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Last year, as we heard from my noble friend, your Lordships’ Science and Technology Committee reported on the topic of allergy. Its approach to the subject was a general one but it made a number of recommendations on issues that directly relate to asthma. One was that there should be at least one allergy centre led by a full-time allergy specialist in each strategic health authority. It would be the job of the allergy centre to diagnose a patient’s allergy and to develop a treatment plan. Once that had happened, the patient’s condition would be managed back in the primary care setting. In reply, the Government promised to consider establishing a lead SHA and, in August this year, the north-west was approved as the first SHA to have an allergy centre. That is good news, but will the Minister confirm that, provided that the centre proves its worth, we can expect more of the same in other parts of the country?
A number of the public health messages on asthma have a marked similarity to those on obesity. Of course, it is not uncommon for the two conditions to coexist in one individual. Taking exercise and eating plenty of fruit and vegetables both improve lung function. Smoking is a universally bad thing to do if you are asthmatic and if there are others in your house who suffer from asthma, especially children. For me, this is one of the big arguments in favour of banning smoking in public places. Smoking in the presence of a child or while pregnant increases the chances of the child developing asthma. The same applies to stress during pregnancy and allowing children to swim in chlorinated swimming pools. There is some tentative evidence that children should not be given paracetamol in the first year of life; it has been associated with a 46 per cent increase in the risk of asthma symptoms at age six to seven. We should be hearing more of those kinds of public health messages coming from the NHS. It should not only be Asthma UK that is left to promulgate them.
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There can be some serious asthma hazards in the workplace. A whole range of respiratory sensitisers that can trigger asthma are found in a number of working environments. The Health and Safety Executive has been active in promoting good practice in factories and other places of work but, as my noble friend said, the key to the successful management of asthma, as with any chronic condition, is the informed patient.
I read an article in the Lancet the other day that set out three unanswered questions about asthma. What is asthma? Who gets asthma and why? Which factors enable us to predict how badly you will get asthma and how you will react to treatment? Those questions are more or less the only ones that matter. Beyond a certain very basic point, we do not know the answers. A good deal of research is going on in the UK and internationally to try to get closer to those issues, but we surely need to do more. We are still a long way from being able to prevent asthma and just as far away from being able to cure it. How can we better identify patients at an early stage who are at risk of a disease progression? On some of the specifics, can we do a randomised controlled trial to test the hypothesis of a link between paracetamol and asthma, or between eating nuts during pregnancy and giving birth to a child who becomes asthmatic? Can any sort of finger be pointed at domestic cleaning products?
I wonder, incidentally, whether the Minister has seen recent reports in the press that appear to cast suspicion on the triple inoculation against diphtheria, tetanus and whooping cough as being a trigger for childhood asthma. It appears that researchers at the Manitoba Institute of Child Health found that, if the initial dose of the jab is delayed to when a child is at least four months old, the chance of the child developing asthma by the age of seven is less than half what it would be otherwise. That is a pretty dramatic finding. It would be helpful if the Minister could say whether the department is looking at it. The UK has the highest prevalence of asthma in children aged 13 and 14 in the world. We need to establish why that is. If the DTP inoculation looks as though it might be a contributory factor, I suggest that we need to confront the data head on.
In general, progress in understanding asthma and how it works is slow. We cannot, and should not, be satisfied with that against the backdrop of facts and figures that the noble Viscount has cited. I hope that the Minister’s reply will give us a sense of how importantly asthma is taken by the Government, in terms of service delivery as well as research, and that we can leave this debate with at least some measure of encouragement.
3.41 pm
Baroness Thornton: I am grateful to my noble friend Lord Simon for securing today’s debate on this important condition. He knows that I have great admiration for his contribution to your Lordships’ House and particularly for the way in which he manages a difficult condition. A lesser man might regard it as a reason for taking it easy, but not my noble friend. As he pointed out—and demonstrated—asthma is a common condition, but no less serious for that. It affects the day-to-day choices of those who suffer from it and, by association, their families.
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I am pleased to report that the prevalence of asthma has started to plateau, after decades of increase. There has been a fall in death rates and hospitalisations due to asthma, although clearly, as many noble Lords, including the noble Earl, pointed out, there is a great deal more to do. We want to ensure that the improvements that have led to that situation continue.
