Disability: Prevention

HL Deb 14 May 1986 vol 474 cc1160-4

Debate resumed.

4.18 p.m.

Lord Winstanley

My Lords, I hope that after that interesting excursion into maritime affairs, noble Lords will not have forgotten the three fascinating speeches that we heard a short time ago on the important Motion which was so ably moved by the noble Lord, Lord Henderson of Brompton. We are all most grateful to the noble Lord for introducing such a very important subject. As I have said, I hope that noble Lords have not forgotten the three most interesting speeches that we have heard. The noble Lord, Lord Henderson, is to be particularly congratulated for giving this interesting and important debate the international flavour which it undoubtedly needs. I was so glad that he referred to the excellent work of Sir John Wilson and the emergence of the organisation IMPACT following that important meeting at Leeds Castle, because the international dimension in the whole question of the prevention of disability is vital.

The noble Lord, Lord Campbell of Croy, looked rather more widely into the subject as can only be expected from a former Secretary of State for Scotland who was also Minister of Health for Scotland, among other things. The noble Earl, Long Longford, referred to an area of immense importance—that is, the area of genetically transmitted diseases; congenital defects of one kind or another—to which I shall shortly return.

I should like to try to put this whole subject into a slightly different context. We must look at the complete picture. If we look the world over we find that health care resources worldwide do not match health care needs. There is a gap, and the tragic fact is that the gap is continuing to widen. There was a time when we all had great optimism. At the time that the National Health Service was introduced people tended to feel that once the financial barrier between the patient and medical care—whether it be hospital care or the general practitioner or whatever—was removed, somehow miraculously ill health and disease would disappear from the face of the world.

Of course that was totally false. What we found was that certain diseases disappeared—and I shall mention them in a moment—but we also found that as we learned to treat things which formerly we could not treat, as we learned to keep alive people who formerly would not have remained alive, we constantly increased the overall workload. Therefore, we have in our society worldwide people living and requiring regular medical attention who formerly would not be living. So the burden, the workload, continually expands.

One hopes that resources will expand; but I do not think that anybody can expect resources to expand to the extent to which all those engaged in the provision of health care believe advisable. Indeed, medicine and medical care could consume all the resources available if we allowed them so to do. There has to be some kind of establishment of priorities, and we have to find some other way of bridging the gap. We are talking about how we bridge the gap between the resources that we have for dealing with disability and the needs which those disabilities pose.

If we look at what has happened there is an immutable law of medicine that, as we get rid of old diseases—and we have got rid of many—new diseases always seem to rise up to take their places. When we look at the old ones we have got rid of, we seem largely in western society to have got rid of the old deficiency diseases such as rickets. There was a time when we could recognise anybody from my part of the world, Lancashire, by the way they walked, because they all had rickets. The deficiency diseases of the past have now largely gone in our society, although they have not totally gone in the developing nations to which the noble Lord, Lord Henderson, referred.

We have got rid of all those diseases which were perhaps water and sewage-borne, such as cholera, typhoid and things of that kind. We have got rid of many infectious diseases. For example, tuberculosis. At the beginning of this century it was referred to as the captain of the army of death, and now it is hardly a threat at all. It disappeared largely as a result of improved housing conditions and an improved environment in general. It disappeared as result of the new methods of chemotherapy which have resulted in the fact that people once infected do not remain infectious for very long, so fewer people are exposed to that infection. That is another disease which has largely disappeared.

The noble Lord, Lord Henderson, and others, referred to immunisation. Let us look at what has happened regarding smallpox. A vaccination programme was very successful. On the take up of smallpox vaccination, it might be worth mentioning in passing that it is interesting to note that when there was compulsory smallpox vaccination by law, the take up was never as high as when it became voluntary. There are lessons to be learned from that. The fact remains that we have now virtually abolished smallpox. I do not think there is a case anywhere in the world, and it may be that we shall never see another case.

It might be possible to do the same with certain other diseases. Reference has already been made to rubella. The noble Lord, Lord Campbell of Croy, referred to that, and to the fact that a great many seriously handicapped children are born as a result of their mothers contracting rubella during pregnancy. Immunisation has largely put an end to that particular problem; and having done so, it has put an end to a great deal of disability. So it goes on and on, with old diseases disappearing. As they disappear, new ones rise up. One of the more frightening facts that I notice when I look at the scene as a whole is that in our modern, mechanised society, accidents of one kind or another, as a cause of death and disability, now rival the great killers like cancer and heart disease. Those are accidents in the home, on the roads, at work, and in the social environment in general.

There is something that can be done in the way of prevention. Nobody could dispute that these accidents lead to an enormous number of deaths. That is of course a form of disability—it is the ultimate disability. Secondly, they lead to lifelong disability for a great many people. I would not pretend that all accidents could be done away with; that we could avoid them all. But I have no doubt that with proper consciousness of the problem the total toll of accidents could be substantially reduced.

