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The effect on women of being trafficked is absolutely devastating. A report by, among others, the London School of Hygiene and Tropical Medicine, concluded:

In that study on violence and injury during trafficking, 95 per cent of respondents reported physical or sexual violence, 90 per cent reported being sexually assaulted, 75 per cent reported being physically hurt, 36 per cent reported receiving threats to their family, and 77 per cent reported having no freedom of movement. Those who had a degree of freedom generally described being accompanied by minders to prevent their escape. To retain control over each woman, traffickers, madams or pimps create an unpredictable and unsafe environment to keep them continually on edge. Most of the women were also denied access to healthcare during their experience. Immediately following their release or escape, most of them are burdened with numerous and concurrent physical and mental health problems.

What is the extent of human trafficking? At least 12 million people are victims of forced labour worldwide. Of those, 2.4 million are in that situation as a result of human trafficking. Eight hundred thousand women, men and children are trafficked across international borders each year. That is one person trafficked every minute. Approximately 80 per cent of those trafficked are women and girls. Up to 50 per cent of them are minors. An estimated 1.2 million are children. The majority of these victims come from the poorest countries and the poorest strata of the national population. Trafficking is the fastest-growing means by which people are caught in the trap of slavery.

We have no reason to be complacent in this country, bearing in mind that, quite apart from trafficking, 10 per cent of children are sexually

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abused. In 1998, the Home Office estimated that several hundred people being trafficked per year were forced into prostitution. In 2003, the figure rose to 2,800 and, last year, it was 4,000. What is the Department of Health doing about these health problems?

12.27 pm

Lord Addington: My Lords, I thank the noble Lord, Lord Colwyn, who is my friend, for bringing this debate before us today. I want the House to consider another aspect of healthcare where the NHS is rather underperforming: sports medicine, or, to use the correct term, sports and exercise medicine. From doing a little research, I discovered that there are currently only three consultants working in the NHS in that field. It is reckoned that we need a number in the mid-30s to provide basic coverage. According to some doctors in the field to whom I have spoken, at the current rate of training, we will get about a dozen by 2012.

Those statistics mean nothing unless I explain why the issue is important. Sports and exercise medicine is probably what will enable us to maintain a drive for greater physical activity among our population. The Minister for Public Health and the Minister for Sport are so often seen together at events because we recognise that greater physical activity has huge health benefits across the board. Many conditions, including most forms of cancer, are much less likely if you are reasonably fit. As for how you measure that, I have indulged in attacking the body mass index in the past, so I will not go into that again, but I know that someone who is fitter is at much less health risk.

How do we keep someone healthy? We can tell them to go jogging 2.3 miles three times a week, to eat less, to live a virtuous and moral life and not to watch TV too often, but we will fail. We already have. If we get people interested in a competitive form of physical activity—sport—they have an incentive to keep themselves fit. They will not be bored by the process. If noble Lords want proof of this, they need only look at the exercise industry. The way in which most gyms make money is that we all join in January, turn up three times, and forget that they are there by February. The industry itself is pretty open about this, to be perfectly honest. We need a way of keeping people interested, but once we have got them interested—this applies much further down the socio-economic chain and probably in this Chamber, too—we must ensure that they can afford to be fit. By that I mean that people must know how to be fit and how to maintain fitness without fear of injury.

Many of my rugby-playing days were spent at a small club in Norwich. We lost players regularly because they could not afford to be injured. They clamber up and down a roof to do various jobs and cannot afford that knock on the ankle or the bang on the hand. They can no longer take the chance and miss two weeks’ work. As has already been mentioned, if you happen to be medically incapacitated and are on benefits, everything suffers. If we can get a better structure of support from the NHS, these people will be much

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more likely to carry on. They will also carry on if they receive better help to change their exercise patterns as they get older.

The main thrust of what I am trying to say is that the NHS does not seem to engage in this process of enabling people to maintain exercise in an environment that will encourage them to maintain it. Much of the current thinking about sports science derives from the huge amounts of activity in the private sector devoted to elite-level athletes, who are in effect of another species, both physically and behaviourally, so they are not really my concern here. The fact that Michael Owen may have to go abroad to get his knee dealt with may be an affront to the ego of certain specialists in the field, but it means absolutely nothing to the person who runs out on a Sunday-morning side to play soccer. My concern is about maintaining that sort of exercise.

