NHS: Hospitals

Lord Patel Excerpts

Thursday 8th September 2011 Lords Chamber

[Earl Howe]

My Lords, I am grateful to my noble friend for that question. I am sorry to say that I do not have those figures in front of me, but she is absolutely right to make the point that the independent sector treatment centres introduced by the previous Government were a perfectly proper move to increase choice for patients, and in many cases we have seen the quality of care in those hospitals encourage the NHS to raise its own game. Competition on that basis is highly beneficial.

[Lord Patel]

Will the Minister say what assessment has been made of the causes of low productivity in the NHS?

[Earl Howe]

My Lords, it is clear that one of the causes was that the previous Government—for all the right reasons, I have to say—injected very large sums of additional money into the health service, but alongside that there was no commensurate increase in activity. A lot of the additional money went into settling pay claims. That is not to decry the many benefits that arose from the additional money, but the net effect was a decline in productivity.

NHS: Medical Records

Lord Patel Excerpts

Wednesday 7th September 2011 Lords Chamber

[Earl Howe]

I pay tribute to the work that the noble Lord did when he was a Minister. Yes, the Government are committed to a summary care record, which, for the benefit of noble Lords, is a record that includes a defined set of key patient data, other than for patients who choose to opt out—that is an important rider. Clinicians can then access essential medical information that they need to support safe treatment and to reduce the risk of inadvertent harm, especially during emergency care. To answer the second question that the noble Lord asked, over six million patients now have a summary care record, which is a considerable increase over a few months ago.

[Lord Patel]

My Lords, would the Minister agree that to improve the quality of healthcare we would need comparable indicators of health outcomes? In the absence of nationally collected computerised data, how would we achieve this?

[Earl Howe]

My Lords, the noble Lord is absolutely right. We have to measure performance in order to improve upon it. That is why we are focused on producing an information strategy, which we hope to publish later this year. A lot of work has already gone on and the NHS Future Forum, as he may know, is looking at this area. He is absolutely right that this will be central to the performance management of the NHS.

NHS: University Health Centres

Lord Patel Excerpts

Monday 4th July 2011 Lords Chamber

[Earl Howe]

My Lords, I congratulate the noble Lord for introducing this vexed topic into a health Question. It would be improper for me to comment on the deliberations of the Scottish Parliament.

[Lord Patel]

Can the Minister say what assessment has been made of the impact of the QOF on the outcomes for patients, whether university patients or otherwise?

[Earl Howe]

My Lords, there is no doubt that the QOF had many beneficial effects when it first began, and we recognise those. However, there is a general feeling that it needs to evolve and refocus itself more on those things for which it was originally intended, which were to promote quality and better outcomes in patient care.

Health: Hepatitis C

Lord Patel Excerpts

Monday 20th June 2011 Lords Chamber

[Earl Howe]

My noble friend is absolutely right that early diagnosis is always a good thing for this condition as it is for many others. We know who the risk groups are, and therefore the important thing is to target screening and testing at those groups. Predominantly, the at-risk groups are injecting drug users or former injecting drug users; they account for well over 80 per cent of cases of hepatitis C. Those groups are the focus of our efforts in primary and community care, and especially in prisons.

[Lord Patel]

My Lords, does the Minister agree that some ethical issues might arise in the mass anonymous screening of blood samples if a treatment was available for the disease that was being screened?

[Earl Howe]

In the case of hepatitis C, treatments recommended by NICE are of course available that, if taken early enough, can dramatically affect the course of the disease. I think we are in danger of straying into legislative territory that is perhaps the occasion for a wider debate as to how, if at all, we might expand the scope of the Human Tissue Act so as to reach those cases that I think the noble Lord is referring to.

Health: Hospital-acquired Infection

Lord Patel Excerpts

Tuesday 7th June 2011 Lords Chamber

[Earl Howe]

My Lords, as the noble Baroness knows, we expect trusts and primary care organisations to utilise funds from within their global budgets to meet the requirements that I have just outlined, such as those in the NHS operating framework. These requirements are mandatory, and it appears that over the past few years, trusts and primary care organisations have really got to grips with this problem.

