Local Tuberculosis Services

– in Westminster Hall at 11:00 am on 30th April 2008.

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Photo of Julie Morgan Julie Morgan Labour, Cardiff North 11:00 am, 30th April 2008

I am pleased to have the opportunity to discuss tuberculosis today and delighted that my right hon. Friend the Minister will reply to the debate. I am sure that she is aware that it has come about as a result of the report, "Putting Tuberculosis on the Local Agenda", which was published by the all-party group on global tuberculosis, which I co-chair with the hon. Members for Arundel and South Downs (Nick Herbert) and for St. Ives (Andrew George). The group is supported, and was inspired, by RESULTS UK. The report was produced in conjunction with the British Thoracic Society, with which the group works closely on the issues.

TB is a common and deadly infectious disease. It most commonly attacks the lungs as pulmonary TB, but it can affect any part of the body, including the brain, lymph glands, intestines, kidneys, spine, bones, joints and even the skin. During the Victorian era, it was so much part of life, so inevitable and so little understood that its existence was completely accepted as a fact of life. In the early 19th century, it may have accounted for one third of all deaths. Indeed, some argue that the UK gave TB to the rest of the world, emerging as it did from the cramped living conditions of the industrial revolution. They say that we exported it with our engines and armies and rolled it around the world.

Many people today can still remember friends and family who were struck by TB in this country up until the 1950s, and people live with the consequences of having TB. When antibiotics came, everybody thought that TB would be consigned to the history books and that it would be a disease of the past—that was a strong belief in this country.

One of my first jobs was as a social worker—I worked in a TB hospital in Sully in south Wales. At the time, my colleagues and I thought that the people we saw would be the last to have TB. The hospital is now closed, and we thought that there would be no need in future for the treatment that we gave to people but, sadly, today more than one third of the world's population has been infected by TB and new infections occur at a rate of one per second. The emergence of drug-resistant strains has contributed to the new global epidemic and, in March, the first UK case of extensively drug resistant tuberculosis was reported in Glasgow; it was noted with a lot of publicity and is of great concern.

The all-party group began to work with the British Thoracic Society in early 2007. The society expressed concern that the chief medical officer's action plan, "Stopping Tuberculosis in England", and the National Institute for Health and Clinical Excellence guidelines, "Clinical diagnosis and management of tuberculosis, and measures for its prevention and control", which were published in 2006, were not being implemented. At the same time, rates of TB were rising. Since the Health Protection Agency's new surveillance system was put in place in 1998, the incidence of TB has increased by a remarkable 42 per cent., from 5,658 new cases in 1998 to 8,051 in 2006. The group is pleased that the trend appeared to stabilise in 2007, but we do not know whether that was a one-off or whether the trend continues. However, we now consistently see, year-on-year, more new reported cases of TB than hepatitis C and new diagnoses of HIV. Actually, in some parts of the country, particularly London, the rates of TB are equivalent to those found in Asia and sub-Saharan Africa. The situation is serious.

The report is made up of two surveys, both of which were carried out in 2007. The first was an online survey and the second a paper survey that was sent to all primary care trust chief executives. It followed the publication of the Department of Health TB toolkit in June 2007, "Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in England", which was a guide to help PCT commissioners to implement the NICE guidelines. The group was pleased with the response to its survey. More than 70 per cent. of PCTs responded, which was excellent, and we intended the survey to be sent out in both England and Wales.

Photo of Julie Morgan Julie Morgan Labour, Cardiff North

I am pleased to give way to a fellow member of the all-party group.

Photo of Ann Cryer Ann Cryer Labour, Keighley

On the role of PCTs, do my hon. Friend and the Minister agree that it would be useful if they or other bodies encouraged ethnic communities to desist from stigmatising those with TB and their families? I have some experience of that: one or two of my constituents have put off seeking treatment for TB because they did not want the extended family or community to know about it. It would be useful if PCTs could persuade communities to desist from such behaviour.

Photo of Julie Morgan Julie Morgan Labour, Cardiff North

Stigma is an important issue in relation to TB. It prevents people from seeking treatment and makes them hide their condition from their family and friends. PCTs need to take that important issue on board.

