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The question here is how we will achieve this aim. The document about the Olympics gives examples of how it might be achieved. However, the fact that we have a huge event that people watch on television will not guarantee greater participation, although it may encourage it in a few areas. It became blindingly obvious to me when it was pointed out that it may encourage people to take sport more seriously and push on to the next level but it will not necessarily encourage people to take up sport. This may be because it is discouraging to see the world’s best when you are wandering around without the basic skills.

How will the Government tap in and allow greater participation? Will the Department of Health make sure that there is better funding for basic-level coaching? This could be about movement and the ability to participate in sport occasionally. If you occasionally play five-a-side football and keep yourself fit enough to do so, exercise and sport will combine.

Do the Government have a definitive method for counting the increase in exercise? The same applies to interest in sport. If there was such a measure, at least we could tell whether we were succeeding or not. There is no guarantee. If the Government turn round and say, “Our gains are more successful than anyone’s in the past for increasing participation”, we will have a good excuse for bringing to account the relevant Minister, because this is the first Olympics where the Government have said that this is one of their goals. We must have realistic, minimum targets.

I now turn to a matter for which the Department of Health must bear sole responsibility: the provision of sport and exercise medicine. I asked about this a couple of weeks ago—the exact date escapes me—and the Minister pointed out that in 2005 the Government gave a commitment to provide enough consultants in sport and exercise medicine. The figures that I have are that there are eight trained individuals, whereas it is reckoned that we need 72 as a basic requirement. In the medical system, consultants are required to pass on information and to make sure that people have the necessary support.

There is a movement to replace certain kinds of drug therapy with exercise therapy. That relates to the obesity strategy and so on, but I will not go into that. The noble Baroness can take as read my criticism of the body mass index as a guide to obesity. The index fails to take into account that someone may be heavier built and that muscle per volume is much heavier than fat. My favourite statistic relates to Pinsent and Redgrave. When they won their last medal, they were simply heavily overweight as opposed to obese. The body mass index is a blunt instrument, which does not apply to anybody who is taking exercise that allows an increase in muscle mass. People can get heavier and fitter. This kind of exercise does not apply to this chart.

Why is it important that we have this extra guidance? One of the younger Members of this House—he is not in his place—who along with me is regularly required to compete with another place at various silly events, damaged his knee. It was a muscle tear—nothing serious. The doctor told him not to exercise for six weeks. If you leave a muscle not working for six

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weeks, it gets weaker, the tendons and ligaments around it are left in worse shape and, when you go back to using it, it is more likely to be damaged. That is a basic level of ignorance that is shocking in a doctor. How can we get people at the top who will ensure that when this occurs, if the doctor does not know what to do, he will consult on up—or indeed sideways, for physiotherapists?

We need people in place. If we take into account that these doctors are necessary for the implementation of the strategy, what are we doing to make sure that they are there? We have provided the training posts—usually by shifting funds around, or so I am told—but we are not providing the consultancy posts. People have dropped out of the training because there is no end place for them. If you are a registrar and you want to train, you might think, “I’ll further my career—oh, there’s nowhere to go, so I’ll stop doing the training”. That is perfectly natural in that situation; I am sure that if any of us was in a similar one, we would do the same. What are we doing about this?

I see that my 10 minutes are up. I suggest to the Minister that we need answers on this. Without them, much of what the Government are doing here becomes simply meaningless.

4.11 pm

Lord Ramsbotham: My Lords, I thank the noble Baroness, Lady Knight, for giving us the opportunity with this debate to raise issues of public health that are sometimes rather difficult to get into that context. I shall concentrate entirely on the issue of prison healthcare because although it is not currently in the public health agenda, I submit that it should be. Prison health is a public health issue.

When I took over as Chief Inspector of Prisons in 1995, I was surprised to find that, in the whole of the United Kingdom, only prisons were not part of the NHS. Prisoners were in the NHS before they went into prison and when they left prison they went back into the NHS, but while they were in prison they disappeared from the NHS radar. Prison Service healthcare used to claim equivalence with the NHS for maintaining this, but how could that be when only 10 per cent of prison medical directors were qualified to act as GPs in the NHS?

There was no properly structured nursing force, particularly for psychiatric nursing, not least because there were no career opportunities for people to develop careers inside such a small organisation as prison healthcare. There were therefore far too many short-term agency nurses, employed at great expense, which did not contribute to consistency or continuity of improvement, if such a thing was possible. What is more, prison doctors did not have access to notes on people before they came into prison, nor did doctors, after someone had been released, have access to notes made in prison almost without going to the trouble of getting an affidavit.