A lot of the credit for this must go to healthcare professionals for implementing and working to evidence-based guidelines and to organisations such as Asthma UK and the British Lung Foundation for working as true partners of the NHS by providing information and tools to help people better to manage their condition, as mentioned by several noble Lords. We are supporting improvements in understanding asthma, its causes and how it should be treated by investing in research, as the noble Earl mentioned. He rightly listed the obvious questions. For example, we have invested £4.75 million over five years in the Biomedical Research Centre at Guy’s and St Thomas’s to work on a range of aspects of asthma, including treatment for chronic asthma and prevention.
Research by the National Primary Care Research and Development Centre in November 2006 found that GPs in the UK are leading the world in the efficient management of chronic disease, the use of information technology and the uptake of financial incentives to improve the quality of services.
The Quality and Outcomes Framework for primary care has certainly helped to drive up performance in asthma care. Asthma UK’s independent review, to which several noble Lords have referred, has shown the dramatic impact of good-performing primary care practices on reducing hospital admissions and deaths. We are keen that those lessons should be learnt and that those practices should become more widespread.
A number of new developments will have an impact on the provision of services to people with asthma. I say to the noble Baroness, Lady Tonge, that the Department of Health has been leading the development of a breathlessness pathway for primary care trusts. Its main purpose is to set out the commissioning requirements for primary assessment of the patient through specialist and sub-specialist care, inclusive of diagnostic investigations, treatment interventions and follow-up arrangements for improving the care of people with breathlessness resulting from obstructive lung disease, including asthma. We hope to publish the pathway before the end of the year. I think that that is health service code for what the noble Baroness was referring to as regards patients needing to have a personal pathway available to them.
Baroness Tonge: How will PCTs be assessed on how they implement those pathways in their areas?
Baroness Thornton: I hope that I will come to that. We have also been developing a national strategy to improve the care and management of chronic obstructive pulmonary disease. We aim to publish this early next year. The strategy will include raising awareness of good lung health, accurate and early diagnosis, the proactive management of patients and the development of respiratory networks at both the national and the local levels. As we develop the strategy, we will be keen
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The other key to the management of asthma is appropriate support for those in the community. This approach to the management of all long-term conditions was reaffirmed in High Quality Care for All, the recent review of the NHS carried out by my noble friend Lord Darzi. The review makes a commitment to ensure that practitioners have the necessary skills to provide effective care. For those professionals working in the field of asthma, this will build on the excellent programmes run for many years by the National Respiratory Training Centre. High Quality Care for All also sets out ambitious plans to offer personalised care plans to everyone with a long-term condition and to drive improvements in both primary and community-based services. These ambitions have been reflected in local plans developed in every strategic health authority in England.
We think that the best way for service providers to achieve the proactive management of long-term conditions such as asthma is through personalised, tailored packages of care with more regular review. To support this, we have developed disease management information toolkits to inform decision-making at both the regional and the local levels. The use of the toolkits helps to build up intelligence across health and social care by providing key data and guidance for every primary care trust in England. The toolkits support decision-makers, commissioners and front-line providers in gaining a better understanding of those long-term conditions that are having the greatest impact on local health populations in terms of the use of emergency day beds and other healthcare resources.
We know that self-care is absolutely vital, as several noble Lords said. Asthma was one of the first conditions to be included in the NHS Choices series of guides. The guides focus on advice about lifestyle, information about conditions and the treatments for them, and advice and support on living with a condition. In addition, we are making further investment in the Expert Patients programme to increase the capacity of course places available to offer patients from 12,000 to 100,000 a year by 2012.
On the specific questions raised by noble Lords, the noble Viscount, Lord Simon, and the noble Baroness, Lady Tonge, both mentioned the importance of dealing with children with asthma. In September 2004, the National Service Framework for Children, Young People and Maternity Services publication included an exemplar patient journey on asthma, which I know Asthma UK has made a priority. I did some work with this organisation many years ago and indeed we were addressing the issue when I was talking to its representatives about how to get this into the hands of every teacher in the country. I am glad to see that progress has been made, because the patient journey on asthma in childhood exemplar forms part of the framework and its implementation is key.
The noble Baroness, Lady Tonge, the noble Viscount, Lord Simon, and others mentioned a national framework.
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The noble Lord, Lord Colwyn, and others raised the issue of health professionals being trained in the treatment of asthma. We will introduce modularised—a terrible word—accredited training packages and we will strengthen educational governance to ensure that all clinical staff have the opportunity to develop their skills throughout their careers. We regard asthma and chronic conditions as an important part of that.