As I was saying, we intended the survey to cover England and Wales, but because of the different health structures in Wales, we need to have a specially worded survey. We hope to include it in our next survey, but I have had a number of discussions with key professionals in Wales. As a Welsh MP, I am pleased that we will be able to include Wales in our next survey.

The report gives us a pretty good picture of the state of TB services throughout England. I do not intend to go into the details of the results of the survey. I have written to request a meeting with my right hon. Friend the Minister, and I hope that she will agree to it. Also, the British Thoracic Society has asked for a meeting with the chief medical officer. It is important, however, to draw attention to some of the report's key findings, and to the chief medical officer's foreword to the TB toolkit, in which he says that

"we strongly recommend that all PCTs plan for TB service provision. This applies just as much in low TB prevalence areas, since population shifts can rapidly change the prevalence of the disease in areas where it has historically remained low".

It is therefore important that the recommendations are followed even in areas where there are low TB rates.

This Victorian disease is on the march again. Not a single PCT thought that there would be a fall in TB in its area, yet the overwhelming majority—68 per cent.—said that they had no plans to deal with the expected increase in cases. That analysis was supported by hospital-based TB clinicians, 88 per cent. of whom believed that TB cases were set to increase in the next five years. For TB to be controlled, the Government must take real leadership and co-ordinate a response at all levels of our health service. PCTs must implement national guidance to allocate TB resources appropriately, strategic health authorities must ensure that TB is given the priority that it requires, and the Government must put systems in place at national level.

Step 1 of the toolkit is to identify an appropriate person as the TB lead, regardless of the incidence of TB within the PCT area. That individual will be in a position to take strategic decisions and influence commissioning at board level. The all-party group's survey found, however, that 50 per cent. of primary care trusts had not taken even that first step and had not identified a lead. In those that had, the position was often filled by people who did not have a strategic role and who could not influence decisions, such as nurses, health visitors and even a hospital-based clinical lead not employed by the PCT. Will my right hon. Friend therefore look at the local uptake of national guidelines on TB and ensure that the Department drives forward implementation? The key point about TB patients is that if they are not looked after well, their family and local community will have a higher chance of catching TB, given its infectious nature. That is why it is so important to treat the disease early.

The next important thing to do, after identifying a TB lead, is to ensure that there are properly funded TB services. Delays in diagnosis can lead to drug resistance and increased expense. Our report found that PCTs were not identifying appropriate funding, and three quarters of hospital-based TB clinicians have seen no increase in resources since the action plan was published four years ago. Similarly, the jobs of many TB nurses are under threat or review, and many nurses complained of being under-resourced.

Why are PCTs failing to allocate the appropriate resources to TB? We suspect that it is because of the clear lack of priority afforded to the disease. Areas with high incidence rates are usually poor, with many competing priorities, while those with low incidence rates are not putting plans in place, despite the chief medical officer's warning. TB rates have recently stabilised to some extent, and we welcome that very much, but there is no room for complacency. I therefore ask my right hon. Friend to ensure that regional directors of public health make PCTs give TB the priority that it should have.

I want now to raise a number of issues relating to leadership. First, I congratulate my right hon. Friend on making TB prescriptions free on the national health service from September 2007, which will certainly remove some of the barriers to seeking treatment.

Secondly, it is right that local decisions should be made by local health authorities, but some problems must be addressed centrally. For example, a fifth of patients with suspected TB are not seen by the TB team within two weeks of presenting themselves, as directed by the chief medical officer. We have had a big drive on waiting lists, and the issue clearly needs to be addressed.

There is also an issue about whether screening policy is any use. There needs to be a debate about that to decide whether it is. If it is any use, it needs to be improved.

Another big issue is that the majority of PCTs are not proactive in raising awareness of TB, which can lead to delays in diagnosis and unnecessary deaths. For example, a little girl from London was diagnosed with TB only two days before she died at a hospital in the south of England, and the same happened to two health workers in Nottingham. We want to see the same investment in awareness-raising for TB as for other comparable communicable diseases, such as sexually transmitted infections and hepatitis C.

