the workforce. In Africa, where I work, we have long recognised that the scarcest commodity is not money but skilled health-worker time. Do we in the UK use skilled health-worker time to best effect? Do we always make sure that people are working, as the Americans say, at the top of their licence, as opposed to doing things that other people in the system can do? This is not just about getting rid of paperwork for professionals; it is about making much more radical changes.
While Africa leads the way in changing health roles globally, the UK leads the way in developed countries—for example, with the expanded role of nurse prescribers and of nurses more generally. As I said, this is the highest cost, which is one reason why it is the most difficult area to tackle, and why people never tackle it. I understand the political traps of taking on the doctors or nurses to make some of these changes, and I understand that it would create winners and losers. However, it is not good enough to leave this to the local level. First, they cannot do it; you cannot make the changes necessary at local level. The headquarters has the responsibility of ensuring the capacity and capability of an organisation, and it is not doing so at all at the moment. Of course, this need not be top-down; it should be developed with practitioners and people at local level. However, as many people have said, the Government have a responsibility to ensure that there is an appropriate framework here for the future. Of course, if it is not sorted out, we will not see change.
My point is that this is not just about economic costs. The other question that needs to be looked at alongside it is: who will give the care? I will take 30 seconds more to refer to the fact that this is not just about professionals. We must not slip into the lazy assumption that the NHS is like a commercial insurance system, and that patients are simply customers. Care is not given just by professionals but by many carers. It is given by neighbours and voluntary organisations; it is given in a wide range of different ways. The NHS and social care form a social system rather than an insurance system. There are roles for carers, patients and families, and we need to redefine those as well. People can do more for themselves. We see examples in other countries of people doing much more in the way of monitoring. We see them delivering dialysis for themselves. Of course, these examples also produce improvements in quality and in cost.
In conclusion, I would be very interested to hear what both the Government and the Opposition say about the challenges that the report sets them in setting out the position for the future and a long-term vision. I will also ask the Minister a specific point, as a first step towards that. Does he accept that a changed, new NHS of the type described here will require a new, radically different workforce strategy, with changed roles for doctors and nurses, and changes in professional education? If he says that that is the responsibility of NHS England, as I suspect he will, will he then ensure from the Government that NHS England, in developing its strategy, will take proper account of the 60% of the NHS budget and of the changes that need to be made there as well as elsewhere?
Antibiotic-Resistant Bacterial Infections
Lord Crisp Excerpts(10 years, 9 months ago)
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Lord Crisp
To ask Her Majesty’s Government what is their assessment of the risks posed by antibiotic-resistant bacterial infections; and what plans they have to reduce such risks.
Lord Crisp
My Lords, first, I thank noble Lords who are taking part in this debate and say how much I look forward to their insights, which I know will come from very different perspectives. I suspect that there will be an enormous amount of agreement. I know that the Government are taking this matter extremely seriously and that, in the words used in my Question, they recognise the risks and are developing plans to reduce such risks. I hope that this debate will enable them to be even more bold and creative in their approach.
I will talk for a moment about that shared understanding, which I will put in very simple layman’s terms. No doubt others will expand on it. The first point is that antibiotics have been a great benefit to humanity in tackling everything from TB and pneumonias to sexually transmitted diseases and bacterial infections of all kinds—not just in this country of course but world wide, including in some of the poorest countries of the world. I happen to chair Sightsavers, which uses an enormous amount of antibiotics in dealing with trachoma in the poorest countries of the world.
Antibiotics are the basis of much modern practice. We assume now that we can tackle infections. Infamously, it was the American Surgeon General who said in 1968 that,
“the war against diseases has been won”.
Those words no doubt came back to haunt him. The problem is that the bacteria are fighting back, in large part due to misuse—people failing to complete courses of treatment and therefore to wipe out the infection. The bacteria did not know that the war was over; evolving and becoming drug resistant, the stronger ones survived. The result, as we know, is that globally we have multidrug-resistant TB, and infections that cannot be treated in countries as disparate and different as India and Israel. This has been known for a long time, and the problems coming forward have been known for a long time. It was the House of Lords Science and Technology Committee’s 7th report in 1998 that first drew attention to this. In the same year, the World Health Assembly raised it as a serious issue.
There has been considerable research over many years. I am indebted to one of the world’s experts, Professor Otto Cars of Uppsala University in Sweden, for setting out the evidence for me. It is compelling. Imagine a world without effective antibiotics. Our English Chief Medical Officer, Dame Sally Davies, said that if we do not take action, we may all be back in an almost 19th-century environment where infections kill us as a result of routine operations. We will not be able to do a lot of our cancer treatments or organ transplants.
It is not just the burden of disease that is at issue here but the economic impact. It has long been known to be significant, but new work coming forward from Professor Richard Smith of the London School of Hygiene and Tropical Medicine, and Professor Joanna Coast of the University of Birmingham, suggests that, when wider impacts are taken into account, the costs are even higher than anticipated. These economic arguments are extremely important in raising the issue up the world priority list. It is significant that the World Economic Forum sees antibiotic resistance as a major threat. There are other important issues around animals that I will not mention in this short debate. My noble friend Lord Trees will say something about them.
