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The problem is that the rhetoric, overall, has not been matched by delivery. The biggest challenge is public health priorities in disadvantaged communities—lifestyle ill-health. The hon. Member for Gateshead, East and Washington, West was absolutely right to draw attention to the enormous health inequalities in this country, which are growing under the Government. The key issue is access to health services and reaching those
hard-to-reach individuals who are not benefiting from the screening that has been introduced for others across the country.
It is extraordinary that remuneration for GPs continues to discriminate against those who work in disadvantaged communities. The NHS Confederation has argued that the minimum income guarantee, which hits GP practices in disadvantaged communities, should be reformed, along with QOF. At the moment, QOF pays out less money to GPs in disadvantaged communities than it does to those in the leafy suburbs.
Why are public health budgets cut whenever financial constraints are imposed? Why is it being proposed that work in London on HIV prevention for gay men should be cut by 36 per cent.? The common thread is that all the financial incentives for PCTs around the country under budget pressure are that they should put money towards meeting treatment targets, rather than into prevention. That problem will remain until those incentives are changed.
My slot in the debate is very limited, so my final remarks have to do with preventing fractures. The national hip fracture database is a fantastic initiative to drive up standards and quality of care, and it focuses on preventing fractures. In the UK, 310,000 patients suffer fractures every year. The treatment of osteoporosis is key: 3 million people suffer from the disease, and the social and hospital care costs of their fractures amount to some £2 billion a year. Proper treatment for all osteoporosis suffers could cut the fracture rate by 50 per cent., yet the Government have excluded osteoporosis treatment from the QOF arrangements in the negotiations that are under way. That is a big mistake. Osteoporosis was not mentioned in Monday’s announcement, and the Government should think again.
2.11 pm
Dr. Howard Stoate (Dartford) (Lab): This year, the NHS will have been in existence for 60 years. When I was preparing for this debate, the sobering thought occurred to me that I have been qualified for slightly more than half that time. I want to begin by paying a huge tribute to the 1.3 million people who work in the NHS, as they have created what I still believe is one of the best health services in the world, if not the very best. I hasten to add that that is not in any very large measure due to my efforts, although I hope that I have contributed at least a small amount.
There have been huge changes in the NHS since its inception, but a big disappointment has been that it has been unable to become a prevention service. Over the decades it has concentrated on being a treatment service, and my memories of my early days in the NHS make it easy to see why.
When I started in general practice, five of us shared a small Victorian building. Patients had to climb a steep flight of stone steps to the front door, which meant that disabled people simply could not get in. We had no practice nurse, no computers and no proper medical records apart from the ordinary GP notes that, of course, could not be searched. That meant that it was almost impossible to set up anything approaching a screening or properly preventive service.
We did what we could, of course. We immunised children and, when people came to see us, we took the opportunity to check their blood pressure and so on.
However, we could not systematically screen patients, as we had no way to recall them or to call them in for checks. We certainly had no system to follow up everyone whose cholesterol was outside the normal range or whose blood pressure was over the top.
Things have changed radically. Now, I work in a large, purpose-built surgery with 11 consulting rooms, eight partners and three full-time nurses. We have a professional team of managers to help us make sure that people are called in when necessary, and an enormous array of ancillary staff and health professionals are attached to the practice who offer a range of services that was simply unknown when I began as a GP. That has made a massive difference.
On top of that, we have access to community services such as heart failure clinics and nurses dedicated to looking after people with Parkinson’s disease or continence problems—the list is very long. Modern computerised systems and almost paper-free records mean that in a few seconds I can find out exactly how many people’s cholesterol is above the recommended level, or how many people with diabetes have not had regular check-ups or the retinal screening that they need. The fact that GPs can do all that almost instantaneously means that we can contact people, call them in, remind them when they are due for health checks, and so on. That has made a massive difference to how people are treated, and makes screening and prevention a real possibility.
Norman Lamb: I recognise the changes for the better that have been introduced, but the hon. Gentleman will have seen the impact on public health budgets around the country and in his area of London. Does he accept that the combination of treatment targets that put intense pressure on PCTs and payment by results has ensured that the incentive is to link payments to treatment rather then prevention?