To conclude, the all-party group plans to produce a report annually. I would be grateful if the Minister could give me a personal assurance when she responds that more will be done to ensure that PCTs prioritise TB and that national guidelines are implemented through the director of public health and the other means available. Guidelines on what should be done have been set out nationally, and we are now looking for implementation and for PCTs to take this deadly disease seriously.

I urge the Minister to make a commitment that the Government will use awareness campaigns, in particular, to prevent this disease from getting out of control. I should emphasise—this is what makes the global situation so sad—that TB is easily cured, but it is important that we have early intervention. I remind her that the incidence of TB in New York in the late 1980s and early 1990s was similar to that in many of our cities now, but the administration there sat on their hands, not realising that they were on the brink of an epidemic that ultimately cost them billions of dollars in public money to resolve. I therefore urge my right hon. Friend to continue leading on this issue.

I end, however, by saying what a great job the British Thoracic Society is doing in highlighting these issues with the all-party group and RESULTS UK.

Photo of Dawn Primarolo Dawn Primarolo Minister of State (Department of Health) (Public Health) 11:15 am, 30th April 2008

I congratulate my hon. Friend Julie Morgan on securing the debate. I know of her passionate work as one of the chairs of the all-party group on global tuberculosis and I am aware of her concern, which she reiterated today, that the fight against tuberculosis should remain a priority in this country.

My hon. Friend reflected on the history of the disease. When I was a child, TB was present in my extended family before immunisation was introduced, and I remember subsequently having vaccinations. As she rightly said, all of us, but particularly those of us of a certain age, remember the challenge posed by this disease.

My hon. Friend is right that TB is a massive international health problem. The World Health Organisation estimated that 1.6 million deaths resulted from TB across the world in 2005. In England, the development of drugs to treat TB, together with improvements in housing and health throughout the 20th century, led to a steady decline in the number of cases. That was reflected in an all-time low of 5,000 cases in 1987. However, she is right that there has been an upward trend since the 1990s. In 2006, more than 7,500 cases were reported in England, with the London region accounting for 40 per cent. of all cases. Although the overall rate in the UK is low, at around 14 cases per 100,000 of population, TB remains a concern because the incidence is increasing and rates are high in certain inner-city areas, as well as among people born abroad.

As my hon. Friend said, the chief medical officer published his action plan in October 2004, which included key recommendations for action. He acknowledged that TB is so common in certain parts of the world that we must expect a continuing influx into this country of people who were infected, or who developed the disease, abroad. She touched on that when she urged us not be complacent about the challenges that we face. Although measures are in place to detect active disease in migrants entering the country for six months or more, who are subject to immigration control, such measures are unlikely to solve the problem of TB in this country. That is because about 80 per cent. of cases of active disease among such people occur only after they have been resident in this country for two years or longer.

My hon. Friend Mrs. Cryer touched on an important point when she stressed the need to encourage those who fear that they have the symptoms to seek diagnosis, advice and treatment. As she said, they should not be put under unjustifiable pressure to feel that their symptoms are somehow shameful and that they must conceal them.

In considering all those points, it is right to focus on strengthening services to improve early detection. That includes raising awareness among the population and health care professionals, especially in the primary care setting, of the need for the highest awareness of TB, on a continuing basis. The Government strategy needs to drive early detection and diagnosis, and to ensure that patients complete their courses of treatment.

Our strategy is to help to strengthen NHS provision across the board. To help to implement the TB action plan the NHS, the Department of Health and the Health Protection Agency have been working closely together, to make sure that we bring our resources to bear on the issue. My hon. Friend the Member for Cardiff, North mentioned the TB toolkit that we published in June 2007 for the NHS, to help commissioners take local demographics into account when planning TB services, respond quickly to changes in demography that may have an impact on risk in the future, and be very aware of the risk. The toolkit's commissioning section is a practical guide for PCTs to use, so that they can ensure that an appropriate range of services is being commissioned and provided within that rational framework. The delivery section discusses a number of best-practice issues, including the use of specialist centres providing a multi-disciplinary team approach, with TB nurses co-ordinating a package of care. It also recommends that TB services should follow the National Institute for Health and Clinical Excellence guidance on diagnosis and treatment of TB, which was published in March 2006.