I congratulate the Chief Medical Officer on drawing this issue to the attention of the country and of the world in her 2011 annual report. I also congratulate the Government on supporting her to raise the matter at the World Health Assembly at the G8 summit and, I hope, at the UN in September. Her report sets out the issue in detail and notes that there are some drugs that are the last line of resistance, to which we should give special attention now. She and the experts who wrote Chapter 5 of her report drew attention to a number of solutions.
The first is new drugs, but at the moment there are few antibiotics manufacturers and few new antibiotics in the pipeline. Thanks to AstraZeneca, I understand more about the business model and the problems in dealing with drugs of last resort. The simple issue is that they are kept on the shelf; they are in reserve. It is important that we have them, but they do not get used very much and they do not lead to sales. Therefore, the economic model does not work. Even with the more common antibiotics that we use more regularly, we only use them for a short period as therapeutic drugs, not as long-term drugs that will produce a long-term income and therefore provide a return on the massive investment required for development.
AstraZeneca and many others argue that there is a need for very substantial changes to regulation to allow for shorter and easier development times, and even for antibiotics to be treated as a different category of drugs. They also point to the need for investment to secure development. This also makes the argument that vaccines are important in heading off disease. I well understand that not every new drug or vaccine is a significant advance, but there is enormous scope here for Government, and the public and private sectors, to work together to develop a new way of developing these drugs. My noble friend Lady Mar will say a bit more about vaccines in a moment.
Another aspect of the issue is the development and use of new diagnostics. If we can get people into treatment faster, we will be quicker to control the bacteria. At the moment it can be days before technicians know what strain they are dealing with.
The third and perhaps biggest point is about better stewardship and conserving what we have. This is even more difficult, but it is the basis for everything else. The CMO’s report describes good practice that will achieve this. There are 10 top tips for effective antibiotic prescribing that should be followed in this country. Imagine for a moment the situation in every country in the world; every clinic or village in China or India needs a battery of actions. There is a need for education professionals in those areas to have the equivalent of our 10 top tips, as well as for greater public awareness and education. That is no easy task. We should remember that many of us in our country do not take drugs in the way that we should. Also, in those countries we must tackle counterfeit medicines and restrict over-the-counter sales. We should also see changes to harmonise regulation. This is phenomenally difficult, but it is not enough to put our own house in order; we will be affected by what happens elsewhere in the world.
We need all these approaches combined: new drugs, new diagnostics, better practices and stewardship, action across the whole healthcare system and, indeed, across the whole world. Here I come to the point that I really want to talk to the Government about: this needs remarkable political effort. It is about reframing the issue and building political support, and I will be interested to hear what the Government have in mind.
I will make two points. First, this is an enormous threat. Indeed, you can galvanise people around the threat: it is real and it will impact in terms of illness and economy. However, it is also an opportunity. I am indebted to my friend and colleague Dr Ilona Kickbusch, and to Professor Cars, for pointing out that we should treat antibiotics as a global public good and that there is an alternative way of seeing this problem. It is about a vision of a world in which the peoples of the world really do in practice have a right to health and healthcare, something most nations have signed up to—many, like ours, since the UN declaration of 1948. In that world, nations develop, share and look after those things, such as antibiotics, which are a benefit to us all.
We have already seen how this can be done in tackling other threats such as global pandemics. Although there is always controversy about that, nevertheless great progress has been made in creating a network for surveillance and tackling issues. There is more to do. We have also seen it with the millennium development goals, working towards a vision where no woman dies as a result of pregnancy, although there is much more to do there as well. In other words, I am arguing for setting ourselves the goal of preserving antibiotics for the future as one of science’s great benefits for humanity, and for driving this forward politically and technically, in every way in which we can.
My second point is simply that the UK can play an extraordinarily important leadership role here. It is well respected in health. We have the credibility of having a health system which seeks to look after every person within it. We also have credibility because of the world-leading role that has been played in development; here I compliment both this Government and the previous one. We can be bold and ambitious in taking a lead. No nation is better placed to do so, with our connections in the Commonwealth, across the Atlantic, and in Europe. The key is to bring together a group of like-minded countries, as this and previous Governments have done on other things, starting with those who are already taking this seriously. We should set out a vision and pathway, and take on these issues step by step. The Chief Medical Officer has already started this, but it is important to add political weight and depth to her work. It is not just about health but about economics and foreign policy. It is a step in building a better world, where we have and share the means to offer better health to everyone.
I therefore look forward to hearing the Government’s response to these points, and to knowing how they will turn their undoubted commitment in this area into something even bigger and bolder. Will they seek to take a global lead on this? How will they do so? I also greatly look forward to hearing from other noble Lords.
NHS: Health Workers
Lord Crisp Excerpts(11 years, 10 months ago)
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Lord Crisp
To ask Her Majesty’s Government what steps they are taking to promote changing the roles and skills mix of health workers in the National Health Service to improve access and quality, and reduce costs.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, local healthcare providers must be free to manage the composition and skills mix for their workforce so as to best meet the demands of the communities they serve. We are working together with the professions and partners on key initiatives that will help healthcare providers make more informed decisions on the shape of their workforce to achieve better outcomes in both patient care and value for money.
