Pharmaceutical Research and Development Spending
Lord Patel Excerpts(1 year, 7 months ago)
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Lord Patel (CB)
My Lords, I might end up repeating some things that have already been said, but that will just reinforce the important aspects of this debate. I thank the noble Lord, Lord Hunt, for initiating it, and the noble Baroness, Lady Wheeler, for introducing it.
I was going to try to focus on two things. One was clinical trials and the other was potential research into dementia. We know that clinical trials are an important part of domestic R&D, an important source of revenue for the NHS and a critical way of delivering early access to promising treatments for patients. As has already been mentioned, in the 2018-19 financial year, in addition to the revenue generated, there were £30 million of pharmaceutical product cost savings from trials supported by the NIHR clinical trials network. Numerous studies have also shown that research-active NHS facilities deliver better patient outcomes.
It has already been said that the UK has slipped down the global rankings and our reputation as a reliable destination to locate clinical trials is taking a hit. The National Institute for Health and Care Research found that there were about 28,000 participants recruited into clinical trials in 2021-22, compared with over 50,000 in 2017-18, and patients in different parts of the country, as the noble Baroness, Lady Walmsley, has already mentioned, have wildly varying experiences of being able to participate in research. The noble Baroness gave the particular example of cancer research. As she said, cancer patients in west London are 71% more likely to be asked to take part compared with those in some other areas. That is quite shocking, because cancer research trials were one area where we excelled.
The pandemic obviously had an impact on this decline. R&D leaders in the NHS estimate—again, as the noble Baroness, Lady Walmsley, mentioned—that we lost something of the order of £0.5 billion. But it cannot be ignored that the UK was beginning to decline pre Covid, and our post-pandemic recovery is lagging behind that of other countries. Even Spain has now overtaken us in the world ranking of clinical trials. We are now number 8, whereas some years ago we were number 2.
There are ways that we can tackle this, including by streamlining the slow set-up of recruitment to studies. So can I ask the Minister what the Government are doing to prioritise the recovery of industry clinical trials in the UK and ensure that research is embedded as part of routine NHS care across the whole of the UK? I think he has a golden opportunity as a new Minister to get some people into his office and demand that we change this declining position. Clinical trials should be a key part of our NHS research agenda.
I will now return to some aspects of dementia research that the noble Lord, Lord Goodlad, mentioned. It is the ambition in the life sciences vision of the Government to escalate novel treatments for dementia. As has already been mentioned, Alzheimer’s Research UK is concerned that the government commitment to research into Alzheimer’s is now slowing—to put it mildly. We know that dementia is the world’s biggest health challenge, with almost 1 million people in the United Kingdom alone suffering, and we know the heartbreak it causes not just to individuals but to their families.
Traditionally, this area has been risky for investment, but the commitment of dementia researchers over many years has led to some recent scientific breakthroughs and a growing pipeline of new treatments in clinical trials from which we in the United Kingdom are not benefiting. In recent news, a treatment called Lecanemab has shown in initial phase 3 clinical trials that it can slow down patients’ decline in memory and thinking. It is very promising. Taking these together, this means that dementia research is at a tipping point of progress. Continued life science investment is crucial to delivering the safe and effective treatments that people with dementia desperately need.
Over the past five years, we have seen an overall decline in the number of dementia trials being initiated in the UK and the number of participants in each trial. The noble Baroness, Lady Walmsley, mentioned how Germany, France and other countries have outstripped us in initiating dementia clinical trials, which is sad to have to admit. One of the reasons is that as a country we identify the problem at a later stage of the disease. We currently diagnose people with dementia too late, so their condition has progressed beyond the point where they are eligible to take part in clinical research. There is therefore a need for the NHS to address the diagnostics of dementia. Again, the point has already been made about government investment, which declined from 2018-19 to 2019-20. So the plea for the Government to have a plan to focus attention on dementia research is well made and I hope the Minister will say whether the Government have a plan to take forward research in dementia as identified in the Life Sciences Vision report of July 2021.
Primary and Community Care: Improving Patient Outcomes
Lord Patel Excerpts(1 year, 8 months ago)
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Lord Patel
To move that this House takes note of (1) the role of primary and community care in improving patient outcomes, and (2) the need for reform.