[Lord Patel]

My Lords, the Government are to be commended on insisting that all hospitals publish their infection rates for Clostridium difficile and MRSA on a weekly basis, which we can monitor on the website. It is interesting to note that one or two hospitals stand out by consistently having higher numbers while the rest make dramatic reductions. What is important, however, is that there has been no reduction in central venous line or other central line infections. I hope that the Government have a strategy similar to the one on MRSA and C. difficile to insist that hospitals reduce their rates of central line infections.

[Earl Howe]

My Lords, the noble Lord makes an important point. We have consciously limited the extent to which it is a requirement to publish data to the most prevalent infections that need to be addressed. That is not to say that other types of infection are less important; they are extremely important. However, we would expect a ward-to-board policy to operate within each trust so that the boards of trusts bear down on these infections as hard as on others.

NHS: Reform

Lord Patel Excerpts

Monday 6th June 2011 Lords Chamber

[Earl Howe]

My Lords, I accept that a number of aspects of the Government’s proposals have caused concern in many quarters, and that is why we have chosen to pause in order to listen and reflect on those concerns. As I have said, we will be bringing forward proposals shortly to improve the Bill. I hope that those proposals will meet with widespread acceptance. I think that it is fair to say that it is not the main principles which the Government have laid out that have been the subject of controversy but rather the detail and the implementation, which we are looking at most closely.

[Lord Patel]

My Lords, does the noble Earl agree that if we are going to make the proposed savings in the health service of £20 billion, some form of reconfiguration of how health services are delivered is inevitable? If that is so, which would he prefer: a market-driven reconfiguration, or a planned one that will contain costs in the future?

[Earl Howe]

My Lords, the way we have set out the Health and Social Care Bill means that, wherever possible, decisions on service reconfiguration will be taken at the local level. That will mean that all stakeholders locally, not only the NHS but local authorities, social services and patient groups, will buy in to and contribute to whatever decisions are taken. So my answer to the noble Lord is this: it should be a considered process of decision-making taken locally.

Public Bodies Bill [HL]

Lord Patel Excerpts

Monday 9th May 2011 Lords Chamber

[Lord Winston]

My Lords, I have not decided whether I shall vote for or against the amendment if it is pressed. I shall listen very carefully to the Minister’s response.

One of the greatest ethical issues involved in this treatment is its lack of accessibility. It is a highly privileged treatment, because it is mostly in the private sector. It is true that the NHS provides some, but many health authorities have based their fees to some extent on the private sector. Therefore, the hard-pressed PCTs have not been able to offer as many treatments as many people recommend.

When I left practice running a large IVF clinic some five or six years ago, we were charging very much less than is currently charged by clinics. We were still able to turn more than £1 million a year over to research and provide the Hammersmith Hospital with a great deal of surplus income, which was then used to treat other patients.

One of the key issues with which the HFEA has not dealt is the high cost of IVF treatment. In my view, it is a scandal. There are clinics that treat patients for around £3,400 a cycle. It is only when you look at their websites that you see that they are charging up to £1,100 to £3,200 for drugs that should be obtained on contracts at around £500 to £700 per cycle. Embryo freezing will be increasingly required if we are to limit the number of pregnancies that result in multiple births by transferring just one embryo each time. One clinic in London charges £915 for embryo freezing. That is for a mechanised treatment that is extremely easy to do in the laboratory. If that were not enough, the storage fees are £325 a year. Given that liquid nitrogen, which is what the embryos are stored in, costs a few pence a litre, that seems somewhat excessive, even allowing for the costs of regulation. I am afraid that the HFEA has shown itself to be completely unable to deal with this issue at all. This privileged treatment is a shocking issue.

Secondly, one thing that the HFEA claims to be doing is giving accurate information to patients. This morning, I trawled a few IVF clinic websites. A prominent clinic in London—which I can name but will not—argues on the front page of its website a 69 per cent IVF success rate. That figure is repeated twice on the website. It is only when you delve into the small print that you realise that it is nowhere near that. That is the cumulative success rate over several cycles of treatment. Another clinic argues that it has a 30 per cent success rate in women over 40 or 42. That is a biological impossibility given that the implantation rate alone of a patient under 40 is something around 18 per cent per embryo—at best 25 per cent. What the site does not say is that this is for pregnancy but not delivery of a live baby. It does not take into account the vast number of miscarriages that presumably these patients are going through. This kind of misinformation occurs again and again.

