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Mr. Field:
Although the time constraints are not quite what they otherwise would be, I nevertheless thank you, Madam Deputy Speaker, and my near neighbour, the hon. Member for Hackney, North and Stoke Newington (Ms Abbott). I agree with much that she has said so far, particularly about how the disease can almost seem like something out of the pages of bygone novels—although I recently read the autobiography of the former football commentator and journalist Brian Granville, who came from a relatively wealthy London family, but who suffered from the TB in the late 1940s. The hon. Lady said that hitherto the main concern was about immigrant groups in our part of central London, as well as in relatively poverty-stricken groups. Does she recognise that the increase in tuberculosis now poses a
threat to health more generally, rather than just within the most poverty-stricken groups to which she has referred?
Ms Abbott: There is no doubt that as TB is on the rise again, it will inevitably become a threat to the health of the general population unless we take the correct measures and give the right support in order to reach out to the groups in which it currently flourishes. TB is horrific whoever suffers from it, but it could again become a threat to the health of the general population.
Hackney faces a particular crisis. The most recent figures for Hackney show that we have 60 cases per 100,000 people, compared with 15 cases per 100,000 people nationally, and we have one of the highest rates in Europe. I became more familiar with the issues to do with TB partly through my general casework, which I am sure is also true for the hon. Gentleman, but also by dealing with a case that was brought to me by my constituent Andrew McCabe. I do not wish to detain the House, nor do I wish the Minister to answer questions about a specific case. However, I would like to read into the record the life and death of Philip McCabe.
Philip McCabe was a TB patient in Hackney who died on 6 February 2007, at the very early age of 36. Following an initial two weeks’ treatment, a failed discharge saw Philip sent home completely unsupported. He spent four days alone in a state of collapse, having suffered a seizure on the day of discharge. He was returned to Homerton hospital by ambulance, but accident and emergency staff refused to admit him. They sent him home, informing no other party—neither his GP nor their Homerton hospital colleagues who were treating him as a TB out-patient—of his return.
Personal and clinical contact was non-existent. Philip was left unsupported, and soon his medication—given to him as supervised consumption, through community directly observed treatment—was handed to him for an unspecified period. Untaken medication was later found when he died. Although Homerton hospital was aware of the problem, no action was taken, and it continues to claim, quite incredibly, that there was a 97 per cent. compliance rate. The patient was not monitored for the dangerous side-effects of TB medication, which can cause liver damage, especially when taken with alcohol. There was intermittent telephone contact, followed by a seven-week period of no contact because his TB nurse was on extended leave.
Philip developed liver failure, which was not noticed by Homerton hospital. This eventually led to his readmission, but only at the insistence of his GP. The hospital initially resisted. During this whole period of out-patient care, no liver function monitoring was undertaken. There were no weekly multidisciplinary meetings, and this led to some very serious prescribing errors. When his TB nurse eventually returned to work and realised that there had been a lack of contact, he phoned Philip’s pharmacist. Together, they decided that he needed immediate intervention. He arrived at Homerton hospital on 2 February 2007, and was kept in A and E for four hours. At the end of that time, the staff excluded him because of his demands.
The security guard who escorted him from the premises took pity on Philip, however. He was suicidal, distressed and clearly very ill. He had no keys to his flat and no money; he just had a large suitcase. The security guard
called Philip’s mother in Lancashire, and she rang and begged the hospital to readmit him. However, she was told that it could not do so, because he would have to re-register, so as not to extend the waiting time—for the sake of the records and the targets.
Despite the fact that Philip was excluded, there is no video of what happened in the accident and emergency unit. He did not receive medical intervention. He was transferred to a psychiatric ward in a neighbouring borough and became lost in the system. Having entered the mental hospital, he decided to discharge himself the following evening, as his physical health needs were not being met. Within two days, he was dead.
This is not an atypical story about a TB sufferer. Philip McCabe’s life was chaotic, and he presented with many of the issues that are prevalent in the populations that I described earlier. However, there is no question but that his final weeks were tragic, and his brother—my constituent—and others in his family are continuing to raise questions about his treatment.