The noble Lord, Lord Colwyn, and the noble Earl, Lord Howe, both mentioned allergies and allergic disease. The research at Guy’s and St Thomas’s will focus on a prevention that includes allergic aspects. Diagnostic investigation to support that focus, including allergic aspects, is outlined in the 18-week breathlessness pathway, which includes specialist bronchial challenge tests and a pathway test for immune function. The north-west SHA is taking forward this work in looking at improving allergy services, as has been mentioned.
The noble Lord, Lord Colwyn, asked how we record asthma admissions to make it easier to monitor them. We record asthma admissions and finished consultant episodes associated with asthma in the hospital episode statistics, which are provided at all levels. The noble Baroness, Lady Tonge, mentioned the training of nurses in the community. In addition to the proposals outlined in A High Quality Workforce for all health professionals, Modernising Nursing Careers focuses on developing fit-for-purpose education on long-term conditions.
I shall deal with the other questions in writing, as I am conscious that my time is nearly up. Should we be worried about inoculating young babies with the DTP vaccine? We urge parents not to leave their children vulnerable to those serious illnesses because of an unproven claim that there is an extra risk. There is no substantive evidence, as far as the department is concerned, that the DTP inoculation puts babies at greater risk of asthma.
I say to the noble Baroness, Lady Tonge, that an assessment will need to be designed by the Care Quality Commission as part of the development of the independent performance assessment of providers and the effectiveness of PCT commissioning. We are quite familiar with that, as I recall.
I thank noble Lords for the many points that they have raised. There is no doubt that long-term conditions such as asthma present a massive challenge to health and social care, as well as to families and communities. I assure noble Lords that we will continue to support and encourage the NHS to ensure that people with asthma receive the care that they deserve.
[The Sitting was suspended from 3.53 to 4 pm.]
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Financial Institutions
4 pm
Lord Bilimoria asked Her Majesty’s Government what is their assessment of the effectiveness of international financial institutions such as the International Monetary Fund and the World Bank.
The noble Lord said: At the conclusion of the Bretton Woods conference in 1944, to universal applause, John Maynard Keynes paid tribute to his colleagues, who he said had performed a task appropriate,
I often speak of the wealth of talent and experience that exists in your Lordships’ House; however, I do not think that any of us today, in the limited time offered to us, will be claiming the title of “prophet” or “soothsayer”. What we can do, however, is look at the financial crisis that is upon us and ask what has happened, why it has happened and what must be done so that it does not happen again.
As many of your Lordships know, I have had this debate in the ballot for a number of months. Not only am I delighted that it is taking place at such an important and appropriate time, but I am grateful to those Peers speaking in the debate today, many of whom are recognised as world experts in this field. I welcome the Minister to this House. I congratulate him on his appointment, and we look forward to his response at the end of the debate.
If recent events have taught us anything, it is that the global institutions set up after the Second World War, such as the UN, the IMF and the World Bank, so appropriately created for that time, are now so out of step with our time. As reported in the Times, there are three kinds of organisations: those that make things happen, those that watch things happen and those that wonder what happened.
Take the IMF, an organisation of over 2,700 employees, with access to resources in excess of $363 billion. With all those resources, where was the IMF last year when this crisis started to unfold? Where were the IMF’s warnings as the world sleepwalked into financial meltdown? And today, when we are in the grip of the crisis, where are the IMF’s proposals on how to end it? The question we have to ask ourselves is: if the IMF is not mandated to fulfil that important function, why not? To its credit, the IMF’s 2007 Global Financial Stability Report in fact recognised that the US housing market was slowing down. However, it said that,
- “this weakness has been contained to certain portions of the subprime market ... and is not likely to pose a serious systemic threat”.
Ironically, the stress tests that formed the IMF's evidence base for this report were produced by none other than Lehman Brothers.
A core function of the IMF is to act as the lender of last resort, but even there we have seen that it is not the lender of first choice. Take the Asian crisis of 1997, when South Korea ignored the advice of the IMF and came out the better for it. Today Iceland and Pakistan, for example, have both turned elsewhere first before approaching the IMF.
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I want to make it clear that this is not a blame game. It is about finding a new mechanism that will enable the global community to work together. I heard President Clinton say that, whereas countries have historically always been interdependent on one another, today countries are integrated with one another. We have all heard the saying that when America sneezes, the world catches a cold; we can now see that we all catch that cold the very same day. Today we see the Indian stock market anticipating the actions of the US Secretary of the Treasury before they have been announced. Today we see India, a country still without a fully convertible currency, having to react swiftly to the challenges and opportunities presented by our integrated global economy.
