Examination of Witnesses (Questions 823-839)
MR IVAN
LEWIS, MR
ALAN BELL
AND MR
JOHN BROMLEY
18 APRIL 2007
Q823Chairman: Good morning. Thank you
for coming. Could I welcome you, Under Secretary of State, and
also Mr Bell and Mr Bromley for coming today. I am Lady Finlay;
I am chairing this Sub-Committee on Allergy. This is being web
cast and we will be going round asking questions. There is a Members'
note of declared interests so we will not run through those prior
to any questions because it is all there and will be published.
Could I ask you if you would formally like to introduce yourselves
for the record, and then we will go into our questions?
Mr Lewis: Thank you very much Lady Finlay. I
am delighted to have the opportunity of appearing before the Select
Committee. I am Minister for Care Services in the Department of
Health. Essentially I have two sets of responsibilities: one is
for children's health and the other is adult social care. I think
we would all agree that allergies are a massively important issue
for the many, many families that are affected by them and it is
an issue which perhaps has not had sufficient priority or profile,
historically, but the impact that allergies can have on the entire
family is quite serious indeed. So I personally think we have
quite a long way to go in terms of, first of all, giving this
issue the priority status that perhaps it deserves, but also in
the way that we diagnose allergies and also obviously both health
and social care response to families experiencing this particular
condition. I will leave it at that in terms of opening remarks.
Q824 Chairman: Thank you. Mr Bell?
Mr Bell: Good morning, I am Alan Bell; we have
met before. I am at the Department of Health and I led the recent
review of allergy services by the Department.
Mr Bromley: My name is John Bromley. I am the
Head of National Service Reviews, so I look at all at the clinical
reviews in the Department of Health.
Q825 Chairman: Could I ask you the
first question and start off by asking you about the government
departments and how they work together. The Council for Science
and Technology Report on "Health Impacts—A Strategy
Across Government" recommended that the health agenda should
be considered across all government departments when developing
policies. Can you explain to us how you work with other departments,
particularly in relation to the needs of allergy patients and
how these needs are taken into account?
Mr Lewis: I think essentially, if the NHS is
to move from what it has been, effectively a sickness service,
to a health service, the reality check for all of us is that there
are a whole variety of factors which impact on people's health
and well-being, many of which are not within the controls solely
of the Department of Health, so it is absolutely essential that
we make a reality of the rhetoric around joined-up government.
Anybody who has been anywhere near government knows that it is
one of the more challenging tasks that we face because joined-up
working is not the same as sitting around the same table at Cabinet
Committees, frankly: it requires a far more integrated and profound
way of looking at different policy areas than that. I can give
a specific range of examples of how, relevant to this issue, we
are trying to work in a more corporate way. First of all, at ministerial
level, there is a Domestic Affairs Cabinet sub-committee on public
health. That is underpinned by a supportive structure at official
level of programme boards, including the Health Improvement Board.
So essentially you have a ministerial oversight of a number of
groups of officials working on specific programmes and policies.
In terms of our work with other government departments on a bilateral
basis, if you like, which is relevant to the focus of our discussion
today, we are working very closely with Defra on air quality issues.
Defra chairs an Air Quality Interdepartmental Group, which meets
every couple of months, and there is an Air Quality Forum which
brings together other stakeholders from outside of government
as well as the relevant government departments. In 2005 we issued
joint guidance with the DfES on Managing Medicines in Schools
and Early Years Settings, and that includes specific guidance
on anaphylaxis, which obviously is a welcome and important step
forward. We obviously have to work very closely with the Health
and Safety Executive to exchange information on occupational allergies,
and in terms of looking at our policies on indoor air quality
we did work closely with the Department for Communities and Local
Government and they also worked with us in terms of their proposals
for ventilation rates as part of the Building Regulations. In
terms of children and young people, obviously there is a Minister
for Children, which is a very, very important step forward. There
is the Every Child Matters strategy, which seeks, more than anything,
to demonstrate the case for the earliest conceivable intervention
with children and young people, whether it be through the NHS
or whether it be through the education system in formal childcare.