The Bridge fertility clinic offers a 71 per cent pregnancy rate per blastocyst treatment and 67 per cent success rate for pre-implantation genetic diagnosis. As someone who has been intimately involved with pregenetic screening of this kind, I find those figures, frankly, quite incredible. Perhaps they depend on very few patients being treated and a good deal of luck. But that is highly misleading. These treatments have not been validated by the HFEA. Presumably, that is why it has allowed advertising to continue.

Then we come to the ways of promoting treatments that are not acceptable in this country. There are several clinics in London alone that offer their services in, for example, Mauritius—that is one of the Harley Street clinics—the USA, India and Spain. There they can display all sorts of unvalidated success rates on their websites and in addition can offer treatments that are not acceptable in the United Kingdom, such as multiple embryo transfer. Why has the HFEA not withdrawn the licences of those clinics? Why has it not argued that this is dishonest and dangerous?

Then, of course, we have the question of the database, which has been referred to already. The database ought to be very valuable but, sadly, in practice it is useless because we cannot follow up patients in the long term. That is a very serious issue. As the Minister knows, epigenetic issues—early experiences in development from fertilisation onwards—may have a profound effect on our health when we become adults. IVF in this country is not followed up in this way, so we have no way of knowing whether some of the treatments or exposures of the human embryo may be more likely to cause damage at a later date.

Then we have the question of another issue, which the HFEA seems to have been totally powerless to deal with. That is the issue of treatments without any evidence base that they work. Let us take the example of immune therapy, which is charged at anything from £1,000 to £3,000 a time, in addition to the already high fees of IVF. Where is the evidence that immune therapy actually improves the success rate of pregnancies? I do not know of that evidence—and, indeed, the treatment may even be damaging or harmful to the patient’s residual immune system.

Then we have preimplantation genetic testing, which is testing of embryos genetically when IVF has previously failed. I accept that preimplantation genetic diagnosis works, as the noble Lord, Lord Walton, has said, and it is a valuable technique in a few patients. However, there is actually no evidence base showing that preimplantation genetic testing in people who do not have a genetic defect, as widely used by many clinics, provides a helpful and improved chance of a pregnancy afterwards. The control trials and the control evidence are not there, and this treatment—if it is done at all—should be done on a research basis. However, the HFEA has failed to license it on that basis. The same applies to the treatment of assisted hatching. These are not small treatments; preimplantation genetic testing is charged in one clinic at £2,690 in addition to the £3,000 or so charged for the IVF and the £800 to £1,000 for the drugs that the patient pays for. At this stage, patients who are desperate will do anything to ignore the avarice of the people who might be treating them. This is a massive issue, as it is with another treatment, widely offered, of assisted hatching, in which a little piece of damage is done to the zona pellucida around the embryo or egg in the hope that it might improve the pregnancy rate. Over many years it has not been shown to be really effective, but it is still widely sold without any proper regulation.

We have heard from a number of speakers in this debate that the HFEA is the envy of the world. If it is the envy of the world, why has no other jurisdiction accepted this method of regulation? It is not used in Singapore, the USA, France, Israel or Australia, the countries that are most successful at reproductive treatments. I am not suggesting for a moment that we should not have a proper culture of regulation or a proper ethical standard in how we deliver medicine, but the current workings of the Act of Parliament are now not suitable for the original purpose. We have outgrown it. With the burgeoning private practice that has occurred with this treatment as a result of the failure to fund it in the health service, we have an increasing problem, which is very far-reaching.

It is true that there are virtually no good academic units in the United Kingdom that really produce cutting-edge research in the field of reproductive biology where it applies to humans. That was not true 30 or 40 years ago, when we led the world, in places such as Cambridge, London, Edinburgh and many other centres in Scotland. Now we cannot find people to appoint to chairs in reproductive medicine. The chair at Hammersmith was left vacant for three years after my retirement, and eventually they decided not to seek anyone to fill it. They could not find somebody who was a suitable academic because people are being attracted to the highly lucrative business that IVF provides. In my view, this is a very serious problem.

