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15 Oct 2008 : Column 319WH—continued
The European regulation of 2004 was agreed at the end of 2003. As is usual in European legislation, what emerged from debate in the Council was a political compromise. Industry stakeholders at the time were supportive of our approach and the concessions that we
negotiated. In particular, they were pleased that the introduction of the requirement to introduce electronic identification and the individual recording of sheep was delayed until the beginning of 2008. We also secured a derogation that enabled the UK and Ireland to continue to use our system of batch recording until the introduction of EID, while the rest of Europe had to double tag their sheep.
I acknowledge that some countries in Europe are not affected; none the less, those are the facts. Unfortunately—the hon. Member for Ceredigion alluded to the matter—we, but not Ireland, lost that derogation in 2007 due to repeated compliance issues identified by three consecutive Food and Veterinary Office missions. It is worth pointing out that those compliance issues, together with our difficulties in 2001, did not help our negotiating position on EID.
The legislation took effect in 2005, and it called upon the Commission to report to the Council by June 2006 on the implementation of EID, and especially on whether the implementation date needed to be changed. The report, when it emerged in November 2007, confirmed that further analysis would need to be made jointly with industry, particularly of the economic impact of the introduction of EID and individual recording.
With the active help of Administrations across the United Kingdom—I shall not speak for Wales, although I hope that Members representing Welsh constituencies will accept that DEFRA is working closely not only with the Welsh Assembly but with the Scottish Executive and the Northern Ireland Assembly—we submitted an evidence dossier to the Commission in order to influence its report. Although there were some disease control benefits, as my right hon. Friend the Secretary of State said, the cost of EID outweighed the benefits; and we identified ongoing concerns about the ability of EID to cope with our high-volume markets.
Armed with that evidence, we persuaded the Commission to propose delaying the introduction of EID, and at Council we secured a delay until the end of 2009. That has been welcomed. Officials, with the help of the industry, have worked closely with the Commission to identify and resolve the real practical difficulties that the UK sheep industry will face with EID and individual recording, some of which have been described today. As a result, we were successful in securing changes to the regulation that phases in the individual recording requirements. Those changes will allow industry further time to adapt to the new requirements, and they will reduce the record-keeping and form-filling burden, particularly for older non-electronically identified sheep.
There are benefits to EID, but I shall not extol its virtues as time is short. It is generally agreed that Great Britain would not have implemented it, as my right hon. Friend made clear. The costs outweigh the benefits.
Mark Williams: The comments of the Secretary of State, to which the Minister alluded at the start of her speech, are very welcome. How much analysis has been undertaken of the financial effect on the small family farms that many of us represent, and the bigger economic picture that affects the marts and abattoirs? I appreciate what she said about the technology, but what about the broader economic picture? It is fundamental to the rural community.
Jane Kennedy: That is a fair question. I assure the hon. Gentleman that a regulatory impact assessment was undertaken. He also asked about a figure of 18 per cent. If he will allow me, given my newness to the subject, I shall get proper answers and write to him and the other Members who have participated in the debate giving the details that he seeks.
The House may be interested to know that there is considerable activity in the European Parliament on EID. The chairman of the European Parliament agriculture committee, Neil Parish MEP, has been working closely with industry representatives, and there was a joint industry presentation at the EP regulatory committee on 7 October. However, the Commissioner has made it clear that the regulation will not be reviewed before implementation, notwithstanding the fact that my right hon. Friend has made it clear to Commissioner Vassiliou that he believes that the Commission should conduct the review that its report said was necessary. Unfortunately, the Commissioner believes that too many member states have already invested in the implementation of EID for there to be any support for a review in the short term.
As I said, I cannot speak for Wales, but we are working closely with the sheep industry to minimise the burdens that will be imposed by introducing EID. In particular, it is our intention whenever possible to make use of the derogations and flexibility provided for in the EU regulation, a factor alluded to by other speakers.
In the last few seconds left to me, I congratulate the hon. Member for Ceredigion on securing this debate. I assure him of the Government’s continued determination to assist sheep farmers to respond to what could have been a disastrous regulation. We have been working to ensure that it will be implemented in such a way that the benefits that we foresee can be maximised.