Lord Crisp
I thank the Minister for that reply. As he knows, changing job roles in the health service can be done well to great benefit or it can be done badly and be detrimental to services. Given that a recent report from the All-Party Parliamentary Group on Global Health has provided the evidence for what works, can I ask him, first, how will the Government make sure that Health Education England and other national bodies give this a much higher priority and provide the support that local organisations need to make this happen? Secondly, to avoid the problems of failure, how will the Government ensure that the Care Quality Commission and other national bodies provide the leadership needed to make sure that failures do not happen?
Earl Howe
My Lords, the noble Lord’s Question addresses the central issue facing the NHS, which is how to deliver the best outcomes for patients and do so in the most cost-effective way. He is right to single out the role of Health Education England because I believe that, in conjunction with local providers who will be feeding in their view of what the workforce priorities are in their local areas, together with the Centre for Workforce Intelligence, which has a horizon-scanning capability, we can at last crack a nut that has been so difficult to crack in the past, that of good workforce planning in the NHS to make the workforce as productive and effective as we can. He is also right to single out the CQC because in areas such as staff ratios, the commission has a role in making sure that providers have thought about the right way to deliver care in individual settings.
Drugs: Prescribed Drug Addiction
Lord Crisp Excerpts(11 years, 10 months ago)
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Earl Howe
I am well aware of the point that the noble Lord appropriately raises. Stigma is an issue and we need to take account of the risk of it. That means that quite often when treatment services are provided to those who are addicted to medicines, they take place in a different setting from those administered to addicts of illegal substances.
Lord Crisp
Will the Minister recommend that, given that withdrawal from legally prescribed drugs is every bit as dangerous as withdrawal from illegal drugs, more should be done, for example, to print warnings in bolder lettering on packaging, to put notices in doctors’ surgeries and to make the public and the patient more aware of this issue as well as making doctors more aware?
Earl Howe
I agree that dependence on prescription medicines can be just as devastating and debilitating as dependence on illegal drugs. The round table on addiction to medicines has agreed actions to improve public and professional awareness of the risk of dependence. They include a review of the updated warnings on prescription painkillers by the Medicines and Healthcare products Regulatory Agency and the development of further materials for GPs and other healthcare practitioners to support patients in understanding the risks.
Health and Social Care Bill
Lord Crisp Excerpts(12 years, 2 months ago)
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Lord Crisp
My Lords, I had not intended to speak on the amendment, but I want to say a word or two in support of what the noble Baroness, Lady Williams, has just said. She and others have referred to the rift that has been created as the Bill has gone through Parliament and been discussed in the country. I am sure the Minister recognises that, but I know that he also recognises that now is the time to move towards healing that rift. Many people have, for whatever reason, been scared by what has been said and many people have also been scarred by what has been said. The noble Baroness is absolutely right to draw attention to the second part of the amendment and the opportunity that it gives to start to bring people together around the practicalities. We talk about the legislation but many people out there have to talk about the practicalities and how you make it happen—something with which many Members of your Lordships’ House, including the noble Lord, Lord Newton, are very familiar.
This has also been about failing communication. I believe there is now more that unites people than divides them. There are many things that people agree on. There are still some very significant differences and, like the noble Baroness, Lady Williams, I am not a fan of the Bill. It has been a damaging process but now is the time for healing. It would be good to see some cross-party approaches to bringing people together in a positive fashion to deal with the practicalities, rather as is laid out in the second part of the amendment.
Earl Howe
My Lords, I think that it is important for me to begin by acknowledging fully the force of the wonderful speech by my noble friend Lady Williams, and indeed acknowledging the powerful points made by other noble Lords regarding the climate of opinion among the medical royal colleges and others in relation to the Bill. I cannot fail to be conscious of the suspicion and doubt expressed by many members of that community, although I have to say that opinions vary as to what the real views of some of the royal colleges are, bearing in mind that only a small percentage of their members were canvassed. However, I cast that aside because I am very aware of the validity of the points made by the noble Lord, Lord Owen. The Government are undoubtedly fighting a battle to convince the medical community of the merits of the Bill, a battle that we have so far not won. I can therefore very readily confirm to my noble friend that the first thing we would wish to do once the Bill reaches the statute book is to build bridges with the royal colleges, the BMA and all those who have an interest in seeing this Bill work, to make sure that its implementation is securely grounded. I completely agree with her that the Government should work with NHS staff, all our stakeholders and, indeed, patient groups during the coming months to make sure that implementation really is a collaborative process. I hope that the undoubted wounds that have been created will be healed, and healed rapidly.