There were particular problems with the lack of professional oversight from all the NHS arrangements for such oversight that exist in hospitals and elsewhere. The only oversight was from my own inspectors, among

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whom I had a doctor and a nurse, but then we inspected only every five years. That was not good enough for overseeing the whole system.

Why is this a public health issue? Because every single prisoner, with the exception of about 30, is going to come out. The physical and mental health of that person is therefore a matter of interest for the public among whom they are going to be released. They may have physical ailments that, unfortunately, flourish in the prison environment, such as varieties of TB and all the blood-transmitted viruses such as HIV and hepatitis C. People age in prison; indeed, they age much more quickly in prison than they do outside. Children in prison can stay with their mothers until they reach the age of 18 months.

Then, there are the dreadful mental health statistics, with at least 70 per cent of prisoners suffering an identifiable personality disorder and about 500 requiring transfer into secure mental health accommodation because their condition is such that prison is wholly inappropriate as a place to hold them. Thankfully, since 2004, prisons are part of the NHS and healthcare provision is offered by primary, secondary and mental healthcare trusts. This is not the place to comment on the patchy nature of that provision, particularly in mental health, but it is important to have an overall direction and strategy for how healthcare is delivered. There is a great danger that unless you have consistent oversight of what is done, particularly for those with mental health problems, they will come out of prison worse than they went in. That is avoidable and inexcusable.

I say as an aside that I have always thought that one reason why prisons should be regionalised—as the noble and learned Lord, Lord Woolf, recommended in his report following the Strangeways riots in 1990 and as picked up by the only White Paper on prisons, Custody, Care and Justice, published in 1991—is to avoid prisoners having to leave their own region. That would give regional NHS authorities an opportunity to have some control over what is done with and for their own people, whose treatment will be their responsibility on release. Prisoners should have a proper physical and mental health assessment when they enter prison and plans should be made to treat anything discovered while they are there, taking the opportunity of the sentence to make real progress. For people with mental health problems, that can include the development of a sustainable lifestyle with the clear understanding that what is established should be carried on elsewhere. This is where I believe that public health clicks in. It would be irresponsible to do less than I have outlined. It would be irresponsible to the public to whom the prisoner is returning.

Today the Bradley review on diversion was published. It concentrates largely on people in prison who have mental health problems. It contains 82 recommendations, and the Government have announced that they accept all of them in principle. However, there is obviously work to be done. I was fortunate enough to speak to the noble Lord this morning but I have not yet read the report. I asked him particularly whether his report contains signposts suggesting that public health authorities need to get on to what he is proposing and make it their responsibility for carrying it out. He said that it

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does. One of the things that he has recommended is a national programming board with an advisory board to serve it. That national advisory board will not achieve anything unless there is a part of the NHS which is responsible and accountable for seeing that those recommendations are delivered.

Prison healthcare is comparatively new to the NHS, and many different trusts are involved in contract work in different prisons, but what matters is that one part of the NHS should be responsible for overseeing the consistency of that treatment, wherever it is given. Oversight of the provision from these various trusts also is needed to ensure that every prisoner has the assessment needed to ensure that this opportunity is not missed. It makes absolute sense for public health authorities to be given that responsibility. I urge the Minister to pursue this matter with her department after this debate.

4.19 pm

The Lord Bishop of Ripon and Leeds: My Lords, I am very grateful to the noble Baroness, Lady Knight, for her perceptive intuition in inspiring this debate at this crucial moment when the press is dominated by the possibility of a flu pandemic which would challenge considerably our public health agenda. I want in that context to draw attention to the Department for Communities and Local Government paper issued this week on Faith Communities and Pandemic Flu. I thank Monsignor John Devine and the Faith Communities Consultative Council for their input, and I stress the crucial importance of faith communities in any pandemic.

I am very grateful for the measured government response to the current flu threat, both in calling for vigilance and in combating irrational panic. It is crucial that, should there be a pandemic, anyone infected stays at home. It is equally crucial that those not infected continue both to work and to support those who are ill. Basic respiratory and hand-hygiene standards, such as the use of tissues and careful hand washing, are key to our care for one another. That fits in closely with the issues raised by the noble Baroness, Lady Knight, about hygiene in hospital. It applies also to hygiene within our communities and would do so very particularly were there to be a pandemic.

I also welcome and affirm the ethical framework of the DCLoG document: that in a pandemic all people matter equally. In that context, the prayer and worship of faith communities matters crucially. That would provide support for those who are ill and strength for those not infected to provide help for others. I particularly commend, from that document and elsewhere, the development of flu-friend networks which can be based in churches, mosques or other faith communities or elsewhere whereby there is organised provision to collect antivirals for vulnerable people. That is something that can be set up locally—it must be set up locally; it cannot be set up in any other way—and would provide a structure whereby help can be provided in the event of a pandemic.

