Influenza Pandemic (S&T Report)

My Lords, I add my congratulations to the Science and Technology Committee on their report, which is beautifully argued, concise and clear. It makes clear recommendations to the Government. I congratulate our Government—I know that the Minister will be delighted to hear this—on having got as far as we have in this country with contingency planning. I add my voice to that of others in saying that we appear to be better prepared than most, although that does not mean that we are well prepared enough. Some serious points have been made in this excellent debate, some of which I will touch on briefly, and some which I shall address more substantively. The number of available doses of Tamiflu was addressed by several noble Lords—particularly the noble Lords, Lord Broers and Lord Mitchell. How can the decision be made that 14 million doses of Tamiflu are enough? It could well be argued that they will be too many, and equally well argued that they could be too few. The thinking behind the decision, however, is not clear to us, and was clearly not obvious to the committee. It would good to hear the Minister address that point. Secondly, our level of preparedness for making vaccine was raised by the noble Baronesses, Lady Masham and Lady Sharp of Guildford, and the noble Lord, Lord Patel. Why did we not move faster, as the Americans seem to have done, to work on vaccines when we are world leaders in some kinds of vaccine production? Thirdly, I have a short but difficult question for the Minister: who will be the key protected workers? It always seem that, when we talk about key workers, we think of health workers, the fire service, perhaps the clergy—as the right reverend Prelate the Bishop of Southwell and Nottingham suggested—and perhaps members of the Government and, possibly, the Opposition. I can see the Minister shaking his head, but I have argued the point. However, we always forget that, in order to enable a lot of those people to get to work at all, there are those who provide childcare and care of the elderly. The decision as to who the key workers are, who get the first go at the vaccines and drugs—if the drugs are going to be used prophylactically—is an important question that the Government need to address. Lastly, I have a short but difficult point which many have made, including the Science and Technology Committee: what is going to happen with having a Minister at Cabinet level with responsibility for addressing the possibility of an avian flu pandemic, or other major contingencies? Can the Minister give us an answer today? I am representing the noble Baroness, Lady Finlay of Llandaff, in my speech, because both she and I were invited to, and supposed to be at, the Anglo-French Colloque chaired by the noble Lord, Lord Stevenson of Coddenham. We agreed that she would go and that I would stay and make at least that part of her speech that other noble Lords had not yet made. I will indicate the points that are hers and not mine, which seemed to be fairest way to deal with that. I have several points that I wish to make myself. The first is one on which I have the greatest personal experience—the readiness of the National Health Service, and, in particular, the PCTs, should a pandemic arise. The committee’s report expresses considerable concern over the readiness of the NHS to deal with an outbreak of avian flu. Questions have been raised about the stockpiling of drugs and the capacity of the system to deal with a surge in primary care consultations. The Royal College of General Practitioners, and others giving evidence, argued that a contingency plan for 5,000 to 10,000 additional flu-like consultations a week—compared with a normal 30 consultations per 100,000 for flu and a pandemic standard of 250 per 100,000—begs enormous questions of our contingency planning. What will the Government do to ensure capacity? Is there sufficient capacity in the system at all, or will we want to bring it in from, say, Germany, where doctors have been striking because of pay and coming here to spend their weekends? Alternatively, will we want to stop international travel, which will render that impossible? Will be want to bring in retired doctors to increase capacity and, if so, what arrangements are being made to enable that? Is there sufficient energy and capacity in the PCT system to cope? My honourable friend in another place, Steve Webb, the Member for Northavon, did a survey of PCTs, published earlier this month, suggesting that some 20 per cent of them are affected so severely by the current NHS shake-up that their plans for a possible outbreak of avian flu lack urgency. That suggests that 80 per cent do not feel like that, but 20 per cent is too many. It is a serious point. My own experience of chairing an NHS trust, and at the King’s Fund, suggests that it takes something like 18 months to two years for organisations to recover from reorganisation. If we are facing the possibility of a pandemic in the relatively near future, we cannot take the risk of reorganisational chaos. Is it therefore now time to stop driving the changes so hard—indeed, to call a halt to mergers? I knew that the Minister would shake his head. It seems that there is at least an argument for calling a halt to rapid change in the system. My first substantive question to the Minister