We are not getting the support and knowledge within those medical professions at the front end. It is down to the NHS to maintain this support, but the structures are not there. People are still told to rest when they have an injury, but that will weaken muscles and shorten tendons, which means that they are more likely to be hurt when they go out again to play. Unless we start to address this by having greater levels of knowledge—this will start with pressure and information coming through from consultants—we will not be able to maintain people’s activity at the proper rates. The advantages of greater physical activity will dwindle, and no matter how much we pontificate and tell people to engage in it, there will come a point when they say, “How do I do it? Something has gone wrong with my life. How do I get back?”.

I have ignored the fact that it simply hurts to have an injury, and it will carry on hurting if it is not treated properly. But my main experience in talking to people doing various types of sport is that it is often the fear of losing income that stops them playing. If we can somehow address this, we will back up many of the other good schemes. The question that I really want to ask the Minister is—and I think that I will have to ask it again on other occasions, because it is a bigger subject than I initially thought—what is the Government’s thinking on bringing sports and exercise medicine much more into the mainframe of the NHS, particularly at the initial point of contact, the GP?

12.34 pm

Lord Crisp: My Lords, I too am grateful to the noble Lord, Lord Colwyn, and indeed to others, for laying out for us what patients are feeling and saying right now. It is their reality that is truly the starting point for our debate.

I am speaking, as I suspect many noble Lords will know, as someone who was privileged to be Permanent Secretary to the Department of Health and Chief Executive of the NHS in England for more than five years. Part of that privilege was the contact with the staff throughout the country and with the heart of the NHS. I note here the comments of the

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right reverend Prelate the Bishop of Worcester; I agree with him that paying attention to the heart as well as the mind matters.

Based on my experiences as Permanent Secretary and Chief Executive, I shall discuss some of the underlying issues that we are talking about today. Why are all major developed countries experiencing problems with their health systems? Why are costs rocketing? Why is affordability the key question in France, the USA and Germany, and why, in all those countries, are patients demanding more?

The first underlying issue, which I do not want to spend too much time on here, is that we are getting older. As we get older, we face more problems. We have more complex needs and tend to suffer from several problems at the same time—co-morbidities, in the language of the profession. But there are three other issues on which I want to spend more time. To my surprise, I have gained a deeper insight into them from spending the last six months looking at health in developing countries in which these issues are even starker and from which I will, on another occasion, argue that we have something to learn.

First, how can we afford the new technologies? Secondly, how can we turn the raised expectations of the public and the ever growing interest of people in health to good use in managing our health service? To put it another way, how can we as patients and citizens influence decision-making? Thirdly, how do we move upstream to concentrate on the causes of ill health and on keeping healthy rather than giving all our attention to dealing with problems of illness and disease? These are the three issues that we need to address if we are to make progress. I shall make a few comments on each of them.

We have in this country an exceptional biomedical research industry. I believe that 20 of the top 100 most prescribed drugs were developed here, and we are second only to the United States on most research measures. New medicines, new therapies and new technologies are developed every year, and every health system in the world agonises over how to pay for them and whether the sometimes small increments of benefit are worth while.

We have NICE—the National Institute for Health and Clinical Excellence—in England and Wales to help us to assess the effectiveness and cost-effectiveness of these innovations, and to make judgments with the involvement of patients. I am a fan of NICE. We need to evaluate new technologies, which are not all worth while, and NICE has developed some very rigorous methodologies to do this. I am not surprised that, while I was Permanent Secretary, it was the organisation from which most countries most wanted to learn.

I also feel, however, that the current situation is rather absurd. We want new medicines. We need them. I suspect that many of us in this House take aspirins, statins or some other drug regularly. We want to benefit from that science, but we are forced by circumstances to concentrate on putting up barriers to using them.



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The drug companies also have a problem. They need to spend millions on sales and marketing to recoup their development costs. In some cases, I believe that as much as 40 per cent of pharmaceutical companies’ costs are in marketing and sales. Carrying on as we are will mean a continuing escalation of tension between drug companies and payers and between patients and health systems worldwide, not only in the UK, and an escalation in costs.