Refractory Angina
4.30 pm
Mr. George Howarth (Knowsley, North and Sefton, East) (Lab): Refractory Angina is a painful condition that affects up to 50,000 people in the UK, many of whom have had unnecessary treatment. At this point, I should like to express my gratitude to councillor Ken McGlashan, a colleague and friend of my hon. Friend the Member for Knowsley, South (Mr. O'Hara) and I, for drawing our attention to the problem, and to Professor Michael Chester, who has provided much of the briefing that I am making use of today.
Compared with a decade ago, much is known about how to treat the condition, yet because awareness of that knowledge is low, many patients live in unnecessary fear, and our health care system does not adequately cater for them. Improving care for refractory angina is important because it can make a direct improvement to patients’ lives. Greater knowledge and awareness can save unnecessary operations and improving care teaches us lessons on how to structure our health care system’s rewards and incentives.
Before I talk about the availability of treatment for the condition and the associated challenges, I should first explain the difference between stable and refractory angina. According to the British Heart Foundation, stable angina is an increasingly common condition and affects around 1.2 to 1.4 million people. Improvements in medicines, coupled with technological advances, have allowed more angina sufferers to be treated than ever before, which is welcome. However, inevitably, those approaches are certainly not universally effective, and a growing number of patients experience severe debilitating symptoms that do not respond to the measures available—in other words, refractory angina. Typically, refractory angina patients are frightened, confused and vulnerable. Most have previously undergone cardiac procedures that have afforded temporary relief of the symptoms, but which have failed after a period. Long-term recurrence of symptoms following bypass surgery and angioplasty is well known and although many patients undergo further procedures, that are not appropriate for a growing number of others. That is particularly true for elderly and infirm angina sufferers, for whom the risk of further surgery can outweigh the benefits.
Refractory angina is characterised by disabling symptoms of chest pain, breathlessness, significantly impaired function and poor quality of life—the last of those things applies both to the sufferer and their carers. Sufferers are often further burdened by misconceptions about the causes and implications of their chest pain, and many hold the incorrect belief that the symptoms of what is in fact usually a stable condition are warning signs of an imminent heart attack or even death.
How does the NHS respond to such patients? I should first say that the problem is not new. The March 2000 national service framework for stable angina recognised the existence of the problem of refractory angina, but set no targets. In 1999, Baroness Hayman, then a Health Minister, responding to calls for a national strategy to deal with the condition, stated:
“I do understand that refractory angina is a difficult and distressing problem...There is a growing recognition of the problem and the likelihood that the number of people who suffer from refractory angina will increase”.
We have a growing problem and, at the moment, no clear strategy to address it.
As Baroness Hayman predicted, the number of sufferers has increased. That is partly because when the number of revascularisation procedures rises, so does the number of patients whose symptoms return after a period of post-procedural remission, often within three years of the operation. Another reason is that we have an ageing population, and the elderly tend to want to avoid invasive procedures if possible. That is certainly understandable in the case of invasive coronary interventions such as percutaneous coronary intervention, which is also known as stents, for stable angina, because even small risks of a heart attack, stroke or death increase in significance when such procedures are performed only to relieve symptoms.
In 2002, the European Society of Cardiology, prompted by the work of the UK National Refractory Angina Centre, sponsored a special study group to investigate the problem of refractory angina. Based on its estimates, there could be as many as 50,000 sufferers in the UK. More recently, the respected Cheshire and Merseyside Cardiac Network and the North Wales Cardiac Network predicted that, in their regions, where there is a population of around 2 million, there will be 2,400 sufferers by 2017. If that estimate is correct, the NHS might expect to have 78,000 sufferers to cater for by the end of the decade.
I said that refractory angina is characterised by disabling symptoms of chest pain, breathlessness, significantly impaired function and, additionally, poor quality of life for sufferers. Often, sufferers have misconceptions about the causes and implications of their chest pains, and many believe that the symptoms are warning signs of imminent heart attack or death, so their ability to manage their condition and lead healthy lives is unnecessarily affected. Many sufferers dramatically reduce their levels of activity in the mistaken belief that that will reduce their risk of heart attack. In fact, on the contrary, in doing that, they increase the risk and, at the same time, their quality of life diminishes. People with refractory angina become frequent attendees at GP surgeries, undergo multiple emergency admissions to hospital and suffer exacerbated chest pain. Many patients and carers live in an unfounded perpetual fear of sudden death.