Within weeks of his brother’s death, Andrew McCabe wrote to the director of public health with a number of issues, including the records of Philip’s directly observed therapy—the therapy that was supposedly observed by a pharmacist. He was worried about the calculation of the medication levels, about the lack of monitoring, and about the lack of personal contact between the TB team at Homerton and the out-patients department there. He was also worried about the policy of excluding people from TB treatment on an ad hoc basis, about the lack of communication between departments, and about the use of prescriptions.
As well as raising those specific questions about the treatment of his brother, Andrew McCabe raised more general questions about policy and practice in relation to TB in Hackney. He also asked, not unreasonably, if he could sit in on Hackney’s TB strategy group. He pursued these questions over many months, and finally, on 21 November last year, the Healthcare Commission wrote back to him to tell him that it was upholding his complaints. It would be useful if I could read some of the things that the commission said in its comprehensive report.
The commission pointed out the failings in the way in which the primary care trust had dealt with Andrew McCabe’s complaints. It said specifically:
“Mr McCabe has, in essence, raised several questions regarding the basis of the commissioning contracts and obligations between the PCT and Homerton University Hospital NHS Foundation Trust. He has also questioned how the PCT monitors the quality of the services provided by the Hospital. In my opinion, these are legitimate questions, which the PCT have failed to answer in a timely and sufficiently detailed way.”
“In my opinion, the PCT were incorrect in not answering the complaint”
until another complaint had been reported.
The Healthcare Commission continued:
“By effectively putting on hold its commissioning responsibilities and obligations for the duration of”
“I consider that the PCT failed to address your concern either appropriately or with due urgency. Furthermore, any delays in the receipt of appropriate clinical advice...should not have been used by the PCT as a means of further avoiding its role and responsibility...The PCT needs to review the way in which it
answers such justified commissioning questions and how it monitors the standards of its commissioned services. The PCT need to provide Mr McCabe with a clear and detailed account of its commissioning performance indicators and compliance reports.”
The Healthcare Commission, then, was not satisfied with the PCT’s policy in refusing to allow Mr. McCabe to sit in—not to be a voting member, but just to sit in—on the TB strategy working group.
The Healthcare Commission was similarly critical of the strategic health authority’s response to Mr. McCabe’s complaints. The commissioner said that he was
“satisfied that the SHA did not reasonably or appropriately respond to the concerns which you had brought to their attention.”
It seems to me that this represents quite comprehensive criticism not necessarily of the treatment of Mr. McCabe’s brother, but certainly of the treatment of Andrew McCabe’s complaint.
I got involved in this case quite soon after Philip McCabe died. I wrote on 20 February 2008 to the chief executive of the PCT about the points that Philip’s brother had made to me. I will not detain the House with all the letters that went backwards and forwards, with the holding replies, or with the months of delay between one letter from the PCT and the next. However, the inordinate delay from February 2008 to the end of 2008 finally culminated in a meeting between myself, Jacqui Harvey, the chief executive of the City and Hackney PCT, and Dr. Lesley Mountford, the director of public health.
I do not wish to be unduly critical of these ladies, who have no doubt devoted their lives to public service, but I was mildly surprised that after 10 months of correspondence with me about their treatment of Andrew McCabe and about their policies and procedures relating to tuberculosis generally, they seemed to have so little grasp of the facts and issues involved. Jacqui Harvey told me things during the course of the conversation that seemed to me improbable. She claimed that they were absolutely confident that they could track every TB sufferer in Hackney, because of comprehensive port-of-entry screening for TB.
I travel in and out of the country fairly regularly and I do not see people being screened for TB, so it seemed improbable that it was happening, even with airlines from countries where TB is much more prevalent than it is here. Of course, when I wrote to the Home Office I found out that we do not have comprehensive port-of-entry screening. I cannot understand why, 10 months after I started writing to them, the chief executive of the PCT and the director of public health should try to say something different. They claimed to be training housing officers, people in social services and so forth. I wrote to housing and social services about the training provided for identifying TB sufferers, but I have yet to receive a reply.