Lord Patel (CB)
My Lords, I am pleased to open the debate today. I thank the Minister and all noble Lords who have their names down to speak and look forward very much to their contributions. This debate takes place at a time when the whole NHS is under immense pressure, with media headlines such as “NHS in crisis”, “End of general practice as we know it” and “Will we have an NHS in the future?”, to quote a few. The focus of today’s debate is primary and community care—the backbone of our health service—how its performance affects patient outcomes, and whether there is a need to reform the primary care service.
Primary care has been the bedrock of the NHS since its inception in 1948. It has been revered by patients and has delivered huge health improvements. When Nigel Lawson—now the noble Lord, Lord Lawson of Blaby—said that the NHS was a national religion, it was because of patients’ love of its primary care services. The two professional groups worshipped by the people were the general practitioners and nurses in primary and community care, not the brilliant obstetricians, colorectal surgeons, palliative care doctors and—I say on behalf of the noble Baroness, Lady Murphy, who had to withdraw because of cataract surgery yesterday—not even the psychiatrists. Primary care is now in a different place. It is still the bedrock of the service, but the foundations are shaky, even crumbling. Unless fixed, the whole system will collapse.
What is primary and community care? It is the first point of contact for healthcare and is provided mainly by GPs, but also increasingly by nurses, dentists, optometrists, pharmacists and many other allied health and care providers, including physiotherapists, mental health nurses, care co-ordinators and, in the community, health visitors, specialist nurses, midwives and end-of-life carers. The system is about caring for people rather than treating specific diseases. A system designed to work as an integrated team, with the patient as its centre and focus, has now been broken through incoherent policies, being starved of resources, and a lack of attention to the need in primary care to develop a technologically driven healthcare system and the infrastructure and professionals needed for an efficient and effective system to run.
Primary care is the setting for 90% of patient contacts, involving some 26 million patients a month. Huge increases in demand are putting pressure on the whole system and leading to long waits in general practice, emergency care and planned care. These pressures have created the biggest single fall in public satisfaction with the NHS in decades. A recent survey suggests 68% of patients do not feel they will receive timely treatment if they fall ill, 50% think it is harder to get a GP appointment and 40% think the service has deteriorated. With general practice under immense pressure, recent data from the GP Patient Survey and the British Social Attitudes survey suggest two-thirds of people are dissatisfied with service provision, with the quality of care received perceived to be an issue.
If the problems in general practice and its performance are not resolved, it will lead to the demise of general practice as we know it and, in turn, the collapse of the whole system of primary care and the wider healthcare system. We will see a repeat in general practice of what has happened in dentistry, where 90% of NHS dentists are not accepting any new adult patients.
Putting aside the rhetoric, GP numbers are declining, despite higher numbers in training. Recruitment and retention are poor. More GPs are retiring early, with pressures of work, bureaucracy and pension rules cited as reasons. Reports of nearly 57% of GPs working three days a week or less and increasing numbers doing only private work—approximately 1,500 at the most recent count—are a worry. The service may become more privately driven.
Contracts and the independent status of general practitioners dominate all discussions related to primary care. The small-business model of GP contracts is still favoured by professional organisations, but a House of Lords report suggested that model is not fit for purpose. A recent Policy Exchange report, At Your Service, advocates a universal shift to a fully salaried model over time as part of wider reforms in primary care. More and more younger general practitioners are choosing to be salaried.
Of course, no change in service delivery can occur without general practitioners being part of it and, importantly, playing a leading role. General practice can and should provide that leadership, but at the same time recognise that strong leaders remain strong and gain respect by at times letting go of some strongly held values, such as their gatekeeper role or even their responsibility for minor contractual issues. I am sure GP professional organisations are aware of this: my conversations with them suggest that they are not averse to change, but wish to be involved in any policy developments. The workforce issues are not confined to general practitioners. Similar problems exist with nursing, health visitors and community care professionals, all of whom are a crucial part of an effective system of primary care.
Of course, there have been efforts to try to improve the system and deliver patient care. The establishment of primary care networks, starting in 2019, is one key example. While the majority of general practices belong to them, not all do. Success at delivering service at scale in primary care—that is the important point—by PCNs has been variable, and now the BMA is threatening to withdraw its support, with lack of resources and contractual issues given as the reasons for doing so. Some other measures undertaken to improve service are the recently established diagnostic hubs and the recent involvement of pharmacists in blood pressure monitoring.
