Tokyo Nutrition for Growth Summit

Lord Rea Excerpts

Tuesday 28th January 2020 Lords Chamber

[Lord Rea (Lab)]

My Lords, I am grateful to my noble friend Lord Collins, because he has chosen a subject on which I did some work 55-odd years ago, based in Lagos in Nigeria. The MD thesis that came out of that study was called Interactions of Nutrition and Infection, so it was very relevant to tonight’s Question. The study was modelled on the Newcastle Thousand Families longitudinal study, which observed a cohort of babies born successively in May and June 1947 and followed up for a number of years afterwards.

Lagos presented very different problems from Newcastle when randomly selecting which families to include in the study cohort. In the end, we were able to follow 420 randomly chosen infants in 250 families. All the children were seen every three months, when they would be weighed, measured and a note made of any illnesses that they had suffered. A visit to the child’s home was made if they did not attend the clinic. They were each allocated an illness score, depending on the severity and duration of the illness. It was possible to relate the illness score—equivalent to morbidity—to their nutritional state and growth over the previous three months, as well as to certain measures of social status such as the parents’ work, education, housing and so on. A weighted sample of well-off Nigerian professional families living a western lifestyle was included to act as a comparison with typical Lagos children. Their nutritional state and pattern of illnesses were very similar to those of typical western children of the same age, but the latter recovered much more quickly than the typical Lagos children from each episode of illness, which in their case was usually less severe.

It is not possible for me to describe the methods of study and analysis in any detail in a short speech, so I will not bore noble Lords with more research details. This type of study has been used in several other longitudinal studies in the UK and the US, and other developing countries.

The well-known signs of malnutrition, such as oedema and skin changes, were not overtly present in most of the children, but—apart from the chosen well-off group, of course—their mean weight and, less so, height was well below the norm, running at barely the 50th percentile of the better-off western norm. However, as I said, malnutrition was not overtly visible. If they were observed playing with other children, for instance, it was difficult to label them as malnourished.

Common childhood infections were present in children of all nutritional and social levels, but there was a tendency for them to be more serious and longer-lasting among those most underweight for their age, who more frequently developed pneumonia or diarrhoea as a complication. This pattern was shown most clearly in measles; the vaccine was then not yet available.

Tropical diseases did not present a great problem in Lagos, apart from some helminth infestation that did not seem to do much harm. Malaria was rare, unusually for Nigeria, because all parents used Nivaquine—that is, Chloroquine—as soon as their child had a fever, so the malaria parasite was more or less drugged out of the city. Compared with this group, a group of children of the same age in a village 20 miles outside was absolutely saturated with pneumonia. They had 2 grams less per 100 millilitres of haemoglobin, too.

It was possible on fuller analysis to show that the illness scores were higher in the most underweight children. Statistically, the episodes lasted longer and more frequently developed into pneumonia or diarrhoea. This tendency has led clinicians to concentrate on treating acute infections, neglecting nutrition in busy clinics. Supplementary nutrition is in fact not acceptable to an acutely ill child, but appetite usually returns during the recovery period—though less so if the child is already undernourished or the illness episode was severe.

I see that I am running towards the end of my time. All noble Lords will have received emails from UNICEF asking us to ask DfID an enormous number of very apposite questions, which we have no time to do—but I am sure that the Minister and her department will have scrutinised them extremely carefully. The most important thing is that the funding for nutrition should continue and possibly be augmented. As I have already passed my time, I will call it a day.

Health: Alma-Ata Declaration

Lord Rea Excerpts

Monday 22nd January 2018 Lords Chamber

[Lord Bates]

It is the key rulebook of the World Health Organization, but we should also remember that in the intervening 40 years we have had the sustainable development goals. Sustainable development goal 3 on health contains many of the provisions in the declaration. The sustainable development goals, unlike the millennium development goals, apply to all countries that sign them, not just least-developed countries.

[Lord Rea (Lab)]

My Lords—

[Baroness Sheehan (LD)]

My Lords—

--- Later in debate ---

[Lord Bates]

The noble Baroness particularly mentioned the programme partnership arrangements but we have changed that and distribute the money through a different mechanism to many similar organisations. I must put on record the fact that the UK Government and the people of the United Kingdom can be proud as they have done more in the area of family planning and providing access than any other Government. We initiated the first family planning summit in 2012, and we held the last one in 2017. We have made huge commitments in this area and are the second-largest donor, in overall terms, in this very important area of giving women control over their own lives and futures, which is important not only for the economy but for education.

