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Westminster Hall
Thursday 9 June 2005
[Derek Conway in the Chair]
Coronary Heart Disease
Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Coaker.]
2.30 pm
The Minister of State, Department of Health (Ms Rosie Winterton) : It is apt that we are holding this debate during "Help a heart" week. My own week started at my gym in Doncaster on Monday, when I helped to launch the British Heart Foundation's drive to raise awareness of heart disease among women. I was pleased to encourage those who were taking part in the bike marathon—if not to take part myself. I was able to make the point that we must do more to raise awareness of heart disease among women. This debate is an excellent opportunity for me to repeat that message.
I am sure that all hon. Members will join me in paying tribute to the British Heart Foundation and all the other voluntary organisations that work tirelessly to provide information, research and support for cardiac patients. They have made, and continue to make, an invaluable contribution to the success of the national service framework for coronary heart disease.
Five years ago, we published the national service framework. We chose to make coronary heart disease one of our top priorities for very good reasons. It was the single biggest cause of death in the United Kingdom, killing more than 110,000 people in England in 1998, including more than 41,000 people under the age of 75. When we launched the NSF, there was little systematic primary care for those suffering from heart disease. There was little systematic cardiac rehabilitation. There was little systematic care for those suffering from heart failure.
Back then, seven out of every 10 accident and emergency departments were unable to give life-saving clot-busting drugs. Three quarters of patients dialling 999 for help did not get those drugs within the so-called "golden hour". Some cardiac care units would even refuse to treat patients over a certain age. Possibly worst of all, there were appallingly long waits. Patients could wait a whole year just to get a hospital appointment, a further year for diagnosis and up to a further two years to get treated.
The national director for heart disease, Dr. Roger Boyle, recalls the trepidation he felt on his appointment when he saw what was required. When we introduced the NSF for coronary heart disease, my right hon. Friend the Member for Darlington (Mr. Milburn), the then Secretary of State for Health, wrote:
"The NHS of old will be unrecognisable by the time we have finished our ten year programme of modernisation. This Framework will transform the prevention, diagnosis and treatment of coronary heart disease. It will help professionals to give better, fairer and faster care everywhere, to everyone who needs it. We want a service that is amongst the best in the world. Our people deserve nothing less."
So here we are, halfway through our 10-year vision. Dr. Roger Boyle's progress report, "Leading the way", which was published in March this year, sets out the remarkable progress that we have made. We set a target to reduce mortality from heart disease and related diseases by 40 per cent. by 2010. The latest figures show that we have achieved a 27 per cent. reduction already. We are well on track to hit the target. Almost all people experiencing chest pain for the first time are seen by a specialist clinic within two weeks. Fifty-four per cent. of people having a heart attack are treated with clot-busting drugs within an hour of dialling 999, compared with just 24 per cent. when we started out. An extra 22,500 patients are treated within the "golden hour".
Dr. Andrew Murrison (Westbury) (Con): What is the national service framework target for offering rehabilitation to people who have been discharged from hospital after an acute event? What percentage of people leaving hospital after an acute event get that rehabilitation?
Ms Winterton : I was going to come to that later. As the hon. Gentleman knows, the Healthcare Commission produced a report earlier this year that showed that there were problems in that area. The target is to offer cardiac rehabilitation to something like 85 per cent. of people discharged from hospital following a primary diagnosis of heart attack or after coronary revascularisation. That target has not been met yet. The aim is to achieve that over a period of 10 years, but more work needs to be done in that area. I will come back to that later.
Waits for outpatient appointments are down to an absolute maximum of 17 weeks. They will be no more than 13 weeks by the new year. Waits for a diagnostic angiogram are no more than six months for 95 per cent. of patients. Waits for bypass surgery or angioplasty, which were previously up to two years, are now less than three months. A national network of smoking cessation services has helped hundreds of thousands of people to give up, lowering smoking prevalence from 28 to 25 per cent. We estimate that about 2.5 million people in England are now protected with cholesterol-lowering drugs, compared with about 300,000 in 1997. Nearly 2 million children receive a free piece of fruit at every school day, setting them up with a healthy start in life.
Those improvements have happened because people in the NHS have made them happen. They have changed the way in which they work to deliver a better service to patients. Just the other week, I was in Manchester to open a new catheter laboratory, which is part of our investment in better and quicker diagnostic services. The Greater Manchester cardiac network has some excellent examples of new ways of working. For example, it is training generic cardiac cath lab staff, who can be from a number of professional backgrounds, including cardiac radiographers, cardiac physiologists, or cardiac nurses.
The result is that staff are not tied to a single part of the cath lab's work—they can cover more widely, work more efficiently and speed the patient's journey though the diagnostic process. We should take pride in those achievements. They have been made possible because the NSF was not just put together in Whitehall. It was developed as a collaborative process, bringing in key
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stakeholders: people, including patients, who had been working with the problems, and who went back to the field to help to solve them.
The NSF was developed and is being implemented by the people who really understand the issues and are passionate about making things better for patients. The Government have played a vital part in that. Unprecedented and sustained investment has been one element of our success story: close to £750 million of public money for new and expanded specialist cardiac hospitals; 19 major capital developments in hospitals from Newcastle to Plymouth since 2000; and as much as £750 million a year on statins alone. On a smaller scale, money for public access defibrillators is also saving lives. There are 61 across the country so far and that is set to rise, with 3,000 further defibrillators being installed throughout England.
The critical thing is that the new money has not just brought "more of the same". The imagination and determination that the NHS has shown in implementing change has been extraordinary, and it has paid off. In 2002, more than 3,000 patients suffering from coronary heart disease were given a real choice about where they were treated. We have gone even further: now, all heart patients are being given a choice of which hospital they would like to be treated in, which is empowering patients and giving them more control over how the system treats them.
Steve Webb (Northavon) (LD): I am interested in the issue of choice. The Minister said that all patients are now given a choice of at least two hospitals. In a county such as Cornwall, where there is just one major hospital, what does that choice mean in practice?
Ms Winterton : The choice means that patients will have the opportunity, if they so wish, to travel further afield. As I know from my constituency, there are people who sometimes wish to take up the options that are available if it means that they can have their operation more quickly. For some people, it may be more convenient to be treated elsewhere. That is the vision that we need to bear in mind for the future. If a person wishes to go to a different area of the country, perhaps to be near relatives, that choice should be available to them.
Mr. Kevan Jones (North Durham) (Lab): Does my hon. Friend agree that it is important to have the specialisms in certain regional centres? For example, in the north-east, most of my constituents with coronary heart disease go to Middlesbrough, which is a considerable way from my constituency, but it is a centre of excellence to which people are willing to travel to get the best treatment available.
Ms Winterton : My hon. Friend is absolutely right. We must bear in mind that the more that we consult with patients about how they wish their treatment to be provided, particularly patients with heart problems who have used services in certain areas, the more we are able to work with them, as we have tried to do in devising the sort of services that my hon. Friend described. People want the very best care and they understand the need for
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specialist centres in many of these areas. This is not about the NHS being in charge of the patient; it is about the patient being in charge of the NHS.
We have made cholesterol-lowering drugs available over the counter, giving patients increased power to make their own decisions. We have looked at new types of services, for example, rapid-access chest pain clinics, which are transforming the way in which patients are treated. For heart attacks, growing numbers of paramedics are taking clot-busting treatment to the patients, improving their chances of survival. We are in the middle of a pilot study to assess the viability of using angioplasty to unblock arteries as the emergency treatment of choice.
The quality of care experienced by patients undergoing heart surgery is improving. These days, surgeons are operating on patients who have a much higher risk of dying because they are older and more frail in many cases, but the proportion of patients who survive is growing. There has been a 30 per cent. drop in mortality for older people and the most ill, a 30 per cent. drop in mortality for women and a 50 per cent. fall for patients suffering from diabetes. More and more lives are being saved every day.
Five years ago, few people would have believed that we would come so far in just a short time. Aiming to go from an 18-month wait just for surgery to an 18-week wait all the way from GP to surgery would have been thought very optimistic, but we are now sitting down and creating credible and affordable plans to do just that. It will be a challenge, but we have much more to do to deliver cardiac services that fully meet the aspirations of patients, the public and professionals.
To return to the point made by the hon. Member for Westbury (Dr. Murrison), some key areas were identified by the Healthcare Commission's report in March. We must see improvements in prevention, in care for heart failure patients and in rehabilitation. Heart disease is a chronic disease as well as an acute one, so we need to provide better care for the 900,000 people in Britain who are living with heart failure. We need to help people to manage their own condition as a routine part of their lives.
We need to be much more effective in the way in which we prevent heart disease. The public health White Paper "Choosing Health" sets out a radical new agenda for delivering that aim, looking at ways to give personalised, practical support to people to make healthier choices and to lead healthier lives. Health inequality will also be a critical challenge. To overcome the inequalities that still exist, we need much greater efforts in those areas that are hardest hit by disease—more effective prevention services, more identification and treatment of people who are at risk of disease and better rehabilitation.
Sheffield has shown how it can be done by delivering a tailored programme of support to 51 practices in the most deprived areas of the city. By 2003 in Sheffield, there had been a 23 per cent. fall in the mortality rate in the most deprived fifth of its population, compared to a 16 per cent. decline for the city as a whole.
We have come a long way in the past five years but that does not mean that we should slow down. When we wrote the national service framework five years ago, we had to make tough choices about priorities and what
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was practicable at the time, so we concentrated primarily on disease in the arteries. The excellent progress that has been made in those areas has given us the scope to look for new areas in which to strive for the best.