There needs to be another way of looking at this—a way of getting alignment between the developers of technology and the payers, a way of ensuring that new research concentrates more on the things we as a society need and that involves more joint development of drugs between payers and researchers, a way of cutting out some of the marketing costs, and a way of achieving greater transparency over research assessments. Sir David Cooksey’s report, which was published yesterday by the Treasury, sets out a new way of creating this collaboration. I very much welcome it, and I hope that the Department of Health will be very much a part of that sort of development.

The second issue is in many ways similar and similarly paradoxical. As individuals, most of us spend a lot on our health—on healthy eating, diets, exercise, vitamin supplements and the like. We do take responsibility for our health, but as patients we are too often left feeling helpless, and as citizens we are left feeling disenfranchised. We have a population interested in health that is very often simply in opposition to the people who are, genuinely—I say this with feeling—trying to serve them. We need to break down that opposition and find a way of resolving the paradox that as individuals we take responsibility for ourselves but as citizens we are unable to. I suspect that of the three issues that I am briefly raising here, this is the most difficult.

The third issue is well known. Why cannot we spend more effort on promotion of health and prevention of disease and create a health system that is focused on early health and not on late disease? Here, there are some things that we could do more quickly. Over the past few years many people have put forward the idea that the NHS needs to be taken out of the Department of Health so that it can be managed in a more professional fashion. People are suggesting, for example, a sort of BBC arm’s-length five-year agreement between the NHS and the department. Most recently, the idea seems to have acquired some political impetus. Noble Lords will not be surprised to know that I have given it a lot of consideration, and indeed there are attractions. But it is not a simple matter. I have heard a number of over-simplistic ideas put forward. There needs to be very clear accountability for an organisation that, in a few years’ time, might spend £100 billion of taxpayers’ money.

What is often missed in that debate is that, just as the NHS might benefit from being free of the department, the department would benefit from being free of an over-riding requirement to concentrate on the NHS. A department “for” health could provide the focus we need to concentrate on health—early health—on cross-government approaches to health and ways of tackling the big killers, the diseases of

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affluence: obesity, inactivity and bad diet. I hope that the Government are considering those very difficult issues as well as how to give more freedom to both the NHS and the Department of Health.

I have set out in as many words as this short debate will allow the issues which I believe we should find more time to examine more often: how to harness research, how to build on people’s own interest in health and how to focus on health, not illness. These are absolutely critical in any debate on the current state of the NHS.

12.41 pm

Lord Parekh: My Lords, I, too, thank the noble Lord, Lord Colwyn, for initiating this very important debate. I would sum up my answer to his question about the state of health of the NHS in one sentence: it is undergoing some convulsions but its life is not in danger. The NHS has made considerable progress while the Labour Government have been in charge of it. If one looks at certain obvious statistics one sees that since 1997 we have gained 50 per cent more consultants, 35 per cent more clinical support staff, 35 per cent more hospital doctors and 34 per cent more GPs. But those are bare statistics. In a very important way there has been a profound cultural change in how the NHS has been constituted in the past few years. Patients feel that they are valued and at the centre of attention and they know their rights, and medical staff are aware that they are accountable to patients and to other bodies for what they do. Many of us who have been around for quite a while have been feeling these profound changes in the NHS. So while I compliment the Government on all that they have done, I want to highlight four or five important issues that worry me a little.

First, the results of the expenditure of resources do not seem commensurate with the amount spent. For example, GPs have been given very generous contracts—and I spend all my time among friends and relations who are GPs. On average, they earn about £100,000 to £125,000 a year, a figure which we professors simply envy. I do not begrudge them at all, but I think that in return for that one could expect that the range of services would be wider, the premises more efficient and the services offered to patients administratively more competent. I do not see those changes. And it seems the same with NHS trusts. They have been given a considerable amount of money and freedom to run their affairs but their administrative and management capacity, especially in matters financial, has not kept pace with the amount of responsibility they have been given. I do not know how much attention is being paid to ensuring that the people in charge are suitably trained.

