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21 May 2008 : Column 103WH—continued
Everything that I am about to say about hepatitis C is probably true also of hepatitis B, but, sadly, there is not even a strategy within the NHS to deal with HBV. The Hepatitis B Foundation, which is calling for such a strategy, told me that the Department of Health has not carried out any research to ascertain the figures for the disease, but it estimates that there are about 320,000 carriers of HBV in the UK at present, many of them in a chronic condition. Worldwide, 350 million people are
known to be chronically infected with HBV, and between 0.5 million and 1 million people die with the virus every year. It is second only to tobacco as a human carcinogen, causing 50 per cent. of all liver cancers. HBV can survive in dried blood for up to one week. It is 100 times more infectious than HIV, which may surprise people. Worldwide, the most common infection route is vertical transmission from mother to baby but, like HCV, HBV is a common disease among injecting drug users.
Fortunately, a vaccine is available for preventive treatment of HBV, but, sadly, the UK is one of the few countries in Europe that has not yet implemented the universal vaccination policy recommended by the World Health Organisation. In fact, 85 per cent. of countries throughout the world have already adopted it. There are reports that some doctors in general practice are charging as much as £160 for the vaccination—for a single HBV vaccination—probably in the belief that the patient will be reimbursed by their employer, which is not always the case. Fortunately, several drugs are available to treat HBV sufferers, but only about 1,500 patients are receiving such treatment in the UK annually.
The hepatitis C virus was identified in 1989. Such viruses are relatively new. HCV is the biggest cause of chronic liver disease in the world. It also damages kidneys, white blood cells and the thyroid gland.
Mike Penning (Hemel Hempstead) (Con): I am interested in the point the hon. Gentleman made about the virus being relatively new. In his expert opinion, is the virus a new one or is it that we have only recently discovered it using new techniques? Is it new, or has it always been there?
Dr. Iddon: I cannot answer the question exactly, but the virus would have been around prior to 1989. It was detected in 1989 and researched, and we are where we are today. I do not think that it has been around for a very long time. We are still discovering new hepatitis viruses, and they have been given letters of the alphabet from A to E. We may be up to G now.
HCV is an enveloped ribonucleic acid of the flaviviride family and is incredibly difficult to destroy. It is capable of surviving in dried blood for up to three months—much longer than HBV. It has a high mutation rate, and it is thought that six strains, each with 40 sub-strains, currently exist, which are capable of spontaneous mutation. That is the problem. For that reason, it has not been possible to develop a vaccine for preventive treatment of HCV.
The Hepatitis C Trust believes that as many as 500,000 people may be infected with HCV in the UK, with 90 per cent.—certainly 80 to 90 per cent.—of them being completely unaware that they are carrying the virus. An estimated 130 million people are affected by HCV worldwide.
The earlier a person is diagnosed with HCV, the easier it is to treat them. Treatments are more limited for HCV than they are for HBV. Treatment for HCV is carried out through combination therapy. The complete treatment programme, which combines a daily tablet of ribavarin with a weekly injection of alpha interferon, costs an amazing £15,000, and not everybody is cured. About 55 per cent. of the people who undergo the combination therapy will be cured. The rest will not, and they may or may not live longer.
People tell me that the combination therapy is not very nice. I have spoken to several people who have undergone it. It lasts between six months and a year, and most people cannot work while they are undergoing it.
The cost is £15,000 per year, but I put it to my hon. Friend the Minister that the cost of a liver transplant, even if a liver were available to transplant into the patient, is considerably more than preventing people from getting HCV in the first place or treating them when they have been infected by it.
Mrs. Ann Cryer (Keighley) (Lab): I am interested in my hon. Friend’s comparison of costs of transplants and so on. Would a person be healthier as a result of a transplant rather than the treatment? He said that the treatment was unpleasant, and that people are reluctant to have it.
While I am on the subject, would my hon. Friend support an assumption in favour of donation of organs after death? We do not seem to be progressing at all with receiving organ donations. I mention that because my second late husband, John Hammersley, died from liver cancer. I think that he would have been too old for organ donation, but it still grieves me to think that I was never asked whether my first late husband’s organs could be used. He died from injuries resulting from a motor car accident and was taken to hospital with me. We are lacking in this area. Will my hon. Friend explain his position on the matter?