That gives me the opportunity to pay tribute to my hon. Friend the Member for Stockton, South (Ms Taylor) for bringing the crucial issue of electrical disorders of the heart to the attention of the House and the Government. Arrhythmias, or irregular heartbeats, range from being a minor inconvenience to being potentially fatal. Sufferers can experience palpitations, dizziness or blackouts, which have a significant impact on the quality of their lives. When death occurs, it can be sudden and without warning. It can be visited on all ages, but it occurs predominantly in the young. However, there is a good deal that the NHS can do to tackle the problem, which is why we added a new chapter to the national service framework, following on from that successful campaign, to help to ensure that patients receive high-quality support, expert diagnosis, effective treatment and effective rehabilitation.
I am sure that my hon. Friend will join me in putting on record our gratitude to Cardiac Risk in the Young, to the Arrhythmia Alliance and to STARS—the Syncope Trust and Reflex Anoxic Seizures—which helped to put together the new chapter. Thanks to their hard work, I am confident that in the years to come we will have as fine a story to tell on that chapter as we have for the first chapters of the NSF.
The far-reaching successes that we have had in improving the quality and timeliness of heart services show the true nature of the NHS, its fitness for purpose and its ability to meet raised expectations. The NSF has not been left to gather dust on Whitehall shelves, but been taken on and delivered on with enthusiasm. That has meant real results for patients. In 1997, the death rate for heart disease and stroke was about 140 per 100,000 of population. By 2003, that figure had been reduced to about 100 per 100,000—a reduction of more than a quarter. Thanks to the hard work of all involved, lives are being saved. Our task now is to ensure that we achieve as much in the next five years as we have in the five years since the NSF was written.
2.51 pm
Dr. Andrew Murrison (Westbury) (Con): I welcome the latest addition to the NSF—chapter 8, on arrhythmias and sudden cardiac death. I have read it and it contains some fairly impenetrable bits, which I have highlighted but will not read out. Instead, I draw the Chamber's attention in particular to the table on page 10, which is masterful and will undoubtedly make a great contribution to those who are tasked with dealing with this difficult range of conditions. It is a good document and congratulations are due to all who were involved in producing it.
While I am in a congratulatory mood, I would also like to say a big "Well done" to all the health care staff and scientists who, in relation to coronary heart disease, have made such a big contribution to improved longevity since the 1970s. The Minister talked at length about the past five years, but our perspective should be longer than that. I was not impressed by the somewhat graceless introduction to the "Leading the Way"
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document published in March 2005, particularly the remarks by the then Secretary of State for Health. His comments implied several things, but the suggestion that 1997 or 1999 were year zeros was particularly unhelpful. We must appreciate that long-term trends have continued since 1997 and 1999—I shall explain how those trends have continued more or less unchanged during that time—so for the Government to take credit where credit is not due is wrong. I hope that they will have the humility to admit that much of the improvement achieved is owed to the efforts of others, in many cases international others, and not necessarily to the interventions of the British Government during that period.
We have dealt at length with high-tech medicine and what happens in hospitals, but it is important to note that in coronary heart disease much of the prognosis is due to what happens outside hospitals. In my intervention, I sought to press the Minister on rehabilitation services, about which I shall say more during my speech. First, I would like to take her back to the middle of last year, when the British Heart Foundation published a report suggesting that 60 per cent. of the improved mortality for coronary heart disease over the past two decades was attributable not to hospital intervention, but to the reduction of major risk factors. If we are serious about continuing to reduce coronary heart disease, we must focus on that. It is tempting to focus on the high-tech, the exciting and what goes on in hospitals, particularly tertiary centres—we all do it, but in truth we need to examine the factors that make it more likely for someone to have a cardiac event or, if they have a cardiac event, a bad one. Sixty per cent. of the improved mortality being due to the alleviation of remediable factors is a very impressive statistic, particularly in the context of the increase in obesity.
Mr. Kevan Jones : I agree with some of the points that the hon. Gentleman is making. In Durham, for example, local pharmacists are managing clot-busting drugs in the community, so that people no longer have to present at hospital to receive them. Does the hon. Gentleman agree that such schemes improve not only people's lives, but the effectiveness of the drugs?
Dr. Murrison : Yes, I think so. The other point that we need to make is that the Healthcare Commission is quite keen that we should take treatment closer to patients, and I entirely agree, whether we are talking about clot-busting drugs administered by paramedics or statins prescribed over the counter in pharmacies. That work has made a big contribution, which is all to the good, but we should bear it in mind that things could get worse.
The Select Committee on Health pointed out that the rising levels of obesity in this country might mean that our children and grandchildren have higher mortality from coronary heart disease than our own generation. That is of great concern. This country's rate of increase in obesity is matched only by Samoa and Kuwait—the situation is that bad. It is very important that when considering coronary heart disease Ministers focus on factors that are remediable. One of the biggest of those, literally and metaphorically, is obesity. It would be interesting to hear the Minister say how she thinks we might address that ticking time bomb, which looks as
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though it could make life expectancy, particularly in relation to coronary heart disease, worse for future generations in this country than it is for our own generation.
Let me take the Minister a little further back than 1997. A number of comments in "Leading the way—Progress report 2005" were disingenuous. The graphs printed in that report tell a good story. They are truncated graphs—by and large, they do not go much further back than the mid-1990s, or the early 1990s in some cases, and those that relate to treatment start from 2000. That is a pity, because if the graphs had gone back to the 1970s, we would have had a better idea of how trends that have continued during the past seven years were established in the 1970s, particularly those relating to life expectancy and improved mortality and morbidity from coronary heart disease. Page 8 of the report purports to show how mortality has fallen since 1996, but even that truncated graph shows that the trend had been going in that direction since at least 1993–94. The report does not give us information about the situation before then, but if we go back to primary sources, we find that mortality has been improving since the 1970s and that what we have seen more recently is a continuation of that trend. It is important to reflect that in such a report. On page 9 is the claim that health inequalities have narrowed over the past six years, when in fact the steepest decline happened in the late 1990s—in 1997–98. I do not think that the Minister would take credit for that. When we are considering such statistics and graphs, it is important that the words used to describe them are accurate. There are some misleading remarks in the report, which makes it an overly political document. That is a pity.
On page 10 are a couple of rather busy charts comparing how this country is doing with a range of other European countries, but again it is important to note that many of them are not really comparable to the UK. If we went out on the street and said to someone, "Would you compare the UK to Bulgaria, Hungary and the Russian Federation?", they would probably stand aghast. It is disingenuous to claim that we are approaching the mid-point of that range of European nations in terms of our experience in coronary heart disease. In fact, if we compare our experience with those of truly comparable countries, we are doing far less well—and we are not improving against those countries at all.
Of the countries in what we might call developed Europe, we are doing better than only Finland, which has its own problems, of which the Minister might be aware, and Ireland, so we cannot crow too much about how we are doing against international benchmarks. The claim that we are rapidly catching up is not borne out by the evidence, and to say that we are in the middle of the pack is a damning indictment if we are to include countries such as Bulgaria and Hungary, whose experience in coronary heart disease is disastrous. Countries such as Australia and Norway have bested us in terms of improvement in mortality. That is a pity, and we need to work out why that has happened. In celebrating the improvements achieved in this country, we must compare ourselves with countries that are truly comparable and work out why we have not done better.
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The Minister will hear that refrain from my colleagues and I rather a lot in the coming months, but when we are trying to determine how we are doing and how we might do better, it is important that we compare our experience with other truly comparable countries.
Ms Dari Taylor (Stockton, South) (Lab): The hon. Gentleman is discussing how we compare and to whom. Is it not also appropriate to compare in date order? From the late 1990s to today, premature deaths from heart-related diseases have fallen by 27 per cent. Surely it is appropriate also to speak about that figure and acknowledge its veracity.
Dr. Murrison : I thought that I did that when I said that I welcome the improvements that have been achieved. However, we cannot be complacent and we must compare ourselves with other countries. For example, we must accept that a working man in this country is twice as likely as a man in Italy to die from coronary heart disease. We have to ask ourselves why heart disease is a relative unknown in France compared with this country. There is a raft of reasons for that—we could think of one or two off the top of our heads. Nevertheless it is important that we compare our experience and how we are managing coronary heart disease and other conditions with comparable countries. We cannot simply say that our performance has improved by X per cent. over so many years, because to do so would be complacent. Of course we all expect improvements over the next 10, 20 and 30 years. We all anticipate that mortality and morbidity from common forms of disease will improve—we would be horrified if they did not, particularly given the amount of money that the Government have spent on the health service. The trick is to spend that money wisely and in the way that will get maximum benefit. At the moment, it looks as if we are not doing as well as we might compared with other countries. To say that we are doing well because we are approaching the mid-range of European countries is disingenuous if we are comparing ourselves with countries such as Hungary, Bulgaria and the Russian Federation. The man in the street would say that those are not comparable countries, and I would tend to agree.
Mr. Kevan Jones : Does the hon. Gentleman agree with a lot of Conservatives who think that 1997 was year zero and that nothing happened before that? We had 18 years of a Government who did not give these issues the same high priority as the present Government. Does he have some comparable figures that say whether in the same period other countries have reduced deaths by 27 per cent., which is no mean achievement?