One of the most respected academics in this field is Professor Alison Murdoch, in Newcastle, who has pointed out something really quite interesting. I take her view very seriously as I believe that hers is an example of a really well-run, ethical practice. She points out that regulation of in vitro fertilisation is now far greater than regulation of, for example, abortion. That does not seem to make sense. I listened very carefully to the right reverend prelate the Bishop of Guildford. However, does he really believe that the protection of the embryo is more important than the protection of the foetus or the protection of research on the newborn child, the patient who is pregnant or the elderly patient who may be about to die from various diseases? Surely the notion of centralising our research under one body makes good sense, because we can then have a rational basis for important ethical decisions. I shall listen with great intent to how the Minister responds to this debate. However, I am not convinced that, even if we vote for this amendment, it would be a good idea to vote for the preservation of the HFEA as it stands.

[Lord Patel]

My Lords, I shall be brief as we have been debating this for a long time. I spoke to this issue in Committee and, apart from the noble Lord, Lord Winston, and the noble and learned Lord, Lord Mackay of Clashfern, who is not in his seat, I was the only one to argue against preserving the HFEA’s current status and role, particularly on the clinical side.

I start by agreeing with the noble Lord, Lord Willis of Knaresborough, about the medical research authority. I totally agree with him that the Academy of Medical Sciences report has been widely accepted and backs the establishment of such an authority. It will also have an ethics committee because, according to the report, it will take over the national ethics service, which is currently run separately. It will therefore have an ethical body to assess the ethical issues related to all medical research. There cannot be any doubt about that. Last time, the noble and learned Lord, Lord Mackay of Clashfern, asked—and I have his permission to repeat the question—whether, in the interim, the Minister will find a way of establishing such an authority before the legislation is put in place.

I turn to the HFEA and its other role. Yes, it is true that we should all feel a glow when we mention the HFEA. When it was established, soon after the birth of Louise Brown, a voluntary licensing authority established by the Royal College of Obstetricians and Gynaecologists and the Medical Research Council had been operating for two years. Its creation gave both clinicians and the public the confidence that the newspaper headlines of the time—that monsters would be created in Petri dishes—would not be realised. It is true that in its formative years the HFEA did a fantastic and useful job in establishing and licensing premises for delivering good care to those requiring IVF treatment. Yet the world has moved on. More than 1 million children the world over have been born following IVF treatment.

There is no reason to think that the clinical care provided for patients requiring infertility treatment, including IVF, is any different, or should be any different, from the care provided for children with cardiac anomalies. Both treatments are properly regulated by the CQC and the professional organisations. We hear of units being shut down because of poor outcomes; so let us consider the recent performance of the HFEA. How should we measure it? We should measure it against the success rate for IVF. As the noble Lord, Lord Winston, mentioned, apart from spurious claims, there is no evidence that our outcome for patients requiring IVF treatment is any better than anywhere else in the world; in fact, it is poorer than in some other countries. Measured against promoting better outcomes for the patients, the HFEA has not delivered.

NHS Reform

Lord Patel Excerpts

Monday 4th April 2011 Lords Chamber

[Earl Howe]

My Lords, I am grateful to my noble friend and can give him those assurances. He is right: we have somehow got ourselves into the position of having a National Health Service that is, in essence, managerially and administratively led instead of being clinically led. That has happened by a process of accretion and slow and steady development. We need to get back to one of the principles that the incoming Labour Government articulated in 1997 when they introduced primary care groups. That was an attempt by them to do exactly what we are trying to do: to have clinically led commissioning in the health service. Unfortunately, to my mind, primary care groups morphed into primary care trusts and thereby became administrative units which became more and more divorced from clinical decision-making.

I can reassure my noble friend that we do not want to dilute the principle of clinically led commissioning. We believe that it is right and that we can build on the experience of the past; not just primary care groups, but also the good parts of fundholding, which had some good elements, and practice-based commissioning groups, which the previous Government introduced. This is an important opportunity, as I said earlier, to capitalise on the NHS as it now is and to shed some of the unhelpful elements that get in the way of driving quality and patient care.