[Lord Rea]

The Alma-Ata conference and declaration changed the attitudes of Governments and health planners by demonstrating the cost-effectiveness and humanity of universal primary care as compared with possibly more prestigious but very expensive secondary care hospitals. Is that not relevant to the situation we have in this country today, with hospitals full of patients with chronic diseases which could have been prevented and could certainly be cared for in the community if we had properly funded primary and social care?

[Lord Bates]

We need to remember that, in Alma-Ata in particular, we are referring to some of the poorest countries in the world. We have the best health service in the world. That is not just my word; that was recognised by the Commonwealth Fund, which produced that statistic saying that we have the best healthcare. It is a tremendous service. In many of the countries that we are dealing with, people have to travel for days or weeks to get any sort of health intervention. We need a priority to ensure that those people are brought into the ambit of the sustainable development goals so that they get the healthcare they need and we save lives as well as being mindful of the important responsibility we have in this country.

Neglected Tropical Diseases

Lord Rea Excerpts

Monday 3rd April 2017 Lords Chamber

[Lord Rea (Lab)]

My Lords, the noble Baroness, Lady Hayman, deserves our thanks for asking this Question and for her persistence with NTDs. She makes sure that these debilitating diseases are not neglected, at least in your Lordships’ House. Because these diseases are now mostly treatable, the accent up to now has been on medication, with less emphasis on prevention. But the underlying causal factors will allow the diseases to return, requiring repeated medication if they are not addressed. An example of this is onchocerciasis, or river blindness, where it is extremely difficult to eliminate the insect vector—a tiny blackfly. Repeated courses to treat river blindness are often necessary.

Tackling the causes, as at least two if not three previous speakers have said, requires the introduction of clean water, sanitation, improved hygiene and vector control where possible. As my noble friend Lord Stone said, this is encapsulated in the acronym WASH, which is now very much part of the NTD programmes of the WHO, DfID and other agencies. Of course, WASH plays a big part in the control of other diseases and the elimination of extreme poverty. We should remember that the provision of clean water and sanitation was and still is a basic part of all public health, dating from the time of our great-grandfathers in the 19th and early 20th centuries. Much earlier, water-borne sanitation was used by the ancient Romans, but with the decline and fall sanitation was also lost. Can the noble Lord, Lord Bates, give us a report on international progress with WASH programmes across the board and DfID’s part in them?

I also repeat the request of the noble Baroness, Lady Hayman, for information about the development of new vaccines for NTDs. In particular, I wonder whether we are having success in developing new point-of-care rapid diagnostic tests. These can greatly increase the cost-effectiveness of treatment programmes because it is possible to identify people who are not carrying the disease.

As a further point, the Leprosy Mission is concerned that not enough is being done to control and eradicate that stigmatising neglected disease. There are still pockets around the world where it is not eliminated. Can the Minister say whether DfID’s role in this will continue—it already plays a certain part—and, I hope, be stepped up?

Finally, I follow other speakers in hoping the Minister can assure us that the UK’s contribution to the international collaboration on NTDs will continue to be adequately funded, Brexit or not, and help to achieve the UN’s sustainable development goals.

UN: Sustainable Development Goals

Lord Rea Excerpts

Tuesday 16th June 2015 Lords Chamber

[Lord Rea (Lab)]

My Lords, we should all be grateful to my noble friend Lord McConnell for initiating this very timely debate on an extremely important subject. Looking back, I think it is fair to say that most people working in international development agree that the millennium development goals, now about to expire, provided a useful framework for action to improve health and, to some extent, reduce poverty in the developing world, whether or not those goals were fully achieved.

The post-2015 SDGs, which we are considering now, have been developed as a result of very wide consultation, which helps explain why there are so many of them—17 goals, with an average of 10 targets each, is a seemingly unmanageable number. It apparently proved difficult to narrow the number down even this far, since every nation had its own set of priorities. For each target, there still needs to be further scrutiny on how to measure and assess whether they have been achieved, how to monitor them in the future and, particularly, how they should be financed. Much of this work is ongoing and will continue until they are finally ratified at the end of the year, and after that too. Until then, there is a window of opportunity to hone the detailed targets further. The noble Baroness, whom I welcome warmly to her seat, will undoubtedly tell us about DfID’s work on the SDGs.

I will concentrate on goal 3, covering health, particularly the fourth part of it which is to,

“reduce by one-third pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment, and promote mental health and wellbeing”.