Dr. Stoate: I listened to the hon. Gentleman very carefully, but I do not recognise the problem that he describes. The QOF system set up under the new GP contract is almost completely evidence based. It is reviewed every year by the British Medical Association and the Department of Heath to ensure that it reflects best practice. Everything that GPs do has a dedicated outcome and a proper scientific base, which means that we know that what we are doing is worthwhile medicine and that it genuinely improves patient care.
A few years ago, if a patient with suspected cancer came to see me I had to beg, borrow and steal an urgent out-patient appointment. If I was very lucky, and ready to call on the old boys’ network, I might have been able to get one in a month or two. Now, I can guarantee such a patient an appointment with a cancer specialist within two weeks, and probably a lot sooner.
We are now able to do things that were simply not possible in the old days. I can get open-access MRI scans and endoscopies, and I can investigate people far more rigorously inside the practice. That means that I am more likely to reach the correct diagnosis far sooner than would have been possible in the days when I had to wait for a consultant to confirm my fears.
Mr. Quentin Davies: My hon. Friend is making an extremely good and effective speech, but he just mentioned that he can now get patients presenting with cancer or other serious symptoms a consultant-level appointment referral within two weeks. That is a fantastic improvement on the two or three months that it used to take. Does he agree that that would not have been conceivable without targets? Has he noticed that the Conservative party proposes to abolish the targets on which that performance is based?
Dr. Stoate: My hon. Friend makes a valuable point, and it is deeply regrettable that the Opposition seem hell bent on getting rid of targets. He is right to say that targets have driven up standards in the NHS hugely and that they have massively improved patient outcomes. We are now able to measure the number of people with particular conditions. We can check that they are properly managed, recall those who need further treatment, and ensure that they are on the best drugs available. That is the way to go.
Although the history of prevention has not been very good, I have tried to make it clear that we are now at the point when we can take advantage of modern techniques to ensure that preventive medicine is used properly, but there are risks. As I noted in an earlier intervention, the previous Government appeared to want to improve patient outcomes and health but did not ensure that treatment was evidence based. The checks that doctors were required to carry out under the 1990 GP contract quickly led to disillusionment, because they were not based on anything that could be recognised as good patient care.
The National Screening Committee has made it clear that it will recommend treatments to the Government only when there is evidence to prove their effectiveness. That is very important. There used to be the so-called “stands to reason” test among GPs: doctors would say that it stood to reason that measuring a person’s blood pressure or cholesterol would do them some good. Yet that is not so, because there must be evidence that proves that interventions in those circumstance will change outcomes.
Getting such evidence is difficult, and that is why it has taken longer than I had hoped for the National Screening Committee to recommend triple A screening. It has now made that recommendation, because the evidence that that screening is worth spending on is now sufficiently solid. It has been shown that triple A screening can save around 1,600 lives a year among those men over 60 who are most prone to the diseases that it can detect.
I should like to take this opportunity to pay tribute to the Men’s Health Forum. Along with Ministers and the all-party group on men’s health, I have worked very closely with that organisation to ensure that interventions shown to be worth while and to provide value for money are adopted. As a result of all our hard work, the Prime Minister has announced that the programme that we have been advocating would be taken up. That is a great improvement over relying on interventions that might not have been so effective and might have wasted public money.
The NHS has a rosy future. New money is still being put in every year, and I am also pleased that the Prime Minister is not afraid to promise continuing reform.
Unless we continue to reform the NHS and to reconfigure services, we will have no way to ensure that patients get access to the most modern treatments, in the most suitable setting and with the most appropriate staff mix. It is important that we continue our programme of reform, to ensure that all patients have access to what they need.
Choice is also topical. In his latest speech, the Prime Minister said to us that he wants to make sure that patients are at the centre of choice. Patients now have a choice of where they are treated, to a large extent when they are treated, and to an increasing extent by whom they are treated. That is important, because if we are to expect people to take more responsibility for themselves and for their own health care, they have to have access to the information they need, and they have to feel that they, not the Government and not necessarily their doctor, are in charge of their condition. It is their condition, their body and their future; they must be central to making decisions on what happens. I believe that if we give patients that right, they will rise to the occasion and take the responsibility to improve their own health outcome, which will be important to improving their long-term condition.
