[Mr. Martyn Jones in the Chair]
I am pleased that my hon. Friend the Member for Derby, North (Mr. Laxton), who is chairman of the all-party group on hepatology, secured this debate. Unfortunately, he is unable to be here because he has had a minor operation in hospital that involved his mouth and it would have been a little difficult for him to deliver his speech. With the kind permission of Mr. Speaker, I have been asked to open the debate in his place, as vice-chairman of the all-party group.
We have only one liver, and it is a vital organ. Because I am a chemist, I have always described it as the chemical factory of the body. It processes all our waste metabolic products after the body has abstracted the vital carbohydrates, fats and proteins and the essential vitamins and minerals on which our life depends. If it begins to fail, a backlog of toxic chemicals throughout our system causes us all sorts of problems, and multiple organ failure results in death if those toxic products are not removed. We cannot ignore that vital organ—it is precious and, as I have said, we have only one.
Liver disease is caused by inflammation of the liver, or hepatitis, which can be provoked by alcohol or other drugs or by various viruses. It can also be provoked by antibodies directed at the liver. That is called auto-immune liver disease, and it predominates in women and is possibly genetically linked. Other causes of liver disease are excessive iron or fat deposition in the liver and a variety of much rarer diseases that are difficult to detect. Inflammation can become chronic and progress through cirrhosis of the liver, which is a scarring of the tissue, otherwise known as fibrosis, and has a high mortality rate, to cancer of the liver. I hope that my hon. Friend the Member for Norwich, North (Dr. Gibson) will appear here to tell us more about cancer of the liver.
A number of viruses affect the liver, the most common being hepatitis A, B, C, D and E. Only B, C and D can cause long-term disease, and the hepatitis D virus can survive in our bodies only if we are also infected with the hepatitis B virus. Carriers of those viruses might not exhibit symptoms of the disease, and indeed they can be carried for long periods. There are simple tests to detect them, which can be followed by a liver function test if necessary, and even by a liver biopsy, which is not a pleasant procedure, or a less interventional procedure known as ultrascan.
There are two reasons for my interest in the debate, both of which arise from my interest in hepatitis C. Early in my parliamentary career, a constituent called David Fielding came to see me. He was extremely ill with hepatitis C, which he had contracted through contaminated blood transfusions. David was a haemophiliac. Tragically, his brother, who was also a haemophiliac, died after contracting the same disease in the same way. Eventually, David Fielding was admitted to the Manchester Royal infirmary. Just before Christmas one year, when he was in critical condition and expected to die, he and his long-standing partner decided at long last to get married.
Then David received what I expect was the best Christmas present that he or his family will ever receive. A call came from Jimmy’s hospital in Leeds, saying that at long last a matching liver had been found for him. The hospital had been looking for one for quite some time. He was rushed across the Pennines in an ambulance and thankfully, he is alive today because of that important liver transplant. Before the transplant, he looked awful. I met him several times and he was always yellow, full of the jaundice that people with failing livers experience.
I am pleased to report to the House that today, David is well and without the hepatitis C virus. He is campaigning to bring to the surface the truth about contaminated blood, much of it collected from prisoners in American jails, and has been to every sitting of the Archer inquiry, the results of which will be out later this year. I have given evidence to it, and I hope that our Government will take note of Lord Archer’s findings for the sake not only of David Fielding but of all the other people who are seeking the truth about the blood that transmitted to them viruses such as hepatitis B or C or HIV. An estimated 2,000 to 3,000 haemophiliacs received contaminated blood in this country before the Department of Health realised the huge risk of imported, contaminated blood.
My point in telling that story is to highlight the need for more people to register as potential organ donors. There is a staggering 500 per cent. projected increase in demand for liver transplantation in the next six to 10 years, which is a very short time span, and a similar projected increase in the incidence of liver cancer. Even with a vigorous organ donation campaign, there will not be enough livers to save all the lives that will be at risk. That is one reason why I have supported stem-cell research, which might allow us to grow tissues in the laboratory for the repair of organs such as the liver. Some 38 people die from liver disease every day in this country, and 100 people on the waiting list for liver transplants die every year. The huge shortage of livers for transplantation means that early diagnosis and treatment of liver disease is a far better option.
The second reason for my interest in the debate comes from my interest in the misuse of drugs. Whether they are controlled, prescription or over-the-counter drugs makes no difference. I am the chairman of the all-party group on drugs misuse. Some 80 per cent. of those who contract the hepatitis C virus, which I shall call HCV, do so as a result of injecting drugs and sharing syringes and other paraphernalia with other people. That is particularly the case in prisons, where we could do much more to prevent the spread of blood-borne diseases. Anyone in contact with the blood of an HCV or hepatitis B carrier is likely to pick up the viruses, as they are readily transmitted through contact with blood.
People such as David Fielding, who contracted HCV as a result of blood transfusions, have been extremely reluctant to campaign on the subject because of the stigma associated with it. However, the late Anita Roddick, of The Body Shop fame, who was a patron of the Hepatitis C Trust and contacted HCV as the result of a blood transfusion during childbirth, more than 30 years before the disease displayed symptoms throughout her body, was brave enough to campaign. HCV can lie undetected for such long periods without a patient feeling the symptoms, which start with dreadful fatigue, headaches and depression, leading to the other difficulties that I have mentioned. Anita’s husband has given the Hepatitis C Trust permission to use her image, and people will see posters advertising its work in the medical magazines and in public places throughout Britain. I wish to put it on record that we are very grateful to Anita Roddick’s family.
We chose to request the debate this week because it is national tackling drugs week—I shall be spending some time with the co-ordinator of our drug and alcohol team in Bolton on Friday—and because last Monday, 19 May, was the first ever world hepatitis day. It involved 200 patient groups in 15 countries and was co-ordinated by the Hepatitis C Trust, helped by all the organisations with an interest in liver disease.
Deaths from infectious diseases, cardiovascular diseases and cancer have been showing a strong downward trend in recent years, but, tragically, deaths from liver diseases in that same period have been showing quite the opposite: a strong upward trend. Sadly, the UK is the only developed country exhibiting that upward trend.
Obesity leads not only to diabetes but to fatty liver disease. Non-alcoholic liver disease may develop in people who have insulin resistance and type 2 diabetes. The condition is mostly preventable, of course, through exercise and by eating healthier foods, and I am pleased that the Government are paying attention to obesity.
