HC Deb 01 March 2002 vol 380 cc1002-10

Motion made, and Question proposed, That this House do now adjourn.—[Angela Smith.]

1.32 pm
Dr. Jenny Tonge (Richmond Park)

May I say what a pleasure it is to speak on a health issue for once?

The lack of treatment of respiratory diseases, which I shall also refer to as chest diseases, concerns me greatly. The British Thoracic Society ran a display in the Upper Lobby of the House—I hope that at least some hon. Members saw it—to try to highlight the issue of respiratory diseases. Such diseases kill one in four people in the UK and impose a huge burden on health and the economy. As heart disease cases have decreased, the burden of chest disease has actually increased. In 1999, 150,000 people died from respiratory diseases, 139,000 died from coronary heart disease, and 119,000 died from cancer, excluding lung cancer. In other words, respiratory diseases are the biggest cause of death in the United Kingdom.

Some 43 per cent. of those deaths are due to some form of pneumonia; 23 per cent. to cancer of the lung, nasal cavities, larynx or pleura; 20 per cent. to chronic obstructive lung diseases such as emphysema; and 16 per cent. to rarer diseases such as tuberculosis, cystic fibrosis, acute infection, pneumoconiosis and—believe it or not—choking. Having said that, TB is on the increase again, and choking is a quite common cause of death.

One in five deaths from cancer—one in five—are caused by lung cancer. It is not widely known among the general population that more women die of lung cancer than of breast cancer. Before I leave the subject of lung cancer—many of the issues that I am raising deserve a debate of their own—I understand that my noble Friend Lord Clement-Jones has got through the other place his Bill to ban tobacco advertising, which fell in the last Parliament. Will the Minister tell us what the situation is in respect of that Bill and when, after five years of Labour Government, we will see a ban on the advertising of tobacco, which greatly contributes to deaths from lung cancer?

Death rates from respiratory disease have fallen by a third since 1968, and over the same period deaths from coronary heart disease have fallen by 53 per cent. That is very welcome, but since 1984 the number of deaths from respiratory disease has stayed constant, while deaths from coronary heart disease have fallen by another third, which suggests that we are not doing enough to tackle respiratory disease. I am sorry to give the House even more statistics but it is important to get them on the record. Deaths from occupational lung diseases such as mesothelioma, the asbestos-related disease, have risen, with a 75 per cent. increase between 1988 and 1998. That is another disease that needs a debate all of its own because it is a huge issue.

I recently asked a parliamentary question to find out the cost to the health service of treating respiratory disease, and I received the response that the Department did not have precise details of the cost, but it estimated that respiratory disease accounted for approximately 6 per cent. of hospital expenditure, 13 per cent. of primary care expenditure and 12 per cent. of pharmaceutical expenditure."—[Official Report, 30 January 2002; Vol. 379, c. 426W.] The British Thoracic Society has given a figure of £2.576 billion of expenditure in 2000. I do not know what that figure represents as a proportion, but it sounds as if it is rather higher than the percentage given in the response to my parliamentary question. Perhaps the Minister can clarify that.

There are clear socio-economic factors affecting respiratory disease. Men between the ages of 20 and 64 in unskilled manual jobs are much more likely to die from obstructive respiratory disease such as emphysema or tuberculosis, and there are other marked class differentials. They are 40 times more likely than professional people to die from emphysema or chronic bronchitis and nine times more likely to die from tuberculosis. That has implications for our policy on housing and the alleviation of poverty. In the 1990s, 29,000 working years were lost due to respiratory disease in those doing unskilled and manual labour. I find it difficult to get my head around such statistics, but they sound very impressive.