It seems to me that after spending 10 months sending me a series of holding replies, the chief executive, Jacqui Harvey, and the director of public health, Dr. Lesley Mountford, thought that they could have a holding conversation with me—without addressing any specific concerns. To add insult to injury, when I raised the question of Mr. McCabe attending the TB strategy group just as an observer, Jacqui Harvey accused me of trying to rush her into a decision. I cannot believe that after 10 months of letters, anyone could describe that as “rushing” someone into a decision.
At the beginning of this year, I went to Dr. Figueroa, a public health consultant who chairs the TB strategy group. He spoke very passionately about removing the stigma in relation to TB. I share his concern. However, he was less able to answer the detailed questions that I asked about the way in which directly observed therapy was managed, about record-keeping, and about the response of the PCT to the Healthcare Commission’s report. It is hard to escape the conclusion that, certainly in relation to this issue and perhaps in relation to others, the PCT is presiding over a culture which, although it may pay lip service to public engagement, does not genuinely welcome it.
One of the things that concern me about the correspondence and meetings that I have had with the PCT is the fact that it says that it cannot audit the services that the provider, Homerton hospital, is offering TB patients. Apparently, that is because of the nature of the contract between the PCT and the hospital. If PCTs are contracting such important services in a way that prevents those services from being audited, there must be something wrong with the contracting process.
I am also concerned about the possibility that the Health in Hackney scrutiny commission is not taking TB as seriously as it should. Only three days ago, members of the commission chose to vote against including TB in the Health in Hackney work programme for the following year.
I am concerned about the way in which my constituent was treated. There are unresolved concerns about the sort of health care that his brother received. However, I do not want to end my speech without paying tribute to extraordinary work done at the grass roots by the TB outreach team in Hackney. When I leave the House this evening I shall visit a night shelter in Stoke Newington, in my constituency, to see the population of homeless people and sex workers whom the outreach team—which I believe is under-resourced—attempt to treat and support. We need more outreach teams and a more comprehensive approach. However, having met the persons involved, I want to pay tribute to their dedication and commitment.
It seems to me—and the Healthcare Commission confirms this—that the PCT has not dealt properly with the complaints made by my constituent Mr. McCabe. There is more to be done in engaging the public. Why should it take a year to decide whether someone—an informed, educated person whose experience of TB comes from being his brother’s carer—should be allowed to attend some meetings as an observer? Why should the PCT complain, 10 months after the issue was raised, that it is being rushed?
More generally, let me say this. We know that some of the populations in which levels of TB are rising are difficult to reach—for instance, drug users, sex workers and the street homeless—but I also know that many of the failed asylum seekers and would-be economic migrants who have come to this country are particularly hard to reach because they do not want to engage with the authorities. Many of them do not have a GP. The notion that GPs can identify TB among many of my constituents is unrealistic, given the demographics of my constituency. Rightly or wrongly, the Government have pursued policies in relation to illegal migrants and failed asylum seekers that are designed to make their
situation so difficult that they will return to their countries. Tragically, however, many are not doing so, and they are forming a population of super-socially excluded people who, as I have said, are particularly hard to reach.
I am concerned about the absolute level of TB in Hackney. It may well be that, according to some measures, Hackney is doing better work in relation to TB than other areas, but that does not mean that it is doing well enough. I am concerned about this rising public health threat, especially as the marginalised status of many of the sufferers—be they street homeless, people with substance abuse problems or failed asylum seekers—means not just that they are difficult to reach, but that it is not possible to apply as much political pressure and to tug as strongly at the heartstrings of the nation as it is on behalf of other groups who are subject to other ailments.
The battle against TB was a success story, but TB is on the rise again. It is especially on the rise in inner-city areas of London and in other conurbations. Good work is being done, but more needs to be done. In particular, PCTs need to do more in engaging and involving the public and must not set up unnecessary barriers, especially those PCTs with populations who tend to find it hard to engage with the authorities in the first place.
