Medical Innovation Bill [HL]

Lord Hunt of Kings Heath Excerpts

Friday 24th October 2014 Lords Chamber

[Lord Turnberg]

As we have heard, my Lords, there is a degree of uncertainty surrounding certain aspects of the Bill that we have been trying to clarify. It is on that account that I have tabled Amendment 31, which sets out the need for a code of practice in which the Secretary of State describes in somewhat more detail what the Bill is about and how it should be enacted. I hope that it will be helpful to have that in the Bill.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a fascinating debate, both in Committee and at Second Reading. We are all very grateful to the noble Lord, Lord Saatchi, for listening carefully and bringing the amendments that he has today, and for agreeing to a roundtable discussion between Committee and Report, which is a very constructive response to some of the issues that have been raised.

I say at once that I am absolutely with the noble Lord on the need to encourage innovation in our NHS, but the more that I have listened to the debate, the more convinced I am that it is not so much a question of the law but more one of actual practice within our NHS. I am afraid that we have to face up to the fact that there is a culture of regulatory processes and funding procedures that often get in the way of introducing innovation. For me, the Act that the Bill will become will be a signal to the NHS.

The noble Lord, Lord Blencathra, raised some interesting points about some of the problems that we have at the moment. He talked about off-label medicines. The Minister responded by saying that the Government are committed to innovation and gave a number of examples, which were welcome, but the point that I would put to him is that we now have a situation where NICE produces technology appraisals of new innovative procedures and drugs that clinical commissioning groups are essentially breaking the law by not implementing. He knows that they are under a requirement to fund the use of those procedures and medicines within three months of the technology appraisal being issued, yet we know from research by patient groups that the actual implementation is patchy. We could do an awful lot in relation to innovation if we insisted that people locally did what they were required to do.

My second point relates to the drug budget, an issue that the noble Lord raised. A few months ago the Government concluded an extremely interesting agreement with the branded drug companies, so that for five years the cost of branded drugs in England, apart from modest rises in inflation, will be fully met by the pharmaceutical industry. This is a very good agreement and one that I very much welcome. We still hear people in the NHS saying that they cannot afford the new drugs, yet the industry has promised to pay back any increase in the cost of those drugs over what they are paying now plus a modest increase in inflation. Here is a wonderful opportunity at last for the NHS to move quickly in widely adopting new medicines, but somewhere in the system someone is stopping it. I have read the NHS England five-year plan and it says nothing about the introduction of innovative new medicines.

I am sorry that this is a little outside the noble Lord’s Bill and I hope that he will forgive me, but this is about innovation. I am genuinely puzzled, and we will come back to this point, about why the Government did not rush to insist that the NHS took advantage of the agreement. In fact very few people in the NHS know about the agreement. My concern is that the rebates that the drug industry is going to give will be used for other purposes, which would be a very big mistake.

I hope that the Minister will agree to the amendment; I strongly advise him to do so, or at least to consider it. It is clear from the speeches that have been made that there is some confusion about the circumstances in which the noble Lord’s provisions are going to be made. Earlier in our debates, the noble Earl essentially said that doctors would have a choice when it came to whether, in relation to a given medical treatment, they would use this Bill’s provisions or rely on the traditional approach, the Bolam test. The noble and learned Lord, Lord Woolf, said that they are not alternatives and, in the circumstances raised by one noble Lord where there was not time to get the advice of the clinicians that is provided for in the noble Lord’s Bill, you would rely on the Bolam test. I am only a lay person, but I suspect that there is a risk of doctors not catching the nuance of that distinction. It is clear from the various letters that we have had from many of the medical bodies that there is some concern about this. I know that the noble Lord will speak and I strongly endorse his amendment on the regulation-making power, but I strongly advise the Government to agree to issuing guidance to the medical profession in this regard. There is a danger of some confusion and such guidance would be useful. If the noble Lord is not able to accept this amendment today, perhaps he will give it some further consideration.