I am also very worried by the rise in the number of cases of pulmonary tuberculosis. There was a 22 per cent. increase in the 1990s, which is horrendous when one considers that when I was a junior hospital doctor we thought the disease was dying out. It was also very disturbing to find out a couple of years ago that we had run out of vaccine. As the House probably knows, that became a saga because only one manufacturer made TB vaccine and it has taken some time to put the situation right. There are questions to be asked about that, including whether all those who should be vaccinated against TB have indeed received the vaccine. I am particularly concerned about 11 to 14-year-old schoolchildren, many of whom must have missed out when no vaccine was available.

World comparisons of respiratory disease rates reveal that the UK has twice as many cases as the European average. Only Kyrgyzstan, Kazakhstan, Turkmenistan, Uzbekistan and Ireland have higher death rates from respiratory disease rates than the UK. That is according to the British Thoracic Society. I find those statistics very depressing.

Another debate could be had on asthma in children. I will not go into great detail, but I am sure that everyone either has someone with asthma in their family, or has a close friend or relative who has a child with asthma. It is a serious problem in this country today. It is thought to be because of traffic fume pollution, but whatever its cause, asthma is the biggest cause of childhood illness.

I could go on quoting statistics damning our neglect of respiratory disease. The extent of the burden of lung disease is largely unrecognised and we need a huge investment in services. The introduction of national service frameworks—NSFs—for other diseases and making health authorities and trusts target other diseases, such as cancer and coronary heart disease, might sound good, exciting and right, but the result is that trusts and health authorities tend to neglect less glamorous diseases that are not the subject of Government targets.

I object to the notion that we are targeting cancer—what does that mean? Cancer varies from a serious or catastrophic, illness that kills within weeks or months, to a mild, easily treated illness. What do Ministers mean when they say that they are targeting cancer? Does it not mean that other diseases are excluded from the spotlight? I suspect that that has happened to respiratory diseases. Someone with boring old emphysema has little chance of being targeted by anyone, even in the absence of a ban on tobacco advertising.

My local hospital has 1.2 whole-time equivalent—I love that sort of statistic—and excellent consultant physicians to deal with respiratory disease, but the population served by that hospital numbers 330,000. According to the Royal College of Physicians, the British Thoracic Society and the British Medical Association, we should have one specialist per 80,000 people. My local area should have four consultant chest physicians, not 1.2, however excellent the 1.2 are. On 22 January, I tabled a parliamentary question asking the Secretary of State what recent discussions he has had with the BMA or the British Thoracic Society concerning the number of respiratory specialists needed in the NHS. The answer was: We have not had any recent discussions"—[Official Report, 22 January 2002; Vol. 378, c. 766W.] with either organisation about that subject. Apparently, it is not a big issue in the Department of Health.

My area also has insufficient respiratory nurse specialists to cope, especially in view of the large number of children with asthma; and for 15 per cent. of the year, because of holidays and study leave, we have no chest physicians practising in the area. The majority of patients with chest diseases are not seen by a specialist; they are dealt with by people who have other expertise. Waiting lists for respiratory function tests are increasing, and a significant proportion of lung cancer patients—one of the targeted diseases—are not seen within the two-week national target period because of the lack of consultant manpower. There is no specified acute lung unit or respiratory specialist cover for patients in the intensive care unit.

My constituents and those in other constituencies around our local hospital are extremely badly served in respect of respiratory disease. The only way to improve matters is to get more doctors and nurse specialists. I fully understand why we do not have enough specialists, but we cannot debate the subject without saying what a disgrace and a scandal it was that the previous Government allowed the number of doctors in training—and nurses as well—to fall to such an extent. I could introduce hon. Members to young people in my constituency who have the right A-levels to go to medical school but who could not get a place anywhere because so many medical school places had been cut. That was one of the great national scandals of the last 20 years.

Please will the Minister find us some chest physicians from somewhere, just as the Government are finding surgeons to do joint replacements? Perhaps other countries would oblige and send surgeons here and save our people from the biggest killer in the UK today, respiratory disease. I look forward to the Minister's reply.