I am very sorry that all this time later, my constituent, Andrew McCabe, is still trying to get answers to questions, but I am glad that two years after Philip McCabe died—so sadly and so alone—I am able to raise the issues his death highlights on the Floor of the House.
4.16 pm
Mr. Mark Field (Cities of London and Westminster) (Con): I will not detain the House for long, and I appreciate that the great bulk of the comments of the hon. Member for Hackney, North and Stoke Newington (Ms Abbott) concerned a particular constituency case. As I am sure she and the Minister are aware from the title of the primary care trust under discussion, it covers a small part of my constituency in the City of London, where we have Barts hospital and a thriving and growing residential population. Most of my constituents are based in Westminster and look to St. Mary’s, Paddington as their local hospital, and others of them look east to the London hospital, but the Homerton plays an important part for those of my constituents who live in the City of London.
To be fair, some of the concerns and problems in my constituency are on a much smaller scale than those in the hon. Lady’s, but an increasingly large street-sleeping homeless population has become a growing problem in particular. Tremendous and positive strides forward had been taken on that, but it has become more of a problem over the past year or so, and I fear that it will continue to be so.
Ms Abbott: Does the hon. Gentleman agree that one current problem is the numbers of eastern Europeans among the street homeless? With the collapse in the economy and their not being able to access public funds—I am not disputing that—there is a very worrying rise in their numbers among the street homeless, and there are simply not the resources to deal with them.
Mr. Field:
I entirely agree. Another feature worth mentioning is that a considerable number of street sleepers in the City of London are employed. They are people who have come to this country to find work, and
who find it so expensive to get any housing that they utilise the open spaces in the City of London. The hon. Lady is right that there has been such a rise in the five years since the 10 new nations joined the European Union, and particularly around the Victoria area, given the importance of the Catholic cathedral in Westminster to much of the population concerned.
I hope that the Minister will make a few general points, as well as respond to the specific points in the hon. Lady’s speech, and that she touches on some of the issues to do with screening of the migrant population in particular risk areas. The hon. Lady referred to the port-of-entry screening. I entirely agree that much of this problem is in every sense beneath the surface in that, as she pointed out, a significant number of illegal immigrants do not register with GPs and play no part with any officialdom. Given the concern about general health—I would be interested to know the answer to this, because I am not an expert on tuberculosis—what advice is the Minister getting from public health experts about the precise nature of this threat? Is there a real threat to the population at large?
With that in mind, what steps are being taken to ensure that there is proper port-of-entry screening for migrants coming from specific target countries where there is much risk, and that more care is taken of street sleepers? Are we ensuring that where there is any risk of TB starting in that population, proper public health steps are being taken? I appreciate that it is important that we do not get hysterical and make a big fuss, but those of us who represent inner-city areas recognise that the sheer hyper-diversity and hyper-mobility of the population makes not just TB but other diseases a real concern.
Ms Abbott: The hon. Gentleman mentioned port-of-entry screening. There seems to be an opinion among the professionals that comprehensive port-of-entry screening would not be practical and would increase the stigma. My argument is simply that people should not say that there is port-of-entry screening if there is not. If it is seen not to be effective and to have too much stigma attached, let us not do it. It is misleading to pretend that we have some port-of-entry screening when we do not.
Mr. Field:
I thank the hon. Lady for her intervention; she obviously has become more acquainted with the nuts and bolts of this issue than perhaps I have had reason to do hitherto. We do not wish to become hysterical about this, but great and increasing mobility is part of what it is to represent our large city. I suspect that even in Bristol—the Minister must have found this in her constituency—there is an increased amount of mobility and great diversity in the population. I hope that she will be able to touch on some of these strategic issues, as well as deal with the specifics raised in the contribution made by the hon. Member for Hackney, North and Stoke Newington. Stigma is not an issue of which I, for one, have become especially aware. The hon. Lady rightly pointed out that TB was so widespread at some times that no great stigma was attached to it; it applied throughout all areas of the population. The single most important thing for us to do, on behalf of all our constituents, is to give our level best to ensure that a public health problem that we thought had been
consigned to history remains just that and does not become a major problem in the years and decades ahead.
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