[Lord Patel]

My Lords, the Statement suggests that the Government are satisfied with the performance of the health service, both fiscally and in the quality of care it provides. It is therefore surprising that the Statement also says that we need to improve productivity and quality. How does an economic regulator promote competition based on quality?

[Earl Howe]

The economic regulator will do two things. It will fix prices for the purposes of the tariff and it will preside over the marketplace—such as it exists—in healthcare so that anti-competitive conduct will be prohibited. It will bear down upon conflicts of interest and anti-competitive practices of all kinds and, in conjunction with the NHS commissioning board, it will ensure that the pricing system in the NHS incentivises quality. There are, as the noble Lord knows, a number of levers that we can use to do that through the tariff.

Health: Obesity

Lord Patel Excerpts

Monday 4th April 2011 Grand Committee

[Lord Patel]

My Lords, you cannot really find fault with the logic of the noble Lord, Lord McColl—do not eat and you will not put on weight. The problem is that for most of us, if you mention food we want to eat. I am going to focus on strategy, but I cannot find fault in his logic.

The noble Lord has already referred to the fact that obesity is recognised as a major public health problem and that it may well be getting worse. A policy review of several countries, including the United Kingdom, finds common themes. All express concern at the prevalence of obesity, thought to be the result of over-consumption of energy-dense foods and inadequate levels of physical activity. Few countries have specific strategies; instead, obesity is tackled through separate policies of nutrition and physical activity. Policies often in general terms identify sets of actions without any firm commitments—often interventions that focus on schools, workplace and active transport. What is noticeable is the absence, almost, of fiscal and legislative interventions from policies; neither are the policies funded. The interventions are poorly supported by research or evidence. The proposed measurement of the effectiveness of policies is weak and not clearly formulated. The strategy to tackle the so-called “tsunami of obesity”, which threatens several countries in the world, is largely concerned with options for ways to develop policies rather than a set of interventions to reduce obesity.

We have known about the associations of obesity and disease, and the noble Lord, Lord McColl, mentioned some of them. There are some 17 different diseases that we know of that have associations with obesity, costing the health service in England in the region of £4 billion—costs that will exceed health costs due to tobacco and alcohol use. The joint report in January 2011 of the Academy of Medical Sciences and the Royal Society of Edinburgh—and I declare an interest as a fellow of both—made some key recommendations on diabetes and obesity that have implications for policy research and management of patients with obesity and diabetes at individual and population level.

Obesity, as everybody understands, is a condition characterised by an individual having excess body fat caused by higher energy intake than expenditure. Excess energy is stored in the form of adipose tissue. Statistics have already been mentioned and are clear: 25 per cent of the adult population is obese and 65 per cent may well be overweight, while 23 per cent of children at reception in school are obese or overweight and 33 per cent of 10 to 11 year-olds are obese or overweight. Those are important findings from the child measurement studies. The pester power of children and the pushing of calorific foods to children by shops contributes to this. A well-known politician reportedly asked:

“As Britain faces an obesity crisis, why does WH Smith's promote half-price Chocolate Oranges at its checkouts instead of real oranges?”

When he said that, he was much applauded by the population and by the citizens. The politician was David Cameron.

I turn to the current Government’s strategy, or what it might be. We await the publication. The public health White Paper suggests that the Government will take a holistic approach with emphasis on personal responsibility and choice, but they will be reluctant to use regulation or legislation. The focus will be on voluntary agreements with industry through public health responsibility deals. Interventions are likely to be based on strong evidence, but there is not enough strong evidence, especially as NICE is asked to put the obesity interventions review on hold. There are suggestions that the Government will use the famous “ladder of interventions”, beginning with the least intrusive—information, education and so on—but regulation of industry or individuals will be used only if the initial steps of the ladder do not work. That is the well known nudge theory which involves no regulation, prompted choice and co-operation with the private sector, and it will be subject to strict post hoc evaluation.

I ask the Minister: what is the evidence that the nudge theory will work? What is the roadmap to evaluation? What measurements will be used and who will carry them out? A major plank of the policy is the responsibility deal. Who will lead that responsibility deal? Who will be responsible for it? Could the noble Earl comment on the reports that several charities and consumer organisations have withdrawn, seeing it as industry influencing consumers rather than reforming their business practices?