NCDs, by which I mean obesity and diabetes leading to heart disease, stroke and cancer, cause most of the deaths and the greatest burden on health services in developed countries such as our own. However, they now also cause more than half of all deaths in the developing world. Unlike the MDGs, which were aimed at the developing world, the post-2015 sustainable development goals have a worldwide application. The determinants of NCDs are wide but can be summarised as being associated with the post-industrial physical and nutritional environment in which most of the world’s population lives or is affected by. Unsuitable, often processed, food leads to obesity, overweight and diabetes, even among the poorest. This, with lack of physical activity, underlies heart disease, stroke and some forms of cancer. Tobacco smoking, the main cause of many cancers as well as heart disease, is still very prevalent, especially in the developing world. Atmospheric pollution also plays a role, particularly in the mega-cities of the developing world, in which an increasing proportion of the world’s population now lives.

Many of these determinants are touched on in the sustainable development goals. Obviously, I will not spell them out as that would be very tedious and take too long, but here are a few examples. Target 4 under goal 3, to,

“reduce … pre-mature mortality from non-communicable diseases”,

is felt by some to be discriminating against older people. The word “avoidable” might be a better word than “pre-mature”. Little changes such as that would improve those targets. Target 3.a, to “strengthen implementation of” the WHO Framework Convention on Tobacco Control, needs to be emphasised. Target 2 of goal 2, to end malnutrition, should also include obesity as well as stunting and wasting; discouragement and, if necessary, regulation to reduce added sugar and fat in processed food and soft drinks should be included at some point.

Physical activity and atmospheric pollution are covered in goal 11, which concerns cities and includes targets on housing and mentions road safety,

“with special attention to the needs of those in vulnerable situations”.

Here I would include cyclists and pedestrians in order to encourage physical activity, and there are many other ways in which urban design can encourage a healthy lifestyle. More places in the draft document could be tweaked beneficially, but a short debate is not the place to lay them out in detail.

I have been briefed for this speech by the UK Health Forum, of which I declare an interest as its honorary president. Its detailed response to the draft SDGs will come shortly to the Department for International Development, Public Health England and the international section of the Department of Health, which I think is now called NHS England.

Earlier, I asked the noble Baroness how DfID is approaching the September summit finalising the SDGs. I hope that she will talk about that. I would also like to ask her how, and at what level, the UK is approaching the imminent Addis Ababa meeting on the financing of the SDGs, because on that everything else depends.

Arts: Contribution to Education, Health and Emotional Well-being

Lord Rea Excerpts

Thursday 25th July 2013 Lords Chamber

[Lord Rea]

My Lords, I, too, thank my noble friend for bringing this important area before the House. I feel somewhat diffident speaking with those of such calibre. Previous speakers have shown that a good story well told can have a very big impact, which probably should be a rule for my future speeches. As a former medical practitioner, I will speak today on the effect that the arts, in the broadest sense, can have on health. Here, I am using the long WHO definition of health, which considers it to be not only the “absence of disease” but also,

“complete physical, mental and social well-being”—

a condition we aspire to but seldom achieve individually and probably never as a whole society.

This definition is useful because it recognises that health is not only physical but includes emotional and social components, factors which have tended until recently to be neglected in healthcare. Sir David Weatherall, when the regius professor of medicine at Oxford University more than a decade ago, explained how scientific medicine, which dominated the last century, changed the emphasis in healthcare from the whole patient and whole organs to diseases of molecules and cells. This caused many to feel that medicine had become reductionist and dehumanising. Although himself a molecular scientist, Professor Weatherall said that,

“we will now start putting the bits … together again … The old skills of clinical practice, the ability to interact with people, will be as vital … as they have been in the past”.

Since then the need for this is becoming more widely accepted but dehumanised healthcare is still the experience of some patients. The events in Mid Staffs, although not the rule, unfortunately are not unique. But, despite increasing pressures, most patients in the National Health Service receive expert, considerate and friendly care.

Where do the arts fit into this health story? The three components of health—physical, mental and social—are not separate entities. We all know the much quoted phrase created by the Roman poet Lucullus 2,000 years ago:

“Mens sana in corpore sano”.

The relationship between mental and physical health has now been demonstrated in a number of studies. Cheerful or normal people live longer and recover from illness more quickly than depressed people, who place a very heavy load on the National Health Service. The immune response of non-depressed people is better. My noble friend Lady Jones cited a number of other instances where mental health and social care can have a big impact on people’s physical health.

The relationship between social deprivation, even relative deprivation in prosperous societies, and physical and mental health and longevity is well known and is being increasingly better understood through the world-wide studies of the social determinants of health being led by Professor Michael Marmot of University College London. That is as relevant to the UK today, when our health problems are largely due to long-term, non-communicable diseases, as it was 100 years ago, before the era of antibiotics. Living conditions, nutrition and lifestyles are among the most important of these determinants. Here it should be emphasised that lifestyles are not simply a matter of individual choice, they are a product of economic and social pressures. It is only the exceptional individual from a deprived background who can battle their way to overcoming these commercial and social pressures and live an optimally healthy life.