Certainly the Every Child Matters agenda seeks to bring all government
departments together to look holistically at the needs of children
and families, starting from the beginning of a woman's pregnancy
and all the way through to the beginning of primary school and
then beyond. So I think there have been advances in terms of interdepartmental
and cross-government working, but I personally think—not
just on this issue but on a whole range of issues—that if
the big picture challenge is to secure the health and well-being
of local populations it is no longer enough simply to regard that
as the responsibility of the Department of Health or Primary Care
Trusts at a local level; there really has to be a joined-up approach.
My own view is there needs to be a much closer relationship between
PCTs, local government and the voluntary sector in every community
and we need to move away from a woolly notion of partnership to
a more hard-edged notion of a genuinely integrated joined-up approach.
Q826 Chairman: Could you just explain
why allergy comes under your remit as care services? Is it just
because it has been lumped on you or is there a specific area
of activity?
Mr Lewis: I think I would be in serious trouble
if I described it as having had it lumped on me. As I said at
the beginning, my responsibilities are clear—they are children's
health and social care. If you looked at the other Ministers'
responsibilities it would not necessarily be simple to decide
where responsibility for allergies would belong in terms of any
one Minister's responsibility. I think it is a difficult call
to make, if I am frank, because it covers acute NHS care, primary
care, social care, and with kids it has relevance, so there is
a whole range of policy areas. I think it could sit with several
members of the ministerial teams—public health—so
why it is with me—and, as I say, I will not use the word
"lumped" on me—I am not totally certain.
Q827 Earl of Selborne: The Cooksey
Review has recommended that the Medical Research Council funding
and the National Health Service research funding be coordinated
through an Office for Strategic Coordination of Health Research.
Can you tell us how you would expect this to impact upon the level
and allocation of funding for allergy research?
Mr Lewis: Obviously we first of all have to
consider properly Cooksey's recommendations. The interim oversight
group for the Office for the Strategic Coordination of Health
Research was only established in January, and it is at the moment
discussing the detail of how the recommendations made by the Cooksey
Review will be taken forward. That Office for the Strategic Coordination
of Health Research will be working with UK health departments
and the Office of Science and Innovation to define our health
research strategy going forward, and that will include the strategic
direction for research into particular disease areas. To be very
frank with you, at this stage I cannot tell you the level of financial
commitment that will trigger over the next few years—as
much as anything else, as Members of the Committee will be aware,
the Comprehensive Spending Review deliberations are not concluded—so
in terms of being absolutely clear about the level of government
resource that will be available in this area at this stage it
is not possible for me to say that. Would I hope that, by having
the Cooksey recommendations and the new structure that will be
created as a consequence of Cooksey's recommendations, it will
lead to a higher priority being given to allergies and a clearer
focus? Clearly I believe that that will be the case but I cannot
give you a tangible commitment on how much additional resource
this may trigger.
Mr Bromley: One thing I would like to say is
that we in the Department spent quite a lot of time to try and
get the organisation up to speed as quickly as possible, so that
it could make a bid as part of the CSR 2007. So it has made a
bid and I think that bodes well for the future. Effectively it
is a question of timescale but we wanted to get the organisation
up and running so that it could do that.
Q828 Earl of Selborne: The case that
Sir David Cooksey made very persuasively, I felt, for bringing
together this Office for Strategic Coordination was the mismatch
between some of the basic work done very effectively by the Medical
Research Council and the inability to get this translated into
clinical research. Given that the MRC has funded such work as
molecular mechanisms of allergy, and at the other end of the spectrum
there is this great need to get this translated into clinical
research, where would you expect the emphasis to change if the
Office for Strategic Coordination gets into its stride?
Mr Lewis: I think we would want obviously better
coordination; we would want a clearer strategy going forward because
I think if you look at the history it has not been particularly
impressive and I think that is why Cooksey's report was so important.
So more focus, greater priority, clearer focus on the outcomes
we are seeking to achieve. I think the Committee will be aware
that £4.75 million has been allocated over five years to
the National Institute for Health Research, specifically to look
at allergy. I would hope that essentially it would lead to more
resource but a clearer focus on allergy as an issue in terms of
research in this country.
Mr Bell: If I may briefly add to that as well.