is: can he reassure this House that clear guidance and sufficient support have been given to PCTs to enable them to cope? Secondly, can a halt to changes and mergers now be made? Thirdly—a point made by other noble Lords—will the Minister encourage close links between PCTs and local authorities? The whole point of PCTs being organised as they are at present is that they should share boundaries with local authorities. The evidence in this report, showing that local authorities have not necessarily taken all this seriously enough, suggests that urgent measures must be taken on board and that local government needs to be encouraged in that respect, as the noble Lord, Lord Jenkin of Roding, and the noble Baroness, Lady Byford, made clear. The Government need to take on board a specific question for local authorities: have the Government encouraged local authorities to take on board local questions, such as isolation of an outbreak should one occur? Fourthly, are there plans in place in PCTs? It did not seem that the committee heard sufficient evidence to satisfy it about the local availability not only of antiviral drugs, but of antibiotics, oxygen—which we rely on local pharmacists to supply—and other drugs and supplies that might be needed. Can that situation be reviewed now, rather than at the beginning of a possible pandemic, when it may well be too late? If the Minister is able to reassure us about that and tell us that the current planning blight that emerged in evidence to the committee and elsewhere will be lifted to allow proper preparations, I believe that the House will be very relieved. My second major area of concern, which the noble Baroness, Lady Finlay, shares, concerns rationing and how PCTs will encourage self-management. How will district nurses be encouraged to ration their services? How will triaging be worked? How will GPs know how to ration antiviral drugs? What about the other drugs, which the noble Lord, Lord Patel, mentioned? What about the rationing of vaccines, if we do not have enough for everybody? Who are key workers? What decisions have been made about whether drugs should be given prophylactically and to whom, or whether they should be given only in confirmed cases? At what level of diagnostic certainty does dispensing come into force when we have no quick, definitive diagnostic test for avian flu thus far? The noble Lord, Lord Patel, made that point. Will the Department of Health monitor outcomes to inform the prescribing algorithm? How will district nurses care for the sickest at home so that massive hospital admissions can be prevented and isolation maintained? Will we be able to recruit a sufficient number of retired district nurses to help? Indeed, can the Minister tell us whether any planning has been done by Government, the chief nurse or the Royal College of Nursing on this? We need to know. My third area of concern is about the flu surveillance unit of the Royal College of General Practitioners—and I must declare an interest as an honorary fellow. Other noble Lords have also made the case that the flu surveillance unit has an international reputation, but it does not know about its funding beyond April and has spent 18 months trying to get reassurance on it. Can the Minister give us reassurance on it? The Health Protection Agency and primary care trusts gave interesting evidence to the committee. Mrs Hutchinson’s evidence was that it took some time—how can I put it better?—to sort out the relationship. There was also Pat Troop’s evidence about the squeeze of resources on the HPA at the time of the review of arm’s-length bodies and the ongoing budget squeeze. None of us wants to see a proliferation of arm’s-length health bodies, but it makes sense in the present circumstances, with a pandemic possibly on the horizon, for the HPA not to feel blighted or squeezed, as the noble Lord, Lord Mitchell, said. Similarly, the Royal College of General Practitioners’ flu surveillance unit needs to be reassured that it has a future and can carry on with its excellent work. It is surely a question of priorities until it is clear whether we face a pandemic. On my fourth area of concern, I shall quote the noble Baroness, Lady Finlay, on the issue of research:"““If research projects are not in place and ready to start in the event of a pandemic, then potentially many lives will be lost unnecessarily. Protocols must be worked up in detail and be through the different regulatory hoops for data and sample collection, for comparing the efficacy of single versus multiple antiviral drug regimes, and for comparing the therapeutic management of complications and infections. If the projected figures are right, then at least 50,000 will be so ill they will die. After a few hundred cases it could become clear how the severely ill should be managed, if they are all systematically studied. One model would be to use a cluster randomisation design so that, for example, all cases in Nottingham received one form of treatment such as steroids early when their lungs were affected but another cohort, say in Swansea do not. We have no idea if steroids will confer a survival advantage by suppressing the immune inflammatory response to the virus or will impair survival by precisely that anti inflammatory effect allowing the viraemia to progress. Yet if the question is answered in