Dr. Murrison : Let me correct the hon. Gentleman. I did not say that 1997 was year zero; I said that that is the impression that one gets from the Government. The March report underscores that impression, because in the remarks that it makes and the statistics that it presents, it suggests strongly that everything good started in 1997—or, to be fair, 1999, when the Labour Government's spending plans kicked in, the first two years having been Conservative spending plans by design.
To answer the hon. Gentleman, yes we have those figures. They are readily available, and, if he remembers, I went to some lengths at the start to describe what has
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happened since the mid-1970s—about the time that I went to medical school. Around that time, improvements in relation to common forms of disease, particularly coronary heart disease, became evident. We need to take a longer-term view and look back further than 1997 or 1999. The figures are commonly available, and I am sure the Library will be more than happy to provide the hon. Gentleman with them.
Ms Dari Taylor : The issue is so important that I do not like the idea of our bandying facts across the Chamber as though they were the central feature of the debate. I ask the hon. Gentleman to consider his comments well. The head of the cardiothoracic service at James Cook university hospital in Middlesbrough, has stated:
"We have seen a huge improvement compared with the late 1990s when we had people dying on the waiting list. The system now has the extra capacity that we needed to do the job."
It is important that the hon. Gentleman acknowledges that the Government have invested an enormous amount of resources and have prioritised. It would be foolish of him not to do so.
Dr. Murrison : The hon. Lady is being a little unfair. I started my remarks by being complimentary, in particular about the new chapter 8 on arrhythmias and sudden cardiac death, and I would be the first to acknowledge—as I have done—that there has been increased spending in the past seven years. It would be ridiculous if I did not do so. I am more than happy to say that and to welcome that. Of course there have been improvements; had there not been, I would be standing here laying into the Minister for not improving the health service given the money that she and her colleagues have spent on it. It is axiomatic that there have been improvements, and I am sure that the hon. Lady's colleagues who were in Parliament during the 1980s and 1990s would have had the good grace, looking back over comparable five-year periods, to say the same. The basis of my thesis is that, for many reasons, the improvements started in the mid-1970s and have continued since. Let us hope and pray that they continue for many years to come, whichever Government the country is fortunate or not to have.
Health inequalities are dear to the Minister's heart, and I am interested in them as well. I welcome the spearhead group heralded in the public health White Paper, and I have no doubt that it will achieve lots of good things. However, to introduce a slightly parochial note into my contribution, I observe that many of the Government's initiatives—the five-a-day initiative, the local exercise action plan, fruit in schools, free pedometers and so on—miss out one group of people in need: the rural poor. As the Minister knows—I have written to her about the issue and I have raised it in the House—in focusing our attention on the large areas that are seen to be in need, we run the risk of ignoring a small but significant population in rural areas that are otherwise held to be extremely prosperous, such as the one that I am fortunate enough to represent. If we continue to ignore the rural poor in such initiatives, we risk health inequalities opening up even more. As one who practised as a doctor before becoming an MP, I can say without a shadow of doubt that the most crashing poverty that I have seen has been in rural areas. I am
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reluctant to see those people slip back even further, so I will be interested to hear what the Minister says about how, in all the worthy initiatives aimed at reducing health inequalities, she will address those who stand a real risk of being forgotten.
I mentioned rehabilitation briefly in my intervention, and I was grateful for the Minister's response. However, we are at risk of being overwhelmed by high-tech hospital medicine, and doctors and politicians are at risk of forgetting what happens to people after they are discharged. I know from my own practice how easy it is for people who are discharged, having had their cardiac event and gone into hospital to get better, to be seen by the system as "sorted". Well, they are not, and so much can be done through rehabilitation to improve outcomes for people who have had an acute coronary event. It is clear from the Healthcare Commission's survey of patients published yesterday that there is some way to go. It said that 63 per cent. of patients did not get rehabilitation post-event, which is well short of national service framework targets.
Those who are Afro-Caribbean or Pakistani are in a worse position—the figures are 87 per cent. and 79 per cent. respectively If we are concerned about reducing health inequalities, those statistics must worry us a lot. It would be interesting to hear from the Minister in her winding-up speech how we are going to address that shortfall in rehabilitation, particularly in respect of ethnic minorities. Further more, older people and women are less likely to be offered rehabilitation. That is particularly relevant this week, with the British Heart Foundation's welcome campaign to improve heart health for women. Let me say how much I welcome the work of the British Heart Foundation, in particular the excellent work done by British Heart Foundation-sponsored nurses. I hope that the Minister, when formulating her plans for improving rehabilitation after coronary heart disease, will bear that work in mind and work on it so that we can improve services for people in the community.
We all accept that we need to bring services closer to patients, and the various reports point in that direction in relation to coronary heart disease, so I would like to promote the use of intermediate care services, particularly community hospitals, in the provision of some of that rehabilitative service. I hope that the Minister, in designing services for people after they leave hospital, will bear community hospitals in mind, because they have a contribution to make in rehabilitating people with coronary heart disease. In my area, I have experienced the problem of rehabilitation falling between two stools: the responsibility was imaginatively taken on board by a district council and now, hopefully, is being taken on by a primary care trust. However, it is worrying that such services are often not owned by anyone in particular. We need to ensure that rehabilitation is regarded an essential part of someone's management after an acute event, rather than a bolt-on added extra, as tends to be the case at present if the statistics in the reports are to be believed.
In the context of women's health, we need to worry that in the youngest age group—16 to 19-year-olds—29 per cent. of women smoke, compared with 22 per cent. of men. In the remaining age groups, the reverse tends to be the case, but in that very young group there is a problem among women. This week, because of the
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British Heart Foundation's campaign, it is useful to consider how we can turn that situation round, given the need to focus on preventive factors in reducing mortality from coronary heart disease. We also know from the Healthcare Commission report that women are less likely to be referred for cardiac rehabilitation, less likely to join a scheme and, having joined it, more likely to drop out of it. That is worrying, and it will be interesting to find out from the Minister how she thinks that we can improve that situation.
Let me make a few points, in no particular order, on which I hope the Minister will respond. Yesterday, my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) bravely undertook CT scanning by a company called Lifesyne on Victoria street, which involved his having a CT scan of his heart. We all went along too, and it was very jolly. Such scanning is state of the art and is not something that I would necessarily ask the Minister to incorporate into the NHS. However, on a more prosaic level, may I ask whether she will place more emphasis on scanning for aortic aneurism? That is a particular problem, which is relevant in the context of today's debate because we are discussing cardiovascular disease. It is a major cause of avoidable mortality and morbidity, particularly among certain ethnic groups. I am afraid that the subject is continuing to be neglected, and it would be useful to hear how the Minister thinks that the position might be improved.
It would also be interesting to know what discussion the Minister has had with her colleagues on the illegal importation of cigarettes. That is a particular problem in relation to young people and those on low incomes. In the context of health inequalities, the latter group is particularly important. If we were to walk a couple of hundred yards down the street, over Westminster bridge, I have no doubt that we would find someone selling some of those products. It seems ironic that that practice is going on so close to this place and it would be useful to hear how the Minister is tackling the importation of such products, which harm so many people on low incomes.
Finally, I ask the Minister what she is doing to improve the reluctance of many primary care physicians to incorporate innovation into their practice. We have seen in the press recently that our practitioners tend to operate conservatively—I use the word with a small C—in comparison with their international colleagues. It seems that we have some way to go to incorporate innovations into primary care practice in this country. Although the annual increase of 30 per cent. in the use of statins, for example, is very welcome, one wonders whether many such innovations could be incorporated more rapidly into routine primary care in this country. We need to decide why we tend to be fairly conservative in our primary care in this country compared with other countries.
3.16 pm
Ms Dari Taylor (Stockton, South) (Lab): I am pleased to have the opportunity to speak in this debate. I believe—as I am sure does everyone in the House—that coronary heart disease remains one of the most serious medical problems for us to cope with and to produce medical and lifestyle responses to.
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I listened to the Minister's speech with care and was delighted to hear her say that she had been down to the gym this week, the outcome of which was positive. I also went to the gym this week, but the outcome was not particularly positive. I tried to register and the young person behind the desk gave me a booklet on lifestyles and said, "Come back next week and maybe we will discuss how and in what way we can put you right." I felt thoroughly uncomfortable about that response, but I intend to take her up on the offer.
The Minister also said that she was very pleased with the involvement of charities and voluntary bodies, adding that they were positive and persuasive in their involvement in this area of work. I should like to echo that statement, and make it clear that my involvement in this area has not come from anything particularly personal. It has come from my involvement in the issue of cardiac risk in the young—a valuable experience.
I want to start by referring to and quoting from reports from local clinicians in my constituency. I used part of one of the quotes earlier, but the quote is so worth while that I should like to return to it. The local head of cardiothoracic services at James Cook university hospital, Dr. Jim Hall, made it clear to all of us that there has been a huge improvement in the work of cardiac specialists since the late 1990s. I have not gone into the detail this time, but he ended by stating:
"The system now has the extra capacity that we needed to do the job . . . We now have a full complement of highly-trained staff, which allows us to treat more people, more quickly."
This was responded to by Dr. Roger Boyle, the National Director for Heart Disease, who said that James Cook university hospital was a flagship centre for cardiac treatment, and that it was
"probably the most efficient unit in the country and the sort of model we would like others to build for their own services."