The Committee will be aware that one of the recommendations of
the Cooksey Review was to establish a Translational Medicine Board
to work jointly between the new National Institute for Health
Research and the Medical Research Council, to give a strategic
direction for translational research within the context of the
overall health research strategy. That is something that we certainly
propose to take forward once we have OSCHR itself up and running
properly.
Q829 Lord May of Oxford: My question
sort of relates to this but a particular aspect of it, in that
clinical allergy research often involves long-term prospective
studies that require funding over many years and a lot of it is
not in the elegantly precise, sexy imagery of molecular biology
where you can do nice, clean precise things. So there are two
kinds of tensions: one the long-term and one the fact that it
does not fit some people's image of what is the best kind of basic
research. When you couple that together with the disconnection
that the Cooksey report seeks to address between our excellence
in clinical research and perhaps in a global league table positioning
near the top in delivery of healthcare, I wanted to ask how do
you see the new arrangements affecting for the better funding
for these kinds of long-term prospective studies?
Mr Lewis: I think we would say that Best Research
for Best Health, which is obviously the new strategy, is all about
ensuring stability in terms of research funding. We think it also
opens up the possibility of sustained funding specifically for
high quality research proposals, epidemiological studies and clinical
trials. We think that that strategy offers a significant new opportunity.
I suppose an example of that is the resource that has been allocated
that I referred to earlier over the five-year period. There is
the NIHR, which also provides a key mechanism through which the
Department of Health will deliver the new research and development
strategy. So I think there is a framework now which gives us an
opportunity to create a longer-term, more stable approach, but
in the end we will be judged by the difference that that makes
and at this stage that new framework, that new strategy is at
a very early stage in its conception. I think we would say that
what has happened to date has not been satisfactory, has not always
been as good as it needs to be and that the health research strategy
that we have published will make a real difference in that respect.
Q830 Lord May of Oxford: More specifically,
the clinical research by its nature is linked to allergy services,
so precisely how will the OSCHR coordinate this kind of research
when the allergy services themselves are being commissioned locally
by individual Primary Health Care Trusts?
Mr Lewis: The link between practice and research
is obviously one you will be far more aware of than myself, but
it is absolutely clear. What we have is nine organisations now,
essentially Strategic Health Authorities, and the PCTs in every
locality are responsible to those Strategic Health Authorities,
and it would seem to me that there is an opportunity there in
terms of perhaps one of the Strategic Health Authorities taking
lead responsibility and being a conduit in terms of making sure
that in what is happening there is a link, there is a direct correlation
between research and practice at a local level. It would be a
nonsense to suggest—I am not sure how many Primary Care
Trusts there are these days—that there could be a realistic
or credible relationship at Primary Care Trust level and research,
but I think certainly Strategic Health Authorities, which are
organised on a regional basis, would also of course—and
maybe we ought to make more of this—have coterminosity with
Regional Development Agencies, which also obviously have a role
to play in terms of research. So I think that may be a model that
we need to explore as a Department and maybe one option, as I
say, would be to get one of the Strategic Health Authorities to
take lead responsibility.
Q831 Lord May of Oxford: One other
follow-up question, of a more technical kind too, is that it has
been suggested to us by some of the people we have talked with
that it would be extremely useful if there was a coordinated central
disease registry that held details, in so far as they are available,
of allergy patients' genotypes, phenotypes and responses to various
types of treatments as a unified and coordinated whole. What is
the Department's view on this?
Mr Lewis: My initial response to you is that
I do not have a view.
Q832 Lord May of Oxford: I would
have thought your initial response might be it would be a bloody
good idea!
Mr Lewis: I am not sure. You always have to
look at whether the infrastructure that we need to create to ensure
that we have that database—I do not think my official agrees
with you that it would be a bloody good idea, by the way, judging
by the note just passed to me! I am sorry, you are not supposed
to say words like that in such august surroundings! The reality
is that I will go away and reflect on that and consider whether
the benefits really do bring the added value that would be necessary
in terms of the cost in investing in the infrastructure. If the
cost brings real added value and real benefits then it is something
that we ought to look at, absolutely. But I think the case is
not proven.