NHS: Health and Social Care Act 2012 Reforms

Lord Hunt of Kings Heath Excerpts

Wednesday 22nd October 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, let us come back to the Question, which is about funding. If the picture was so rosy, why is it that a record number of NHS trusts and NHS foundation trusts are in deficit? If the picture was so rosy, what does the Minister have to say about the report a couple of weeks ago by the Nuffield Trust? It states:

“Prompt access to services has declined … In mental health services, demand”,

is,

“outstripping capacity for urgent care and for younger people. The wellbeing of frontline staff in both health and social care is”,

deteriorating. When he says that the Government are not ashamed of what they did, who is he speaking for? Is he really speaking for the Prime Minister and the leadership of his party?

[Earl Howe]

I am indeed and the NHS is under pressure for the reason that the noble Lord has just quoted—demand has risen dramatically. However, productivity has also risen dramatically, which it failed to do under the previous Administration.

NHS: Cancer Diagnosis and Treatment

Lord Hunt of Kings Heath Excerpts

Monday 13th October 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what is their assessment of the report by Cancer UK highlighting gaps in the provision of National Health Service cancer diagnostic and treatment services.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, there has been significant growth in the provision of cancer diagnostic tests and treatment over the course of this Government. For example, urgent GP referrals for suspected cancer have increased by more than 50% since October 2009. NHS England is taking action to support the NHS to improve performance, including establishing a cancer waiting times task force. We are investing an additional £750 million over four years to improve diagnosis and treatment of cancer.

[Lord Hunt of Kings Heath (Lab)]

My Lords, on the question of waiting times, can the noble Earl confirm that the 62-day target for cancer treatment has been breached in the last two quarters? Can he say why that is and can he confirm that it is really a result of the shambles that Mr Lansley’s changes have brought to the NHS?

[Earl Howe]

My Lords, the noble Lord is correct that although most waiting time standards are being maintained there has been a dip in the 62-day pathway standard in the last two quarters. However, survival rates are improving and we are treating a record number of NHS patients for cancer. Last year, 450,000 more patients were referred with suspected cancer than in 2009-10. That is an increase of 51%. In addition, campaigns such as Be Clear on Cancer have been exceptionally successful in raising awareness of symptoms. In large part, that is what has accounted for the pressure on the waiting time standards: in a way, the campaigns are a victim of their own success.

Ebola

Lord Hunt of Kings Heath Excerpts

Monday 13th October 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, first, I thank the noble Earl for repeating the Statement. I start by echoing his words by paying tribute to NHS staff members and members of the Armed Forces and of the Diplomatic Service who have been heavily involved in the Ebola response both at home and in West Africa for many months. I am sure that we have all been horrified by the devastating scenes reported on TV as the virus has spread. People will also be worried by reports of a second case of Ebola in Dallas. There will be particular concern that that second case has occurred in a health worker. We look to the Government for reassurance.

The noble Earl repeated the point that the Chief Medical Officer expects there to be a handful of cases. Perhaps he could say a little about what modelling has been undertaken to estimate the potential number of cases. What is the range of those estimates? Is a handful of cases the worst-case scenario? He will be aware of the independent review of the Government’s response to the swine flu pandemic by Dame Deirdre Hine, who said that the only predictable thing about such events is their unpredictability. Can the Minister confirm that the Government are planning for the worst-case scenario so that there can be no sense of complacency?

It is also right that we should consider further measures to ensure that we are fully prepared should an Ebola case be identified here. I would like to ask the noble Earl about the Government’s position, as there seems to have been some confusion. Last Thursday, a statement on the Department of Health’s website read:

“Entry screening in the UK is not recommended by the World Health Organisation, and there are no plans to introduce entry screening for Ebola in the UK”.

Just 24 hours later the Department of Health changed its position. Will the Minister say what official advice on screening his right honourable friend received from the Chief Medical Officer and from Public Health England? Did screening have the support of the Chief Medical Officer? In interviews over the last 48 hours the Chief Medical Officer seemed to be saying that there is no evidence to support the effectiveness of the screening programme that the Government are putting in place. Can the Minister confirm that?