I am grateful to all noble Lords who have spoken in this debate. In particular, I listened carefully to what the noble Baroness, Lady Thornton, had to say, as I always do. The question posed by her amendment is, on the face of it, “How can we improve Part 3?”. The answer that she has given us is, “To postpone it”. However, the subtext of her question is, “Why should we have Part 3 at all?”. I am happy to set out once more exactly why it is essential that we have Part 3 —and not just have it, but have it without delay. We need it for two compelling reasons: to protect patients’ interests, and to help the NHS meet the significant quality and productivity challenges it faces. They are benefits that I am afraid the amendment would stop in their tracks.
Part 3 sets out a clear, overriding purpose for regulating NHS services—to protect and promote patients’ interests. That contrasts with Monitor’s duty under the National Health Service Act 2006, which is merely,
“to exercise its functions in a manner consistent with the performance by the Secretary of State of his”
functions. That 2006 duty is not adequate as it stands. It does not mention patients’ interests and it is unclear. However, that duty is what would apply if Amendment 300A were accepted. The amendment would also discard the recommendations of the NHS Future Forum that Monitor should have additional duties: first, to involve patients and the public in carrying out its functions, as my noble friend Lady Cumberlege and the noble Lords, Lord Patel and Lord Warner, rightly emphasised; and, secondly, to enable integration.
It needs to be made clear that the provisions in the Bill interlock and are interdependent. Deferring Part 3 would not achieve the continuation of the status quo, but it would leave an NHS without strategic health authorities and primary care trusts and without a comprehensive and effective framework for sector regulation. There would be no organisation with the powers needed to support commissioners in developing more integrated services. That is something that the noble Baroness, Lady Finlay, and others have rightly demanded. There would be no organisation capable of enforcing requirements on providers regarding integration and co-operation. Neither would there be sector-specific regulation to address anticompetitive conduct that harmed patients’ interests. The powers that currently exist to enforce advice of the Co-operation and Competition Panel would no longer be available. Instead, it would be reserved to the OFT to consider complaints under the Competition Act, rather than by a sector-specific healthcare regulator with a duty to protect patients’ interests.
I mentioned protecting patients for a good reason.
Health and Social Care Bill
Lord Crisp Excerpts(12 years, 2 months ago)
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Lord Crisp
My Lords, like, I suspect, every other Member of your Lordships’ House, I very much respect the way in which the Minister has handled the Bill and his willingness to engage in debate. I sit here as a Cross-Bencher listening to what seems to be the healing of a rift between the coalition parties, if I may put it like that, but I also see—my postbag is full of this, as I am sure everyone else’s is—a rift with the medical profession, the nursing profession, midwives and others. Even though this approach may deal with some of the issues that they have wished to raise, I do not see that it will deal with the much more fundamental issue of the loss of trust and unity that seems to have been created as part of the passage of the Bill. Can the Minister say something about how he believes that that will be handled? These issues go far beyond your Lordships’ House, as we all understand.
Earl Howe
The noble Lord is right. The stance taken by a number of medical bodies and members of the medical profession is of course a matter of great regret to me and my ministerial colleagues. I say to them and to the noble Lord that once the Bill has been approved by Parliament, as I sincerely hope it will be, that will be the time to re-engage with the medial profession and work with it to ensure that the Bill delivers on the promise that we have held out for it and that we still believe in. The principles that the Bill embodies, which the medical profession has always said that it supports, can then be given substance in the form of the improvements that we would like to see delivered to patients. From all the comments that I have heard from doctors and others who are in doubt about the Bill, most of their concerns revolve around its implementation and what it will mean in practice, rather than the principles that it enshrines. We need to look forward collectively and work together to make the NHS work better.
Health: Non-communicable Diseases
Lord Crisp Excerpts(12 years, 7 months ago)
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Lord Crisp
To call attention to the worldwide incidence of non-communicable diseases; and to move for papers.
Lord Crisp
My Lords, it is a privilege to open this debate on such an important issue, which sadly affects, or will affect, the lives of all Members of your Lordships' House, either directly or indirectly through family members. In talking about non-communicable diseases, I am talking about diabetes, cancer, cardiovascular disease, respiratory diseases and mental health. You may ask why I am drawing attention to this at this time, because these diseases have been with us for a long time. The reason is that this is a growing problem. It is now the biggest set of health issues globally and the fastest growing set of health issues in every continent, including those afflicted by HIV/AIDS. We are ill equipped to deal with them, and we need a new and concerted effort to confront them.
When I put forward this proposal for a debate, I actually wrote, “To draw attention to the worldwide epidemic of non-communicable diseases”. Somebody in the Table Office, quite rightly I guess, chose to change that to “incidence of non-communicable diseases”, reasoning that an epidemic is something that is spread and communicated. In the ordinary sense of the word, however, we are dealing with an epidemic. As far as we know, these diseases are spread not by infection or biological process but they certainly are spread by social processes. Diet, the availability of food—healthy and unhealthy—smoking, alcohol, lack of exercise, stress and social pressures, which may in turn lead to overeating, alcohol, smoking and so on, are all key factors in the major spread of these diseases. They are sometimes called the diseases of affluence but, as I will say later, they also strike the poorest in the world.