I was impressed that the voluminous briefings we have all received all cry out for a need for change in primary care that delivers three things: workforce, infrastructure and technology, including IT. Various recent reports have come up with suggestions for improving the primary care system: the report Fit for the Future: A Vision for General Practice, produced by the Royal College of General Practitioners; the At Your Service report I mentioned from Policy Exchange; and the Fuller Stocktake report by Dr Claire Fuller, an eminent general practitioner, which was commissioned by NHS England. All of these reports have suggestions for an integrated system that delivers primary care at scale. In commenting on some of the reports, the King’s Fund has suggested that tinkering with “more of the same” will not produce results. Reforms need to be driven from the bottom up, by the people who do the work.
Undoubtably, we need a primary care service that delivers at scale, is fully integrated with other parts of the health and care system and, above all, is responsive to patient needs and delivers better patient outcomes and health improvement. So what is the way forward? My personal view, which I hope noble Lords would support, is that first and foremost we need political recognition that an effective primary care system is a prerequisite to a sustainable NHS. To this end, proposals for change to make future primary care fit for purpose have to be led by the Secretary of State for Health and Social Care. The words from the Prime Minister and the Secretary of State hitherto are encouraging and I hope they will be followed by some actions.
On the other hand, this House has an opportunity to play an important role by setting up a special Select Committee to report on the future of primary and community care, identifying possible barriers and solutions that could make important contributions to making primary and community care fit for purpose and fit for the future. I hope this gets support from noble Lords.
As for questions for the Minister, I have only one: is there a recognition by the Government that primary care is now in intensive care? None of the piecemeal reforms, mostly of process, will work. Strong, bold leadership is needed to bring about the system change it needs. Otherwise, it will die, and with it the NHS. I beg to move.
Lord Patel (CB)
My Lords, at the outset, I respectfully associate myself with the Minister’s comments and wish Her Majesty the Queen well.
I thank all noble Lords who spoke, and the Minister in particular for taking the debate and answering at length. Your Lordships spoke not just with passion but with real research behind it in finding out what the problems are with primary and community care. I hope the Minister got the information he needed, as was highlighted by everybody.
It was striking that in this debate, unlike others, no speaker tried to get at the government policies. There were no combative speeches; they all tried to help resolve the problem we now face in primary and community care, which must urgently be fixed. There is one message I suggest the Minister takes back to his ministerial colleagues—by the way, it is a good idea that they and their advisers all get a copy of today’s debate. In his meetings with his colleagues, the Minister should highlight the important issues that were raised today. I still say that primary and community care are in intensive care; if we do not rescue them soon, they will die. The problem will not be worse any more, because it will not be there.
I could summarise every speech, but I will not do that. They all made very important points. I say to the noble Viscount, Lord Eccles, please keep coming back; as the noble Baroness, Lady Hodgson, said, you are not past your sell-by date.
I ask the Minister to take this matter seriously. We hope the new Secretary of State recognises that primary and community care need fixing. I appreciate all the support I had for my proposal for a special Select Committee and hope the Liaison Committee listened very carefully. I thank noble Lords for today’s debate and for contributing; I appreciate it very much.
Integrated Care Boards
Lord Patel Excerpts(1 year, 8 months ago)
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Lord Patel (CB)
My Lords, the recent Civitas report put the UK second from bottom in patient outcomes in key areas of cardiovascular disease, cancer and a reduction in life expectancy. Can the Minister say what role commissioning should play in improving patient outcomes?
Lord Kamall (Con)
On patient outcomes, the noble Lord is quite right: we need to look at the statistics—where we are doing well and where we are not doing so well—and then focus efforts at not only the national level but the local ICB level, to make sure there is the appropriate commissioning. Indeed, one responsibility of the local integrated care board is to look at what services are needed in the local area and make sure that they are commissioned.
General Practitioners: Shortage
Lord Patel Excerpts(1 year, 10 months ago)
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Lord Kamall (Con)
My noble friend makes a very important point, and she referred continually throughout the passage of the Health and Care Act to practices in rural areas. We have looked at the challenges and have asked GPs about this in surveys, and we know that there are problems about the reduction of working hours, administrative burdens, some stress and burnout, and some issues about equitable distribution. One thing we do have is the Targeted Enhanced Recruitment Scheme launched in 2016, which has attracted hundreds of doctors to train in hard-to-recruit areas by providing a one-off financial incentive.