The balance of economic power in the world is changing dramatically. The US, the European Union and Japan together contribute approximately 60 per cent of global GDP, and yet emerging countries with large surpluses are today investing huge sums of money in developed countries. These rising stars of the world economy need to be better integrated and represented in our global financial institutions. In short, the world’s top table needs to change—it needs more seats.
The world is returning to where it was some three centuries ago, with India and China once again set to emerge as the two dominant economic superpowers. Yet neither country has a place in the G7 or the G8, and India remains excluded to this day as a permanent member of the UN Security Council. The chairmanship of the World Bank remains the gift of the President of the United States. For what reason? That America was once the bank’s biggest funder by far. Today, however, it is just one of many. If the World Bank is to be for the world, surely its governance should reflect today’s economic reality, not yesterday’s. Similarly, does the managing director of the IMF need always to be European? Why not an American? Why not an Indian? Why not the best candidate for the job?
There is no question but that America is by far the most powerful country in the world today, but, looking ahead just 20 years from now, when China and India are economic superpowers alongside the EU and America, will it, for example, seem appropriate for the headquarters of the IMF, the World Bank and the UN to all be located in one country?
Contrary to recent events, we should be proactive, not reactive, and look at what is right for the world as it is today and as it will be tomorrow, whether that be a reformed World Bank—by the world, of the world, for the world—or a reformed IMF that would be genuinely global in its funding and in its scope, acting as an economic firefighter but, more importantly, as the steward and guardian of the global financial system. We need a mechanism for global financial institutions that can promote free trade without hampering free trade. We need regulation that is neither light-touch nor heavy-handed but balanced to protect consumers globally; to promote transparency; to prevent; to predict; to lead by example; and to argue forcefully that trade is not a zero-sum game.
The Brookings Institution said earlier this month:
“Public institutions need to be the vehicles by which leaders take public responsibility for the public interest ... The International Monetary Fund is in the doldrums, waiting for a new global mandate in the midst of a serious global financial crisis. Member
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Today it is Britain that has shown leadership in the international community through the announcement of its £500 billion rescue package for its financial sector, a sum that dwarfs America’s $700 billion package even at today’s exchange rates, and America’s economy is more than six times larger than Britain’s. In advance of the meeting of world leaders on 15 November, I urge the British Government to follow in the tradition of Keynes at Bretton Woods and to lead the way with boldness, confidence and authority in reforming our global financial institutions. Over 60 years ago those institutions were born out of the Second World War. Now they need to be reborn out of the global financial crisis as institutions that are fit for purpose for today and for tomorrow.
4.10 pm
Lord Desai: We are all grateful to the noble Lord, Lord Bilimoria, for initiating the debate. He has said much with which I agree entirely, so I shall confine myself to what I can add to the debate. First, when President Nixon announced on 15 August 1971 that America would shrug off its role as a key currency in selling gold at $35 an ounce, the IMF died. It should have been given a decent burial immediately because it had no function to perform once the particular combination of a world of capital controls and fixed exchange rates was gone. It had been a vision created by John Maynard Keynes in Bretton Woods. It served its purpose extremely well between 1945 and 1971, but in subsequent meetings that had to decide on a regime of flexibility in rates, noble Lords will recall that it was individual countries themselves that took the initiative to fix, in a series of meetings, what the system of flexibility in rates would be, while Europe took a lead and set up the European Monetary System, and so on.
The IMF completely missed the petrodollar crisis, let the third world get into unsustainable debt, and in 1981 started bullying everyone about their macroeconomic balances. The IMF had the wrong macroeconomic model for developing countries and ruined many of them. Indeed, it performed a signally negative role throughout the 1980s and 1990s. Today the IMF is a moderately good macroeconomic forecasting body, somewhat like the National Institute of Economic and Social Research, although it is not quite as good. I suggest that we should abolish the IMF at the first opportunity and merge its macroeconomic forecasting unit with either the World Bank or the Bank for International Settlements, which is a glorious institution when compared with any of the others. One can be absolutely bloody-minded about the IMF, and I agree strongly with the noble Lord, Lord Bilimoria, that it did not do anything in either the current or any previous crises. Indeed, last March I was taking part in a BBC programme while the IMF was holding its spring meeting. I then managed to roundly abuse the institution and say that it should be abolished, so I am not saying anything on the spur of the moment.
Institutions that have outlived the function for which they were set up should be abolished forthwith, not reformed. There may be a need for an institution at the
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