Can the Minister also say who is in charge? He will remember concerns as the 2012 Health and Social Care Bill went through the House about the fragmentation of public health and about responsibility for it seeming to be split between Ministers, the Chief Medical Officer, Public Health England, local authorities and the NHS at local level. There will be questions about who is in charge and who is accountable.

The preparation exercise undertaken this weekend was of course extremely welcome. The Minister will know that a patient was transferred from Newcastle, where they have negative pressure beds, to the Royal Free, where they have what are called Trexler beds. The current advice—which has recently been revised—from the Advisory Committee on Dangerous Pathogens is that patients can be handled in either type of bed. Can the Minister comment on that? If only Trexler beds are recommended, is he satisfied that the NHS currently has only two such beds, both at the Royal Free? Can the Minister update us about progress on the proposed second unit planned in Newcastle, which he mentioned when he repeated the Statement?

While border checks and preparation exercises are important, the public will want to be reassured on three key issues. The first is that treatment is available, and that all necessary steps are being taken to develop a vaccine. The second is that the NHS is prepared and that staff are sufficiently aware of the symptoms. The third is that public information is readily available. I will take each in turn.

On treatment, although there is currently no specific treatment for Ebola, there is an experimental medication called ZMapp which the British nurse who was treated here was offered and took. Will it be standard practice to offer that medication to patients, and are the Government satisfied with the current supply of it in the NHS? The best assurance we could give people is that there will be a vaccine which will be made easily accessible to those who need it most. Can he update the House a little more on progress in its preparation?

With regard to preparation, is the Minister satisfied that all relevant NHS staff, including GPs, know how to identify Ebola, the precautions to be taken in any presentation and the protocols for handling it once it has been identified? Can he give an assurance that safety equipment is of the standard stipulated by the WHO? He will be aware that it is a cause for concern that breaches of protocol and the quality of safety equipment have been cited as potential causes of the infections in Spain and the US.

What plans do the Government have in the area of public awareness? Has the Minister considered introducing a telephone advice line? Does he consider that it would be wise to temporarily increase the number of clinicians available to answer NHS 111 calls?

The UK has, rightly, pledged £125 million to assist Sierra Leone in fighting the outbreak. However, with cases doubling every three to four weeks there is widespread agreement that the response of the international community in general has to date been slow and inadequate. The window of opportunity to halt Ebola will close very shortly, and I ask the Minister what extra steps the Government are taking to help the affected countries with resources and clinical expertise? What are they doing to mobilise action by the international community?

Finally, do the Health Secretary and the noble Earl accept that improving global health systems is the best way to prevent these outbreaks, or at least to ensure that such outbreaks are caught before they get out of control? It is indeed shocking that the index case for this outbreak was identified 10 months ago. My own party, along with the Governments of France, Germany and Senegal, among others, has called for universal health coverage to be placed at the centre of global development, yet the UK is currently opposing such plans at the UN. Can the Minister explain the Government’s opposition to this?

NHS: Cottage Hospitals

Lord Hunt of Kings Heath Excerpts

Monday 13th October 2014 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am sure that we are all grateful to the noble Lord, Lord Naseby, for raising this interesting Question. I enjoyed his heroic defence of the 2012 Act and the remarkable—and really quite dangerous—changes it brought about. I thought that today’s Times was an interesting read, and I recommend it to the noble Lord.

The role of cottage hospitals in the National Health Service is a very interesting question. We do not really call them that now; we call them community hospitals. It would be fair to say that they have had a mixed experience in the past few years. They are valued by the local community but are often at risk from the centralisation of services, and have tended to see their role downgraded over the past few years. Like the noble Lord, Lord Naseby, I was interested in the comments of Simon Stevens, the NHS chief executive, when he spoke about the experience of what he called running smaller, viable hospitals in other countries. I should be interested to know from the noble Earl, Lord Howe, what he thinks about that. Does he think that clinical commissioning groups should be encouraged to reverse the flow of services away from community hospitals into larger, centralised services? If he agrees, what attitude does he think that the regulatory bodies are likely to take? I am thinking here particularly of the Care Quality Commission, which has the responsibility of regulating all hospitals and care institutions.