Lord Patel (CB)
My Lords, in 2017, a House of Lords report recommended that the current small business model of primary care is not fit for purpose. The same has been said by the Royal College of General Practitioners, which produced a report; the British Medical Association; two think tanks, the Nuffield Trust and the King’s Fund; and, more recently, Policy Exchange, which produced a report on the model being fit for the future. Is it not time that the Government had plans to look at future models of delivering primary care? If they do not have such an intention, does the Minister agree that the House of Lords should set up a Select Committee to follow on from the excellent report produced on the NHS in 2017?
Lord Kamall (Con)
I thank the noble Lord for that question, but I should explain to him that I have been warned for exceeding my powers, as it were, in the past. I think setting up a Select Committee is a bit beyond my powers. The noble Lord and I, and many noble Lords across the House, including previous Health Ministers of all parties, have had this conversation, and we know that the old-fashioned model of a five to 10-minute appointment with your GP, only to be referred elsewhere and into secondary care, is broken in many ways. We need a much more modern model. We have seen primary care take on some of the functions of secondary care, but we have also seen, at the GP level, that the GP does not have to do everything, and that there are other workers such as nurses, physio- therapists and pharmacists who can do more of what the GP has done in the past.
Coronavirus: New Cases
Lord Patel Excerpts(1 year, 10 months ago)
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Lord Kamall (Con)
As I said, we are keeping everything under review. We called our strategy Living with Covid-19 as opposed to “We’ve Got Over Covid-19” because we knew it could come back at any time. We have seen that, with the omicron variant, some medication is less effective. We continue to monitor that, and we are ready to stand up the measures that may be needed if the number of cases dictates that, on the advice of the JCVI and the UKHSA.
Lord Patel (CB)
My Lords, we all agree that the numbers are increasing by the day. Can the Minister say what is driving this rise in numbers? Are particular groups driving the rise, and if so, is the policy based on that information?
Bread and Flour Regulations: Folic Acid
Lord Patel Excerpts(1 year, 10 months ago)
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Lord Kamall (Con)
I hope the noble Lord appreciates that there is debate here. He has written to me a number of times about Professor Wald’s paper, which has been put before the advisers in the department. I think what we are seeing is scientific contestation: some people say that the science is settled, but others say that you have to be very aware of the unintended consequences. The NHS website advises people with certain conditions not to take folic acid, the worry being that, for people who do have levels of folic acid, we may end up solving one problem and unintentionally creating another.
Lord Patel (CB)
My Lords, we have now discussed the scientific validity several times. The Minister arranged a meeting, and I thought we had resolved this issue. Which scientific evidence is confusing the departmental advisers?
GP Access
Lord Patel Excerpts(1 year, 11 months ago)
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Lord Kamall (Con)
I am sure the noble Lord will remember from the debates on the Health and Care Bill that that Act provides for workforce plans every five years. In addition, Health Education England has been commissioned to do work on workforce needs of a much more decentralised nature, rather than top-down from Whitehall and Westminster: at the trust level and the CCG level and, in future, at the ICS level to look at needs and the mix of skills that are needed to serve local populations.
Lord Patel (CB)
My Lords, following on from the Question asked by the noble Lord, Lord Hunt, does the Minister agree that there is a need to rethink the model of primary and community care in the light of shortages, and considering that more and more GPs are now providing only private healthcare—at the last count, there were 1,500 of them—and 57% of GPs are working three days a week or fewer?
Lord Kamall (Con)
There are indeed a number of challenges. One is that many GPs are nearing retirement age and some are worried that their pension will be affected if they carry on working. Also, as an IPPR report recently said, the nature of illness and patient expectations have changed but the model of care has remained the same throughout. We expect five-minute appointments with referrals, but what we need in primary care is a much more networked model, with GPs, nurses, mental health officials, pharmacists, link workers and charities providing a joined-up service so that it does not always have to be the GP.