I am delighted to hear that. Those are confident statements about a locality that invariably in the past failed to attract sufficient clinicians. We had serious problems, but now we are developing medical models. That is not just down to the fact that we as a Government are investing—which we are—but down to the fact that we have some excellent clinicians who are developing good services creatively.
James Cook hospital handles over 6,500 patients a year—that is a phenomenal number—for my constituency and for others on the Tees. Many people in my area live lives that are stressed, just like my own, and have lifestyles that they would like to improve; many live in multi-deprivation situations. The fact that they have such an incredibly valuable and excellent cardiothoracic service is very important to us all.
As many in the House today know, my interest in heart diseases began in a personal way: the tragic death of a close family friend's son. Levon Morland was 22 years old and died in his sleep. He was diagnosed as suffering from Wolff-Parkinson-White syndrome. He was an active, fit, young man who lived life to the full. He believed his consultant, who said to him, "Your condition is a bit of nuisance. Get on with your life." He now has no life to get on with. His death was not just tragic, it was shocking. That shock was added to by the fact that Levon was not the only 22-year-old to suffer from a potentially fatal heart condition, which, frankly,
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appeared to be unacknowledged by the medical profession. I was dismayed when I started to look at the research into the area to find that four, and possibly eight, young people die a week from a heart condition that can regularly be diagnosed and treated. Those young people are invariably in their late teens and early 20s, and are always under 35. So, eight young people who are under 35 and are often in their late teens are dying every week from a condition that medics could understand, explain and prescribe for.
That shocking statistic was compounded for me by the fact that some of those people had been diagnosed with a serious heart condition, but had not received appropriate treatment. Some had shown symptoms of potential heart problems, such as breathlessness disproportionate to action, but had still been told that they were possibly suffering from stress or asthma. Some had witnessed the sudden death of a relative, genetically related, but had failed to receive any medical treatment that could have put their minds at rest. A screening process could have put their minds at rest about death not occurring due to an inherited condition. Such a service was not available, even though symptoms are so well documented.
It is also the case that when sudden death occurs, the pathology states that it is probably due to heart disease, but there is no defined cause or analysis referring to potential genetic consequences. There is no follow-up with relatives, who could inherit the disease.
Mr. Kevan Jones : Does my hon. Friend agree that large numbers of deaths go unrecorded because they occur, for example, in swimming pools and are recorded as drownings? Documented cases suggest that a lot of young people are dying of sudden cardiac arrest.
Ms Taylor : My hon. Friend is absolutely right. That is also well documented, and the factual evidence is well produced. All of us, including me, have always put the medical profession on a high and wanted to respect it; indeed, we do respect it. However, reading this research, I started to feel more than uncomfortable about how young people were simply not accorded the medical seriousness that they deserved.
The death of my close friend, a man of 22, followed by my coming fifth in the ballot for private Members' Bills, catapulted me into the world of cardiac diseases, especially those affecting young people. Two years ago, I took the decision to use my private Member's Bill opportunity to table the Cardiac Risk in the Young (Screening) Bill. That was my clear approach to ensure that we aired, understood and used the available information to bring the Department of Health's attention, and that of the medical profession, to this serious problem. After one or two battles, the Department of Health—particularly Dr. Roger Boyle—was very supportive. Eventually, I withdrew that Bill, on the clear basis that a national service framework into arrhythmias and sudden cardiac death would be written. I am most grateful that it has now been written.
I was delighted that a national service framework was to be written, primarily because of the figure that I have already stated. We have looked at the information since the late 1990s and have seen a blueprint, or medical model, that people can use and perceive to be valuable for
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diagnosis and for determining prognosis. I believed that such an NSF for cardiac risk in the young was appropriate, and the new chapter of the NSF on arrhythmia and sudden cardiac death was launched. I was pleased, as was Cardiac Risk in the Young. I shall not labour the point, but hundreds of parents out there are delighted that a politician with no medical background whatever had the support and the determination to bring the issue to the House. They are delighted that an NSF has been launched; they understood its veracity.
Dr. Sharma from the CRY charity gave excellent support. I was delighted that he was part of the group who wrote the NSF chapter. Sometimes, all of us have to be exposed to areas that we do not know much about and this was the case for me. I felt at one stage that I was going through a mini-degree in medicine and, as a mere social scientist, that was one serious battleground. Nevertheless, I am grateful for all the support, and am delighted that the NSF has now been written.
The framework contains statements about which CRY has been lobbying for a long time. The NSF says:
"People with arrhythmias should receive timely and high quality support and information, based on an assessment of their needs"
by an appropriate clinician. That is now guaranteed through the NSF. It also says:
"When sudden cardiac death occurs, NHS services should have systems in place to identify family members at risk and provide personally tailored, sensitive and expert support, diagnosis, treatment and advice to close relatives."
The NSF also states that although people may want to say that they are merely suffering from breathlessness,
will not be ignored or sidelined as stress. Medics will always take such symptoms seriously, and the evaluation of families who may have inherited diseases will also be brought centre stage into medical diagnosis.
I am very grateful to the Department of Health, and to Dr. Roger Boyle in particular, as well as many others around Great Britain, for making cardiac risk in the young a recognised heart disease through the NSF. The NSF provides a blueprint that will prevent fatalities. That approach—national standards, key interventions, sets of measurable goals—is very valuable, and is beginning to state how people will be treated.
We shall be watching for progress. I will want to know that four or eight young people under the age of 35 are not dying every week from sudden cardiac death when symptoms have been ignored. I will want to know that the medical profession has acknowledged such symptoms and has done all that it can to prevent them from causing a fatality.
There is always a "but", and I have come to it. The framework is an excellent way forward, but I have some serious concerns—again, they come from cardiac specialists—to put to the Minister. I hope that she will acknowledge them and, over time, find a resolution to them. There is a national shortage of electrophysiologists—we have only 64 nationally—and they play a crucial part in diagnosis. There is also a shortage of back-up infrastructure. We have too few cardiophysiologists—the people who work on the
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management of cardiac devices—and too few specialist nurses to provide the patient support and explanation that is crucial if the NSF is to show an appropriate understanding of the disease.
Finally, cardiac risk in the young has been a poor relation for a long time. If the NSF is to be implemented, that specialism has to be specifically promoted. I hope that the Minister will reassure me that she is well aware of the concerns that I have outlined, and that they are being addressed.
I am pleased to be here today, and I am very pleased that the new chapter to the national service framework on arrhythmias and sudden cardiac death has been launched. It was well overdue, and it is excellent to know that it is in place. I am absolutely delighted that it acknowledges emphatically that one does not have to be over 50, or overweight, or to smoke cigarettes, to have a heart problem; fatalities can occur among fit, athletic and healthy young people in their early 20s.
3.32 pm
Steve Webb (Northavon) (LD): As a social scientist, it is a pleasure to follow another. More important, it is a pleasure to follow an hon. Member who is acknowledged across the House as having acquired a great deal of expertise in this area. Those of us who are not currently Ministers know how difficult it is to point to something that we have achieved, so I pay tribute to the hon. Member for Stockton, South (Ms Taylor) for her work, and congratulate her on the demonstrable achievement of the addition of a chapter to the national service framework. I am sure that all hon. Members received postcards from Cardiac Risk in the Young, and it is good to see all that work coming to fruition.
It is always important to salute progress and achievements, and we all welcome the existence of the NSF and its focus on a number of aspects of coronary heart disease. The reduction in mortality rates—27 per cent. over about half the period for which the target is 40 per cent.—is clearly welcome. All my remarks should be set in that context. I also welcome some of the successes that the Minister has trumpeted. The administration of drugs within the so-called golden hour, and the reductions in the more extreme waiting times for heart surgery are clearly welcome, although I notice that average waiting times have started to drift up. Presumably, that is a corollary of tackling the extreme cases—there must be some trade-off—but overall it is good news.
However, the hon. Member for Westbury (Dr. Murrison) is right to mention the "what if?" question and the "what are we comparing that with?" question. It seems that, before the NSF came into force, the number of fatalities from coronary heart disease was falling. Therefore, the chances are, although we cannot know what would have happened, that some of the improvement would have occurred anyway, as he said. It is important not to overstate the impact of interventions. We need to be sober about it and to consider the important comparative data. May I say very gently that I assumed that, after she understandably saluted the progress, the Minister would admit honestly to any omissions and problems,
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but she sat down. Justice was not done to the big problem areas. Some of them have been touched on in the debate, and I should like to flag up some others.
For example, one would not have thought from the Minister's speech that—I quote from the King's Fund:
"When compared to Western European countries with comparable economies and levels of development, the United Kingdom still has the worst mortality rates"
for coronary heart disease. Obviously, one can spin numbers in all manner of ways, but the brute fact is that we have an awfully long way to go. As the hon. Member for Westbury said, we would not dream of having health outcomes as poor as those of some countries, so comparing ourselves with those countries does not help us to make a sober assessment of what has been done. There is a danger that we might get carried away. It is worth keeping the context in mind.
The national service framework is supposed to deal with a range of things—prevention, diagnosis, treatment, rehabilitation. There has been a lot of focus on the fall in mortality rates but we are not making enough progress in other areas, and prevention is an important one. I imagine that, if I were a Minister at the Department of Health, I would spend most of my time thinking about the national health service, because that is the lever that can most readily be pulled. Prevention is a lot more difficult.