I am very grateful to the distinguished noble Lords who are taking part in this debate and I know that they are bringing great expertise and knowledge in the fields of mental health, diet, cancer and coronary heart disease. I am particularly delighted that my noble friend Lady Hayman is returning to speaking in the House. My task is to set the scene, identify some of the key strands and ask just a few questions of the Government. Let me start with the context of the diseases.
I am not going to give your Lordships a lot of statistics but will try to limit myself to a few which scope and shape the problem. Now, 60 per cent of deaths in the world are due to these diseases—twice the number due to communicable diseases. This has changed markedly in recent years and is growing fast. While these diseases are associated with ageing, as they are with affluence, it is noticeable that a quarter of the deaths from them globally are in people under the age of 60. If we look at the UK, a quarter of the deaths from these diseases are in people under the age of 70. They are what we in the Department of Health and elsewhere would tend to call, or have called, preventable deaths. If I might take one example to show the pace of growth, diabetes is one of the fastest growing diseases and there are now 300 million people in the world affected by it. It is estimated that there will be 500 million by 2030. The numbers are vast: in India, it is 52 million people; here in the UK, it is something like 2.8 million people and growing fast. I believe that the noble Lord, Lord Kennedy, will have more to say on this.
These diseases are often called diseases of affluence. Indeed, as societies develop more of these diseases become more prominent. In Europe, 85 per cent of deaths are now due to these diseases but they hit the poorest population in a society worst. If we think of those causal factors such as smoking, diet and so on, we can understand that. Globally, Africa is the fastest growing area for non-communicable diseases. This is not just about death. It is also about disability and dependency, and the long-term and economic impacts in both the treatment of these diseases and lost productivity. This has been authoritatively estimated as being of the value of $47 trillion over 20 years. One-third of that is in mental health and I am sure that my noble friend Lady Murphy will have more to say about that. What is also noticeable about those costs is that $7 trillion of them are in low and middle-income countries—in other words, it is disproportionately hitting their economies.
I have already alluded to the fact that perhaps the most significant issue here is prevention. Up to 40 percent of cancers, 80 per cent of type 2 diabetes and much of heart disease and stroke are preventable or can be delayed to the advantage of both patients and of costs. I have already mentioned the causes which, again, your Lordships can see in one simple statistic: 7 per cent of UK hospital admissions are due to or related to alcohol, diet, exercise, smoking and, of course, obesity. I know that the noble Lord, Lord McColl, will be talking more about obesity and diet but in the UK 25 per cent of people are now in the category labelled as obese. In India—this may be much more surprising— 45 per cent of children in its cities are underweight and 25 per cent are overweight, so they are being affected by both aspects of the problem. I read an extraordinary story in the newspaper, perhaps reminding me that I should not always believe what I read there, that something like half of the Indian Cabinet has had gastric bands fitted—in other words, surgical devices to restrict the size of their stomach to prevent overeating.
So we have here a picture of a set of diseases that are distinguished by applying to us all, rich and poor, in every country in the world. They are driven by social factors as well as others, require a massive focus on prevention and, crucially, cannot be handled in the same way as the diseases of the previous century. Diseases have changed since health systems were set up. Our systems in the UK, for example, based on hospitals and doctors, were set up largely around episodes of care coming in and being dealt with—being killed or cured, if you like—whereas another way of thinking about these non-communicable diseases is to talk of them being long-term conditions. Those conditions last, and we live with them, for many years. Over those years a typical patient will have some acute episodes where maybe they need to be in hospital, they will have a lot of self-care and they will get care from neighbours and social services as well as from health services. They need a completely different pattern of care from the ones that our systems deliver.
The South African Minister of Health, Dr Aaron Motsoaledi, says that incentives in all our systems are in the wrong place. In talking about diabetes, he asks why we pay only a certain amount to the people who prevent diabetes, much more to the people who treat diabetes and the highest amount possible to those who deal with the complications of diabetes. We have a system that incentivises the highest level of treatment as opposed to one that incentivises prevention. I know that there are no simple answers, no one has the answers and the situation is changing all the time, but here is a real opportunity for global learning and working with others around the world on how to deal with this growing epidemic.
This debate is timely. I was extremely fortunate to be successful in the ballot because two weeks ago, on 19 and 20 September, there was a UN summit on non-communicable diseases, which was attended by virtually every country in the world and 34 heads of state. This got very little reporting in the UK, which was understandable, given what else was going on at the time, including the economic situation, but I am pleased to have the opportunity with this debate to draw a little attention to this set of issues and to what happened at that summit.
The summit was important; it was part of a process of the world, as it were, starting to agree what will replace the millennium development goals when they come to fruition in 2015. As noble Lords will know, those goals were set in 2000 for reducing deaths from TB, HIV/AIDS and malaria, as well as reducing child and maternal mortality. These are wholly admirable and there has been a lot of progress. We always need priorities. However, one of the negative impacts of priorities is that other things are deprioritised, and over these years we have seen that as more money has gone into communicable diseases and, rightly, into child and maternal care, systems and resources have moved to those areas at the cost of non-communicable diseases. We have seen systems broken up as priority has been given to those areas. In due course, we will need to move beyond the MDGs and think about global targets and priorities for non-communicable diseases. I suspect that over the next two or three years there will be other debates in your Lordships’ House around these issues as the collective will moves towards some target-setting.