We also have in modern society the emergence of what are called stress diseases. It is a rather ill-defined term, and those who use it do not always know precisely which diseases are stress diseases. It is nevertheless a fact that a life from which all stress was removed would not be a very satisfying life. Indeed, we know that an element of stress is necessary in a person's life for full health. But stress which is excessive, or stress with which the individual cannot cope, is of course a potent cause of disease and disability, and perhaps ultimately chronic illness and therefore a form of chronic disability.

We then have the emergence of the vast toll of disease and disability and death from cardiovascular disease. That is clearly related, as many studies show, to the change in our lifestyle which has taken place over centuries; to effects related to our diet; to our lack of exercise; perhaps the lack of fibre in our diet; excessive animal fat, and things of that kind. One can argue about those aspects; but there is no question that the high incidence of the disease is clearly linked to the modern lifestyle.

We have had much advice from the Royal College of Physicians, and others, and from the Health Education Council, about ways in which we can change our lifestyle by taking more exercise, eating rather better, and so on, and that that would substantially diminish the incidence of cardiovascular disease. It would also, I have no doubt, diminish to some extent the incidence of cancer, which is one of the other major scourges of the modern world.

Then we have to look at things like smoking. That is self-induced disease. I am bound to say, as somebody who knows a certain amount about it having smoked originally, stopped for 10 years, and then started again—which shows that this is a form of addiction; addiction to nicotine is like an addiction to alcohol or anything else, nobody is wholly safe; once addicted you are always in danger—that the only real cure of that problem is somehow to persuade people never to start.

The sad fact is that we are not being very successful in that regard. Some research that I did two or three years ago showed that of new entrants to universities only one in 10 ever smoked at all. Of new entrants to shop floor jobs in industry—this was done at a time when there were some shop floor jobs and there was some industry, and not all that long ago—nine out of 10 were already established smokers. It is sad information. It shows that the propaganda has not got through to certain social groups among young people—and that is where the hope really lies. It lies in persuading people never to start, and never to develop an addiction which could be difficult to deal with later.

Time is moving on, my Lords. We have referred, of course, and we must refer much more, to preventive medicine in one form or another, and to the kind of thing that the noble Lord, Lord Henderson, mentioned such as screening and things of that kind. The noble Lord, Lord Henderson, used a phrase that I noted down. He talked of, "simple systems of delivery at low unit cost". Here is something we must underline. It is all very well to talk about preventive medicine and to assume automatically that everything we spend with the object of prevention is necessarily well spent.

In preventive medicine, as in therapeutic medicine, one really has to carry out some kind of cost-effective studies. Modern medicine being what it is, if you once adopt a practice and it becomes regarded as necessary for everybody so that they are all exposed to this particular test or to that particular test, and so on, that kind of thing is apt to creep into medical practice like some ritualistic form of religious observance so that it is difficult to stop. A great many people involved in health care the world over are at the moment doing things which are frankly unnecessary, and from which not a great deal of benefit emerges.

When we introduce new techniques like screening, we must look at what we are doing. Are we creating extra work for no obvious benefit? We must do cost-effective studies. May I give examples, my Lords? There are many people in society suffering from diabetes which is undiagnosed. It is perfectly simple to test urine for sugar. That does not consume vast, highly-trained resources. It does not take much time. That is the kind of thing that can be done easily. Equally it is simple to teach women how to palpate their breast in a sensible way so that they feel a lump if there is one. If they feel the wrong way with their finger ends there will always be a lump, but the Health Education Council has been teaching women how to feel their breasts properly so that they can diagnose something early. That is simple. It consumes no resources. However, we have had things such as the mass miniature radiography scheme which consumed vast resources but which gained almost nothing in the way of real benefits because the results were unreliable and in the end all it did was create a false sense of safety and security. Finally it was abolished.

If we talk about screening do not let us fall into the kind of American trap of some of the insurance health care schemes where perfectly fit and healthy patients go along and are subjected to blood tests to the point of extreme exsanguinity; and at the end what have we benefited? Let us make sure that before we introduce a new technique of prevention we examine it carefully, make sure it does not consume resources which are in short supply and are needed for other essential purposes, and make sure that some benefits flow from it in the end. That is the way we have to look at these things.

Before I finish perhaps I may say a brief word about the great importance of genetic diseases of one kind or another. It is a sad fact that modern society seems to have taken evolution by the scruff of the neck. Darwinism and the survival of the fittest no longer applies. We take, and rightly, the most strenuous steps to ensure not only that the least fit survive but that they survive and multiply. We are now finding a very worrying increase in the numbers of congenitally and genetically spread diseases of one kind or another. The noble Earl, Lord Longford, referred to one. We need a great many more genetic counselling centres so that people can seek advice and so that some of these avoidable conditions can be avoided.

We also need to do further research along the lines which have been discussed very thoroughly by the noble Baroness, Lady Warnock, and her committee. I hope that we shall take some active steps. The first thing I should like to see is the establishment of a statutory body responsible for licensing work in the field of embryonic research and responsible for supervising it in general. Having established that first stage, let us then slowly build on but do not stop it altogether. If we once stop it we shall be losing an opportunity of stopping a great deal of disability and preventable hardship. I have spoken for too long. I am grateful to the noble Lord, Lord Henderson of Brompton, and I await to hear other speakers.