I mentioned that contracting hepatitis C can result in mortality, as can contracting the hepatitis B virus, but excessive use of alcohol causes about 25 per cent. of liver disease, and more and more people are dying of it as a result. Younger people are starting to consume strong alcohol at an early age. Tragically, an increasing number of them, too, are being admitted to hospital with liver disease.
Many people with alcoholic liver disease are not actually alcohol-dependent, and they think that they are drinking alcohol safely when they are not. They are drinking alcohol at hazardous levels, and a change in their behaviour could save their lives. I am pleased that the Government are also concentrating on excessive alcohol consumption, otherwise known as binge drinking.
Deaths from alcoholic liver disease have doubled in the past 10 years. Patients with alcoholic cirrhosis are heavy users of expensive hospital resources. They occupy beds, including intensive care beds, that need not be occupied, and they require blood and various medical interventions from the national health service. All of that is avoidable. The NHS could make huge cost savings, and facilities could be released for those who have not made themselves ill in that way.
Heavy alcohol use in the person who carries the hepatitis C virus increases the risk of hepatitic cirrhosis 31 times, and the risk of developing cancer of the liver in an HCV-positive person with cirrhosis is increased seven-fold. The message is that drinking and hepatitis C together greatly increase the risk of mortality.
Everything that I am about to say about hepatitis C is probably true also of hepatitis B, but, sadly, there is not even a strategy within the NHS to deal with HBV. The Hepatitis B Foundation, which is calling for such a strategy, told me that the Department of Health has not carried out any research to ascertain the figures for the disease, but it estimates that there are about 320,000 carriers of HBV in the UK at present, many of them in a chronic condition. Worldwide, 350 million people are known to be chronically infected with HBV, and between 0.5 million and 1 million people die with the virus every year. It is second only to tobacco as a human carcinogen, causing 50 per cent. of all liver cancers. HBV can survive in dried blood for up to one week. It is 100 times more infectious than HIV, which may surprise people. Worldwide, the most common infection route is vertical transmission from mother to baby but, like HCV, HBV is a common disease among injecting drug users.
Fortunately, a vaccine is available for preventive treatment of HBV, but, sadly, the UK is one of the few countries in Europe that has not yet implemented the universal vaccination policy recommended by the World Health Organisation. In fact, 85 per cent. of countries throughout the world have already adopted it. There are reports that some doctors in general practice are charging as much as £160 for the vaccination—for a single HBV vaccination—probably in the belief that the patient will be reimbursed by their employer, which is not always the case. Fortunately, several drugs are available to treat HBV sufferers, but only about 1,500 patients are receiving such treatment in the UK annually.
The hepatitis C virus was identified in 1989. Such viruses are relatively new. HCV is the biggest cause of chronic liver disease in the world. It also damages kidneys, white blood cells and the thyroid gland.
I am interested in the point the hon. Gentleman made about the virus being relatively new. In his expert opinion, is the virus a new one or is it that we have only recently discovered it using new techniques? Is it new, or has it always been there?
I cannot answer the question exactly, but the virus would have been around prior to 1989. It was detected in 1989 and researched, and we are where we are today. I do not think that it has been around for a very long time. We are still discovering new hepatitis viruses, and they have been given letters of the alphabet from A to E. We may be up to G now.
HCV is an enveloped ribonucleic acid of the flaviviride family and is incredibly difficult to destroy. It is capable of surviving in dried blood for up to three months—much longer than HBV. It has a high mutation rate, and it is thought that six strains, each with 40 sub-strains, currently exist, which are capable of spontaneous mutation. That is the problem. For that reason, it has not been possible to develop a vaccine for preventive treatment of HCV.
The Hepatitis C Trust believes that as many as 500,000 people may be infected with HCV in the UK, with 90 per cent.—certainly 80 to 90 per cent.—of them being completely unaware that they are carrying the virus. An estimated 130 million people are affected by HCV worldwide.
The earlier a person is diagnosed with HCV, the easier it is to treat them. Treatments are more limited for HCV than they are for HBV. Treatment for HCV is carried out through combination therapy. The complete treatment programme, which combines a daily tablet of ribavarin with a weekly injection of alpha interferon, costs an amazing £15,000, and not everybody is cured. About 55 per cent. of the people who undergo the combination therapy will be cured. The rest will not, and they may or may not live longer.
People tell me that the combination therapy is not very nice. I have spoken to several people who have undergone it. It lasts between six months and a year, and most people cannot work while they are undergoing it.
The cost is £15,000 per year, but I put it to my hon. Friend the Minister that the cost of a liver transplant, even if a liver were available to transplant into the patient, is considerably more than preventing people from getting HCV in the first place or treating them when they have been infected by it.
I am interested in my hon. Friend’s comparison of costs of transplants and so on. Would a person be healthier as a result of a transplant rather than the treatment? He said that the treatment was unpleasant, and that people are reluctant to have it.
While I am on the subject, would my hon. Friend support an assumption in favour of donation of organs after death? We do not seem to be progressing at all with receiving organ donations. I mention that because my second late husband, John Hammersley, died from liver cancer. I think that he would have been too old for organ donation, but it still grieves me to think that I was never asked whether my first late husband’s organs could be used. He died from injuries resulting from a motor car accident and was taken to hospital with me. We are lacking in this area. Will my hon. Friend explain his position on the matter?
I know of the tragic loss of my hon. Friend’s second husband from liver cancer. Although as a chemist I have limited knowledge of medicine, I am in favour of opting out of organ donation, rather than opting into it. That is a controversial topic in this place. I have carried an organ donation card for decades and renewed it recently to ensure that my name is still on the list, although I am afraid that I am almost 68 and my organs are a bit knackered compared with those of a younger person, so they may not be useful any more.
In March 2001, the Department of Health commissioned a hepatitis C strategy for England, which was released for discussion in August 2002. I am pleased that the hepatitis C action plan for England was published in July 2004. The all-party group on hepatology, which was formed only in 2003—in the presence of the late George Best, who was one of our original patrons—and the Hepatitis C Trust became concerned about the implementation of the Government’s plans, so we jointly published “The Hepatitis C Scandal” in March 2005 to voice our concerns about that area of clinical practice.