I occasionally wonder about the charts in reports that show, for example, the prescription of statins rising exponentially. On one level, if that is producing favourable outcomes, I think, "Great". But then I wonder how high the graph should go. Do we want people to need such drugs at an increasing rate? Do we want to keep trying to catch up, or do we want a Minister to stand up in the House of Commons one day and say, "I am delighted to say that fewer of these drugs had to be prescribed this year because they were not needed"? I do not say that such drugs have not made an important contribution, or that it is not important for them to be available, but in the long term prevention should be our starting point.
The evidence is rather mixed. The King's Fund, assessing the coronary heart disease NSF, says that progress on prevention
"has been mixed—smoking rates are slowly coming down, but fruit and vegetable consumption has not improved and rates of obesity are rising."
I should be interested if the Minister said a little more about that, because she did not say much about obesity. Where is the Government's strategy up to? How long has it been in place? Are there any early signs of progress? Obesity is an issue across the developed world, but things are going in the wrong direction. Are we storing up problems for ourselves further down the track? I shall be grateful for her comments.
There are concerns that, although mortality rates are improving, prevention is looking less good. This year, the King's Fund published survey evidence on the prevalence of coronary heart disease—how many people have it now. That shows the numbers going in the wrong direction. The King's Fund cites the health survey for England of 2003, which shows an increase in the prevalence of coronary heart disease in both men and women in 1994, 1998 and 2003.
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One would not have expected that after listening to the Minister's description of how wonderful the last five years have been. One would not have thought that coronary heart disease became more prevalent between 1998 and 2003. Again, I should be interested in the Minister's reflections on that. If fewer people died during that period, that is great, but what is coming down the track? How confident can we be that, with dietary problems and the growing prevalence of the disease, the improvements in mortality rates might not slow but, ultimately, reverse?
The second omission from what the Minister said, although it was clearly present in the contribution of the hon. Member for Westbury, was rehabilitation. Yesterday, the Healthcare Commission published evidence on the subject, of which I am sure the Minister is well aware. That indicates some real problems. People are not necessarily being shoved out of the hospital door, but they are being discharged without adequate preparation or advice, and they are having to come back in—no doubt they count as extra treatments and so boost the performance figures. That is not what we want.
When we talk about giving advice about lifestyle, smoking, diet and so on, it can sound like nannying, but if I had a heart attack, I would want to know whether it was sensible for me to take active exercise, regular exercise or a bit of mild exercise, whether there were things that I should stop eating and whether it mattered that I smoked once a day. There are lots of things that I would want to know. I would not necessarily want someone telling me what to do, but I would want advice, and that is clearly lacking.
The survey evidence produced by the Healthcare Commission yesterday was based on 4,000 heart patients who have attended NHS trusts across England, so it is clearly a substantive and serious piece of work. The survey states:
"Many patients reported that they are still leaving hospital without receiving basic advice about diet and exercise."
Even when cardiac rehabilitation programmes were available, take-up was
"lower than might be expected, even in 'priority groups' such as people who have had heart attacks."
Not only people who attended hospital with a mild condition, but people who had heart attacks were still not taking part in the programmes. Of those who took part in the survey, nearly two thirds did not take part in a cardiac rehabilitation programme, and that even included people more seriously affected. On the theme of prevention, more than a third of those surveyed were not told about physical activity that would help them with their condition.
Anna Walker, chief executive of the Healthcare Commission, makes a much more balanced assessment of the situation than the Minister. She welcomes the progress that is being made, but wants to see
That is not something for a 10-year framework—it needs to be done now. She wants to ensure that advice on
not 37 per cent. of them, or whatever the figure is—
Ms Dari Taylor : I am listening to the hon. Gentleman carefully and I think that he is making lots of statements that are half right and half wrong. The reality that we must all cope with is ensuring that we are able to employ sufficient numbers of the right people with the right qualifications. We regularly find that in hospitals and educational establishments there is a demand and finance, but that the training of people is slow to catch up. Does he acknowledge that much of the system is in place but that, if we do not carry it through over a period of three or 10 years, we will not match people's expectations because, frankly, we will not employ the appropriate people?
Steve Webb : If the chief executive of the Healthcare Commission, who I would defer to for expertise on such matters—I do not know whether the hon. Lady would—had said at the start of the national service framework that she wanted everything done tomorrow, I would accept the hon. Lady's point. However, she is saying that halfway through the process there is an extraordinarily low take-up of rehabilitation services. I would have thought that five years was enough time to train people. Part of the problem is not training but systems. If I am discharged from hospital having had a heart attack, there should automatically be someone sitting down with me and talking me through exercise, diet and everything else.
A lot of the advice is described in the survey as basic. I do not imagine that it takes a huge amount of time to train people who are already medics to give basic advice on diet and exercise after heart problems. The chief executive of the Healthcare Commission is unlikely to make irrational and implausible demands. She is saying that the system could and should already be in place with the resources available now. As the hon. Member for Westbury said, that aspect of the process is not necessarily the most glamorous but it is vital. To put in context what the Healthcare Commission is saying about its importance, the chief executive says that
"further progress towards European standards will be hampered if access to rehabilitation, advice before discharge and routine follow-up care are not addressed."
I want to touch on one more issue before drawing my remarks to a close, and that is the subject of health inequalities. I was interested in the example that the Minister gave from Sheffield, and I was encouraged that additional interventions in deprived areas can produce above-average results, which must be a good thing. Five years through the process, how near are we to nationwide action on health inequalities? Pilots and localised studies are great, but have we closed the gaps in inequality between socio-economic and ethnic groups that were flagged up at the start of the process? I appreciate that such data is always out of date and that there is always a dirty great lag before we know anything, but is there anything at all that we can tell? Is there any early information? Is health inequality rising or falling in the field of coronary heart disease, or is it too soon to say? I hope that the Minister will address those questions.
If one is selective about the national service framework, one can tell a good story. The Minister, with her customary charm, told a good story. It sounded good as far as it went, although it overstated where we are in comparison with what might have happened
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regardless. Progress has been made and we should salute those in the national health service and in the charitable sector who have helped to make it happen—the British Heart Foundation and others must be acknowledged. This is not something that I often say, but it worried me when the Minister stopped talking because she felt that she had said everything that there was to say. When she speaks again later, I hope that she will say a lot more about what she did not talk about, about areas in which progress is not being made, and about what is coming down the track. If the incidence of coronary heart diseases is rising and diet and obesity trends are moving in the wrong direction, are we not storing up a lot of trouble for ourselves? Does not more emphasis have to be put on effective preventative action and rehabilitation?
3.46 pm
Mr. Kevan Jones (North Durham) (Lab): May I say how glad I am that this debate is being held? It was programmed for the dying days of the previous Parliament and had to be withdrawn, but it is important that the issues raised by Members about how to make progress in the future are heard. There are clear problems with how to organise the health service but at the end of the day, the fundamental issue is money. Investment in the health service came up as an issue during the general election campaign, and the Government are clearly achieving results of which we can be proud.
The reduction of 27 per cent. mentioned earlier is no mean achievement and represents about 25,000 lives saved. Anyone who has had a family member die from a heart attack will know that it is a sudden and tragic way of losing someone and that it affects not only the person who died but the remaining family members. Likewise, people who have suffered from, or whose family members have suffered from, coronary heart disease will know the poor quality of life that that leads to.
The use of clot-busting drugs, which has increased by only 25 per cent. since 2000, is making a real difference. I referred earlier to an experiment in my constituency in which pharmacists are helping to dispense such drugs. That is a new way to ensure that individuals that need them get clot-busting drugs, and it makes a real difference.
Reference has also been made to prevention, which is important. I am glad to hear that the Minister was exercising this morning, and I look forward to seeing you, Mr. Conway, next Tuesday at WeightWatchers. If I do not see you there, I will ring Mrs. Conway to see if she can persuade you to attend.
The policy that we have put in place for primary care trusts has a key part to play in reducing coronary heart disease, because PCTs are addressing prevention and trying to ensure, certainly in my constituency, that changes are made in people's diets and lifestyles.
I want, in my brief speech, to mention the chapter on cardiac risk in the young. I chair the all-party parliamentary group on cardiac risk in the young. My hon. Friend the Member for Stockton, South (Ms Taylor) pointed out today that some 400 young adults a
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year suffer sudden cardiac death. I spoke earlier about the tragic consequences of sudden death. It is terrible when it happens to older people, but there is nothing one can say to families after the sudden death of fit, healthy young people, such as those whom I have met through my work on cardiac risk in the young. One cannot put oneself in the shoes of people who have lost a healthy child who was in the prime of their life.
I, like my hon. Friend the Member for Stockton, South, became involved in this area of work through the death of Levon Morland, who was a family friend of mine, too. He was a healthy, fit young man who was, sadly, taken from his family. I pay tribute to my hon. Friend for introducing a private Member's Bill, the Cardiac Risk in the Young (Screening) Bill, during the previous Parliament. She withdrew it, following the Government's commitment to include the chapter in question. That is a good example of the way in which Back Benchers can make a difference. As someone who also piloted a private Member's Bill through the House last year, I encourage any new Member to enter the ballot and to consider how to make such a difference. The hard work that my hon. Friend did will pay dividends.
I pay tribute, also, to the Minister at the time in question, Melanie Johnson, who unfortunately lost her seat at the general election. She gave a commitment to take the matter seriously, without which the chapter would not have been included.
The Cardiac Risk in the Young (Screening) Bill received cross-party support, and the all-party group also has such support. We grew, after the debate, from a membership of seven to more than 55. We have our annual reception on the Terrace next Wednesday, and hon. Members are welcome to attend. I am pleased that the Minister has agreed to speak at the reception to highlight this important issue.