Dr. Iddon: I know of the tragic loss of my hon. Friend’s second husband from liver cancer. Although as a chemist I have limited knowledge of medicine, I am in favour of opting out of organ donation, rather than opting into it. That is a controversial topic in this place. I have carried an organ donation card for decades and renewed it recently to ensure that my name is still on the list, although I am afraid that I am almost 68 and my organs are a bit knackered compared with those of a younger person, so they may not be useful any more.
In March 2001, the Department of Health commissioned a hepatitis C strategy for England, which was released for discussion in August 2002. I am pleased that the hepatitis C action plan for England was published in July 2004. The all-party group on hepatology, which was formed only in 2003—in the presence of the late George Best, who was one of our original patrons—and the Hepatitis C Trust became concerned about the implementation of the Government’s plans, so we jointly published “The Hepatitis C Scandal” in March 2005 to voice our concerns about that area of clinical practice.
On 23 May 2006, we published the results of a survey of primary care trusts and NHS hospital trusts. Questionnaires were sent to all of them, and as we received the answers we marked the implementation of the plan on a scale ranging from one to 10—one being poor and 10 being the best. About 63 per cent. of PCTs responded, but only 8 per cent. of them demonstrated effective implementation of the hepatitis C action plan laid down by the Government, with a further 56 per cent. demonstrating that they had taken some action and the remainder—36 per cent.—demonstrating only minimal implementation of the plan in 2006. Where a
patient lived at that time very much determined whether they received a diagnosis or, having received a diagnosis, treatment for hepatitis C virus infection. Indeed, our report was titled “A Matter of Chance”. In 2006, 65 per cent. of NHS hospital trusts responded, and 39 of the 85 hospital trusts reported significant delays for treatment. Waiting times varied from one week to one year, which is unacceptable.
Jointly, with the Hepatitis C Trust, our all-party group has just repeated that survey. Our current report, “Location, Location, Location”, was published on 14 February this year. About 84 per cent. of PCTs responded on this occasion. There has been a significant improvement since the last survey, but still only 36 per cent. of PCTs are implementing the hepatitis C action plan for England effectively this year. I am pleased to say that Bolton PCT—my own PCT—is one of the best, scoring nine out of 10 points. Unacceptably, 15 per cent. of the responding PCTs have demonstrated minimal or no implementation at all, while 49 per cent. demonstrated that they have taken some action. Mid Essex PCT scored no points, Dudley PCT and South West Essex PCT each scored one point, while Lincolnshire NHS Teaching PCT, Western Cheshire PCT and Newcastle PCT scored only three points. Those were the worst responders among the primary care trusts.
Some 59 per cent.—37 of the 63—of the NHS hospital trusts that responded reported that some of their patients had to wait more than three months for their first consultation at the hospital. In addition, they said that referral waiting times to see a consultant varied from three to 20 weeks and that patients waited a further two to 24 weeks for treatment to commence. Adding those figures together gives an unacceptably long period, which we need to reduce. Less than two thirds—62 per cent.—of responding NHS hospital trusts are confident that they will have the necessary infrastructure in place to ensure that all hepatitis C positive patients can start treatment within 18 weeks, which is the target for December 2008 set by the Government.
The Government’s action plan was launched more than three years ago and its limited implementation is putting a lot of people’s lives at risk, so we are calling for action now from the Secretary of State for Health in four ways. First, we want the introduction of a world-class commissioning pilot in the treatment of those diagnosed positive for HCV. Secondly, we want a good practice model developed for service organisation and delivery as part of a wider reform strategy for the diagnosis and treatment of HCV carriers. Thirdly, we want the Secretary of State to incentivise general practitioner HCV case-finding by inclusion in a quality and outcomes framework. Fourthly, we want the Government to conduct a national audit of GP practice for HCV, based on the model being piloted for cancer referral and diagnosis. Those campaigning on behalf of patients with hepatitis B virus want similar progress made by the Department of Health.