On 23 May 2006, we published the results of a survey of primary care trusts and NHS hospital trusts. Questionnaires were sent to all of them, and as we received the answers we marked the implementation of the plan on a scale ranging from one to 10—one being poor and 10 being the best. About 63 per cent. of PCTs responded, but only 8 per cent. of them demonstrated effective implementation of the hepatitis C action plan laid down by the Government, with a further 56 per cent. demonstrating that they had taken some action and the remainder—36 per cent.—demonstrating only minimal implementation of the plan in 2006. Where a patient lived at that time very much determined whether they received a diagnosis or, having received a diagnosis, treatment for hepatitis C virus infection. Indeed, our report was titled “A Matter of Chance”. In 2006, 65 per cent. of NHS hospital trusts responded, and 39 of the 85 hospital trusts reported significant delays for treatment. Waiting times varied from one week to one year, which is unacceptable.
Jointly, with the Hepatitis C Trust, our all-party group has just repeated that survey. Our current report, “Location, Location, Location”, was published on 14 February this year. About 84 per cent. of PCTs responded on this occasion. There has been a significant improvement since the last survey, but still only 36 per cent. of PCTs are implementing the hepatitis C action plan for England effectively this year. I am pleased to say that Bolton PCT—my own PCT—is one of the best, scoring nine out of 10 points. Unacceptably, 15 per cent. of the responding PCTs have demonstrated minimal or no implementation at all, while 49 per cent. demonstrated that they have taken some action. Mid Essex PCT scored no points, Dudley PCT and South West Essex PCT each scored one point, while Lincolnshire NHS Teaching PCT, Western Cheshire PCT and Newcastle PCT scored only three points. Those were the worst responders among the primary care trusts.
Some 59 per cent.—37 of the 63—of the NHS hospital trusts that responded reported that some of their patients had to wait more than three months for their first consultation at the hospital. In addition, they said that referral waiting times to see a consultant varied from three to 20 weeks and that patients waited a further two to 24 weeks for treatment to commence. Adding those figures together gives an unacceptably long period, which we need to reduce. Less than two thirds—62 per cent.—of responding NHS hospital trusts are confident that they will have the necessary infrastructure in place to ensure that all hepatitis C positive patients can start treatment within 18 weeks, which is the target for December 2008 set by the Government.
The Government’s action plan was launched more than three years ago and its limited implementation is putting a lot of people’s lives at risk, so we are calling for action now from the Secretary of State for Health in four ways. First, we want the introduction of a world-class commissioning pilot in the treatment of those diagnosed positive for HCV. Secondly, we want a good practice model developed for service organisation and delivery as part of a wider reform strategy for the diagnosis and treatment of HCV carriers. Thirdly, we want the Secretary of State to incentivise general practitioner HCV case-finding by inclusion in a quality and outcomes framework. Fourthly, we want the Government to conduct a national audit of GP practice for HCV, based on the model being piloted for cancer referral and diagnosis. Those campaigning on behalf of patients with hepatitis B virus want similar progress made by the Department of Health.
Consultants report that immigration brings in both HBV and HCV—their words, not mine—and they believe that we should be screening new arrivals who will be settling in Britain, not tourists I hasten to add, for both viruses, if not all the hepatitic viruses. Hepatitis B and C are ticking time bombs for the NHS, and in light of the evidence I have presented today, I think my hon. Friend the Minister will agree that we need to review both the diagnosis and treatment of those who could be carrying those viruses. They are readily transmitted, blood-borne viruses, so the more people who carry HCV and HBV, the greater the risk of further transmission, with the inevitable consequences for the NHS.
In respect of what my hon. Friend said about increased immigration bringing in more of these diseases, is he aware that a few years ago it was drawn to my attention that members of the Muslim community were reluctant to donate organs, which meant greater difficulty in matching organ donors to organ recipients? I was asked by the then district health authority to do a bit of campaigning with my Muslim community to encourage organ donation. Is it still going on or has it been allowed to slip? There is something in the Muslim religion that is a deterrent to organ donation, but apparently it can be got around with a bit of thought and imagination.
I thank my hon. Friend for raising that matter. It is a sensitive subject. I, too, have a large Muslim population in my constituency, as she knows. I have not personally discussed the matter with my Muslim constituents, but as it has been mentioned in the debate, I promise my hon. Friend that I will have such discussions. I am sure that the Minister and his officials have listened to what my hon. Friend has said. I hope that, in relation to what I have said already about organ donation, we can extend that conversation to the whole Muslim population throughout the country.
The prevalence of HBV and HCV and the mortality rate they both cause is now on the same scale as HIV/AIDS, tuberculosis and malaria worldwide, yet there is nowhere near the same level of awareness of viral hepatitis as of those other diseases. Additionally, there does not seem to be the political will to tackle it. A recent survey of Members of Parliament showed that one third of them think that there is a vaccine for hepatitis C when there is not, 44 per cent. do not know that hepatitis C can lead to cancer—yet it can—and half of them have been contacted by a constituent about hepatitis C. I am not blaming or criticising my right hon. or hon. Friends, but if that is the case among Members of Parliament, how can we expect our constituents to be aware of these dreadful diseases? I have also heard that many general practitioners are not fully educated in the facts I have presented to the House today.
In May 2004, a number of organisations associated with liver disease, including the British Liver Trust—a charity—and the British Association for the Study of the Liver published the “National Plan for Liver Services UK”, which I am sure that my hon. Friend the Minister or other Ministers in his Department have seen. They published the document in an attempt to persuade the Government to develop a national service framework for this major area of clinical practice. What consideration, if any, has the Minister’s Department given to that plan?
In conclusion, I hope that I have demonstrated to right hon. and hon. Members today and to people outside Parliament, including those in the medical profession, that tackling these diseases—liver diseases in general, but particularly the hepatitis diseases I have mentioned—needs to be done much more ferociously; otherwise the ticking time bomb that I have mentioned will explode upon us.
I thank the hon. Member for Bolton, South-East (Dr. Iddon) for securing the debate. It is a shame that more hon. Members are not here to take part—I do not know whether that is because there are political imperatives elsewhere. The subject is important, but it is often neglected. We rarely hear people talking about liver disease of any type, so it will be interesting to explore some of the reasons for that.
The hon. Gentleman referred a number of times to the document “Hepatitis C: Action Plan For England”. I had a little bit of fun while preparing for the debate because I was aware that on 22 February 2007, the Government announced an update to the 2004 action plan. Much to my surprise I could not find that information on the Department of Health website. I asked my researcher to call the Department, which claimed not to have heard of the update. The Minister is looking in a rather worried way at his officials behind him; it would be interesting if he could clarify whether such a document exists. If it does—and I sincerely hope that is the case—does he share my concern that the document is apparently of such low priority that the officials we contacted were fairly clueless regarding its whereabouts?