The national framework is important, and this is the first time that the issue of cardiac risk in the young has been included in it. It will lead to improvements relating to the setting out of treatments for cardiac arrhythmias. My comments relate to the young in particular, but older people can be affected as well, as we all know from the example of the Prime Minister. The condition is also, I am told, the cause of a third of strokes.
I pay tribute, among those who worked on the chapter, to Roger Boyle, who met the group and took the matter seriously. I think that his commitment was welcomed by the families involved and by the Members of Parliament who came to listen to him address the group. I have said before that I pay tribute to Alison Cox, the chief executive of CRY, who makes my life a misery at times by badgering me to do things about cardiac risk in the young. She is truly committed to the work, and should receive recognition. Dr. Sanjay Sharma has also raised the issue.
Now that the chapter has been included in the document, a key issue is genetic inheritance and whether the conditions in question run in families. There is a large body of evidence that they do. More research needs to be done, because we all know that if the conditions are detected early enough in young people the tragic consequences that affect many families can be avoided. That knowledge, and the progress report, "Leading the Way", give encouragement to many campaigning families who have been working hard.
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I want to finish with a couple of pleas to my hon. Friend the Member for Stockton, South about the way in which we evaluate the chapter. It should not be treated as a rigid piece of work, but should be examined in the near future for ways in which we could improve it. Alongside that—CRY is working hard on this—we need to raise awareness of cardiac risk in the young among GPs in particular, and among others who deal with young people, such as teachers and youth workers. If the Government helped with the promotion of such work that would be important.
I do not ask for blanket screening of young people, which would be ineffective, but I am interested in whether it could be available in the future for young people who take part in sport in particular. In other countries, such as the United States, people must be tested for heart conditions before they take part in certain competitive sports. We need to consider whether we could introduce that practice.
I raised a point about coroners—something slightly outside the Minister's area—in an intervention on my hon. Friend the Member for Stockton, South. I know that we are expecting a new coroners Bill. However, coroners need to take seriously the possibility that certain accidents, especially drownings, could be linked to sudden cardiac events, especially in young people. Too often coroners dismiss as drowning, among other things, events that could be sudden cardiac death. That is important, because if we are to improve the situation it is vital to get the statistics right, and to know how many people are dying of such conditions. CRY may well raise that issue in relation to the coroners Bill, but perhaps the Minister could pass on my concerns.
I welcome the advances that have been made; the Government can be proud of what they have done. It is nice that my hon. Friend's Bill has led to a change which, if implemented, will save young lives.
3.57 pm
Dr. Richard Taylor (Wyre Forest) (Ind): Obesity, exercise, WeightWatchers and gyms have been mentioned several times. I admit that I have not been near a gym recently, but for those of us who are slightly older the best exercise is having an office at least a quarter of a mile from the Lobbies. I am thinking of doing a survey of obesity in hon. Members related to the distance of their offices from the Chamber.
I am delighted to speak in the debate, and pay tribute to the hon. Member for Stockton, South (Ms Taylor); there is a lot in what she was saying, just as I arrived in the Chamber, about keeping on jumping up and down and shouting. I am very pleased to see the Minister; she gives some stability to the health team, which is entirely new except for her and Lord Warner, who has moved up to become Minister of State.
As to the extra chapter of the national service framework, I am delighted that the need for quality standards in the treatment of arrythmias has been recognised. Arrythmias were a relatively new subspecialty 10 to 15 years ago. Although the Minister was rather dismissive of everything that happened more than five years ago, many good things did happen then. The NHS was not quite such a political football.
I remember drugs called ACE inhibitors coming out in the 1980s and revolutionising the treatment of heart failure. The first person I gave them to was an elderly
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widow who had retired to my town to die of heart failure. I started her on one of those drugs in a very cautious way. I did not reckon to follow her up because I thought that the outlook was hopeless. Six months later her doctor said, "You'd better see her again; she's going out doing the shopping." That was dramatic.
Clot-busters, which have been mentioned, also came into use in the late 1980s. I hate to rub a sore point for the Minister, but the hospital at which I worked, which no longer sees acute patients, had the door-to-needle time down to nine minutes for clot-busters before, sadly, it lost those services.
Speaking of arrhythmias, treatment has been absolutely revolutionised in the past few years. When I retired, there were few specialists in arrhythmia treatment; now, thank goodness, there are more of them. There are more opportunities for people to be treated and to have abative operations that actually cure some of the serious arrhythmias. There are more opportunities for screening and for interpreting electrocardiograms and the relatively small changes that can herald danger. There is also more widespread use of echocardiograms, which can pick up and measure things such as aortic aneurisms and detect some of the potentially dangerous problems that affect young people. I therefore welcome the quality requirements, which imply that the aim is to make such specialist treatments available to everybody.
I do not want us to forget the first few chapters of the national service framework. Enough has been said about the Healthcare Commission report and about the fact that some very ordinary things still need addressing. The hon. Member for Northavon (Steve Webb) was absolutely correct that systems must be in place when someone who has had a heart attack is discharged. We must make sure that they do not slip through without being put on an exercise programme, a programme to help them stop smoking or a weight-loss programme.
The second issue emphasised in the present chapter is, of course, sudden cardiac death. We must not forget that most cases occur in people suffering from coronary heart disease and involve the sudden arrhythmia or the sudden acute coronary. Obviously, such things will be addressed by better prevention and the better treatment of coronary heart disease and its complications, the arrhythmias. That leaves us with the most distressing issue of all: the sudden, unexpected death of young people. So often, these deaths remain unexplained, and all credit must go to the voluntary groups that have pushed this issue and produced the present chapter of the national service framework.
I come now to the difficult part of my contribution. I do not want to be seen to be undermining the present efforts in any way, because they are absolutely tremendous. However, they raise the question of whether health care prioritisation—I am specifically avoiding the word "rationing"—should be local or central. When the Select Committee on Health carried out its inquiry into the National Institute for Clinical Excellence, we unearthed all sorts of problems. NICE is the first worthwhile, commendable attempt at some sort of health care prioritisation, but we came across NICE blight. As soon as something went to NICE, doctors felt that they could not prescribe it until it had been recommended.
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Sometimes NICE recommendations went against local priorities. Let me quote a witness from a major teaching hospital not very far from here, who was speaking just after NICE had recommended implantable cardiac defibrillators:
"four implantable cardiac defibrillators cost £120,000 and for that same amount of money you could have funded four extra nurses . . . the nurses we could put into accident and emergency very directly stack up against some of the things which NICE have funded. When NICE says yes and it is mandatory, it deprives our local residents of the chance of getting core and basic services."
So there is a way in which NICE recommendations could obscure local priorities.
I am also slightly worried about NSFs. They are mandatory, but they do not exist for many serious illnesses. Are those illnesses disadvantaged? When the Select Committee conducted its sexual health report, we found that under-provision of sexual health services was a tremendously widespread, serious problem. I know that the Government have gone part way to help deal with it by providing extra money, but we wondered whether a national service framework would help. We were told that it would take an awfully long time to get one worked out and that there would probably be no more NSFs in any case. Have the people working on arrhythmias discovered the way round the need for a new NSF? Is the answer to aim for a new chapter to an existing NSF? I am thinking particularly of the NSF for long-term conditions, which concentrates nearly entirely on neurological conditions, but there are so many other chronic disabling conditions, such as the chronic rheumatic disorders. If I organised a powerful voice, as the hon. Member for Stockton, South did, could we get an extra chapter added to that NSF to give it much more strength?
I want now to talk a little about actual suffering and about families who are so suddenly and unexpectedly bereaved. Suffering cannot be measured. There are some awfully trite quotes about how good it is to suffer and how suffering does people such good; they make one absolutely squirm. Wordsworth had it absolutely right when he said that "Action is transitory" and that
So one cannot measure suffering. How do we compare the suffering of a family who has suddenly and unexpectedly lost a perfectly fit teenager with the suffering of a family who is told that their four-year-old son—a delightful, bright kid—has got Duchenne muscular dystrophy? They know that they will see him slowly deteriorate over the next 10 or 15 years and that he will almost certainly die in his teens. How do we prioritise such suffering? I understand that there is the possibility of genetic treatment for that sort of muscular dystrophy and that it could offer a cure. A constituent recently wrote to me, saying that we need an extra £5 million for the research, which could produce a cure for their son before it is too late.
There are so many competing claims for funds. The hon. Member for Stockton, South implied that improving the care for such young people is not as simple as raising awareness or teaching people, including doctors and nurses, about the risks. It also
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requires a tremendous amount of investment in new physiologists, new arrhythmia experts and new specialist nurses. I have letters from radiotherapists telling me that there is apparently an absolutely dramatic new form of radiotherapy, which is available in only one centre in this country. It produces high rates of cure, with little risk of damage or morbidity, but those who wrote to me forecast that patients will soon be going abroad for treatment because there is only the one centre in this country and it is unlikely to be given sufficient priority.
To return briefly to the Select Committee's report on NICE, one of the final recommendations contained these words:
"Prioritisation of healthcare spending is an issue of overwhelming importance, and during the course of this inquiry it has become clear to us that a more open debate on healthcare prioritisation needs to take place."
In their response, the Government point out the huge difficulties that that entails across the whole field of health care, concluding:
"Achieving a comprehensive, empirically-based framework could therefore only be achieved in the long-term."