I hope that this brief description of the factors underlying health will show why the arts are so relevant. As my noble friend said, is not the purpose of art to lift the spirits, open one’s eyes, educate and inspire? The emotional impact of music, so well described by my noble friend Lord Winston and the noble Lord, Lord Cormack, and works of art and sculpture as well as the written word, is often enormous. I would add high-quality media presentations on the radio and television, and let us not forget film as well. I could recite a long list of all the arts which are important. To say that the arts entertain us and cheer us up is only part of the picture. By helping to lift depression, the arts can improve our mental health and this can, in the ways I have suggested, lead to better physical health.

I have not mentioned one important aspect of our culture: the built environment. The noble Lord, Lord Cormack, talked about the majesty of Lincoln Cathedral, and of course there are other inspiring buildings all over the country. Good and imaginative design of neighbourhoods and individual buildings, apart from pleasing the eye, can have important effects on physical health. We have too many boring, or at the worst ugly, housing developments, while thoughtless redevelopment has plucked the heart out of many towns and cities. The result has been a loss of cohesive community support which can have effects on social well-being. The building of arts and cultural centres in many towns and cities has been a positive move that partly compensates for the destruction of city centres, and the evidence is that they have a sizable positive impact on the morale of their communities. However, they cannot replace the need for much more well-designed housing which, as all noble Lords know, would also act as a kick-start for the economy and have a beneficial effect on mental and social well-being. Well-designed housing, apart from being more carbon efficient, can improve mental, physical and social health through aesthetically pleasing design, good spacing, convenience and social facilities. It should also be ergonomically pleasing and more sustainable through well thought-out heating and ventilation. There are examples of excellent projects of this kind in many places throughout the country.

I do not have any specific questions for the noble Baroness, but I hope that she can reassure us that funding for the Arts Council at least will not be cut and hopefully be increased in the next spending round. I hope also that she can say that local authority support for community and other arts projects will be protected in the next round of cuts, which we are told will shortly arrive.

Health: Neglected Tropical Diseases

Lord Rea Excerpts

Wednesday 30th January 2013 Lords Chamber

[Lord Rea]

My Lords, I thank the noble Baroness, Lady Hayman, for bringing this important subject before the House. I was stimulated to take part because half a lifetime ago I worked with children in Lagos, Nigeria, for two and a half years and met with some of these diseases. They can have a debilitating effect by causing anaemia, malnutrition, impairment of immunity or renal failure. Most of them have a secondary host, or vector, which spreads the infection. These include a number of insects and other organisms which have been referred to and described by other speakers. I think noble Lords would agree that nobody living in the Western world would tolerate being exposed to any of these pests. However, people living in poor housing with no clean water or sanitation cannot guard against them. In this context, I would echo the noble Baroness, Lady Hayman, in asking the Minister how far vector control for NTDs other than malaria is being addressed by any of the programmes supported by DfID.

People suffering from these tropical diseases are also subject to the full panoply of other universal infections, such as pneumonia and diarrhoea, which are more likely to be severe because of lowered immunity, caused by one or other NTDs, and associated malnutrition. While welcoming the international initiatives that have been praised by everybody, I have a slight caveat, as did the noble Earl, Lord Sandwich. Anthropologists Tim Allen of LSE and Melissa Parker of Brunel point out in the Lancet that, welcome though treatment of NTDs is, the mass administration of drugs gives rise to a danger that these vertical programmes can undermine already fragile and overstretched healthcare systems. However, I think that with care, co-ordination and collaboration this can be avoided. In fact, if properly managed, these programmes can actually strengthen primary care.

Populations receiving mass medication often do not understand why tablets are being given to everyone, including those with no symptoms, and may not understand or accept scientific explanations of the causes of NTDs. The two anthropologists I mentioned write:

“The availability of tablets is not enough ... dealing with NTDs in a sustainable way will involve a range of factors including behavioural change. Imagining that mass drug administration ‘will make poverty history’ is unrealistic”.

I think that the leaders of the current interest in conquering NTDs are fully aware of this, and I certainly feel that this was given evidence by the excellent research papers that were given at the School of Hygiene and Tropical Medicine this afternoon. As someone who has worked at the grass roots, the observations of the two anthropologists need to be taken into account; they have the ring of truth.