As the hon. Member for Bolton, South-East said, the scale of liver disease is large. It is the fifth biggest killer in the UK, and the only one of the top five that is on the increase. More depressingly, the UK is the only major developed nation showing an upward trend in the number of deaths from liver disease. I do not know whether it is a help or a hindrance to read out some of the statistics, but I shall do so to reinforce the message about the scale of the problem. Up to 2 million people suffer from chronic liver disease in the UK, and most are unaware of their illness. In the past three decades, deaths from chronic liver disease have increased by eight times in men aged 35 to 44 years and seven times in women. In 2005, as many as 13,000 people died from liver-related conditions in the UK.
If those statistics related to any other illness, it would almost be a national scandal. I find it rather puzzling that relatively little attention is paid to the problem, particularly because it also relates to deprivation, which the Government claim that they want to tackle. I do not disbelieve that they want to deal with the problem, but it is worth considering that, in 2006-07, there were three times more liver-related deaths in the hospitals in the most deprived areas than in those in the least deprived areas. Among 25 to 49-year-olds, there were 10 times as many deaths in the most deprived areas as there were in the least. Therefore, when we consider some of the problems that spearhead primary care trusts are tackling, given obesity is one of the factors that can contribute to liver disease, it is important to get some of these messages across.
I shall concentrate most of my remarks on the more preventable aspects of liver disease. There are three main causes of the preventable type: alcohol, obesity and viral hepatitis. The hon. Gentleman rightly spent much time talking about hepatitis and the incidence of it. He was right to point out that, worldwide, the prevalence of hepatitis B and C in relation to mortality is on the same scale as HIV/AIDS, tuberculosis and malaria. Those working in the TB or malaria field feel that they play second fiddle to the HIV/AIDS debate, but nobody ever mentions liver disease in the same context. There seems to be no political interest in the subject. I do not know whether that is because there is a lack of an effective lobby group or if it is because we do not see large-scale pictures on our TVs of people dying. Perhaps there is a stigma about liver disease, because it is often associated with alcohol abuse. Nevertheless, the issue is something that we need to tackle.
Patient groups have united as the World Hepatitis Alliance and are asking Governments to sign up to something called “12 asks” by 2012—[Interruption.]
Thank you, Mr. Jones. Governments are being asked to sign up to something called “12 asks” by 2012, to recognise the impact of the disease and to commit to adopting measures that address the problem from a public health perspective. The UK Government have not yet signed up. Will the Minister tell us when they are likely to do so?
Despite the action plan on hepatitis C, diagnosis is often delayed. A common problem is that GPs know little about the disease and are poor at diagnosing it. That is probably compounded by the fact that there is a lack of specialist nurses to deal with the condition. The hon. Member for Bolton, South-East mentioned the survey conducted by the all-party group. I will not go into the full details of that, but I am pleased to see that some progress is being made. The most telling fact is that two-thirds of primary care trusts are still falling short on some aspects of provision. Steps to improve hepatitis C prevention, diagnosis and treatment must be a higher priority if we are to tackle the problem successfully.
There are some quite simple things that we could do. None of them on its own will make the problem go away or reduce it dramatically, but they could be useful. One suggestion is that we could test in prisons, because 9 per cent. of prisoners test positive for hepatitis C and 8 per cent. test positive for hepatitis B. If those people can be treated or made aware of their condition, we may be able to do something to reduce future transmission.
The hon. Gentleman mentioned drug usage. Again, there seems to be little effort to work directly with drug users on testing to see whether something can be done. I acknowledge that this is a difficult group to work with, but there are people with expertise in working with drug users who could get the message across to some of them.
I wholeheartedly support the sentiments that have been expressed about increasing the number of organs for donation. I say that not only in relation to liver disease, although liver transplants are a classic example of a procedure that has been shown to work; recipients have gone on to have many years of happy and productive life. Yes, the subject is controversial, but the House has shown in recent days that it does not shy away from tackling difficult issues. Personally, I would prefer an opt-out system, but I appreciate that not everybody shares my view. The comments made about ethnic minority communities were very interesting, because we must work with all sectors of society if we are to benefit them.
Recent estimates show that approximately 326,000 people have hepatitis B. I read somewhere that 85 per cent. of developing countries—I assume that it must have been developing countries because it is hard to believe that that is a global figure—have implemented a universal hepatitis B vaccination campaign. However, the UK operates only a system of selective vaccination for high-risk groups. When the Minister sums up, it would be helpful if he outlined whether the Government’s thinking on that has changed. In the past, because new incidences have often been in the immigrant community, the attitude has been that there is no point having a wholesale vaccination programme. Given that the disease is highly infectious and can spread quite rapidly, however, I hope that the situation is under regular review so that the public health impact can be assessed.
The Government are trying to tackle the problem of alcohol misuse, but whichever way one looks at the figures, they are quite a frightening statement about society today. The cost to the NHS of alcohol misuse is £1.7 billion a year. In 2005, 4,160 people died in England and Wales from alcoholic liver disease—a 37 per cent. increase on 1999. The figures for deaths from alcohol-related causes are even starker, with 4,437 people in England alone dying in 1997 and 6,517 dying in 2006.
I recently visited Southampton general hospital and talked to one of the consultant hepatologists. It was fascinating. He said that he could not really show me anything, but that he would just run through his patient list—his work load—for the day, because it was typical of the cases that he was seeing. Compared with 10 years ago, the people on the list were much younger, and there was a higher proportion of women. The other worrying thing was that one person on the list felt that it was pretty much bad luck that she was there at all. She was not a binge drinker and most people—particularly given the drinking patterns in the House of Commons—would not regard her as an alcoholic. This woman simply shared a bottle of wine with her husband every night, and if he is anything like my husband, he will have drunk the lion’s share. Like many others, this lady thought that a few units of alcohol were perfectly acceptable, but she is now faced with a problem.