As well as the human cost, there are clear implications for the efficient use of precious health care resources. An audit in 1998 showed wide variations in refractory angina care practice. There is no doubt that, although dedicated health care professionals in different parts of the country provide what they honestly believe to be the best treatment available, patients are offered dramatically different management strategies depending on where they live.
Despite the growing number of patients with refractory angina, there is currently only one specialist centre available: the multi-award winning and internationally acclaimed NRAC in Liverpool, which has pioneered consumer-centred service design and delivery since 1996, is the only dedicated NHS specialist service for patients suffering from chronic refractory angina. Under the highly respected leadership of Professor Chester, the centre has received a number of prestigious NHS awards.
Last year, he won the highly prized Sunday Times and Henley business school customer experience leadership award.
In 2000, the then Prime Minister described NRAC as
“representing the very best of the NHS”.
The then Secretary of State for Health, my right hon. Friend the Member for Darlington (Mr. Milburn), stated:
“NRAC is leading modernisation in the NHS”,
and in 2003, the then chief executive of the NHS, Sir Nigel Crisp, stated:
“By putting the patient first and making a commitment to customer service, the centre has a vital role in modernising the NHS and making it fit for the 21st century”.
I draw attention to those accolades not to flatter the centre for its leadership, although it deserves immense credit, but to point out that in a national context of highly variable care quality, it is possible to deliver outstanding results and to have a real effect on people’s lives. Moreover, that leads to real and profound efficiency benefits. Published research and audits show that NRAC produces savings that substantially exceed costs by preventing unscheduled admissions and unnecessary palliative procedures. NRAC’s value for money has been endorsed by senior commissioners and Department of Health advisers.
This specialist patient-centred, cost-saving approach to refractory angina management developed at NRAC is available to fewer than 100 of the predicted 10,000 new patients who present with the condition each year. Despite repeated calls going back to 1998, there still appears to be no clear national strategy. It is vital that we have a proper appreciation of the growing scale of the problem to equip local NHS providers with the appropriate knowledge, skills and facilities to be able to respond effectively. There is an added challenge that the very definition of the condition—refractory meaning angina that has resisted treatment—signifies a failure of previous treatments. Perhaps that explains why professional representative organisations representing the cardiologists and surgeons have avoided dwelling on how to respond to the problem.
We need a number of approaches to help the health service address the condition more effectively. First, training should be considered. NRAC has a state of the art multi-professional training programme and has shown that health care professionals can be trained to deliver high-quality refractory angina care.
Secondly, we need to consider funding across the system as a whole. Primary care trusts continue to focus on high-cost palliative revascularisation targets, which were set by the national service frameworks nearly a decade ago, before the full impact of refractory angina was properly understood. It has been estimated that, of the £2.5 billion that will be spent on coronary revascularisation over the next decade, more than £1 billion will be on purely palliative procedures. Much of that will go to pay for expensive equipment brought in from abroad and could be saved if the simple out-patient education programme provided by refractory angina specialists was offered. The cost reductions are not clear, but some experts estimate that it could be as much as 90 per cent.
Thirdly, we need to consider funding for NRAC. Only yesterday, the centre received referrals from Leicester, Inverness, Birmingham and Blackburn. While NRAC
remains the only specialist centre in the country, it is vital that it has adequate resources for the care that it provides directly and also for the education of health care providers further afield so that patients do not have to travel so far for treatment.
Fourthly, we should look at rewarding outcomes. It is no secret that the Department is working on a large set of patient-reported outcome measures that will be published for consultation shortly. It is right that NHS provision should focus on quality, and the proposals are, therefore, welcome in principle. There are a number of detailed points that also need attention for them to work effectively for patients with refractory angina.
PROMs take as their starting point a treatment intervention, but as I have discussed earlier, there are many examples of patients with refractory angina undergoing unnecessary treatments. There is a gap in the process of giving consent. That needs to be quality assured so that we can be sure that patients understand all the issues before an “informed” decision can meaningfully be given. Ignorance of the alternatives is not consistent with valid consent. One solution would be to give patients a checklist of evidence-based alternatives to palliative surgery. At the very least, that would ensure that they have heard of them. It would also reduce medico-legal vulnerability by ensuring that patients were aware of the options before treatment began.