Consultants report that immigration brings in both HBV and HCV—their words, not mine—and they believe that we should be screening new arrivals who will be settling in Britain, not tourists I hasten to add, for both viruses, if not all the hepatitic viruses. Hepatitis B and C are ticking time bombs for the NHS, and in light of the evidence I have presented today, I think my hon. Friend the Minister will agree that we need to review both the
diagnosis and treatment of those who could be carrying those viruses. They are readily transmitted, blood-borne viruses, so the more people who carry HCV and HBV, the greater the risk of further transmission, with the inevitable consequences for the NHS.
Mrs. Cryer: In respect of what my hon. Friend said about increased immigration bringing in more of these diseases, is he aware that a few years ago it was drawn to my attention that members of the Muslim community were reluctant to donate organs, which meant greater difficulty in matching organ donors to organ recipients? I was asked by the then district health authority to do a bit of campaigning with my Muslim community to encourage organ donation. Is it still going on or has it been allowed to slip? There is something in the Muslim religion that is a deterrent to organ donation, but apparently it can be got around with a bit of thought and imagination.
Dr. Iddon: I thank my hon. Friend for raising that matter. It is a sensitive subject. I, too, have a large Muslim population in my constituency, as she knows. I have not personally discussed the matter with my Muslim constituents, but as it has been mentioned in the debate, I promise my hon. Friend that I will have such discussions. I am sure that the Minister and his officials have listened to what my hon. Friend has said. I hope that, in relation to what I have said already about organ donation, we can extend that conversation to the whole Muslim population throughout the country.
The prevalence of HBV and HCV and the mortality rate they both cause is now on the same scale as HIV/AIDS, tuberculosis and malaria worldwide, yet there is nowhere near the same level of awareness of viral hepatitis as of those other diseases. Additionally, there does not seem to be the political will to tackle it. A recent survey of Members of Parliament showed that one third of them think that there is a vaccine for hepatitis C when there is not, 44 per cent. do not know that hepatitis C can lead to cancer—yet it can—and half of them have been contacted by a constituent about hepatitis C. I am not blaming or criticising my right hon. or hon. Friends, but if that is the case among Members of Parliament, how can we expect our constituents to be aware of these dreadful diseases? I have also heard that many general practitioners are not fully educated in the facts I have presented to the House today.
In May 2004, a number of organisations associated with liver disease, including the British Liver Trust—a charity—and the British Association for the Study of the Liver published the “National Plan for Liver Services UK”, which I am sure that my hon. Friend the Minister or other Ministers in his Department have seen. They published the document in an attempt to persuade the Government to develop a national service framework for this major area of clinical practice. What consideration, if any, has the Minister’s Department given to that plan?
In conclusion, I hope that I have demonstrated to right hon. and hon. Members today and to people outside Parliament, including those in the medical profession, that tackling these diseases—liver diseases in general, but particularly the hepatitis diseases I have mentioned—needs to be done much more ferociously; otherwise the ticking time bomb that I have mentioned will explode upon us.
3.1 pm
Sandra Gidley (Romsey) (LD): I thank the hon. Member for Bolton, South-East (Dr. Iddon) for securing the debate. It is a shame that more hon. Members are not here to take part—I do not know whether that is because there are political imperatives elsewhere. The subject is important, but it is often neglected. We rarely hear people talking about liver disease of any type, so it will be interesting to explore some of the reasons for that.
The hon. Gentleman referred a number of times to the document “Hepatitis C: Action Plan For England”. I had a little bit of fun while preparing for the debate because I was aware that on 22 February 2007, the Government announced an update to the 2004 action plan. Much to my surprise I could not find that information on the Department of Health website. I asked my researcher to call the Department, which claimed not to have heard of the update. The Minister is looking in a rather worried way at his officials behind him; it would be interesting if he could clarify whether such a document exists. If it does—and I sincerely hope that is the case—does he share my concern that the document is apparently of such low priority that the officials we contacted were fairly clueless regarding its whereabouts?