I would like the noble Baroness to reassure me if she can that the generous funding going to mass treatment of NTDs is not diverting DfID researchers away from the longer-term, but ultimately much more sustainable, objective of relieving poverty and improving health by strengthening health systems, improving nutrition, ending illiteracy and providing clean water and sanitation. Mass administration of drugs can set the ball rolling, but only through these wider means can NTDs be sustainably controlled and eventually eliminated.

Treatment of Homosexual Men and Women in the Developing World

Lord Rea Excerpts

Thursday 25th October 2012 Lords Chamber

[Lord Rea]

My Lords, many people in the developing world will be grateful to the noble Lord, Lord Lexden, for raising so cogently this important and disturbing issue. Although we may condemn the draconian laws and practices he has described, we should not forget that it is only quite recently in historical terms that this country and other industrialised democracies have repealed laws which prohibited same-sex relationships. Although the law has been liberalised in the UK and other countries in the north, and many prominent people, including MPs and Ministers, are now able openly to declare their sexual orientation, powerful prejudice is still there among a substantial minority of the population. A well-known example of that is the problem that the most reverend Primate has had with some of his bishops both here and abroad. The noble Lord, Lord Lexden, has pointed out that the intolerant and puritanical attitudes to gay sex that prevail in many developing countries may be a relic of colonialism, and that before the colonial era there was a much more permissive attitude.

How does this social and legal condemnation of homosexual people affect their health, particularly in terms of HIV infection? I was privileged to serve last year on the House of Lords Select Committee that looked into HIV and AIDS in the UK, which was chaired very ably by the noble Lord, Lord Fowler. Although sexual orientation and HIV infection are different entities, there are parallels, particularly regarding stigma and social rejection. To quote from the Select Committee’s report, we found that:

“Stigma and lack of understanding can undermine HIV prevention efforts … and can also impact upon adherence to treatment”.

The double prejudice that gay people with HIV suffer from makes it even more difficult for them to get access to treatment and the follow-up which is necessary. In many countries they are thwarted in obtaining treatment by laws and attitudes that criminalise or shun them.

HIV infection was of course first discovered 30 years ago among gay men, so the disease is associated with gay sexual behaviour. However, heterosexual transmission in Africans is now more common than homosexual transmission both at home and among the diaspora. HIV infection itself is nevertheless still much more common in gay men than heterosexuals both here and in Africa; 19 times more common, in one study quoted in the recent excellent report of the Global Commission on HIV and the Law. Stigma and discrimination play a significant role in causing and maintaining these high rates. In Caribbean countries where homosexuality is criminalised, such as Jamaica and Guyana, which are both Commonwealth countries, the prevalence of HIV is around one in four gay men, while in countries that do not criminalise same-sex sexual activity, such as Cuba and the Bahamas, it is only around one in 15. Can the Minister who is to reply outline the response of DfID to this unacceptable situation? I am aware that the Government are concerned about the issue and that they have played an important role in bringing it on to the international stage.

However, there is still a long way to go, with discriminatory legislation being passed or debated in Uganda and several other countries in the Commonwealth and elsewhere; I mention particularly eastern Europe. A fundamental step should be to encourage and support citizens and civil society who oppose these outdated and misguided laws in those countries. We should encourage them to put pressure on their Governments to repeal them as soon as possible.

This is not an impossible task. For example, the UN Secretary-General, Ban Ki-Moon, the Independent Commission on AIDS in Asia and the UN special rapporteur on the right to health, as well as a meeting of Commonwealth Foreign Affairs Ministers, have all recommended repealing laws that prohibit sex between consenting adults of the same sex, as have courts in Hong Kong and Fiji, as was mentioned by the noble Lord, Lord Lexden.

However, action on the ground is less evident than declarations of intent. The clear evidence that punitive discriminatory laws encourage the spread of HIV infection should act as a stimulus to repeal them. I hope that the noble Baroness can outline the moves the Government are taking to encourage international action as well as words.

A further line of attack should surely be to encourage treatment centres for HIV and AIDS to be freely open to people of any sexual orientation. DfID devotes a substantial proportion of its budget to the prevention and treatment of HIV. I hope the noble Baroness can assure the House that the special problems encountered by gay and other sexual minority groups in getting access to medical help are taken fully into account.

Global Fund: AIDS, Tuberculosis and Malaria

Lord Rea Excerpts

Wednesday 4th July 2012 Lords Chamber

[Lord Rea]

My Lords, the noble Lord, Lord Fowler, has, as usual, chosen a topic which urgently needs to be addressed. In three minutes I shall try to cut to the quick.

The Global Fund has been an overall success, as everyone has said. DfID has played a major part in this, recognising its transparency and accountability. In fact, the Global Fund itself recently detected and put right a minor accountability problem within its organisation. It was a small fraudulent diversion of funds, I believe, but that was seen to.