Imaginative ways of contacting people with prayer and support need to be developed locally, including internet prayers and phone numbers advertised alongside

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those provided through the NHS. It is also important that faith communities consider how to adapt their own ceremonies should a pandemic arise, such as, in the Christian community, the receiving of communion in bread alone without the use of a common cup during such a period.

I remain haunted by that government assertion that everyone matters equally. There are many in this country for whom it does not feel like that. This Sunday, I shall be worshipping at St Hilda’s, Cross Green, in Leeds, where there is a particular ministry to asylum seekers, some of whom are terrified by fear of the authorities. In a situation such as that of a pandemic, there will be a particular responsibility on faith communities both to affirm that ethical affirmation of DCLoG and to care for those who often feel themselves to be rejected by others.

I also want to make a quite different contribution to this debate. If the threat of a pandemic is an immediate concern—and it is, and the public health agenda needs to deal with it—so there is the longer-term threat to our public health of alcohol abuse. How are the Government developing their policies to combat such abuse? In the city of Leeds alone, the cost to the local economy of alcohol-related harm is estimated at £275 million a year. The cost to the NHS is vast. The cost to individuals, both temporary and long term, is encountered in damaged lives. I suggest that this is one of the most significant current threats to public health and that we have developed a culture of alcohol abuse that needs determined combating.

I take noble Lords, as I have been, to the accident and emergency department of St James’s Hospital in Leeds. A chaplain has been called to support a family where the grandfather has just died; a precious moment of farewell and commendation that we have all experienced in one way or another. It is Friday night, and this is the casualty unit in a large city, so that farewell takes place in the context of staff struggling in a battlefield, responding to the needs—the genuine needs—of intoxicated strangers. It is not a farewell that I would wish on anyone.

Those who work as professionals in public health are in my experience convinced that action must be taken to limit easy access to cheap and destructive alcohol. The Government seem to have turned their back on Sir Liam Donaldson’s call for significant price rises in this area, but it is not clear to me what other strategy will be able even to begin to deliver us from the human and financial costs being incurred. Responsible drinkers would be little affected by price changes. For those given to abuse, there needs to be a progressive impact to encourage a speedier return to personal health and stability. We have found ways—we could probably find better ways—of doing that for tobacco. Perhaps amendments to the Health Bill on Report will strengthen our response to that particular problem. There needs to be a similar strategy on alcohol.

So much of the human tragedy in our society has alcohol abuse as an element within it, whether it is domestic violence; whether it is increasing numbers of people going to prison and therefore becoming subject to the issues that the noble Lord, Lord Ramsbotham,

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has raised; whether it is to do with broken relationships, or with our ability to take that exercise that the noble Lord, Lord Addington, so ably advocates. There needs to be local work involving primary care trusts and faith communities. There also needs to be government action to promote behaviour that serves the community and to foster personal responsibility. The Government are rightly determined to do that in the case of a pandemic. I look forward to similar commitments on the much longer-term damage of alcohol abuse.

4.29 pm

Baroness Masham of Ilton: My Lords, I thank the noble Baroness, Lady Knight of Collingtree, for introducing this debate on public health, which could not be more topical. I do not think that the debate was planned to take place in the very week when the world is plunged into the vital need of public health across the globe due to swine flu. It may be better referred to as Mexican flu, named after the country of origin, as were Spanish flu and Hong Kong flu. This is a complicated virus, containing pig, fowl and human viruses. The fight to control a flu pandemic will involve many professional bodies, and the public should be kept informed with the correct information and guidance to take the necessary precautions.

Having visited Mexico some years ago and having succumbed to Montezuma’s revenge, resulting in the most violent diarrhÅ"a and sickness, I wonder whether Montezuma has done something to make this virus worse in Mexico. When I flew over Mexico City, there were miles of shanty town on the outskirts of the city and a cloud of pollution hung all around. Many of the so-called houses were tin shacks, and many people were living in poor conditions. Poor housing often contributes to poor health.

The virus seems most complicated. I have a few questions for the Minister, as we did not have the planned Statement yesterday. Does the virus have a window of about three weeks when a person may be infected, but the test does not show positive? Does the manufacture of the quantities of vaccine needed not require thousands and thousands of eggs? Do we have enough eggs? Does Tamiflu have a sell-by date? If so, is our stockpile still in date?