I take it from the comments of the noble Lords, Lord Naseby and Lord Framlingham, that they would like to see an expansion in the services provided by community hospitals. However, that is unlikely to take place unless the regulator believes that it is safe to do so. I would be interested in the noble Earl’s comments on that. I have no doubt whatever that in terms of the current pressure on acute hospitals in particular, the more rehabilitative services and respite care that can be provided locally the better. Perhaps this could be an exciting role for smaller hospitals in the future.

As far as mutuals are concerned, I do not know if either noble Lord has read a report, sponsored by the Department of Health, called Improving NHS Care by Engaging Staff and Devolving Decision-Making: Report of the Review of Staff Engagement and Empowerment in the NHS. I do not know whether the noble Earl will refer to it but it is interesting because, on the one hand, it makes the point that,

“there should be greater freedom for organisations to become staff owned and governed, on a strictly voluntary basis, following detailed consultation with staff and staff-side trade unions”.

Clearly, some thinking is going on, which suggests at the very least that staff ownership—I know a mutual goes much wider than that—is one building block in the establishment of mutual organisations. On the other hand, I put to the noble Earl the comment made by the UNISON head of health—I should declare my interest as a member of UNISON—stating that there was,

“a very real danger that bringing the mutual model into hospitals will be a Trojan horse for privatisation”.

I did not take it from the comments of both noble Lords that that was what they had in mind. I took it that they both saw mutuals as being a support to the National Health Service and that they would not envisage patients paying money to go to those hospitals, which would very much be seen as being part of the NHS—although perhaps not run as other NHS bodies are. I thought that I should raise that issue.

I should also like to ask the noble Earl, Lord Howe, whether another approach could be to extend the foundation trust model. I have just given up chairing a foundation trust where we had 100,000 members, consisting mainly of members of the public but also 11,000 staff members. As members, they elect the governing body of the organisation. The governing body in turn appoints a board of directors. I have found that to be a useful mechanism whereby the board of the organisation is locally accountable. I have found the regular meetings of the governing body to be one of the most challenging experiences as chairman because there was a sense of accountability to the governing body, which represented both the locality and the members of staff.

I wonder whether the noble Earl, Lord Howe, thinks that perhaps we need to refresh the governance of NHS institutions in a way that allows much more mutual ownership. If he agrees, does he not think that clinical commissioning groups are an area where we should start? In our debates on the Health and Social Care Bill, one of my concerns about clinical commissioning groups was that essentially they have no accountability to their local population. One way around this would have been to adopt the foundation trust governorship model. Although the CCG is essentially a membership organisation of general practitioners, it could have a much wider responsibility and accountability as well.

We are all interested to hear the noble Earl’s comments on this interesting issue. I hope that, at the least, we get a sense of where the Government stand in relation to the role of community hospitals in the future.

Learning Disabilities: Premature Deaths

Lord Hunt of Kings Heath Excerpts

Wednesday 30th July 2014 Lords Chamber

[Earl Howe]

My Lords, I can assure the noble Lord that there is currently a whole-system response to the recommendations in the review. As I said earlier, this is a response from NHS England, Public Health England, local organisations and, indeed, Ministers overseeing the Learning Disability Programme Board. I shall take away the noble Lord’s question about a formal annual review, consider it carefully, and write to him.

[Lord Hunt of Kings Heath (Lab)]

My Lords, does the noble Earl recognise that the confidential inquiry showed that there are great failings in the health treatment given to many people with learning disabilities, which probably contributes to their very poor life expectancy? He will be aware that my own former trust, Heart of England, appointed specialist liaison nurses who could help people with learning disabilities find a pathway through their healthcare. Would he advise other NHS trusts to follow that example?