As the hon. Member for Bolton, South-East said, the scale of liver disease is large. It is the fifth biggest killer in the UK, and the only one of the top five that is on the increase. More depressingly, the UK is the only major developed nation showing an upward trend in the number of deaths from liver disease. I do not know whether it is a help or a hindrance to read out some of the statistics, but I shall do so to reinforce the message about the scale of the problem. Up to 2 million people suffer from chronic liver disease in the UK, and most are unaware of their illness. In the past three decades, deaths from chronic liver disease have increased by eight times in men aged 35 to 44 years and seven times in women. In 2005, as many as 13,000 people died from liver-related conditions in the UK.
If those statistics related to any other illness, it would almost be a national scandal. I find it rather puzzling that relatively little attention is paid to the problem, particularly because it also relates to deprivation, which the Government claim that they want to tackle. I do not disbelieve that they want to deal with the problem, but it is worth considering that, in 2006-07, there were three times more liver-related deaths in the hospitals in the most deprived areas than in those in the least deprived areas. Among 25 to 49-year-olds, there were 10 times as many deaths in the most deprived areas as there were in the least. Therefore, when we consider some of the problems that spearhead primary care trusts are tackling, given obesity is one of the factors that can contribute to liver disease, it is important to get some of these messages across.
I shall concentrate most of my remarks on the more preventable aspects of liver disease. There are three main causes of the preventable type: alcohol, obesity and viral hepatitis. The hon. Gentleman rightly spent much time talking about hepatitis and the incidence of it. He was right to point out that, worldwide, the prevalence of hepatitis B and C in relation to mortality is on the same scale as HIV/AIDS, tuberculosis and malaria. Those working in the TB or malaria field feel that they play second fiddle to the HIV/AIDS debate,
but nobody ever mentions liver disease in the same context. There seems to be no political interest in the subject. I do not know whether that is because there is a lack of an effective lobby group or if it is because we do not see large-scale pictures on our TVs of people dying. Perhaps there is a stigma about liver disease, because it is often associated with alcohol abuse. Nevertheless, the issue is something that we need to tackle.
Patient groups have united as the World Hepatitis Alliance and are asking Governments to sign up to something called “12 asks” by 2012—[Interruption.]
Mr. Martyn Jones (in the Chair): Order. Would the hon. Lady like a moment to recover from her cough?
Sandra Gidley: Thank you, Mr. Jones. Governments are being asked to sign up to something called “12 asks” by 2012, to recognise the impact of the disease and to commit to adopting measures that address the problem from a public health perspective. The UK Government have not yet signed up. Will the Minister tell us when they are likely to do so?
Despite the action plan on hepatitis C, diagnosis is often delayed. A common problem is that GPs know little about the disease and are poor at diagnosing it. That is probably compounded by the fact that there is a lack of specialist nurses to deal with the condition. The hon. Member for Bolton, South-East mentioned the survey conducted by the all-party group. I will not go into the full details of that, but I am pleased to see that some progress is being made. The most telling fact is that two-thirds of primary care trusts are still falling short on some aspects of provision. Steps to improve hepatitis C prevention, diagnosis and treatment must be a higher priority if we are to tackle the problem successfully.
There are some quite simple things that we could do. None of them on its own will make the problem go away or reduce it dramatically, but they could be useful. One suggestion is that we could test in prisons, because 9 per cent. of prisoners test positive for hepatitis C and 8 per cent. test positive for hepatitis B. If those people can be treated or made aware of their condition, we may be able to do something to reduce future transmission.
The hon. Gentleman mentioned drug usage. Again, there seems to be little effort to work directly with drug users on testing to see whether something can be done. I acknowledge that this is a difficult group to work with, but there are people with expertise in working with drug users who could get the message across to some of them.
I wholeheartedly support the sentiments that have been expressed about increasing the number of organs for donation. I say that not only in relation to liver disease, although liver transplants are a classic example of a procedure that has been shown to work; recipients have gone on to have many years of happy and productive life. Yes, the subject is controversial, but the House has shown in recent days that it does not shy away from tackling difficult issues. Personally, I would prefer an opt-out system, but I appreciate that not everybody shares my view. The comments made about ethnic minority communities were very interesting, because we must work with all sectors of society if we are to benefit them.
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