the first 1,000 deaths, the subsequently 49,000 projected deaths may be reduced. But when infection hits it will be impossible to write a protocol, obtain funding, get ethics approval and get the data collection system in place. Our regulatory framework around research is tight in this country, yet good research saves lives””." The noble Baroness is arguing that perhaps the Civil Contingencies Act could come into force, as the noble Lord, Lord Winston, suggested, and impose such data collection, but unless all this is thought through in advance, such organised research will not happen and lives will be lost. The noble Baroness argues that,"““it seems wrong to wait and rely on draconian powers when responsible debate and public planning could air views and educate now””." I wholly agree with the noble Baroness on this. Although I am passionately in favour of consent from the public and believe that the ethics approval system in this country is very well organised, I believe that the public will want this research. However, they will need to understand it and to give consent in advance. It would be good to hear from the Minister that this planning is taking place now and that we can expect public announcements about it shortly. My fifth point is also one raised by the noble Baroness, Lady Finlay. What will happen with the devolved administrations in the event of a pandemic and the Civil Contingencies Act coming into force? Will the Cabinet Office, the committee or whoever is going to have responsibility override or impose decisions taken by the devolved administrations and their Ministers? How is planning about different grass-roots protocols being co-ordinated for consistency? How much is being devolved to individual nations? Who is checking on compatibility between nations? Further to the relationship with devolved administrations, will the Minister tell us what is being done with other EU countries, given what we know about the different rates of planning, the joint planning exercise and the fact that avian flu may be reaching Europe via Turkey? A disturbing article in the Lancet yesterday suggested that there is no evidence that Tamiflu will be as effective as people have hitherto suggested. Its authors warn strongly against relying on drugs to stamp out a potential flu pandemic.  They suggest that we may be guilty of a certain amount of complacency. I am neither a scientist nor a doctor, but I found the article—which I have just got from the Library—somewhat disturbing. Its authors suggest that we should be thinking hard about older, more conventional public health measures on hygiene and isolation. They said that barriers, distance and personal hygiene are important factors in preventing the spread of avian flu. They also said that the use of Tamiflu could potentially increase the spread of the flu virus—people might take it when they have the virus, go back to work because they feel badly owing to such a shortage of staff in place, and spread the virus around. In case people do not take that possibility seriously, I remind noble Lords that the Minister was very poorly—not, of course, with avian flu—at the end of last term, when we were debating the dental regulations. He pushed himself to come to work. We need to consider seriously the extent to which we want people to stay at home and not spread the condition. On that issue, the Department of Health has said that it is misleading to claim that Tamiflu and Relenza are ineffective against avian flu. However, in its press release, it stated that it was looking for a back-up strategy. It would be helpful if the Minister could tell us who is looking for a back-up strategy and what kind of strategy they are thinking about. I have a few final points. First, there is a question of alternative treatments. Chapter 7.17 of the report refers to,"““the bank of immune immunoglobulin for future prophylaxis””." Will it be possible for antibodies derived from the plasma of convalescent patients to be used, as the Academy of Medical Sciences was suggesting? Dr Wood of the National Institute for Biological Standards and Control suggested that that would be quicker than making vaccine. Will that be possible, or will it not be allowed because of precautions against the spread of new variant CJD? Will we now do the risk analysis to identify whether the benefits of a so-called fractionation using that plasma outweigh the risks? Will this risk analysis take place now, at the preparatory stage, so that reasonable assumptions can be made about the risk of transmission of variant CJD and about the benefit of reducing influenza morbidity and mortality? That all relates to the preparedness of government and researchers. The public need to know that government and researchers are on the ball. Will there be a Minister at Cabinet level to co-ordinate that? Will regulation of research be considered and questions about risk and benefits be tackled? Will something be done to settle the mood of some PCTs that are worried about what is happening? Can we work out whether we have the right amount of Tamiflu stockpiled? Can we think more about hygiene, protection and isolation? Lastly, above all, as the noble Lords, Lord Winston and Lord Giddens, asked, can we hear more about the Government’s communication strategy, so that the population will trust the Government?