I recognise that the recent Government campaign is all about trying to increase people’s awareness of how much they drink. I was looking at consumption figures from Office for National Statistics, which all had to be revised upwards recently. If one looked at the figures year on year, it looked as though there had not been much of an increase in alcohol consumption. However, the ONS suddenly thought, “Hang on a minute. We are all drinking from bigger glasses”—that is just the sort of thing that the Government tried to highlight—“and alcohol has got a bit stronger.” When it factored in the increased glass size and the increased strength of what people were drinking, it found that consumption rates had gone up by about 50 per cent., which was quite frightening. Most people are not aware of how much they are drinking. I welcome the Government’s campaign, but I hope that it will be backed by the compulsory use of labels showing the number of units in the bottle. I know that there is a voluntary agreement, but it covers only about two thirds of what is on the shop shelves. Compulsory labels would help those who are minded to do something about the problem to decide which wine to drink. They may just choose to drink a lower-alcohol wine because they can drink more of it.
The thorny question of alcohol taxation also arises, although I do not expect the Minister to answer questions on that. Last week, however, I went on a Health Committee visit to Norway, where the cost of wine is astronomical—indeed, the Select Committee drank far less on that visit than on any other I have been on. I do not think that any of us consider ourselves problem drinkers, but if people want proof that pricing can control the problem, our experience in Norway speaks for itself.
A lot of the European evidence shows that increasing tax—there are ways to do that selectively to target problem drinks—has the greatest impact on the behaviour of binge drinkers and those with a chronic drink problem. Such measures are unpopular, but we must consider them in the long run. We must, however, balance that with ensuring that pubs stay viable and do not go out of business. The good old-fashioned English pub provides a useful social function for those who may live alone and who want to meet friends.
The other cause of regret—I hope that this will be tackled later in the Government’s campaign on alcohol—is the lack of thrust behind efforts to tackle binge-drinking. To an extent, the problem is cultural: young people seem to think that it is perfectly acceptable to go out on a Saturday night and drink large amounts of alcohol. That seems to be the thing to do here, but such behaviour is just not cool in many other European countries. We have to work hard with our young people to change attitudes. That will not be easy, but we must find ways to tackle the problems if we are not to replicate them in the future. The younger people start drinking, the longer they will drink and the greater the impact on society will be.
I have not said much about obesity, because that is not what the debate is about. However, one of the messages that is not getting across to people is that being overweight increases their chances not only of developing diabetes or heart disease, but of dying much more quickly from another disease. I would also welcome a little more focus on that, perhaps from patient groups. It must be brought to the attention of MPs.
I want to end by saying that having an alcohol problem and liver disease does not necessarily mean the end of the world for everyone. Some people will die, and that is the end of it, but in some cases, if people stop drinking, their liver can recover and they can have many years of life. I have witnessed both outcomes. The problem is that it is extremely difficult to get access to alcohol rehabilitation services. In Southampton, the only alcohol-specific charity closed down. If one visits a drug and alcohol rehab centre, most of the workers will say that drink is a large part of the problem, but that it is much easier to get the funding and to treat people if there is a linked problem as well as the drink problem. If the Government are serious about tackling the issue, they must stop thinking that problems are always drug-related. They must ensure that there are resources for those whose drug of choice is alcohol, which is not regarded as a mainstream drug of abuse.
I congratulate the hon. Member for Derby, North on his contribution this afternoon, and on stepping into the shoes of the hon. Member for Bolton, South-East. I know the hon. Gentleman fairly well as a good friend of Gibraltar, and can only imagine that he must find his inability to speak the most difficult situation that he has been in for many a year.
The hon. Gentleman spoke brilliantly today—and I am sure that he is a good friend of Gibraltar as well. I apologise for getting the constituencies mixed up.
The work of the all-party group on hepatology, and its reports, have been very useful not only to the House but also to those who suffer so much. Until I took on my Front Bench responsibility I was lucky enough to chair the all-party group on haemophilia, and would like to join in the call made by the hon. Member for Bolton, South-East for the Government to take seriously the current Archer inquiry, so that we can get to the bottom of the problems that so many people have had, through no fault of their own, because of contaminated blood. I pay tribute to the many groups that have been mentioned, in particular the Hepatitis B Foundation, the Hepatitis C Trust, and the British Liver Trust, which have sent us some excellent briefings. I share the concern that has been expressed that there are not more hon. Members in the Chamber for such an important debate.
The title of the debate encompasses myriad problems that can affect the liver. We heard about many of them, and I shall try to cover as many as possible. The Minister knows that I shall not take a party political line in this debate, but I do not understand the Government’s position on immunisation and inoculation, especially with regard to hepatitis B. I was a serviceman for many years and was inoculated, and my wife was an NHS employee for many years, and was also inoculated. It is obviously only in the more advanced parts of the world that inoculation is carried out, and I want to ask the Minister why the Government have not gone down that route. If he cannot answer now, perhaps he can write to us about the exact position.
Time has moved on; I have heard that initially there was concern about immigration, but as we have seen from newspaper figures in the past couple of days, immigration is rising fast, and the issue cannot just be ignored. We must address the question why, when other countries have taken protection against hepatitis B seriously, we do not appear to want to look at the problem. I do not say that it must be done; I am just trying to find out the reason for the situation, because there seems to be pretty good evidence to support taking action. We heard earlier that mutations occur, almost on a daily basis, I think, in the different hepatitis groups, although, as has been said, it is particularly hepatitis C that is affected.
Liver disease as a whole must be taken seriously. As we have heard, 38 people a day die of liver disease in this country. There are many different reasons for that. The liver is a remarkable organ. I am no doctor, although I think there are hon. Members present who are; but the key is that the liver can regenerate. A couple of weeks ago, a surgeon told me that he had removed 80 per cent. of a liver in an operation, and the liver had regenerated. It is a remarkable organ, which can do what most other organs cannot—repair itself, and regenerate. Bearing that in mind, it is frightening that so many people die of liver disease each day, and so many young people—particularly in relation to alcohol—are seeing consultants.
It is not normal for me to praise the BBC, but it has done some excellent research and produced an interesting report on the topic. It spoke to 115 consultants, 101 of whom responded. Seventy-seven said that they were treating patients under 25 years of age for alcohol problems affecting their liver. That is frightening. I am the father of daughters aged 17 and 19. One of them, who is at Portsmouth as we speak, studying marine biology, is, I think, trying to drink Portsmouth dry. I am told that the Royal Marines have tried to do it for several hundred years and not succeeded.
You should be grateful for that.
Absolutely; perhaps that will get some sense into her head.