Secondly, there are two conflicting considerations on the reorganisation of hospitals which are not easy to balance. It is right that the latest medical technology should be concentrated in a few centres, for obvious professional as well as financial reasons. It is also important that there should be supra-regional accident and emergency departments concentrated in certain places, and, pari passu with that, some should be

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downgraded. While that is necessary, it is also important to bear in mind that it conflicts with patients’ preferences and needs. Patients do not feel safe without access to an accident and emergency department that they can reach within a reasonable time. They also prefer to have babies in local maternity units. It causes anxiety to downgrade such facilities to a single midwife-led unit. We therefore have to find ways of balancing the need to concentrate medical and professional resources in certain regional centres with the need to provide local centres. The Government seem to think that smarter communication might solve the problem but I do not think that it is as simple as that. These two considerations have to be reconciled in the light of local circumstances. In taking such decisions, a great deal of attention should be paid to the views of patients, the public and doctors. They should be involved in taking decisions of this kind.

My third concern has to do with the independent sector treatment centres. I am not against the private finance initiative but I have some grave anxieties. In this case, they are poorly integrated into the NHS and do not train doctors in the same way as hospitals. There is too much reliance on foreign—in some cases, overseas—staff. We do not seem always to get value for money. These independent centres also enter into long-term contracts which are not easy to change. I would suggest that, although they are necessary to deal with the backlog, our overall strategy should be to concentrate on expanding NHS facilities rather than relying on centres of this kind.

Fourthly, as the noble Lord, Lord Crisp, said, rationing in one form or another is insuperable. But we must bear in mind that there is an unholy alliance of drug companies, populist media and some groups of politicians who seem to want to make sure, sometimes against the advice of NICE, that certain drugs that might not be recommended because they create a certain amount of popular scare should be widely available. NICE took a very firm stand on, for example, the flu drug Relenza and faced down Glaxo, which had threatened to leave the country. Decisions on rationing are inevitable. Rather than the Government leaving these decisions entirely to NICE, it is very important to involve medical staff who could explain why certain decisions have been taken.

Finally, noble Lords will expect me to say something about the important issue of the ethnic minorities. Their representation on NHS trusts falls far below their number in the country at large and their presence in the profession. How many chief executives are drawn from ethnic minorities? How many people from ethnic minorities are on NHS trust, foundation trust and PCT boards? I would like to know how many members of the NHS Appointments Commission are drawn from the ethnic minorities.

In many areas we are beginning to find that there are redundancies and the contracts of doctors and nurses are being terminated. People who have been in training for some time are being told that they may not be able to get jobs commensurate with their qualifications. Some of my close consultant friends tell me that the burden of redundancy is likely to fall disproportionately on ethnic minorities. I should like

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to be reassured by the Minister that that is not the case and that, should it happen, there will be enough provision to ensure that such decisions are countermanded.

I have full faith in the Minister and the Secretary of State for Health but suggest that the style of administration and the mode of decision-making they have inherited during the past 10 to 15 years need to be radically changed. The NHS is a Labour creation and something to which the party has been strongly committed. It would be a great pity if people felt that they could not trust the Government or the party with the safeguarding of the NHS.

12.50 pm

The Earl of Northesk: My Lords, like other noble Lords, I congratulate my noble friend Lord Colwyn on securing this important debate. Notwithstanding that it is a huge—some might say monstrous—subject, I intend to focus on the national programme for information technology.

At the outset I should make it plain that there are few more fervent adherents of IT than myself. To that extent, and irrespective of the raft of difficulties that have plagued the programme over the past few months, I accept without question that effective use of IT is an essential part of reform of the NHS and the future of healthcare in the UK. But what matters here is the “how”. At the heart of this is recognition that a required, even essential, outcome of reform is improved focus on the needs of the user—that is, the patient. Indeed, NHS Connecting for Health appears to accept this dictum. Its guide to the national programme states:

It adds: “Importantly”, patients,

That is all good and well. But a top-down system driven by centralised control and targeting—the Government’s current proposal—is antipathetic both philosophically and practically to the concept of giving patients more control of their health and treatment. Nowhere is this dichotomy more apparent than in the Government’s approach to the issue of confidentiality of patient data.


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