1.45 pm
The Minister of State, Department of Health (Jacqui Smith)

I commend the hon. Member for Richmond Park (Dr. Tonge) on securing this Adjournment debate. I welcome the debate, and her obvious expertise. As she rightly says, it is always a pleasure to talk about health issues. The debate gives the Government an opportunity to state clearly our policy on the treatment of respiratory diseases by the NHS, to emphasise the importance we give to them and to share with the hon. Lady and others our prevention strategy and the steps that we are taking to improve services for patients with respiratory disease. My right hon. Friend the Secretary of State for Health is meeting with the British Thoracic Society and the British Lung Foundation soon to discuss this important issue.

The range of respiratory diseases that people can suffer from is very wide, and it would be impossible for me to talk about what the Government are doing in respect of them all in such a short debate, although it is slightly longer than we had presumed. I will concentrate in the time available on a few of the major conditions such as lung cancer, asthma, pneumonia and chronic obstructive pulmonary disease. I shall also refer to tuberculosis, which the hon. Lady mentioned.

The hon. Lady suggested—I think wrongly—that the Government's concentration on specific clinical areas had led in some way to a downgrading of the importance of respiratory disease. It is important to spell out that existing programmes have supported action on chest disease. The existing programmes for action on coronary heart disease will lead to improvements in the treatment of respiratory disease, because one of the key risk factors for coronary heart disease is cigarette smoking. It is the key cause of fatal lung diseases, such as lung cancer and chronic bronchitis, and increases the risk of pneumonia. I will refer more to smoking later.

Furthermore, many respiratory conditions are more prevalent in older people. The work being undertaken on the implementation of the national service framework for older people—addressing ageism, the development of a single assessment process and improved access to specialist care in hospitals—will produce improvements in access, prevention, treatment and services for all older people.

The hon. Lady highlighted lung cancer, which is the second most common cancer in England. In April 2001, the Government launched phase 2 of the cancer services collaborative programme, which is already producing some good examples of demonstrable reductions in waiting times for lung cancer treatment. Clearly, we would expect to see significant further progress.

An additional £10 million has been made available each year from 1999 to develop lung cancer services and is being used to help improve access to those services, to enhance the quality of treatment and to bring down waiting times for treatment for lung cancer.

We have asked the National Institute for Clinical Excellence to prepare clinical guidelines on the diagnosis and treatment of lung cancer to supplement the existing service guidance published by the Department of Health in 1998. It is likely that those guidelines will be published in autumn 2003. NICE, in June 2001, published appraisals of the various new generation chemotherapy drugs for lung cancer. We estimate that up to 5,000 patients will benefit from having those drugs available.

The hon. Lady spoke about pneumonia. Many deaths, including deaths from pneumonia, can be prevented by influenza immunisation, which is why the chief medical officer launched the flu vaccination campaign. We are pleased that take-up improved again this year, with 68 per cent. of older people getting vaccinated, compared with 65 per cent. last year. If everyone aged 65 years or over was immunised against influenza, an estimated 5,000 additional lives could be saved. Ninety-five per cent. of all pneumonia deaths, about 25,000 in total, occur in people who are over 65. The incidence of pneumonia increases with age as the immune system becomes less effective and the risk of chronic disease increases. At least 1 per cent. of people aged 65 years and over develop pneumonia each year, and many of them require admission to hospital. Older people who are at a high risk of chest disease are therefore offered immunisation against pneumococcal infection.

Eighty per cent. of patients with community-acquired pneumonia are managed by general practitioners, but most of the NHS costs of pneumonia treatment, amounting to more than £400 million a year, are associated with hospital admission. Prompt treatment in the community could reduce NHS costs and patient morbidity by reducing both the need for hospital admission and the length of hospital stay. Government investment and action in increasing capacity for treatment and the extent to which community and primary care can deal with those diseases is therefore crucial.