I have mentioned how welcome it is that the Government are to introduce triple A screening. Some of the other measures the Prime Minister mentioned, such as screening at-risk groups for heart disease, kidney disease and diabetes, are also important.
Norman Lamb: Does the hon. Gentleman support the introduction of osteoporosis screening into the quality and outcomes framework? The evidence from clinicians appears to be that that would make a substantial difference in preventing fractures.
Dr. Stoate: The hon. Gentleman has just beaten me to it—I was about to mention osteoporosis and pay tribute to him for his comments in that respect. I entirely agree with him that osteoporosis is a worthwhile subject, certainly in terms of secondary screening and prevention. Someone who has had a low-impact fracture—one resulting from a fall rather than a strike by a moving object—should be screened for osteoporosis. People who fracture a joint or a bone in a fall should have a DEXA scan to ensure that they do not have osteoporosis; and if they do have the condition, they can be given appropriate treatment.
Like the hon. Gentleman, I have been calling for osteoporosis to be introduced into the QOF. In fact, only a few weeks ago, I spoke to Laurence Buckman of the BMA and tried to persuade him to ensure that it was put on the agenda for future QOF discussions. We will have to watch this space. Again, however, we will have to ensure that the evidence is there before we rush to decide whether it is a good idea or a bad one. I think that it is a good idea, and I hope that the screening committee will come to share that view in due course.
Norman Lamb:
It appears from the discussion between the BMA and the Government that the Government have given priority to introducing incentives to extend hours rather than to measures such as osteoporosis screening. Does the hon. Gentleman share the concern
of many people that to focus on extended hours to the exclusion of such preventive measures is to miss a massive opportunity?
Dr. Stoate: I do not think that the two aims are mutually exclusive. One of the points I wanted to discuss is capacity in the NHS. The Government’s current policy, which I entirely support, is to ensure that people are treated in the most appropriate place, preferably near their own home, if that is possible. That entails moving more facilities into the community. As I said, that is already happening in my area. More clinics and services are available within communities; people have more things done in the local surgery and they can attend clinics in their local town. However, there is a big issue of capacity in the NHS. We have to decide how the extra work can best and most appropriately be distributed to the health professionals we have available. In general practice, as I said, I now have three full-time nurses, whereas previously I had none. However, we need more: we need health care assistants, so that the nurses can pass on some of the more routine work to them and get on with the clinical management of patients.
The biggest untapped area of capacity in the NHS is pharmacy. I am pleased that my right hon. Friend the Minister of State mentioned pharmacy in her opening speech. We need to maximise the use of all parts of the NHS, and pharmacy is an important part. Almost every community has a pharmacy at its centre; almost all high streets have a pharmacy. Pharmacies are already open for the extended hours that the Government want primary care to be available, and they already provide out-of-hours services. Pharmacists are well motivated and highly trained professionals who, to a large extent, know their patients. I believe that, with the right negotiations with the Royal Pharmaceutical Society, the Pharmaceutical Services Negotiating Committee and others, a good deal could be reached to ensure that pharmacists’ expertise and capacity are fully utilised for the benefit of patients.
I envisage pharmacists becoming far more involved in screening. They can take blood pressure and cholesterol measurements, recall people for follow-up as necessary, and work with local GPs and others to ensure that that capacity is best used. As part of the launch of the pharmacy White Paper, I urge my right hon. Friend to include pharmacy as much as possible in the new screening programme.
2.24 pm
Mr. Peter Bone (Wellingborough) (Con): It is a great pleasure to follow the hon. Member for Dartford (Dr. Stoate), whose colleague I am on the Select Committee on Health. I also welcome the Minister of State’s presence here today, because she has been most helpful in the past.