The Global Fund is a very focused organisation which funds vertical targeted programmes. However, subsidiary aims are to assist and strengthen national healthcare systems and support civil society. Many, like the noble Lord, Lord Parekh, feel that this should have greater emphasis, as only then will the programme initiated by the Global Fund be sustainable. These aims need to be integrated into the general healthcare provision of the countries concerned. HIV, TB and malaria are a heavy burden but they are only part of the whole infectious diseases picture, let alone the increasing role in the developing world of non-communicable diseases.

In April, the Secretary of State for International Development, Andrew Mitchell, said that, following up its already substantial grant to the transitional funding arrangements to take the place of the missing funds from the cancelled round 11, the UK could increase its contribution to the Global Fund very substantially, as the noble Lord said, in 2013, 2014 and 2015 by up to double the current £384 million pledge. Can the noble Baroness give us some indication of how much it will be and when the amount will be announced? What occasion will the Secretary of State choose to make that statement? The money is urgently needed, as already several programmes have had to be either contracted or postponed. I am worried in particular by the postponement of plans to address emerging threats such as resistance to artemisinin combination therapy, in Myanmar—Burma. That of course is the main, if not the only, weapon against the malaria parasite. I hope that, if a donation is made, other countries will be encouraged to contribute to the fund, as the noble Lord suggested will be the case.

Health and Social Care Bill

Lord Rea Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, I should like to ask the Minister to clarify a point of some importance. Many years ago, in the early stages of my neurological career, I was involved in interpreting electroence- phalograms. Subsequently, I was heavily involved in the pursuit of electromyography—a technique for measuring the electrical activity of the muscles in health and disease—and in measuring nerve conduction velocity. I also looked at evoked nerve potentials. A group of individuals grew up in that field originally; it was called the EEG Society. Then there was the Electrophysiological Technologists’ Association—the EPTA—of which I was briefly president. Eventually they came together to form the association of clinical neurophysiologists.

The Health Professions Council regulates 15 health professions, including biomedical scientists and clinical scientists. My understanding is that clinical neurophysiologists, like other clinical physiologists, are not included in or embraced by the term “clinical scientist”. However, I wish to know whether they are covered by the Health Professions Council. If they are not, it is important that they should be regulated. For that reason, if they are not included at present under the terms of the Health Professions Council, I strongly support this amendment.

[Lord Rea]

My Lords, in supporting this amendment I declare an interest. Not only my former patients but I, as a patient, have received skilled help from clinical physiologists. The pacing unit at St Mary’s Hospital, which is run by clinical physiologists, has monitored my pacemaker since it was fitted four and a half years ago. My life has literally been in their hands while they periodically adjust my heartbeat to get the best setting.

The Registration Council for Clinical Physiologists, which has been described, has been trying to persuade the Department of Health to include the profession in the mandatory regulatory framework for health professionals for the best part of a decade. The Health Professions Council recommended in 2004 that clinical physiologists should be included in its regulatory regime, as well as other clinical scientists whose work involves a potential impact on patient safety. The then Secretary of State accepted this recommendation but still no action was taken and has since not been taken despite frequent reminders from me, among others. On my count, 30 parliamentary Questions have been tabled on this issue. It has also been raised in your Lordships' House in a debate on an order to do with the Health Professions Council. I hope that this amendment will serve to speed up the process by focusing the Government’s attention on an overdue step that we feel needs to be taken.

[Baroness Finlay of Llandaff]

My Lords, this group of amendments is very interesting as it reveals the enormous number of people involved in healthcare who literally hold the lives of others in their hands and are not subject to any statutory regulation but are voluntarily registered. I have an amendment in this group which seeks to establish,

“a statutory register of Physicians’ Assistants (Anaesthesia)”

and of other healthcare professionals. I will speak about that in a moment in relation to clinical perfusion scientists.

Physicians’ assistants in anaesthesia already have a voluntary register in place and they applied to the Health Professions Council for registration and had their application accepted. However, that all went on hold with the emergence of this Bill. The Royal College of Anaesthetists does not allow physicians’ assistants in anaesthesia to become associates as they are not registered with the General Medical Council, but it permits them to have affiliate membership. However, the college does not have a regulatory role as such; it is tied up with education and standards.