Q833 Chairman: Does Mr Bell want
to comment in the light of this note?
Mr Bell: I think I had better now! I was simply
going to suggest, as I think the Minister has really, that this
is an issue that does come up quite frequently across a range
of diseases and it is always going to be a case of weighing the
benefits against the costs, which can be quite considerable.
Q834 Lord May of Oxford: There is
a huge comparative advantage we potentially have with the NHS,
which is not exploited nearly as effectively as many of us think
it could be.
Mr Lewis: Can I suggest, to help the Committee,
that we write specifically on that issue because that will mean
we will go away and give it some very serious thought?
Chairman: Thank you, because there are,
I think, 150 PCTs across the country, which is why this link between
research and translation in clinical practice becomes important.
Lord Haskel.
Q835 Lord Haskel: Could we turn to
the effect of allergy on the economy, and can you tell us what
steps you are taking with the Health and Safety Executive to know
the true number of people suffering from occupational allergic
disorders, and as well tell us about the types of jobs most commonly
affected? And can you deduce from that the cost to the nation's
economy?
Mr Lewis: A bit of a tall order, but we can
certainly talk through the work that we do with the Health and
Safety Executive. We exchange information on occupational allergies,
and we have joint membership of Committees and direct involvement
of NHS physicians in some of the Health and Safety Executive's
activities. The HSE uses a number of sources to obtain information
about the number of people suffering from occupational allergic
disorders and their jobs. I think those are outlined in the Memorandum
that we submitted to the Committee. There is a particular database,
which is The Health and Occupation Reporting network, which records
new cases of occupational allergic disease referred to consultant
level, and the details in that respect include the case's occupation,
the industry they work in and the suspected causative agent. I
believe that recently the Health and Safety Executive has also
commissioned an occupational health trained GP reporting theme
and the expectation is that that will provide additional data
and in particular—and I think this will help with evidence—certificated
sickness absence. The HSE, as Lord Haskel is probably aware, has
recently published a report on the costs, in their view, of asthma.
The Memorandum for the Committee included some specific examples
of how the Department and HSE work together—I am not going
to at this stage report those. What is the true cost? There is
no doubt that the cost burden of new cases falls most heavily
on the individual worker and society. The report that was published
estimates that total lifetime cost to society of new cases of
occupational asthma diagnosed in 2003 was ranging from around
£71.7 to £100.1 million, and if comparable numbers of
new cases were diagnosed in future years this would give rise
to additional streams of lifetime costs of similar magnitude.
So that is an attempt to respond.
Q836 Lord Haskel: Thank you. You
did refer to the database, and when we saw Professor Agius, who
runs The Health and Occupation Reporting network at Manchester,
he told us that he thought that this database was under threat.
Has the Department of Health discussed the importance of data
capture with the Health and Safety Executive and will funding
be guaranteed for this project, for this database in the future?
He was obviously concerned that funding was going to be cut off.
Mr Lewis: Lord Haskel will be well aware of
this kind of advice—it says it would be unhelpful for me
to comment. But of course my responsibilities to a Committee of
the House allow me to say that. As I understand it, there are
ongoing contractual negotiations, so the question is, is there
a question mark over this and the answer is yes—that is
the logical conclusion of there being contractual discussions
and contractual negotiations. So to be very frank with you, until
those are resolved we are not clear about what is going to happen
going forward, but that is the truth of the position.
Q837 Chairman: Could I just ask,
it would be helpful for us to have an update as well after this
session because it was on 10 January that we had evidence and
Professor Agius in that evidence commented that the funding had
finished at the end of the month and they are carrying out schemes
partly through reserves of funds and partly through charitable
support, and that was back in January. So if we could have that
in writing afterwards?
Mr Bromley: I will make sure you get an update
as quickly as possible.
Mr Lewis: This is the THOR scheme?
Q838 Chairman: Yes.
Mr Lewis: As I understand it, the funding is
2004 to 2008 and the option in terms of the contract that was
agreed was whether beyond 2008 we would go to 2012, so I would
be surprised if there was an immediate funding problem.
Q839 Chairman: It would be really
helpful then to have it clarified for the Committee.
Mr Bromley: We will write to you.
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