Mr. Edward O'Hara (Knowsley, South) (Lab): I congratulate my right hon. Friend on securing this important debate. I echo his words of commendation for councillor Ken McGlashan, NRAC and Professor Chester. Does he think that it would be useful for the Minister to give a commitment to meet Professor Chester to learn directly from his experience?
Mr. Howarth: I am grateful to my hon. Friend for intervening. It is a very helpful suggestion, and I hope that my hon. Friend the Minister will pick that up when she winds up the debate.
Finally, I will close by quoting from an NRAC patient, who wrote to me on learning of this debate. For the sake of 50,000 patients currently living with refractory angina, his experience eloquently sums up why we need to improve the service the NHS offers such patients. Kevin Mockler said:
“Like many patients who have successful bypass, my angina eventually returned. I am grateful for what was done originally but I felt that I had been ‘forgotten’ by the system and when I was finally seen in the standard cardiology clinic I was told that there was nothing more that they could do. You can imagine how demoralising it is to be told this, especially after hearing all the stories that imply modern advances have all the answers. Eventually I was referred to the National Refractory Angina Centre, who, for the first time, listened to what I had to say and took the time to make sure that I understood my condition. They have helped me enormously and there is no doubt that many more patients like me could benefit if the service was able to cope with the referrals. It amazes me that the NHS appears to have no long term plan to tackle refractory angina. NRAC knows the problem inside out and has been arguing for a systematic approach for years. I think the Health Department should sit down around a table with Mike and his team and work out what it is going to do.”
4.46 pm
The Parliamentary Under-Secretary of State for Health (Ann Keen):
May I say what a privilege it is to be with you, Ms Walley, during your chairmanship of this debate? I congratulate my right hon. Friend the Member
for Knowsley, North and Sefton, East (Mr. Howarth) on his success in the ballot and on taking the opportunity to bring to our attention the excellent services being provided in the north-west for patients with refractory angina.
Coronary heart disease is one of the biggest killers in this country. More than 1.4 million people suffer from angina and 110,000 people have heart attacks every year. A similar number of people die of heart problems in England every year. I am sure that my right hon. and hon. Friends congratulate the Prime Minister and the Department of Health on their screening initiative for cardiovascular disease, which will be rolled out this year for everyone between the ages of 40 and 75.
Since the launch of the national service framework for coronary heart disease in March 2000, we have taken huge steps forward in the detection, treatment and care of those with coronary heart disease and other cardiovascular conditions. Death rates from cardiovascular disease among people under the age of 75 are now down by 44 per cent. from the 1995 to 1997 baseline, saving nearly 33,000 lives in 2006 compared with 1996. We have met our target of reducing premature mortality from CHD, stroke and related conditions by at least 40 per cent, which, I am proud to say, is five years ahead of schedule. Rapid access chest pain clinics are now in operation in all acute trusts, giving diagnosis or the “all clear” to patients within two weeks, instead of the months they used to have to wait.
In emergency care, there has been steady improvement in the time it takes for heart attack patients to receive thrombolysis, which is a treatment with life-saving clot-busting drugs. In 2007-08, 71 per cent. of patients received thrombolysis within 60 minutes of calling for help, compared with 24 per cent. before the NSF was implemented. That exceeds the national target of 68 per cent.
Excellent progress has been made to reduce waiting times for heart patients. Since March 2005 no one has waited more than three months for heart surgery, and since the end of 2005, no one has waited more than six months for an angiograph. I congratulate the health service and its staff on the way in which they have dealt with that capacity and those numbers. We have saved the lives of people we know—families and neighbours—and people whom we will never know.
A £735 million capital programme is providing world-class facilities to treat patients with heart disease where those facilities are needed most. The programme has provided new and refurbished buildings, equipment and technology, including cardiothoracic centres. An additional 72 catheter laboratories have been provided, and 18 others have been replaced. Catheters that go into coronary arteries to look for blockages are an amazing technological advance.
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