Dr. Tonge

I appreciate what the Minister has said about pneumonia, particularly in elderly people. In fact, in the old days it used to be called the old man's friend; it is often a terminal event in many illnesses. However, I must take the Minister up on her claim that the Government have been concentrating on funding primary care trusts and bodies outside hospitals to keep elderly people out of hospital. I do not want to go into the problem of bed blocking and the loss of nursing home places in this debate, but the Department may not appreciate that there is simply not enough community care for elderly people or anybody else. There are just not the bodies, spaces, beds or homes, to care for those people.

Jacqui Smith

That is why our action supporting social services and our success in cutting delayed discharges are important. The development of intermediate care services, particularly services which can respond quickly to the needs of older people with respiratory diseases who remain in their homes, will lead to further progress in ensuring that we catch some of those infections earlier and prevent hospital admission. In that way, we can improve the way in which the whole system works and, most importantly, improve older people's experience of care. Many local authorities and health authorities are using the increased investment that the Government are making available for intermediate care for precisely that sort of rapid response and care in people's homes.

Dr. Tonge

I feel passionately about this. Having been in health service management and administration myself, I know that one can often think that things are happening on the ground when they are not. I assure the Minister that there is not much evidence to suggest that such improvements are happening there. As she is suggesting that intermediate care is progressing and that a lot of facilities are being opened up, will she and her Department consider writing to me—I do not expect her to tell me now—giving examples of just where that is happening, so that I can go and see it?

Jacqui Smith

I would be very happy to do so. I have visited such places and I am willing to write to the hon. Lady about the progress that we are making in delivering on our pledges in relation to intermediate care.

The hon. Lady also referred to chronic obstructive pulmonary disease. As she pointed out, such disease leads to approximately 20,000 deaths each year. It also causes about 90 per cent. of respiratory disability. Expert groups working internationally have developed clinical guidelines for the treatment of COPD, which is shared between general practitioners and hospital doctors. Increasingly, COPD is being managed like other chronic diseases, with skilled teams offering lifelong care and often pulmonary rehabilitation to improve very significantly the quality of life of people with the disease. We have also asked NICE to prepare clinical guidelines for the NHS in England and Wales on the prevention, diagnosis, management and treatment of chronic obstructive pulmonary disease. Development work is currently under way on those guidelines.

As the hon. Lady pointed out, and as I said earlier, smoking is the cause of many serious respiratory diseases. It is the major cause of lung cancer and COPD and almost doubles the risk of pneumonia. That is why our anti-smoking initiatives are so important. Reducing the burden of avoidable disease will be good for the patient, good for the NHS and good for the nation. I am pleased to say that the United Kingdom is now a world leader in smoking cessation.

In the four years to 2003, we have allocated £73 million to the NHS to provide a national NHS smoking cessation service. Excellent results are already being achieved. The results for the first full year of the service, from April 2000 to March 2001, showed that about 132,500 people had set a quit date, with some 64,600 people successfully having quit at the four-week follow-up stage. We have also made smoking cessation aids available on NHS prescription. Zyban was made available in June 2000 and nicotine replacement therapy was made available in April 2001. Substantial resources have been made available to the NHS for this purpose. In addition, almost all NRT products are now available on general retail sale.

Dr. Tonge

The Minister is being very generous in giving way; these opportunities are very useful. What progress is being made with young women and smoking, which is a matter of great concern?

Jacqui Smith

I was just coming to that bit of my speech, although I am certainly willing to add to my letter on intermediate care some more details about progress with young women and smoking. An important element of the overall tobacco strategy is the health education programme, to which some £55 million has been allocated in the period 1999–2000 to 2002–03. The programme involves a mass media advertising campaign that is designed to address the 25-to-45 age group and the development of separate approaches in relation to pregnant women.

We want not only to prevent young women from smoking by carrying out education at an early stage, but to recognise that it is often when women become pregnant that they recognise the importance of taking action on their smoking. There are separate approaches for ethnic minorities, and all these programmes are supported by free telephone helplines offering confidential advice and, where appropriate, referral to local services. I hope that the hon. Lady will agree that those are positive measures that will, in time, help to reduce the dreadful burden of death and disease caused by smoking.