[Earl Howe]

My Lords, the noble Lord makes a good point. Following the recommendations of the UK review of learning disabilities nursing, we have set up an independent collaborative to address that workforce’s needs. We are also working with Health Education England’s 13 local education training boards to develop greater links with the independent and voluntary sector which will help with workforce planning. This year Health Education England increased its national commissions for student learning disability nurses by 4.5%. We are working on a number of initiatives to raise the profile of learning disabilities nursing and promote the profession as an attractive career choice.

Health: Dental Implants

Lord Hunt of Kings Heath Excerpts

Wednesday 23rd July 2014 Grand Committee

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Baroness, Lady Gardner of Parkes, is one of our most active Members and I am sure we all owe her a great debt in bringing this matter to our attention tonight. I declare an interest as a member of the Faculty of Dental Surgery at the Royal College of Surgeons. Last Friday, I attended a celebration of the 50th anniversary of the fluoridation of the water supply in Birmingham. Will the noble Earl join me in congratulating the great city of Birmingham on this achievement? It is interesting that, when one looks at health outcomes, Birmingham is often towards the lower end of the table, but it is way up in the top 10 in oral health. Whatever one’s views on fluoridation—and I also declare my presidency of the British Fluoridation Society—there is no question that it has had a very positive impact in Birmingham and the West Midlands in terms of the number of children who have to go into hospital because of oral issues, which was a point raised by the noble Baroness.

As the noble Baroness said, the use of dental implants has grown rapidly across the UK in the last few years. That has been very welcome to many patients but we know that, on the other hand, alongside this rise, the General Dental Council has seen an increasing number of complaints, particularly regarding the lack of informed consent for treatment, damage to the tissue and bone surrounding the implant, and failures. The noble Baroness was very explicit about some of the health issues that can arise. I have looked very carefully at the briefing provided by the Faculty of Dental Surgery at the Royal College of Surgeons. It makes four points that I will put to the noble Earl, alongside the questions raised by the noble Baroness.

Essentially, the briefing says that it is very important for patients to be given adequate information about the risks and alternative options for treatment. Secondly, patients should be aware that periodontal and peri-implant checks are essential to ensure that problems are detected early. The stability of the implant is threatened by diseases such as the one mentioned by the noble Baroness. I do not dare attempt to repeat its name, although I believe that the noble Earl, Lord Howe, is perhaps braver than me on that. However, this is why checks are essential.

Thirdly, the GDC should consider ensuring that peri-implant assessment and maintenance is part of the normal undergraduate course. Fourthly, I would like to mention the Law Commission draft Bill. We are not to see the Bill, but it contains proposals to give regulators the power to annotate their registrar and indicate specialisms or other qualifications. Given that we are not going to have the Bill—I know that there will be some Section 60 orders—perhaps I could make a plea that this might be considered if a dental order is to be brought forward.

Finally, I refer to a very interesting note I received from the Faculty of General Dental Practice about the standards of training in implant dentistry. This is available from a wide variety of providers in the UK, including universities, royal colleges and hospitals. These standards have been developed to ensure patient safety and protection, and I understand that they also serve as a reference point for the GDC in consideration of patient complaints. The only question I wanted to put to the noble Earl about this is that, although this seems to be absolutely fine, how can we ensure that more dental teams take up these training opportunities?

Clearly, we have a good system where standards are very much developed. The providers have to provide training in line with those standards, and the General Dental Council is there to follow up complaints when there are indications that dentists are not practising according to those standards. I wonder whether the noble Earl thinks that there is an issue of some dental practitioners not doing that, which then has an impact on their provision of clinical services.

Health: Midwives

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My Lords, I do not have information on the confidential enquiry in my brief but, according to international statistics, the NHS remains one of the safest places in the world to give birth. The latest independent CQC survey found that maternity care in England has improved, with women reporting a high level of trust and confidence in the staff caring for them. I shall gladly let my noble friend know the latest that my department has on the issues she has raised.