The fourth report of the 2005-06 Session of the Science and Technology Committee, Pandemic Influenza, asked the Minister whether the Health Protection Agency, responsible for frontline management and the emergency strategy on the flu pandemic, will have enough funds and capacity as some of the agencies have been merged. Is it adequately equipped to manage if the pandemic spreads? Will there be enough testing capacity? Will more people be drafted in to help, and will funds be made available to cope? What are the plans for distribution of antivirals?

For some years, the World Health Organisation and our Chief Medical Officer have been telling us that there will be a flu pandemic. The world is now on full alert. The importance of public health and other organisations coming together and working for the good of society is absolutely vital. There must be good communication with the public and honest, transparent networking.



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As a precursor to my Question on 13 May about the cases of Panton-Valentine Leukocidin—PVL—positive staphylococcus aureus, I am concerned that this public health matter which can come in from the community and affects young, fit people and children who pick it up from playgrounds, sports halls and military camps, can be missed through a lack of knowledge by GPs and hospital doctors. The symptoms are flu-like. The body’s immune system packs up and white cells stop fighting. If not treated, victims can die in a few days. The last case that I heard about was that of a student from Harrow School a few weeks ago, who became very ill with PVL MSSA. This has been a serious problem in the USA. There needs to be very good surveillance and awareness, as there are so many different strains of MRSA. Another concern is that of pigs infecting humans in countries such as Holland. Does the Minister agree that there should be a close working relationship between veterinarians and microbiologists? There should also be close co-operation over the serious problem of variant CJD and blood safety.

Public health is of huge importance in our prisons, as my noble friend has said. With conditions such as HIV and tuberculosis, prisoners need to be on courses of medication. There is no guarantee that they will continue treatment or seek medical care once they are released into the community, especially if they are homeless and have multiple diagnoses. Prisons have different systems that do not communicate with each other, making it difficult to establish an offender’s medical history. Only a few prisons use online systems. On a recent visit to Pentonville prison, which has a high incidence of tuberculosis, it was good to meet a dedicated nurse specialising in TB, who works between prisons. She told us that multidrug-resistant TB was a great concern. With the homelessness and chaotic lifestyle that many prisoners have on discharge, that is a serious public health risk. Drug and alcohol misuse is also a huge problem. When asked how the prison contains an infection outbreak, they recommended that screening within 24 hours of arrival is crucial to safeguarding the prison against the spread of infection.

For many years, I have felt that there should be a good, all-round health education in all of our schools. Children should learn that healthy eating and exercise will give them the best chance in life. They should learn about the dangers of type 2 diabetes and how to avoid it, about the result on their health if they smoke, and about sexually transmitted diseases and substance misuse. There should be more testing in the community for conditions such as venous thromboembolism, or VTE, which accounts for more than 25,000 deaths in England alone, and for so many others which, if detected in time, will save people from having long-term conditions as well as from dying early. Prevention of illness is so important.

I shall end on a positive note. On Tuesday, I went to an exhibition at the Design Centre, “Design Bugs Out”. The Design Council, the Department of Health and the NHS Purchasing and Supply Agency brought designers together with clinical specialists, patients and front-line staff to test an innovative approach to

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procurement. They should be congratulated on that excellent initiative. There was equipment there such as bedside cabinets, a commode with rounded edges and disposable pan, a patient bedside system, a patient’s chair and a porter’s chair—all with curved, smooth edges—an intelligent mattress with an inbuilt early warning system, which allows soiled mattresses to be identified and replaced as soon as they become contaminated. There was also equipment for doctors and nurses, such as blood pressure cuffs and a cannula time tracker. All were easy to clean, to help overcome health-associated infections such as MRSA and C. difficile. This is to promote good clinical care. Equipment is likely to be cleaned properly if it is easy to clean. This exhibition will be taken around the country and I hope that orders will be placed.

I am pleased to learn that the National Institute for Clinical Excellence is increasing its public health promotions. If public health is neglected, it will be at our peril.

4.40 pm

Baroness Barker: My Lords, if persistence is deemed to be an Olympic sport in 2012 I will be there when the noble Baroness, Lady Knight of Collingtree, picks up her medal. I thank her for giving us the opportunity to have this wide-ranging and absorbing debate.

As the daughter of a Methodist minister who was also a chaplain, I found the right reverend Prelate’s speech most perceptive and very moving. The question asked by my noble friend Lord Addington on sport and health prompted me to think that, if you were to ask three different government Ministers what a boxing match was, you would get three different answers. The Department of Justice would say that it is a means of reducing youth offending; the DCMS would probably describe it as a noble art; and the Department of Health would point out its potential for causing sub-cranial neurological trauma and consequently the necessity for it to have a risk management programme attached to it.


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