The hon. Lady pointed out that the private Member's Bill on banning tobacco advertising has been discussed today on Third Reading in another place. The Bill has been supported by Ministers in the other place. The Government are committed to legislating on tobacco advertising during the current Parliament, but of course the fate of legislation that originates in the other House is not for me to decide. Progress will depend on the House authorities and the extent to which parliamentary time is available. It remains an objective of the Government to legislate on tobacco advertising and as I have demonstrated, we have taken significant action to reduce smoking because of its considerable contribution to ill health.

The hon. Lady mentioned asthma. Although asthma prevalence has increased in England, as in western Europe, asthma deaths are falling, almost certainly as a result of better management. I was a little disappointed with the hon. Lady. I know that she was calling for both increased investment and increased emphasis on respiratory diseases, but I do not support the view that she seemed to be advancing at various times that everything in the health service relating to chest diseases is poor or substandard.

Much excellent work is clearly being done in our health service on a wide range of chest diseases by extremely dedicated staff, which will be supported further by the extra investment and reform that the Government are putting in place. Asthma is one area in which better management has been important in reducing deaths.

We are aware that the treatment of asthma can be improved. Our report into the expert patient provided evidence that self-management in asthma could reduce the number of attacks and improve lung function. Professionals can also help people manage their asthma attacks through written plans on managing their asthma and regular reviews.

The hon. Lady raised the important subject of the work force. We recognise that treatment of respiratory disease is a high-priority specialised area. In 1997 there were 109 specialist registrars in respiratory medicine. That figure has increased year on year and by 2001 had reached 257, which represents a significant increase. In 1997 there were 104 specialist registrars in cardiothoracic surgery. By 2001 that figure had risen to 199, an increase approaching 100 per cent. Our projections show that from a September 2000 baseline of 198, numbers should increase to 223 by September 2004.

I agree with the hon. Lady that the previous Government left us a considerable challenge to increase work force numbers. We will continually review future work force needs as part of our national work force planning processes and take action to address any shortfalls. In the longer term, our current supply projections expect a further increase of around 70 trained specialists to be available to take up surgical consultant posts by 2009–10. That reflects the increase in the numbers of doctors in higher specialist training in surgery as a result of the NHS plan and action taken by the Government.

The hon. Lady highlighted the issue of tuberculosis. There is, regrettably, an international resurgence of the disease. We need to be aware of that and take appropriate action. We recently announced plans for a new national infection control and health protection agency to streamline the services involved in the prevention and control of infectious diseases. The new agency will provide an integrated approach to all aspects of health protection, as well as infectious disease control. That will have an impact on infectious chest diseases such as tuberculosis and influenza.

The hon. Lady is right in her assertion that poverty is an important contributory factor in many respiratory diseases. As with many areas of policy, the significant actions taken across government to tackle poverty—for example, significant extra investment in our housing stock, which I have seen in my constituency—will be important contributors.

I hope that the hon. Lady will accept, if not agree with me, that the Government take the treatment of chest disease extremely seriously. We are investing considerable sums into improving lung cancer services. Our expenditure on anti-smoking initiatives will have an impact on the diseases caused by smoking. We are supporting, through the Medical Research Council, research into a wide range of respiratory diseases. We are asking NICE to develop guidelines for lung cancer and COPD. We are taking steps to increase the number of consultants who are available to treat people with lung disease, and we have recently launched a new strategy for dealing with infectious diseases.

I am pleased that we have had the opportunity to address the issue, not least because it enables us to show that the Government take the matter extremely seriously. Along with other initiatives, increased investment in the health service, and reform, have delivered, and will continue to deliver, important results.

Question put and agreed to.

Adjourned accordingly at six minutes past Two o'clock.