Children: Cancer
Lord Patel Excerpts(1 year, 11 months ago)
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Lord Kamall (Con)
I thank my noble friend for the question and for discussing the issue with me previously. As he rightly says, even though it is rare, cancer is the biggest killer of children aged up to about the age of 15. The Government’s new 10-year plan for cancer care is under development. It will address the cancer needs of the entire population, including those of children. We also recognise the severe impact that cancer has on not only the patient but their family and friends, and are focusing in particular on interventions that support patients through difficult journeys of diagnosis, treatment and aftercare.
Lord Patel (CB)
My Lords, research for finding new treatments for cancers, particularly childhood cancers, where the numbers are small, requires international collaboration. Some 42% of current CRUK clinical trials have international partners. The Government are consulting on clinical trials regulation and we have data sharing and protection legislation going through Parliament. Does the Minister agree that it is important that neither the regulation related to clinical trials nor the legislation related to data sharing should in any way jeopardise our international role in clinical trials collaboration?
Lord Kamall (Con)
I thank the noble Lord for the question, which cuts across three of the priority areas in my ministerial portfolio: data sharing, the life sciences industry—in which clinical trials and research play a huge part—and international collaboration. It is really important that we continue international collaboration. However, one of the challenges we face is that we have to make sure that patients are comfortable with researchers having access to their data. As part of that work, we have called in civil liberties organisations to help us along that journey. So, while we encourage more people to share data, we have to make sure that they have those protections. We can have the best systems in the world, but, if people opt out, they are useless.
Long Covid
Lord Patel Excerpts(1 year, 11 months ago)
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Lord Kamall (Con)
The noble Baroness emphasises just how wide, varying and diverse the symptoms of long Covid are. We know that children and young people can develop long Covid, just as adults can. NHS England has therefore not only established specialised paediatric services to provide care for children and young people, but is looking at providing specialist advice and support to general paediatric services as we learn more, as well as co-operating with international partners to learn from their experience.
Lord Patel (CB)
My Lords, the Minister quite rightly referred to the correct definition for people who suffer from long Covid as having a post-Covid-19 syndrome. That implies that people may suffer from multi-organ conditions and, in that respect, training is important. Does the Minister agree that NICE should be asked to publish guidelines for all professionals to recognise this condition?
Lord Kamall (Con)
The NICE guidelines start with the definitions as I have laid out previously, and the NICE definitions are aligned with the World Health Organization. On the noble Lord’s specific question, I will have to write to him.
National Institute for Health and Care Excellence
Lord Patel Excerpts(1 year, 11 months ago)
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Lord Kamall (Con)
I will try my best. If I may, I shall use this opportunity to respond to the noble Baroness’s earlier question. We have seen horizon scanning in regulatory science, which means that ILAP is at the forefront of cutting-edge developments. It is open to commercial and non-commercial, and UK-based and global developers of medicines. As I said, I will write to the noble Baroness with more detail. On doing something about NICE and the NHS, I have constant meetings with the NHS, as do other Ministers. One of the challenges that came up during the passage of the Health and Care Bill—I know that noble Lords who have been Ministers previously made this point—was that Ministers here have to respond on issues but decisions are quite often taken at NHS level.
Lord Patel (CB)
My Lords, I am yet another doctor. In defence of NICE, it has, despite the financial constraint, delivered 50% more appraisals in 2020-21 and is likely to do an extra 20% this year. The important point I want to make is the point made by the noble Baroness, Lady Morgan of Drefelin: patients need to have access to effective treatment sooner. If the appraisals are causing delay, for whatever reason, that is the place where NICE needs help, to get patients early access. For instance, a breast cancer drug that treats patients with triple-negative breast cancers, with a higher mortality, is available in one part of the United Kingdom now, but it is not available in England.
Lord Kamall (Con)
The noble Lord makes a very important point. One of the things we are looking at, so that we will not only be a centre for life sciences but make sure that our NHS is at the forefront of healthcare worldwide, is to make sure that we look at the different stages of medicines when they are approved, if they have conditional marketing, and the different stages of approval to see whether we can get them to patients earlier. As the noble Lord says, we should share the good news about NICE. It issued guidance within 90 days for licensing of 100% of new active substances in 2021-22 and has the highest number of technology appraisals in any year since appraisals began. There is some good news, but NICE recognises that it has to do more and we are in conversation about that.