There is a cultural problem with young people. I shall not be a hypocrite. I was in the military at 16, and I freely admit that we went out and had some beers on a regular basis. I stress the word beers. The groups of young people that my daughter goes out with talk quite openly about the fact that they drink before they go out—normally vodka—until they get to the tipping point. Then they go out and enjoy themselves. That can be done, I stress, only because the pubs are open so late. The Minister has heard me say this before, but a mixed message is going out to young people, because we have what is called 24-hour drinking which, although we know it is not 24-hour drinking, is late drinking, and is expensive. If young people can drink cheaply early on they do not spend so much money when they are out. However, they are already half smashed, to be perfectly frank, before they hit the pubs—not the clubs, but the pubs. That is a cultural and educational problem that we must deal with. If we do not address that with young people the NHS will never be able to cope with it.
We talk a lot about obesity problems, and that is quite right. We all need to work on that; I am working on it myself, and am on a sponsored slim as we speak, but it is massively important not to forget one subject while another is the focus of topical debates in the press.
A subject that the hon. Member for Romsey (Sandra Gidley) touched on earlier in the debate was the availability of organs for transplant. I have a particular interest in that, and have been asking questions, because I am worried that we shall begin to debate an opting-out approach to donation before we have found out how many available organs have not been used. As the Minister may be aware, I have asked parliamentary questions about the number of viable human organs available for transplant that are not used.
I recently received information from the East of England strategic health authority, which happens to cover my hospital trust area. It had 22 patients waiting for a liver transplant, but five viable human livers were not used, and were destroyed.
The hon. Gentleman’s figures are interesting, but we must be careful how we consider this matter. Clearly, he is aware that we cannot put any old liver into any recipient. A large number of organs need to be available so that appropriate tissue typing can be done, and then those 22 people on the waiting list will be able to receive an organ. It is a shame that some organs are unused, but that is the nature of what is available and what is needed. We have to get that right.
I thank the hon. Lady for that intervention. I am very aware that we need to match organs with people, so I went further and asked questions about whether that was the problem. We cannot have people saying, “We couldn’t find a match quickly enough.” The technology exists to keep organs viable for much longer. We just pack them in ice at the moment, which seems a bit archaic in the 21st century. Technology is being piloted at Papworth hospital that will allow us to keep a liver for much longer while we search for a patient whose requirements make them a match for it.
Let me just finish the point. It is not necessarily that we cannot find a match for the organs. Often, the organ deteriorates before we find a match, but the technology exists to assist us in that respect and I want the Minister to address why we are not using it.
I think that the hon. Gentleman has just answered my point. I was going to say that although I understand that what is taking place is a trial it is having good results and there seems to be a reluctance to adopt the technology in the NHS. Is the hon. Gentleman aware whether that was a national decision or whether trusts were just tightening purse strings and not purchasing anything new?
It appears that other countries have conducted the trials and the technology has been adopted. I am afraid that it has something to do with money. I understand that each unit costs about £10,000, but when we consider the number of organs involved and the fact that the NHS budget is about £110 billion, it is not a huge amount. That technology is a way forward and we must look to such technologies before pushing on to the public the great debate that may need to happen. We must be certain that we are using every organ that is donated. Very difficult decisions are taken when an organ is donated, and we must ensure that we use every viable organ wherever possible. The technology exists. Perhaps we need to consider seriously whether the Government can look at that or whether it is just left to a local trust—of course, we all know about the funding problems in different trusts throughout the country.
I apologise for coming into the Chamber late. I was talking to a reporter from The Guardian about articles that we would like to write on myths and cancer. Before people get to the stage of liver transplants, what about picking up the hepatitis viruses that cause the problem? What about developing a vaccine, as has been done in Cuba, to ensure that hepatitis B, for example, is eliminated from the population? Should we not go the way of prevention, rather than looking for livers that are compatible with individuals?
I completely agree. That issue was discussed earlier, but I understand that the hon. Gentleman is not a mind reader. An important point was raised. I understand from the experts that there are real problems with vaccines for hepatitis C, not least because, as we discussed, it mutates so fast. As a result, it is difficult to develop inoculation. I agree with the hon. Gentleman—we should use medicine before surgical practice wherever possible. I hope that the Minister will comment on that.
I apologise for mentioning something that had been discussed before. I do not know whether it has already been mentioned that about 80 per cent. of liver cancers are compatible with infection by hepatitis viruses. People sit up and take notice when the word “cancer” is mentioned, so I wonder whether the way to make politicians and Parliament sit up and take notice is to point out that the chances of getting a cancer—it may take 10, 20 or 30 years—are much greater in the circumstances that we are discussing. Early development of procedures, vaccines and so on might eliminate many of those cancers, which are viewed as rarer but still take thousands of lives down the line—not tomorrow, but in 10 or 20 years’ time.
Again, I agree that whatever we as politicians and the NHS can do in preventive terms has to be the answer to how we make progress. We have heard about how bad the situation is becoming in terms of people having liver problems, particularly as a result of hepatitis; I will come on to alcoholism and obesity. If we do not address those problems early, the NHS will never be able to cope—not to mention the personal impact on anybody who has cancer. If something is preventable, we should do everything possible to ensure that preventive measures are taken. I am sure that the Minister will agree.
Non-alcoholic fatty liver disease has been mentioned. I was very concerned when I read a report that a consultant from King’s College hospital in London had stated that the disease has overtaken alcohol and viral infections as the commonest cause of liver disease in Britain. That is quite a frightening situation, which we as politicians should address. The public do not understand just how dangerous obesity is and how the human body simply cannot take the things that we are doing to it. The liver is one of the only organs that is able to regenerate itself. If consultants today are seeing more people with that disease, which is related to obesity, the Government’s programme needs to be much more focused and sharp. We may need to scare the public into realising the dangers that they are exposing themselves to.
I remember vividly that when I was a fireman back in the 1980s in Essex, the first magistrates court put a driver in prison for drink-driving over Christmas. I think it was in 1983, after a huge Government and public campaign to show how dangerous drink-driving was and the effects that it had. Eventually, scare tactics had to be used. We had won the argument with most of the public, but people were still drink-driving—there are still such people today; sadly, we seem to be going in the wrong direction now—who needed to be frightened. They needed to be told that they would lose their licence and go to prison if they continued to drink-drive.
Public campaigns are quite gentle nowadays. We have talked at length with the Food Standards Agency about whether we should have GDAs—guideline daily amounts—a traffic light system or both. The public are an interesting group of people. They will not listen until they think that something affects them. It is important that a public education campaign explains how dangerous—indeed, terminal—obesity can be. The effects in terms of liver disease could be at the forefront of such a campaign.