[Lord Hunt of Kings Heath (Lab)]

My Lords, did the noble Earl see the report in the Times this morning that the Nottingham University Hospitals NHS Trust maternity unit closed 97 times in a period of 12 months due to pressure? Freedom of information requests have shown that some 62 maternity units were forced to close because of pressures in 2013. Is that not a firm indication of a shortage of midwives? Does it not show that the Government are less than active in seeking to put this right?

[Earl Howe]

It is up to commissioners to ensure that facilities are available to meet the needs of women who are due to give birth. There may be limited occasions when a maternity unit cannot safely accept more women into their care. That is why we have seen some temporary closures of units. Any decision to redirect women is made by a clinician as part of a carefully managed process. It is not something that suddenly happens. However, commissioners need to be alert to the risks for provider facilities that a bulge in births can create.

Learning Disabilities: Community-Based Support

Lord Hunt of Kings Heath Excerpts

Tuesday 22nd July 2014 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what action they are taking in the light of the events at Winterbourne View hospital to ensure that people with learning disabilities inappropriately placed in hospital are able to move to community-based support.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government are working with health and care system partners, self-advocates, family carers and other stakeholders to improve safety, quality of care and outcomes for people with learning disabilities, including reducing significantly reliance on in-patient care, by reviewing people’s care and moving them to alternative, community-based support where appropriate.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am grateful to the noble Earl for that. Can he confirm that the Government set a deadline of 1 June for the transfer of thousands of people with learning disabilities out of institutions such as Winterbourne View? The latest figures show that only one in 10 such residents has actually been so moved. Will the noble Earl accept responsibility for this and tell the House what the Government intend to do about it?

[Earl Howe]

My Lords, the Government’s mandate for NHS England in the current year includes an objective which covers Winterbourne View concordat commitments. He is right that the deadline was missed. We are not satisfied with that and we are working very hard with NHS England to set out our expectations for progress and improved rates of discharge from in-patient settings. NHS England is going to produce an action plan this August but, in the mean time, it is doing three things. It is complying with the transforming care and Winterbourne View concordat commitments, which we have tasked it to do. It will set out what progress it expects to make and by when, with milestones, and it will provide real clarity on what success looks like—an important issue if we are trying to hold it to account—and how progress will be measured.

NHS: Ambulance Response Times

Lord Hunt of Kings Heath Excerpts

Monday 21st July 2014 Lords Chamber

[Earl Howe]

My Lords, I am aware of a number of those tragic cases. It is, of course, up to each response team to decide on the configuration of personnel and the skill mix on each ambulance that goes out. That judgment often has to be taken quickly. Sometimes it is a difficult judgment and, tragically, it is not always the right judgment. However, I know that every ambulance service in the country is mindful of the need to reach patients in emergencies with the greatest possible speed and the right professional skills.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the noble Earl confirm that the average waiting time for the most urgent 999 calls has lengthened in all parts of the country on average in the past three years? What are the Government doing to improve ambulance performance, and particularly could he comment on the very poor performance of the East of England Ambulance Service?

[Earl Howe]

The noble Lord is right. Ambulance trusts are experiencing high demand and we realise that a handful of services have experienced difficulty. Broadly, we are taking action in the short term and in the medium to long term. In the short term, we are supporting trusts with operational resilience plans so that they are better equipped to manage peaks in demand and we are providing clinical commissioning groups with additional funding, as I mentioned in my original Answer. Over the longer term, the NHS England review led by Sir Bruce Keogh is considering whole-system change, incorporating ambulance services.

With regard to the east of England, I met the East of England Ambulance Service NHS Trust’s chief executive, Dr Anthony Marsh, on 8 July to discuss performance since his appointment in January, and he assured me that the trust is now in recovery stage. Having seen his detailed proposals, I accept that judgment.