All we are asking for is the beginning of a debate on prioritisation, so that it is not just groups that happen to have clout and a loud voice that can achieve such dramatic breakthroughs.
Ms Dari Taylor : I have no problems when the Welsh are playing rugby; I can shout as loud as anybody. However, although I agree with much of what the hon. Gentleman says, the issue is not only about having a loud voice, but about unnecessary death and tragedies that could be prevented. I would appreciate it if, in saying the one, the hon. Gentleman would acknowledge the other.
Dr. Taylor : Of course I acknowledge that, but there are other causes of preventable death—indeed, one on which we are awaiting a reply from the Government is venous thromboembolism in hospitalised patients.
To conclude, I return to these fearfully sad problems. I am not quite sure how much can be done to pick up the totally symptomless individual, with no family history or any other reason to have a medical examination, ECG or echo. However, there is every case for better education of all health care professionals, so that if people happen to have ECGs showing minor changes, those can be picked up. Also, the availability of screening for members of the family is drastically important, because it is too awful for one member of the family to have something, but for the others not to be followed up on.
Finally, the last quality requirement in the chapter, on sudden cardiac death, refers to the post-mortem, which other hon. Members have mentioned. Picking up the signs that might be there in such post-mortems is extremely difficult. I am therefore delighted to see that a standard post-mortem, looking for the commonest causes of premature sudden death, has been drawn up by the Royal College of Pathologists. I hope that we will see improvements in the coming years.
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4.12 pm
Jon Trickett (Hemsworth) (Lab): It is always a pleasure to listen to a speech by the hon. Member for Wyre Forest (Dr. Taylor), a practitioner who brings such experience to the House, but he has worried me slightly. Today I scored what I thought was a minor triumph—life as a Back Bencher is not full of triumphs—which is that I persuaded the accommodation Whip to relocate me from Norman Shaw North, which as hon. Members know is the farthest point from the Chamber, to a room in this building. If there is a correlation between overweight MPs and the distance that one has to travel, I am now rather concerned that my weight is about to increase substantially and that my minor triumph will turn out to be a disaster.
To reflect on personal matters for a moment longer, my family lived partly in the shadow of a serious heart attack that my father suffered when he was 47. He has had five more but is still alive at 78, which is a remarkable tribute to the skill of the practitioners and the available medicines. He is still around, and so alert and interested in politics, which sometimes means that I do not have so many minor triumphs, especially when he is on the phone complaining about the last thing that I have said. My family's experience of living in the shadow of cardiac arrest led me to reflect that I might have a genetic propensity to the same kind of problem. However, when reading about coronary heart disease, I made the pleasurable discovery that it might be possible to change my behaviour and thus counter the genetic factors. I therefore decided to try not to put on too much weight. I exercise almost every day—for five or six hours at weekends—and have done ever since my father's first heart attack.
Ms Dari Taylor : Pushing a hoover around?
Jon Trickett : I do not push a hoover around too much—hoovering certainly does not take five hours, anyway.
Most hon. Members have mentioned inequality, and I represent one of the illest populations in the country. A number of measures are used, some of which can baffle the non-statistician and non-medical practitioner, but by whichever measure one chooses, the communities of former mining areas, such as the one that I represent, are extremely sick. For example, the crude death rate in England is 990 for every 100,000, but in the Eastern Wakefield primary care trust, which is my patch, it is 1,130 per 100,000. The standardised years of life lost—that is, the years of life that one might expect to have—is 649 for every 10,000 people in England, compared with 819 for every 10,000 in the Eastern Wakefield PCT. In England, the mortality rate from potentially avoidable causes of death, which includes cardiovascular problems, is 100, but in the Eastern Wakefield PCT it is 132—33 per cent. more.
Unless one argued that people in Hemsworth have a genetic propensity to suffer from cardiovascular and other such problems—I am sure that nobody would argue that—one must assume that the causes of those inequalities and differences in death rates, which are so marked in my constituency and which leave such bleak picture, are largely behavioural, although genetic factors play a significant part. Otherwise, the differences between communities would not be so marked. In my constituency there are even differences within
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communities according to socio-economic factors. It is clear that behaviour and social processes are at the root of much that is happening.
Two sets of behaviours should be addressed in relation to coronary heart disease and sickness generally. The first set is those behaviours that the Government can most directly influence, almost in a managerial way: the wide variety of medical and clinical services that the NHS provides. I particularly welcome the emphasis that the Government have put on that. Although the hon. Members for Northavon (Steve Webb) and for Westbury (Dr. Murrison) made excellent points, they lacked generosity. The spirit of opposition should not deny the ability generously to acknowledge the improvements being made. If one considers how the national service framework has been rolling out, one must accept that major differences are being made in constituencies such as mine and throughout the nation.
As one might expect from my comments, Eastern Wakefield PCT is one of the spearhead group of PCTs in the most deprived areas—in fact, we are among the most deprived anywhere in Europe. There has been a major reduction in waiting times: now nobody waits more than three months for heart surgery and by December nobody will wait more than three months for angiography. Two thirds of all patients now have to wait less than 60 minutes—the golden hour—between phone call and needle time. That is a remarkable achievement, and not acknowledging it shows a lack of generosity of spirit.
Dr. Murrison : Will the hon. Gentleman tell me how the standardised morbidity rate has changed with time in his constituency?
Jon Trickett : I will try to address those issues. I am not quite sure that the SMR is necessarily an indicator of where we would have been had such activities not taken place, since the general trend across the whole of western Europe and all similar societies is heading upwards because of obesity and other such factors. I am not sure that SMR changes measure what would have happened otherwise.
Eastern Wakefield PCT has been seeing remarkable changes. We are now the highest prescriber of statins in West Yorkshire. Most important, there has been a 10 per cent. increase in the number of completed consultant episodes since 2000—I am not going back to 1997, which was the political watershed. In the past five years we have seen an increase from 5,000 completed consultant episodes in coronary heart disease to 5,500. Those remarkable achievements, which have to be welcomed, are the result of active political intervention to change the behaviour of the NHS.
Steve Webb : The hon. Gentleman is making a thoughtful contribution and I fully accept his point about saluting what has been achieved. However, looking ahead, does it not worry him that more people have coronary heart disease now than did five and 10 years ago? Surely the job of Opposition is not merely to say "Well done," but to say, "These are the problems: what is being done?"
Jon Trickett : That is precisely what I will go on to do: ask questions. There is an upward trajectory, not only in
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this country but across the western world. I want to address behavioural factors and say where I think that the Government should do more or accelerate what they are doing. It is the duty of all Back Benchers, and not simply Opposition Back Benchers, to ask questions, but to do so in a spirit of generosity that acknowledges where achievements are being made.
To talk about behaviour and what can and cannot be changed, I have questions about the way in which provision is made to communities such as that which I represent and then go on to the behaviour of the general population. The local health service—I suspect that the issue goes wider than Hemsworth and Wakefield—is undergoing massive transformation. That transformation is in danger of undermining public confidence in the provider institutions, particularly the acute hospitals at Pinderfields and Pontefract. Several separate processes are going on in parallel, all of which are putting huge question marks over the kind of services provided. I will not go into them now, except to mention that the PFI arrangement is desperately needed. There is chronic underfunding: the Government are now increasing funding but it beggars belief that after eight years we have not done more to increase funding to such a sick population as that which I represent, and although we are moving faster, it will take some years to reach the point at which we ought to be. The local hospitals have inherited a financial deficit. In addition, there has been a major consultation process on the reconfiguration of services across the patch as a result of the merger of hospitals.
All that, together with the general reform agenda, is driving a clinician-led process of centralisation which, it is hoped, will produce centres of excellence at Pinderfields and elsewhere, but which is undermining confidence in provision at Pontefract, which serves most of the sick population that I represent. We urgently need stability in local hospital provision. It strikes me that, if we are not careful, that clinician-led process of centralisation that seems to be going on in my patch and across the country will undermine the sense of confidence, locality and community services that is equally important. I suspect that where confidence goes and a choice is offered, people will move to other hospitals—in my area into Doncaster, which the Minister may or may not welcome since she represents the Doncaster area, or Barnsley—at the expense of Pontefract hospital. If those processes are allowed to go on unmanaged, I fear for local coronary care. I know that Ministers are well aware of the problems, but if the Minister keeps her eye on Pontefract and Pinderfields hospitals, I shall be grateful.
The Minister could have made more of issues of behaviour. To return to genetics, behaviour and the social processes that produce ill health and are so manifest in my constituency, it strikes me that, in four areas, rather than simply try to offer an expedited and accelerated curative set of processes, such as better clinical services, we ought equally to consider preventive measures.
The first such area is obvious: smoking. Smoking is a major factor in ill health, particularly in coronary problems. The Government are doing a lot and have a fantastic information scheme—a great deal of public
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information has been in the media, on TV and so on. There appears to be a downward trend in many social groups, although not all—the number of young women, for example, who are still smoking worries me. The Government are doing a good job, but they are being timid about the ban on smoking in public places. We ought to have none of it. Smoking in public places should be ended. There will be a huge debate and huge loopholes in the legislation if we say that pubs and other places can continue to allow smoking in areas where food is not being prepared. It seems to me that that is a huge loophole that ought to be carefully considered.
The second area is nutrition. The Government have introduced the five-a-day principle, which is excellent, and there has also been the recent debate about food in schools, but there is more to be done and I would welcome any comments from the Minister.