Physicians’ assistants in anaesthesia urgently need statutory regulation, given the range of invasive, and potentially life-threatening, procedures that they perform and the knowledge and autonomy of practice required in the roles that they carry out. These practitioners perform tasks that, in the UK, were previously carried out only by doctors. They cannot get indemnity insurance for their practice or apply for prescribing rights, even though they sometimes have to be able to respond in a matter of seconds, not minutes, if something goes catastrophically wrong with an anaesthetised patient while the anaesthetist is outside the theatre for whatever reason. They are on a voluntary register, which provides some reassurance for patients and employers, but that cannot realistically be seen as an alternative to statutory regulation. I think that in 2009 they were identified by the Department of Health as being urgently in need of registration. The Health Professions Council felt that these assistants fulfilled sufficient of its criteria to warrant the recommendation for statutory regulation being accepted.

Irrespective of whether Members of this House have undergone a procedure requiring anaesthesia, would they consent to being rendered unconscious by an individual who was neither bound by a stringent professional code of conduct nor properly registered to practise? After all, we would not get into an aeroplane if we did not know that both the pilot and the co-pilot were appropriately qualified to a very high degree, with ongoing continuing professional registration. We trust them just as we trust these physicians’ assistants, but if something goes wrong in theatre it does so with catastrophic rapidity. When I did my training in anaesthesia, on more than one occasion I saw these physicians’ assistants recognise problems arising before the trainee anaesthetists had done so. They carry enormous responsibility during complex procedures.

I have included other healthcare professionals in my amendment as I am well aware that the Government do not like to have enormous lists in a Bill. My amendment would therefore leave the door open to include clinical perfusion scientists—the other group involved in theatre—whose role is primarily to maintain a patient’s circulation during open-heart surgery, during a period of surgical repair when the heart has been stopped. They were recommended in 2003 for statutory regulation.

There have been two high-profile cases involving clinical perfusion scientists. The first fatality, in 1999, led the Southwark coroner to recommend the immediate statutory regulation of clinical perfusion scientists. The second fatality, in 2005, was attributed to inappropriate drug administration by a clinical perfusion scientist during an operation on a five-month-old baby at Bristol Royal Infirmary. That led to the publication of the Gritten report, which concluded that:

“The incident occurred because of latent weakness that lay dormant for years hidden by healthcare professionals compensating for inadequacies within national and local systems”.

The report recommended that action at national level should include,

“regulation and guidance on perfusion practice in cardiopulmonary bypass”.

More recently, there have been fatalities that have led to clinical perfusion scientists’ actions being questioned by coroners—the most recent of these incidents occurring in 2010 at Nottingham City Hospital.

I do not want to scare people from going in for surgery and I do not want to scare Members of this House who may be going in for surgery, but in the current climate people need to know that these very critical roles are being undertaken by people who are on a voluntary register but do not enjoy indemnity, as they would if they were on a statutory register and subject to the rigours of being statutorily regulated.

Health and Social Care Bill

Lord Rea Excerpts

Monday 5th December 2011 Lords Chamber

[Lord Rea]

My Lords, I oppose Clause 31 which concerns the abolition of primary care trusts. My noble friend has talked about the strategic health authorities and, although not in detail, about the problem of getting rid of PCTs. This is intended to give the Minister an opportunity to give us some information about the implementation of this rather stark clause. For example, what about the actual handover of responsibility from PCTs to CCGs? Will all staff of PCTs be made redundant, thus giving rise to considerable redundancy costs? How many and which staff will be retained and transferred? Will those transferred continue their employment without interruption or will they have to reapply for their new post, which in fact is likely to involve the same or very similar work because the provider trusts providing the healthcare will be the same under the CCGs as they are now? Perhaps my noble friend Lord Hunt will amplify this. He has already said a considerable amount about the abolition of the strategic health authorities. Although the work of PCTs has been criticised, it has been improving all the time over the past nine years and much valuable experience in commissioning has been gained. It would seem logical to transfer as much of it as possible to avoid the expense of bringing in outside advisers and consultants or to make sure that such expense is minimised as far as possible.

Very relevant to the commissioning role of PCTs is a document that was published by the Department of Health just last month, Developing Commissioning Support. It includes former PCT staff among those who will be given a role in providing this support. There are many people in PCTs who have considerable expertise. The report’s emphasis is on a business model in which outside organisations, including the independent sector, play a major role. Can the noble Earl tell us how this will be monitored and how transparent the contracting and subsequent work of these outside organisations will be? On the whole, how long will their contracts be for, and will it be possible to terminate them when necessary?

Expressing a view very sympathetic to mine is a quotation that I have found from a speech that was made five years ago in your Lordships’ House regarding private sector commissioning. It reads:

“I want to sound a note of warning. I am worried that if that really is the way that we are going, it could represent a very serious wrong turning, not least in the context of the future development of effective practice-based commissioning”.