This is a very important area, but one in which public awareness is limited. I agree with the hon. Member for Norwich, North (Dr. Gibson) that if we talk about other effects of liver disease—in particular, cancer—people might start to listen. That is what the newspapers are interested in today. We also need to start to talk about the damage caused to young people. We need a joined-up Government campaign. The Government need to come together on the different problems caused by liver disease. We cannot just talk about the different forms of hepatitis on their own. We have to talk about the effects of alcohol and of obesity.
People who have done nothing wrong—they perhaps had haemophilia and were given contaminated blood—need to know the truth about what has happened to them. I hope that the Government will listen to the Archer inquiry. I stepped down as chairman of the all-party haemophilia group when it first started, not because I was not interested in the group—I was a member—but because I took up Front-Bench responsibilities and I thought that there was a slight conflict of interest. I did not want to jeopardise the group in that way.
I congratulate the members of the all-party group on hepatology for the work that they are doing. It is an excellent group and produces detailed analysis. It is sad that the Government’s action plan is not being addressed, because it is a good one. The Government should ensure that primary care trusts and other organisations throughout the country are implementing the action plan so that we protect all members of the public, not just people who happen to live in a particular postcode and come under a particular PCT.
I congratulate my hon. Friend the Member for Bolton, South-East (Dr. Iddon) on speaking in such a reflective and sensible way. He has highlighted an issue that frankly needs far more oxygen in order to have an impact on many families and individuals. I also congratulate my hon. Friend the Member for Derby, North (Mr. Laxton) on securing the debate and on his work as chairman of the all-party group on hepatology over a significant period.
It is always good to see my hon. Friend the Member for Norwich, North (Dr. Gibson). He has unique expertise on many of the issues that he brings to the House, particularly from a scientific point of view. The notion of needing to move the health service from a sickness system to a well-being system is at the heart of our vision for a world-class health service. It has been mentioned by the Prime Minister, the Secretary of State and Lord Darzi. When we publish the next stage review and the NHS constitution, we need to move from the rhetoric of moving from sickness to well-being and make it a reality. That must happen not only through our national policies but through the decisions, particularly commissioning decisions, made in every local health economy in every part of the country.
My hon. Friend the Member for Bolton, South-East referred to David Fielding. It is appropriate to remember that these issues involve human beings—we are talking about people’s families and their life expectancy—and it is important that we hear stories of hope such as that of David Fielding. Many listening to our debate may be extremely anxious about their future because they have HCV, so it was important to hear about the David Fielding case. It was also right to pay tribute to the courage of the late Anita Roddick. HCV carries a significant stigma, and the fact that a prominent and successful member of society was willing to talk about it was itself a significant contribution. Her family’s ongoing commitment to help with the issue is greatly appreciated.
The hon. Member for Romsey (Sandra Gidley) made a sensible contribution. She spoke about the Government’s commitment, and that of international institutions, to the notion of a world hepatitis day. If such a proposal comes before a future world health assembly, we will consider it. I raise only a slight caution; I think that all hon. Members are aware of it. With so many days and weeks now focusing on a variety of specific issues, the danger is that the notion will become devalued. We need to think carefully about the idea, but in principle I think that it makes some sense.
The hon. Member for Hemel Hempstead (Mike Penning) made a non-party political, helpful and constructive contribution to the debate. I hope that he does not mind my saying so, but I wonder about the parenting skills involved in lecturing one’s daughter about her behaviour during a Westminster Hall debate. None the less, the hon. Gentleman made a serious point about teenagers.
I do not have a daughter. I have two boys, and I share the serious concern expressed by the hon. Gentleman. It is a major issue.
The hon. Member for Romsey and others spoke about children’s and young people’s perception of the dangers and risk of alcohol. Although we have concerns about drug abuse—by no means have we won the argument over the danger of drugs; we still have a long way to go—it is almost as if alcohol abuse is fashionable, has cachet, is trendy and is the norm for young people. We have failed to get across the message that if young people drink to excess it could have extremely serious consequences. It could affect their aspirations and the rest of their lives.
The hon. Member for Hemel Hempstead talked of scaring people. That has its place, but there needs to be a connection between explaining to young people why certain behaviour can have a detrimental effect and them seeing it as being relevant to their everyday lives and their future. The way in which we communicate those messages is crucial. If we are seen as a group of bland politicians lecturing the general public about what is in their best interests, we will not necessarily change behaviour. It is incredibly important for the Government to provide leadership on public health and health education, but the way in which we communicate the message has to be sophisticated and based on evidence of what works, and it has to be segmented to reach the different groups.
I completely agree with the Minister that a bunch of bland politicians is not the answer. The best answer is the sort of support that was given to the all-party group when it first started by people such as George Best. He was a role model and a face—someone that the kids could relate to. Some footballers may be bad role models, but some are good role models and we need to use the good ones to drive this forward.
I agree with the hon. Gentleman. However, we must be careful not to glamorise the issue. We have to be careful when picking role models and celebrities. The late George Best was an important figure, who demonstrated the relationship between his excess drinking and the consequences for his health, and there are others in that position. However, it is important to think carefully about health education and health promotion. We recognise that sending the same messages to different groups does not work. We need to take a sophisticated and segmented approach. I do not speak only of the Government; it is also about society, parents and schools. We have not persuaded a significant number of children and young people that excess alcohol can have a direct impact on their health and life chances. We should therefore seek some consensus on how to tackle these issues more effectively.
It is probably outside my portfolio to say so, but never mind. Adults who collude with young people who drink inappropriately should face serious consequences, whether they run off-licences or similar businesses or whether they are older brothers and sisters—or even worse, parents—who sometimes allow children and young people to drink excessively. I have heard of parents of 13, 14 and 15-year-old young people hosting celebrations and parties within the family home, who preside over situations in which it is acceptable for children and young people to drink excessively. The argument is that they are doing so in a protected environment, but what sort of message does it send out? We all have a responsibility for the messages being sent to our children and young people. Equally, our long history of lecturing and hectoring young people is failing. We have to reflect on the most effective ways of getting the message across.
I come now to the substance of the debate. The Government recognise the importance of liver disease as a public health issue, and the need to ensure that we have appropriate services in place to prevent, diagnose and treat its various forms. As we heard, liver disease is the fifth most common cause of death in this country, for both men and women. It is the only one of the big killers for which the mortality rate is steadily rising. The United Kingdom is the only major developed nation with an upward trend in mortality and we need to understand why.