The UN summit identified six strands of action. The first was that this is not purely a health problem; it is a problem for the whole of government and society—industry, civil society and NGOs as well as health.
The second area was about reducing risk factors and creating health-promoting environments. Of course a lot of this is about individual responsibility for what we eat and drink but there is a lot that can be done through regulation and nudging, through lateral thinking and creativity. To take one terribly simple example, it is about how we design our buildings. Somebody drew to my attention the other day that, in most of our schools, children now stay in the same classroom all day. I was used to a system where I moved from one classroom to another, sometimes quite considerable distances during the course of the day. That meant that, just through the act of being at school, children were doing a certain amount of exercise. The design of a lot of our public buildings and spaces is important.
The second area is about reducing risk factors and creating health-promoting environments. The third is about national policies and systems. The fourth is about global collaboration on regulation, trade and development policies. The fifth is research and development, and the sixth is monitoring, evaluating and learning. The outcomes from that summit are that, by the end of 2012, the Secretary-General must report back to the United Nations Assembly on what is happening. This is starting to move.
The UK has a proud record in development, with what was achieved under the previous Government and, indeed, during the current Government. I am a great admirer of the work of DfID and the priority that has been given to it by this Government. The UK played an enormous role in the development of the millennium development goals. It is globally influential and can play an enormous part in giving this new agenda the priority that it needs.
The Minister knows that I am not, however, an admirer of the NHS Bill, in part because it does not put these long-term conditions and non-communicable diseases absolutely at the centre of priorities. If it had, integration of services would not be an add-on. We would see much closer integration of health and social care, and all the carers together. Nevertheless, there are many good policies in the UK on treating non-communicable diseases and dealing with this problem. I look forward to hearing the Minister say more about that.
I have four questions and challenges for the Government if they are to play this leading role. The first is aimed more at DfID than the Minister’s department, and I will understand if a reply comes later. There is a problem not just of prevention but of access to treatment. In Zambia, for example, 90 per cent of people with diabetes do not have access to insulin. This leads them to a major problem. The World Trade Organisation agreed in 2001 that, in the event of a public emergency, countries could apply for exemption to international patents relating to essential medicines so that they could be produced generically and, therefore, much more cheaply.
In the run-up to this high-level summit, the EU and the US and the pharma-companies argued that this should apply to non-communicable diseases. What is the Government’s position on this? What is the Government’s policy on the use of these exemptions of essential medicines relating to real crises and public emergencies in low-income countries?
The second question applies both to the UK and to the global situation. What do Her Majesty’s Government believe is the role of industry in non-communicable diseases, specifically the food industry? It must be involved, but I note that it is being given quite a prominent position. How will self-regulation work and what evidence is there that self-regulation will have the desired effects? Thirdly, what are the Minister’s views on the research that is required here, and how we can link together non-communicable and communicable diseases?
Finally, I notice that DfID uses MDGs as a method for determining what funds are awarded. Given that people in DfID understand as well as I do that this is the coming epidemic, what will be their role in exercising greater flexibility on this issue, and paying more attention to these diseases in the future? I beg to move.
Lord Crisp
My Lords, I said at the beginning that it was a privilege to introduce the debate, and it has certainly been a privilege to listen to it and to hear the wisdom, insights and wide range of interests of the noble Lords who have spoken. I think that we have all learnt something; I certainly have. It has been very good to have insights from the patients’ perspective as well as from clinicians and everybody else.
This will be a continuing theme. The UN summit to which we have all referred was described as the end of the beginning. Non-communicable diseases will now be a major global theme of those sorts of global meetings. In due course, we will no doubt start to see some targets being set. For the time being, however, I beg leave to withdraw the Motion.
Drugs: Prescribed Drug Addiction and Withdrawal
Lord Crisp Excerpts(12 years, 10 months ago)
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Earl Howe
My Lords, I am not sure that I can answer the latter part of the noble Baroness’s question but GPs are clearly in an important position in this context. They are responsible for identifying patients who need help and for supporting them. I do not think that there is any reliable evidence that doctors are failing to comply with guidelines on the prescribing of benzodiazepines but I am aware that the Royal College of General Practitioners is updating its guidance at the moment. It is working hard to produce that very shortly.
Lord Crisp
My Lords, given the importance of making visible the number of people who are addicted in this way, when will the Government calculate the true number of people addicted to and withdrawing from legally prescribed drugs? That information could be made available from GP computer records. Does the Minster agree that both the NAC and the NTA reports confuse the number of patients taking legal prescriptions with the number of users of illegal drugs?