Against that background, I want to discuss the recommendations in the excellent report by the all-party group on global tuberculosis and the British Thoracic Society. I welcome the recommendation regarding a national TB awareness campaign tailored to local circumstances and aimed at health care professionals and the general public. When my hon. Friend was talking about the report and the results of her survey, and despite the need for considerable improvement, to which I shall return, I felt, like her, very encouraged that there was a quite high response rate within a short time, and awareness in many PCTs of the issues and what needs to be done. I am pleased to say that the Department is providing funding this financial year to take exactly such action as she mentioned with respect to local circumstances and work with health care professionals and the general public. We have also commissioned market research to help us to shape such campaigns nationally, to complement what is happening locally. That research will be translated into carefully targeted messages for health care professionals, and we have funded the UK charity TB Alert to work with PCTs to develop awareness campaigns targeted according to local demographic needs.

The report recommended that PCTs must ensure, as my hon. Friend mentioned, that there is a clearly identified individual within their organisation with responsibility for service provision for TB. I agree wholeheartedly with that recommendation of my hon. Friend and the report; it is one of the key recommendations of the TB toolkit and we intend to take it forward. [Interruption.] It is unusual to be heckled by the intercom system.

Photo of Julie Morgan Julie Morgan Labour, Cardiff North

I thank my right hon. Friend for what she is saying. What can we do about the fact that 50 per cent. of primary care trusts have not identified a lead?

Photo of Dawn Primarolo Dawn Primarolo Minister of State (Department of Health) (Public Health)

The Department is focusing on that work now, and will continue by engaging with PCTs to arrange workshops and discussions with health care professionals, to make sure they know the existing prevalence of the disease and the indications of future risk; the fact that it is a public health priority requiring them to carry out a proper assessment of the risk in their areas; how they should respond to it; and what the public awareness campaigns are. A key factor is the Department's active role in connection with the basis of the recommendations in the toolkit and the report. [Interruption.]

Photo of Edward O'Hara Edward O'Hara Labour, Knowsley South

Order. I think we should soldier on, despite the noise from the intercom.

Photo of Dawn Primarolo Dawn Primarolo Minister of State (Department of Health) (Public Health)

Yes, of course, Mr. O'Hara. I want to reinforce our recommendations to the NHS to follow the toolkit, and to welcome the important points in the all-party group's report, endorsing the advice, and my hon. Friend's comments. Although, of course, the management and organisation of local NHS services is a matter for NHS managers, we shall expect and encourage the local management and organisations to focus on the implementation of the recommendations, and to put sensible plans in place.

I can assure my hon. Friends the Members for Cardiff, North and for Keighley that the Government take the matter of TB very seriously and that, despite our recognition of the devolving of responsibility for many decisions to PCTs, it is still important for the Department as a whole to stay focused on the matter and to encourage PCTs to do likewise. As I have said, our key strategy is to support the NHS and encourage the strengthening of TB services. To promote the use of the toolkit we supported a series of interactive workshops through the strategic health authorities in England and with PCTs. At those events commissioners, TB service providers and other stakeholders are encouraged, using the toolkit, to review and reconsider their local response, not just to current TB issues but to potential future challenges.

Finally, I note that the report proposes, as my hon. Friend the Member for Cardiff, North mentioned, repeating the survey on an annual basis. The timing of the survey was soon after the launch of the TB toolkit last year, and so perhaps we should not be surprised about how far we have to go, and how encouraging the results are; some PCTs have not implemented the recommendations. I shall certainly be interested to see from future surveys how well we have progressed in the work with PCTs, to ensure that the right services are being commissioned; I shall be interested in an assessment of that, and in the chance to consider how effective the changes in the local health service have been, alongside the work identified by the Department. My hon. Friend has clearly identified a major public health issue, which needs to be reinforced through the regional directors of public health; I intend to do that.

Sitting suspended.