In principle, as my hon. Friend the Member for Bolton, South-East said, liver disease is almost entirely preventable. The Government are concerned about the increasing incidence of and mortality from liver disease. A substantial programme of work is already ongoing to tackle liver disease and its main causes, which have been spoken about at length. They are alcohol, viral hepatitis, and obesity. In addition, as my hon. Friend is aware, we are considering the development of a specific programme of work on liver disease to cover health promotion as well as the full range of health services. To inform those decisions, officials have undertaken preliminary work on a range of things, including commissioning a rapid critical review of existing evidence on liver disease epidemiology, treatment and services; asking an ad-hoc group of experts chaired by Professor Ian Gilmore of the Royal College of Physicians to produce an overview report of clinical issues; and holding a series of informal meetings with key stakeholder individuals and groups.
That preliminary work culminated in a one-day workshop last week that was attended by health service commissioners, clinicians and representatives of patient organisations. The participants were asked to identify and prioritise areas for future action. It will be no surprise to my hon. Friends that the top suggestion was for an action plan or national strategy for liver disease—all contributors to the debate mentioned that.
Does my hon. Friend agree that liver disease as a cancer is part of the reformed cancer strategy? It is sometimes described as a rarer cancer, but, nevertheless, prevention is part of the reformed strategy. It should be inclusive and there should be joined-up thinking about the causes that lead eventually to cancer.
I agree entirely with my hon. Friend. The cancer strategy would be less than effective if we did not recognise the direct links between the two. If we develop a national liver disease strategy, a relationship between those two things would be essential.
We must also consider how such a strategy will fit with the next stage review, which we are working on, and how we can ensure better commissioning generally, throughout the country, of liver services. We are considering those things and will say more about what we intend to do in the near future.
I should like to clarify something that the hon. Member for Romsey said on the national plan for liver disease, because there is clearly some confusion. The 2004 national plan for liver disease was produced by the British Liver Trust and the British Association for the Study of the Liver. It is an important document—it is informing our consideration of a national strategy for liver disease—but it is not a Government or Department of Health document, so we have certainly not updated it, nor are we aware that anybody else has done so.
That clarification is important because I would have shared her concerns had the situation turned out to be as she described. We should be clear on where the plan originated and why it is impossible for the Department to update a plan that is not ours. She may need to speak to her colleagues to find out what specifically they were referring to.
I would be happy to write to the hon. Lady and other hon. Members, but I suspect that the appearance of the plan on the website does not necessarily mean that it was a Department or Government production. I shall seek clarification on the matter.
It is essential that we keep the all-party group informed of our intentions. My ministerial colleagues have a commitment to meet directly with my hon. Friend the Member for Derby, North in the near future, and he will be welcome to bring his colleagues with him to debate the matter.
More generally, we are concerned about the increasing incidence of, and mortality from, alcohol-related liver disease, and we are committed to tackling the problem. Identifying harmful drinkers as early as possible will help to avoid the serious damage that harmful drinking has on the health of the individual. Drinking also has a major impact on the wider community and society. We are all concerned about antisocial behaviour, which is increasingly fuelled by alcohol abuse, in our local communities.
The Department of Health launched only this week a much-expanded, £10 million sustained public health and education campaign to raise general awareness of units and the health risks of drunkenness. There will also be more help for those who want to drink less. A £3.2 million investment will establish a series of intervention and brief advice trailblazer projects in health and criminal justice settings. Those projects will identify people who drink at harmful or potentially harmful levels and offer them help and advice. As we know, there is a direct relationship between people who end up in the criminal justice system and alcohol abuse.
The Government are also investing £650,000 in training which could, within 10 years, produce 60,000 new doctors trained to identify and advise or treat people who are drinking too much. Independent reviews into evidence of the relationship between the pricing and promotion of alcohol and harm, and unit labelling, including advice to women on alcohol and pregnancy, are under way. The reviews will form the basis of a public consultation later in the year and may require legislation in future.
Concern about the number of alcohol-related hospital admissions and the rising trend led the Department to put in place a new national vital signs indicator for the NHS from April to measure change in the rate of alcohol-related hospital admissions. That is the first national commitment to monitor how well the NHS is tackling alcohol-related health harm.
On viral hepatitis, hepatitis B and C are relatively uncommon in this country, with fewer than 0.5 per cent. of the general population being chronically infected with either. We are far below the global prevalence rate for hepatitis B or C of one in 12, as quoted by the World Hepatitis Alliance. That said, we cannot be complacent. The absolute numbers are significant and there are effective ways in which to prevent infection and treat those infected to prevent serious liver disease, as my hon. Friend the Member for Norwich, North pointed out.
In recognition of that, a comprehensive range of measures is in place to prevent and control hepatitis B and C infections, including screening of blood donations and viral inactivation of blood products; immunisation against hepatitis B for groups at increased risk of infection; antenatal screening for hepatitis B; services to prevent the spread of sexually transmitted infections; harm reduction services for injecting drug users, including needle and syringe exchanges; and drug treatments for chronic hepatitis B and C infection, as recommended by the National Institute for Health and Clinical Excellence.
The hon. Member for Hemel Hempstead referred to immunisation. An expert committee—the joint committee on vaccination and immunisation—is reviewing the hepatitis B immunisation programme to see whether it ought to be altered. Advice on that is expected later this year. He also referred to the problem of obesity. We have a constant struggle to educate and raise awareness among parents and young people on the impact of obesity. We need to look at how to get our message across more effectively than we have been able to do thus far.
Those are some of the new challenges facing the health service. In 60 years of the NHS, we have never been able to stay still because there are new and constant challenges. How can we spot difficulties before they explode and spiral out of control? The fact that we began focusing on obesity from a significant public policy point of view only recently begs some questions of our capacity to anticipate diseases, conditions and challenges far earlier than we do. Intervention and prevention at an earlier stage would be a far more effective way in which to tackle the problems than dealing with them once they become epidemics.
We recognise the importance of liver disease as a major public health issue and we have a range of measures in place to tackle it. However, we are concerned about the increasing incidence of, and mortality from, liver disease. Therefore, we are considering the need for an acceleration of our approach to the issue and the creation of a national strategy. It is difficult if every time we have a problem we reach for a national strategy rather than local solutions. However, the issue is so serious that there is a strong case to be made for a national strategy that influences commissioning and provision decisions at local level.