Earl Howe
I agree with the noble Lord that it would be very nice to have a better handle on the numbers here, but the two reports found that nationally available data do not actually provide a definitive prevalence estimate of dependence on prescription and over-the-counter medicines, much as we would wish otherwise. The reports, not unreasonably, consider the full spectrum of need in relation to the issue of addiction. The key point here is that, while different people might start taking these medicines for different reasons and may present with a different range of needs, no one at all should be excluded from the treatment and support that they require. The reports distinguish between the two groups of patients, not just those who are dependent on prescription and over-the-counter medicines but also those who are dependent on illegal drug use. That enables us to make some useful comparisons.
NHS: Front-line and Specialised Services
Lord Crisp Excerpts(13 years, 4 months ago)
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Lord Crisp
My Lords, I am grateful to the noble Lord, Lord Turnberg, for giving us an early run at one of the key questions coming out from the Government’s proposals—a question which I might rephrase as: will they work where it really matters, at the front line? I, too, congratulate the noble Baroness, Lady Jolly, for giving us such an eloquent description of why they matter.
There is a great deal to be said for the Government’s proposals—not least the continuation of a 20-plus year policy for a primary care-led NHS and for decentralisation, although, as some noble Lords have pointed out, there need to be limits to both of those. There are of course risks. It will be no surprise that I shall concentrate on the more managerial issues. The Minister knows, but I should say for the record, that I was chief executive of the NHS and Permanent Secretary of the Department of Health for six years; so I am afraid that I know a bit about reorganisations and may be seen by some of my clinical friends in the House as one of the villains of the piece.
I read the Command Paper that came out before Christmas with great interest, particularly where it talked about how to manage the transition. It was well written, as I would expect from former colleagues in the Department of Health, but there were some fundamental gaps that are fundamental risks. I will mention three of them.
The first is the capability of consortia. I have no doubt that there any many good, talented and skilled GPs and people working in primary care who can and will take the lead in this area. I did not find anything in the paper that described how the capabilities of those consortia to discharge that role would be in any way tested. Your Lordships will no doubt know that foundation trusts and NHS trusts go through a critical scrutiny as to whether they are capable of discharging their functions, and that is to be continued under these proposals. As an NHS trust chief executive 15 years ago, I remember going through just such a tough process where people from outside the organisation tested whether our ambition to do something was matched by reality. The optimism of our will to do it was tested against the pessimism of whether we could actually deliver—were we up to the job? I do not know why that is not being put forward here for GPs unless the Government are too eager to get the GPs involved and do not want to frighten them off at that stage. It is important that some testing is done to secure the success of what is intended here. How will the department test the capability of consortia before they are given free rein?
Secondly, as a subset of that, I was again interested to know how consortia would be accountable. I see in the text that there is somebody called an accounting officer who is not really defined other than as the person who will account to the NHS commissioning board and then upwards to Parliament for the expenditure of the consortium. It need not be a doctor, we understand, but there is a question about what their responsibilities and powers are. In some ways it looks like going back to the old system of consensus management that we had 25 years ago where you basically had a doctor and an administrator in charge and you had to get the two of them to agree to get any change going. This was the sort of situation of which Roy Griffiths, in a report for the Conservative Government of the 1980s, said that, were Florence Nightingale back today, she would be wandering the corridors of the hospital wondering who was in charge. That question is still there. How will that arrangement work for accountability?
The third gap, to which my noble friend Lady Finlay alluded, is that these consortia will turn for expertise to private sector organisations, some of which will be from abroad. We know that GPs are saying that, and that it is already happening. They will, for example, turn to people with experience in insurance systems. We have a social contract system: we expect to be able to go to our doctor and know that they will do their best for us, looking at a comprehensive care with some exceptions rather than an insurance system that too often specifies what you can have. There is a big difference between the two. My worry is that there will be a change in the attitude of mind and behaviour in that relationship.
I have one positive suggestion here which the Minister may or may not like. Although there are pathfinders and there is preparation under way, I have not seen anything that suggests there will be any large-scale simulation of these proposals—getting people together and, over a period, encouraging them to play out the various roles to see what will happen. That has been done in the past, and it is an effective way. The question need not be whether these proposals will work but what you need to do to make sure they work as effectively as possible. Can the noble Earl say whether the Government propose to do any such simulation of these proposals before bringing them fully into effect?
NHS: Global Health
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Lord Crisp
To ask Her Majesty’s Government how they will ensure that the subject of global health is included in the education of all health professionals.
Lord Crisp
My Lords, it is a great pleasure to be able to open this debate. I am delighted to see how many noble Lords have decided to take part in it, and I know that a number of others, for reasons of snow and the fact that we already had a large list, have decided not to take part. There is a lot of interest in this subject, and it is something on which there is a great deal of agreement both in your Lordships' House and outside. That agreement is partly the point of the debate, because what we need now is some action.
Professional education in the 20th century has done a wonderful job, not least in the United Kingdom. Life expectancy in the world as a whole has doubled in the century, but the outside world has changed, which means that there is a need for a change in education. There is a broad consensus on what needs to happen, and we can see it happening in many of our leading schools already. As Richard Horton, the editor of the Lancet, has put it:
“health professionals today are not adequately prepared to address the present and coming health challenges—aging populations, chronic diseases, cultural diversity and higher public expectations”.