I hope that the Government will take on board in their strategy several issues that have some evidence as to their effectiveness. They are such simple things as a front-of-pack colour-coded labelling scheme for foodstuffs; a ban on advertising on television before 9 pm of food that is high in fat, sugar or salt; a continuation of the national child measurement programme; information on calorie content on all products; a commitment from local authorities to provide, to protect and to maintain the environment that will enhance physical activity; promotion of research into psychology and anthropology of behavioural change; cost effectiveness of interventions; and, lastly, a ban on trans-fats in all foods, as I have said before. Strategies that demonstrate reduction in childhood obesity are key indicators of success and, therefore, the childhood measurement programme should be continued.

NHS: Standards of Care and Commissioning

Lord Patel Excerpts

Thursday 31st March 2011 Lords Chamber

[Lord Patel]

My Lords, good healthcare systems deliver good standards of care and good commissioning should reflect that. I would like to focus on cancer, the insights that it offers into the performance of our healthcare system and the challenges that it poses in the new healthcare structure. The proportion of deaths attributable to cancer has risen from 17 per cent in 1948 to 27 per cent in 2008. It is predominantly a disease of the elderly. Alongside its human impact, cancer is also costly. The National Audit Office estimates the cost as £6.3 billion and the total cost to society as £18.3 billion. These costs will rise as the population ages and new treatments are developed.

Cancer survival is a key metric of the performance and quality of healthcare systems. It is a function of the population awareness of cancer symptoms, primary and secondary care assessment and referral, treatment quality and effective screening programmes. Each year around one in three people is diagnosed with cancer and one in four will die of cancer.

The Lancet in January 2011 compares the survival of patients diagnosed in England, Wales, Northern Ireland, Denmark, Norway, Sweden, Australia and Canada. All these countries have comprehensive cancer registration and broadly similar healthcare spending and systems. The study examined relative survival—the excess deaths due to cancer after allowing for competing causes of death—from 1995 to 2007. Despite the improvement in cancer survival in the UK, the survival gap—the difference between the UK and the best-performing nations—appeared to have showed only some narrowing in breast cancer but was static in colorectal and ovarian cancer and worse in lung cancer. The difference in survival in lung cancer is equivalent to at least 1,300 avoidable deaths each year if we matched the best in Europe. It has been estimated that this survival gap from England to the best-performing countries in Europe for all cancers accounts for 10,000 avoidable cancer deaths each year.

The healthcare system in the UK is not improving at a fast enough rate to narrow the survival gap. This accounts for thousands of avoidable deaths each year. A far greater proportion of people die within one year of cancer diagnosis in the UK than in better-performing countries such as Sweden. This is due to later diagnoses in the UK; when patients in the UK are diagnosed with cancer, it is more often at an advanced stage where survival is shorter.

The coalition Government published in January Improving Outcomes: A Strategy for Cancer. This strategy aims to deliver health outcomes that are among the best in the world. It aims to do this alongside the seismic reforms that are taking place in healthcare in England. These new reforms as they stand rely on high-quality information and organisation of cancer services. The strategy does not ensure the continued existence of cancer networks, but says that,

“it is likely that GP consortia will purchase services from a new style of cancer network”.

That does not go far enough. Cancer networks are essential organisations to ensure the delivery of improved cancer outcomes and, in particular, the geographical areas that allow robust outcome data to be derived. The centralisation of cancer services since the NHS cancer plan has helped to deliver improvements in cancer outcomes. The National Cancer Intelligence Network is now providing detailed cancer outcome data according to network, PCT and age. These powerful data can be used to improve outcomes.

Much of the variation in outcomes in cancer is due to late diagnosis or referral by general practitioners. There is no process in place for assessing the quality of GPs in the assessment of patients with potential cancer symptoms. The Teenage Cancer Trust survey reveals that one in four teenage cancer patients visited their GP four or more times before referral to hospital. Without cancer networks, there is a danger that the cheapest services will be purchased that meet basic but not world-class quality standards. Healthcare is a complex process and we will never be able to define and record every metric that will contribute to high-quality outcomes. I hope that the Minister will confirm today that there are no plans to abolish the cancer networks.