If my understanding is correct, preventive health services are right, first, because they improve people’s lives—earlier interventions ensure that they do not develop a serious condition, so their quality of life is enhanced. Secondly, preventive measures save money, because treating someone early saves the NHS from having to spend lots of money later on treating them as an acute patient. All right hon. and hon. Members are in favour of preventive health services, such as screening. The job of the Opposition is to prod the
Government and to keep prodding. We have to try to make the legislation that the Government produce more effective.
Today, I shall talk about something that affects people in every constituency in the country, but that has been a fairly acute problem in my area: the treatment of wet-eye age-related macular degeneration. Each year, the condition affects about 40 people in every constituency in the country, and it is the most common cause of blindness. The condition is treatable through a simple series of injections, which either stops the loss of sight that would end in blindness, or restores sight that has been lost. Several drugs are licensed for the purpose; the two most commonly used are Lucentis and Macugen.
It is fairly easy for a patient to recognise the symptoms—they are losing their sight—so they go to their GP, who immediately refers them to a consultant. The consultant sees the patient, then tells him, “You have wet-eye AMD. You could go blind within three months. The good news is that a simple series of injections will stop you going blind. The bad news is that you cannot have it on the NHS—but come and see me two miles down the road, and I’ll treat you at £800 per injection.” The NHS is saying to people that they can go blind, or they can go private and pay for treatment.
Suppose that someone had a bad knee, such that in several years’ time they would need a joint replacement. That would be bad enough. Obviously, it would not be cost-effective to wait; preventive treatment will ensure that that person can keep walking. However, we are talking about someone who will go blind within three months if immediate action is not taken, and the drugs are available. Something is wrong.
The Government have been extremely helpful, and there has been a cross-party campaign to get the problem sorted out. The Minister replied to my speech in my Westminster Hall debate on the issue, and was most helpful.
The Prime Minister has been extremely helpful, too. At Prime Minister’s questions, he rightly said—I paraphrase—that the situation was not right, but that it was a matter for NICE. Surprisingly, just two weeks after he said that, NICE came up with some guidance. The Royal National Institute of Blind People issued a press release immediately afterwards, entitled “NICE delivers early Christmas present to thousands at risk of going blind”. NICE said that primary care trusts should treat people who have wet age-related macular degeneration immediately with the new, approved drugs, Lucentis and Macugen. It put that guidance out to consultation.
NICE does not have a particularly good history on the issue. It introduced guidance last year that said, “We’ll only treat someone once they’ve gone blind in one eye,” which was wholly inappropriate. It generated the biggest response to any consultation by NICE; there was outrage. NICE took that on board, and the Government urged it to look again at the matter. As a result, it came out with the new guideline, which is wholly welcome.
I would probably not be giving this speech if that guideline was being implemented. My PCT, Northamptonshire Teaching primary care trust, knows
about the problem because of the campaign that I have run, which my excellent local newspaper, The Evening Telegraph, has supported, and because the BBC’s “Politics Show” highlighted one of the cases. However, the PCT sent me two letters—just to make sure that I got the message—and, obviously because I am not a very sensible MP, they put a sentence in bold and in capitals, so that I did not miss it. It says:
“NICE has not yet issued final guidance to the NHS on these drugs”.
The rest of the letter says that the PCT will not take any action, and will continue to let people in my constituency in Northamptonshire go blind until NICE eventually issues its final guidance. That is outrageous and there is no moral justification for it. We are talking about spending a few hundred pounds on action that will prevent people from going blind.
The amount that the NHS would have to pay for treatment for someone who goes blind is enormous. Also, what about all the social consequences? I have a constituent, Mrs. Doreen Marshall, a lovely lady in her 80s. She is the carer for her husband, who is in his 90s, and who has some disability problems. They live separately, and they are not a burden to the state. She is going blind in both eyes. If she had not paid to have the treatment privately, the state would have had to pay out millions of pounds over the next few years. It is preventive health services of that kind that the Government are keen for PCTs to take note of. Luckily for Mrs. Marshall, a private company paid her treatment bills. When the Minister winds up, I ask her to reiterate what the Prime Minister said on the subject: PCTs should take notice of what NICE has just said, and should, as a matter of urgency, start to treat people who would otherwise go blind.
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