It is, if you like, the necessary move from a purely doctor and hospital-based model to something much more diverse and local, more community and more person-based. That was a goal of the last Government and I know that it is a goal of this Government. The difficulty as always is to make it happen.
This Question is about global health and the emerging new discipline of global health. Let me explain why I think it is relevant here. I am talking about global health, not international health, which is what we talked about in the last century when we talked about the health of other people. Global health is about the health of all of us—all the issues that affect us all, wherever we are in the world. It is about our interdependence in terms of disease and how it can fly around the world very quickly; in the 14th century, it took three winters for the Black Death to get across Europe, whereas it took three days for SARS to get around the world earlier this century. We are also interdependent in our use of the same staffing and resources and interdependent in terms of the environment and climate change. All kinds of issues affect our health and we began to understand them much better in this past decade than we ever did before.
The second reason is that the diseases from which we suffer have been changing. There are many more non-communicable diseases, and in that context context itself is vital. We are beginning to understand better the social, behavioural, cultural and economic aspects of global health, and the emerging discipline is about taking on these issues and about understanding and acting on the wider determinants of health. Education needs to do this as well.
Thirdly, global health is about recognising that health is about health systems and how healthcare is delivered to individuals and populations. It is not just the theory of the laboratory and lecture room but the reality of the clinic and the community.
The fourth point that drives very many people is that experience in other countries is extremely valuable to us in the UK. Many who are involved in global health are driven by a passion to do something in poorer countries, but it is good for the UK as well. It develops people personally and they can learn from new examples and new experiences, and of course learn about some of the people living in their own country whose origins may have been far away.
Let me refer to the recent Lancet commission report that was published at the end of November, called Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World. The commission was chaired by Julio Frenk of the Harvard School of Public Health, and by Lincoln Chen of the China Medical Board, of which I was privileged to be a member. This was the first such attempt to look globally, with a global set of commissioners, and to learn from innovation everywhere in the world—not just Europe and America—and to do so across all professions on which we could collect data. It draws out some key lessons about how education needs to happen in the future: about how it needs to be interprofessional and transprofessional, going across disciplines and outside them to involve the public. Education needs to be competence-based, systems-based and IT-enabled.
The report also shows how our institutions need to change, breaking down barriers and connecting not just across disciplines but going outside health across locations and countries. Let me mention just one example that brings it alive: the IHI Open School. There are now 80 chapters in universities across world in 28 countries. This is a coming together of medical students to learn via the internet about subjects that are not covered in traditional courses: quality improvement, systems thinking and such like. They are studying in one school, maybe in the UK, but adding to it from elsewhere. This is the sort of model that I think we will continue to see.
The final point about the report is that it talks about transformational education: the effort to create professionals who are able to lead and make change in today's changed world. A brief illustration of the wide-ranging thinking on this in this country can be seen from the activities of two groups: Alma Mata and Medsin. Alma Mata is a 1,000-strong group of junior doctors and young health professionals from other disciplines. Medsin is also about 1,000-strong and made up of medical students. They advocate precisely that global health should be included in the syllabus and set out their vision for the doctor of the future, which is very important as they are the doctors of the future.
It is encouraging to see that the establishment is responding, including the Royal Colleges—and we have two former presidents of Royal Colleges speaking in this debate. To take one example, the Royal College of Obstetricians and Gynaecologists is very concerned about the lack of support for junior doctors who want to work overseas and who want to include that in their training and not be disadvantaged in their careers by doing so. There are also organisations such as the London International Development Centre, which works with six London institutions and runs, among other things, courses of students as global citizens. There is a very much wider view here about what needs to change. Indeed, developments in partnerships between institutions are very ably supported by THET, and I am delighted to know that Her Majesty’s Government through DfID have launched an even more substantial scheme to promote these partnerships.
There is a lot happening in the UK, but this is a worldwide phenomenon and things are moving faster in the US and Scandinavia than here. I can imagine the Minister saying, “Very good, we’re happy to encourage this, but what has this got to do with Government and the Department of Health?”. My answer is that it really does have an impact on us. I stress that this sort of activity is not just for the benefit of foreigners; it is about creating better health professionals who are better able to care for people of this country with our 21st-century diseases and lifestyles.
I suggest three actions. The first is extremely practical. I ask officials in the noble Earl’s department to report to him on what more can be done to help trainee doctors to spend some time abroad as part of their training and to do so in some numbers, not with the odd one or two who take a risk with their careers. That would make this much more mainstream and much more positive.
Secondly, the Minister’s department should meet the universities and the professional education schools of medicine and nursing and the wider health schools to consider the findings of the Lancet commission and decide what action might jointly be taken to develop the education of health professionals and to get some impetus and coordination behind the moves that are happening all over this country.
My third request is that the Minister’s department provides active support for the involvement of NHS people and organisations in the DfID programme of partnership, recognising that this is a difficult time for the NHS but making it clear from the top that this is good thing for people to be engaged in. It is about the future, and there may even be ways of looking at things like the newly announced early retirement scheme, which might actually help in developing these sorts of programmes.