This was five years ago, when practice-based commissioning was the order of the day. The speech went on:

“One has to question whether the ethos and values of a private sector organisation will make it fit for purpose as a commissioner. PCTs have public service values and they are accountable. Private commissioners are differently motivated and they are not in the same sense accountable to the public. The way in which private companies operate is too often hidden by considerations of commercial confidentiality, and it is questionable whether they will be susceptible to judicial review. If the Government want to go down the road of private sector commissioning, we need, at the very least, an open debate about it and about what it will mean for the NHS and for patients”.—[Official Report, 3/11/06; col. 581.]

That exactly expresses my views. It will be interesting to know what the noble Earl thinks of it because they are his very own words, spoken when he was winding up for the Opposition in November 2006 on an Unstarred Question that I asked about the role of the private sector in the National Health Service.

--- Later in debate ---

[Earl Howe]

It is accountable for its decisions at a regional or sub-national level in a real sense. If it was not interacting with the boards, the noble Lord, Lord Hunt, might have a point; but it will be. I think that that is accountability in a meaningful sense. The noble Lord, Lord Warner, talks about budgetary accountability, and I understand that that is a real issue. Of course there will be no budgetary accountability, but there will be accountability for the decisions and actions taken by the field forces.

I was saying that the structure means that all too often neither of the roles that PCTs perform is performed well. GPs, who actually make the clinical decisions, are not properly involved in PCT commissioning; and PCTs do not have the detailed understanding of their communities or the link to other local public services. The result is an unsatisfactory compromise, with commissioning that fails to deliver improvements in health outcomes and local services that are fragmented and not integrated.

It has been suggested by some noble Lords that one could have kept PCTs and parachuted in a whole lot of doctors, perhaps filtering out some of the administrators. Anyone who has visited any pathfinder CCG and put that question to the doctors and other clinicians involved will know the answers to why that would not have been a valid and sensible idea. The way in which services are commissioned has to depend on the judgment of clinicians and the wisdom of establishing geographic areas for commissioning groups that make sense in terms of patient flows and in terms of links with local authorities, social services and public health. It does not make sense to retain structures that, frankly, are administrative constructs that do not necessarily bear any relation to patient flows or relationships with local authorities. These clinical commissioning groups are being created from the bottom up by those who know what is in the best interests of patients, and it is to patients that we must always return in our thinking. We currently spend £3.6 billion a year on the commissioning costs of PCTs. PCT and SHA management costs have increased by £1 billion since 2002-03. That is a rise of over 120 per cent. We cannot make savings on the scale that we need to while retaining the administrative superstructure of the NHS.

The noble Lord, Lord Hunt, suggested that the pathfinder CCGs were being built on nothing at all. They are not being created from nowhere. They are building on, and are indeed a logical development of, practice-based commissioning groups, of which there were a very significant number. There are currently 266 pathfinder clinical commissioning groups covering 95 per cent of GP practices in England. As I have indicated before, I cannot say how many we will eventually end up with, but that will give noble Lords a rough indication of the order of magnitude.

The noble Lord, Lord Rea, quoted some words of mine from a debate of several years ago. I would simply say to him that I was speaking then of something completely different from the Government’s current proposals, and I am grateful to the noble Baroness, Lady Murphy, for pointing that out. These reforms place leadership of commissioning firmly with clinicians. I completely agree that giving leadership to a non-statutory, private-sector firm would be a bad idea. That is why there are very clear safeguards against this happening. With PCTs, I feel that there was a genuine question over where commissioning leadership really lay, and this is very firmly no longer the case.

On Amendment 236A, I must clarify one point. It is not the case that a clause stand part debate on Clause 30 would be consequential if a Division was to be called on Amendment 236A and won. It would simply amend this clause and not entail that it needs to be removed.

I hope that I have sufficiently covered the issues raised by noble Lords. I do not suppose that I have satisfied everyone, but I hope that I have at least indicated the direction of government policy in a coherent way.

[Lord Rea]

The staff of PCTs below management level are going to be rather disappointed that the Minister did not answer my question regarding their employment and the possibility of their being moved over to the CCGs, where many of their functions are going to be precisely similar. Are they going to be made redundant? Is it going to be possible to move staff over smoothly without a break in their employment status?

[Earl Howe]

My Lords, the rules apply on transfer of employment, and we anticipate that around 60 per cent of PCT staff will transfer to clinical commissioning groups, local authorities or the NHS Commissioning Board. It has been necessary to institute a programme of managed accelerated retirement for those for whom there will be no posts. However, this is being done in as friendly and generous a way as possible and the process is working well. But on the noble Lord’s main concern, yes, the terms and conditions of employment should not alter for those who stay.