The third area is exercise. I might be living proof that it is possible, if one exercises, to maintain a healthy physiology in spite of all the problems of ageing and genetic inheritance. The Department has done a lot to encourage physical activity and our understanding of it, but there is more to be done. Local GPs seem to regard exercise referral schemes as a bureaucratic and difficult process. If an individual who presents at a doctor's surgery is manifestly moving towards obesity and might have a number of risk factors for coronary heart disease, the doctor is entitled to prescribe exercise. That is a welcome move from the Government, but GPs frequently lack confidence in the process. There is more to be done on the matter of physical exercise.
I said that there were four factors; I will come to the last in my winding-up comments. However, those three matters—nutrition, smoking and exercise—all touch on what has been described as health literacy. If we are to transform people from passive patients who receive cures when they are ill into active consumers, which is the Government's ambition, the idea of health literacy is a positive one. It has been described in one definition as
"the capacity of an individual to obtain, interpret and understand basic health information and services in ways which are health-enhancing."
That is a fantastic idea. More needs to be done to encourage the understanding of human physiology and what one can do to try to avoid ill health. Behavioural factors might be regarded as individual actions and the Government might not want to be seen as part of a nanny state—that might be the motivation for not pressing hard enough—but if people are to become actively engaged and health literate, more needs to be done. The Government might have to be prescriptive about smoking, nutrition and physical activity in order to produce a population that is health literate and capable of making the educated choices that the Government want people to make.
I have described the levels of ill health in my local area. The Office for National Statistics uses 32,000 statistical units to make its measurements, according to which South Kirkby—a ward of 12,000 or 13,000 adults—is in the 100 sickest wards in the country. One in two households in that ward has somebody who has a long-term, limiting illness of some kind. It is a profoundly ill population as a result of all kinds of problems, but when the ONS asked people in that sick population—as it did in every area—how they would describe their health, 85 per cent. said that it was good
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or very good. That is remarkable given that they live in an area with among the worst levels of mortality and morbidity in the country and that many live with long-term, limiting illness. There is a disjunction between the objective perception of the medical profession or other observer of ill health in the area and people's subjective view. People conclude that they are not living such a bad life because they live in an ill community and think that they are not too badly off compared with their neighbours and peers in the community. They do not understand that compared with the middle-class population or communities in other parts of the country, such as rural areas, they suffer a major health disadvantage.
The statistics that I mention are repeated in every ward in my constituency—and, I dare say, in those of many other hon. Members. The Government's vision of a consumer-led, choice-driven agenda, which is probably benign, is some way away from being achieved if we have such low levels of health literacy in the areas with the highest levels of illness. Any long-term attack on coronary heart disease needs to factor in considerations such as public dissemination of information, the creation of a more actively engaged clinical work force and the slow-down of the kind of reform agenda that is being driven, to some extent, at the expense of locality.
Practitioners in my local primary care trust tell me that they are being set tough targets. They are working hard and I pay tribute to them for achieving those objectives, but the population is deeply scarred by health inequalities. The behaviour of individuals is only part of the problem; poverty and ill health are as strongly correlated as they could be, and the Government need to move faster and further to achieve our anti-poverty objectives. That is the clearest way of alleviating the problems that I describe. From the Conservative Administration, we inherited 14 million people living in poverty; we have taken 1.5 million out of poverty, and it is great to see children and old people targeted in that way, but that still leaves 12.5 million people living in poverty, including many in my patch, and suffering the twin problem of ill health. Nevertheless, I very much welcome the Minister's comments and the national service framework.
4.35 pm
Ms Rosie Winterton : This has been a fascinating debate, in which all hon. Members have made positive comments, although, as my hon. Friend the Member for Hemsworth (Jon Trickett) said, some of the comments by Opposition Members were a little mealy-mouthed.
I hoped that we could use this opportunity to praise everyone who has made such a difference in the delivery of coronary care services over the past five years. I am conscious that I did not spend as much time on what I think are some of the challenges, but I wanted to give all hon. Members the chance to speak and was aware that my speech was quite long. I hope that I touched on those issues, but I wanted to reply in my winding-up speech to matters that I knew would be raised during the debate and to expand on some comments.
Everybody has touched on health inequalities and prevention, particularly the hon. Member for Westbury (Dr. Murrison), who raised the issue of obesity, as did
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the hon. Member for Northavon (Steve Webb). That issue is relevant to the comments of the hon. Member for Wyre Forest (Dr. Taylor) about local priorities and the tension that sometimes exists between national service frameworks and targets, and the taking of decisions at local level about local problems. That leads me to the comments of my hon. Friend the Member for Hemsworth. That is the direction in which we are going, as one can see when one considers the issues set out in the White Paper, "Choosing Health: making healthier choices easier", and in other publications.
I have come fairly new—since the election—to issues such as coronary heart disease and coronary services, but many of the points raised today have been raised in relation to other areas for which I have responsibility, such as diabetes. There is a need to work with people to change their lifestyles and to make it easier for them to choose healthier options. Vital to that is the point made by my hon. Friend the Member for Hemsworth about health literacy. In many other areas, we have very good expert patient programmes, in which we talk to people about how they can use their experiences of a condition to help others to manage the same condition. The hon. Member for Westbury talked about GPs and whether more could be done. I think that it could—through the GP contract and GP specialisms, and through working with practice nurses to expand the availability of information.
I return to the remarks of my hon. Friend the Member for Hemsworth. I know that he will be particularly interested in this point, because of his experience in local government. The relationship between health services, primary care trusts and local government is vital in bringing together the components to build on Sure Start, for example. We must look at how, through schools, we can help to educate people about healthy eating and at how we can use schools as community facilities for increasing participation in sport. We will certainly take that on board and consider whether it is too bureaucratic for GPs to prescribe exercise.
My hon. Friend's constituency contains a spearhead authority. The hon. Member for Westbury talked about the rural poor and how to learn some of the lessons. The idea is that the spearhead authorities consider how to innovate and pass those lessons on to other areas.
I should like to draw hon. Members' attention to some of the local innovation forums that are working jointly with the Office of the Deputy Prime Minister and looking at how public health issues can be taken forward, even through the joint pooling of health authority and local government budgets. That is part of the agenda to decide local priorities and to consider where the inequalities are.
The hon. Member for Northavon mentioned inequalities, which have narrowed but not enough, which is why we need to consider many issues as we take this work forward. That is the next stage for the national service framework, but it is part of a much wider agenda.
I am anxious to ensure that we do not consider coronary heart disease, cancer and diabetes separately. The same factors apply in many cases. Obesity, for example, leads to an increased risk of cancer and diabetes. Some good things have been done for people
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from ethnic minorities with diabetes and we need to translate that into what we do for coronary heart disease.
We need to increase rehabilitation, as the Healthcare Commission said. However, it is important that we link that with other programmes. It should be possible, as we develop services, to say, "If this is the agenda and we are looking at health literacy, somebody should come out with information, having had coronary heart disease treatment, and let's make sure that similar information is provided to people who have had treatment for cancer or diabetes." There should be a way to ensure that we do not work in condition silos or agency silos—I refer to the contribution that local government and health care trusts make to increasing information on prevention services, rehabilitation services and so on. That is an important agenda.
I turn to some of the points that were made by my hon. Friend the Member for North Durham (Mr. Jones) in an eloquent speech about what has been happening to families in his constituency. He has obviously been pursuing some of the issues that have been raised. He talked about what more we can do to raise awareness. We need to take that forward. I should be interested in pursuing that issue with him and my hon. Friend the Member for Stockton, South (Ms Taylor), together with people from Cardiac Risk in the Young, to see what else we can do. Of course, screening families is a quality requirement in the new chapter.
The hon. Member for Wyre Forest raised the issue of screenings for sport. The expert group that examined the new chapter considered that issue and whether there was sufficient evidence to allow us to say whether participation in sport might be a contributory factor to a higher risk of death. It was felt that there is not enough evidence at the moment, but obviously we will keep that under review. Both the hon. Gentleman and my hon. Friend the Member for Stockton, South—she had to leave, but I congratulate her again on the work that she
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has done—mentioned the issue of research, which we will continue to keep under review in view of the new chapter.
As for the number of physiologists and other specialist workers, I hope that it will assure hon. Members to know that we are in discussion with the professional bodies to speed up specialisation in cardiology, so that that speciality grows first, before numbers increase. We are looking into working with professional bodies to consider the new ways of working that I mentioned earlier, and to consider how we can spread good practice to other areas; hon. Members have highlighted many examples of good practice this afternoon. We must ask how we can ensure that we look at what works best in certain areas and translate it to others.
A number of points were raised and I think that I have addressed most of them, but if there are any that I have not, I will certainly write to hon. Members. Perhaps we have previously concentrated on acute and in-house or in-hospital services, but today we have tried to touch on how to ensure that we take the issue out to the community. That is the next and biggest step that we need to take. I am very confident that, given how we are taking forward the agenda—not only on this subject, but in a wider sense—we can make a real contribution to that. The progress report published in March is encouraging, and that is a great tribute to everyone who has worked in the services involved.
There is real open-mindedness about how to change ways of working and how to consider innovation, and it is important that we encourage that. We must be careful not to depress people or to be mealy-mouthed about the issue. We need to give encouragement and to show that the Government are on people's side in taking forward the agenda. Today's debate has shown that. There is more to do, but we are well on the way to doing it.
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