HC Deb 29 March 1984 vol 57 cc551-8

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

10.42 pm
Mr. Lewis Carter-Jones (Eccles)

It is a great pleasure to address the House on a very important issue. I am glad that the Minister who is to reply is, like me, the son of a miner.

Perhaps I should begin by explaining how I came across the concept of the oxygen concentrator. An eminent consultant at St. Thomas's said, "It is all very well doing some work on kidneys, Lewis, but what about trying to do some work on oxygen concentrators?" I must admit that I did not know what an oxygen concentrator was. Indeed, I think that I would forgive the Minister if he had not known what one was until 12 months ago. However, that does not excuse substantial numbers of people in the Department and outside not knowing what an oxygen concentrator is.

An oxygen concentrator is quite a small device. It is driven by electricity. It filters out the nitrogen in the atmospheric air and so allows the user to breath only oxygen. It may be said that it is the outcome of advanced technology, but it is not true to say that it has only just arrived. People were talking about it as long ago as 1968–69.

I shall pay tribute to certain people. I thank Geoffrey Spencer for his help. I have tried to find somebody opposed to oxygen concentrators on medical grounds, but I cannot. I have tried to find people opposed to them on the grounds of pounds and pence, but cannot, so I am left with the imponderable of having a superb piece of equipment, recommended by the most eminent of consultants, cheap in use when compared with oxygen in cylinders, and still not being used extensively.

I express my thanks to a substantial number of people in industry who have told me of ways in which things could be improved. I have received a fair amount of help from the House of Commons Library, and from Malcolm Dean of The Guardian. I pay that tribute because I had to go through a quick learning process. Having done so, I am astounded that this piece of equipment is not used more extensively than it is, because the £9 million spent on oxygen could be used to provide better treatment for five times as many people. That is the challenge, and it has not sprung up on us overnight. It has been with us for a long time.

I am glad that the Minister is to reply to the debate, because he has a mining background, as I do. I recall an uncle of mine who died of silicosis. He died long before some hon. Members who are in the Chamber now were born, in 1929. I was a young boy, but I remember him coughing up his lungs. We could not have stopped him contracting silicosis, but the rest of his life would have been relieved if he had had access to something like an oxygen concentrator.

In March 1969 the Lancet was talking about the oxygen concentrator and saying that it could be used. In the Medical Research Council, Dr. J. E. Cotes of the pneumoconiosis unit at Llandough hospital in Penarth was talking about its use, in view of the increasing cost of medical oxygen. He said, that there was a need for the change in the methods of dispensing oxygen.

The right hon. and learned Gentleman will notice that I am not picking out Ministers to attack in the period between 1970 to 1983. I am trying to get behind the problem. Between 1975 and 1980 there were trials with the DHSS and the MRC, which lead to a report saying that they were aware of the effectiveness of medical oxygen, but they were not aware of the cost. That is a load of rubbish. They were paying for the oxygen, the concentrators, the cylinders and the liquid oxygen. They must have known over 10 years ago about the effective cost.

One of the people who took part in the trial, Dr. Howard of Sheffield, said that the economic savings would become obvious by 1976–77. I am talking about a process which has medical advantages and is preferred by the patient. Everything is in its favour—every mortal thing—and still it is not used.

In 1978, the inventor, Dr. Cooper of Rimer-Alco, was sent a letter from the DHSS in which he was told that enough had already been done to establish the effectiveness of the oxygen concentrator.

The Royal College of Physicians — not exactly a commercial concern—in a report on 2 April 1981 on work already done and on which it had produced interim reports said: Points to be considered include that NHS resources would be used more economically for the purchase of oxygen concentrators than for oxygen cylinders. This is not a political issue. I hope to have a response from the Minister. I hope that he will accept the logic of the case and agree that the patient must come first. The process is desired by and acceptable to the patient. It is wanted by the physicians.

Page 11 of the report states: The high cost of cylinder oxygen is a material constraint which may be greatly reduced by the alternative use of an oxygen concentrator. The Royal college said that all that time ago.

On page 18 its report states: Equipment used by hospital departments of thoracic medicine for use in the home should be budgeted for separately from that for use in hospital. Treasury regulations should be amended to permit the use of oxygen concentrators". The Minister is not at fault, and nor were his predecessors. People within the Department handle the problem, when it should have been put to Ministers long ago. It is a clear case of administrators not bringing to Ministers' notice important issues connected with patient care in accordance with the best medical practice.

In August 1983 the British Medical Journal featured the latest clinical experience of concentrators. It said: Overall the concentrators appeared to be the most economical means of providing oxygen treatment at home and was much preferred"— we should note the words "much preferred"— by patients who had previously used oxygen cylinders. Yet another report was commissioned. It was supposed to be the definitive report. It was produced by the North-West regional health authority, but before it appeared an internal memo was issued on the use of oxygen which said: These machines replace oxygen cylinders for use in the home and are likely to show considerable savings (apart from any patient benefit) where patients required long term oxygen therapy. I have searched for a snag, but I cannot find one. There may be administrative difficulties, but the Minister and I are old adversaries and old friends. He knows that the difficulties must be overcome, because with the same money five times as many people could be treated more effectively with the concentrators. If they are fitted properly in the home, they can be properly monitored and give better service and feedback to the physician.

I must not go on for too long, as I must give the Minister plenty of time to reply, but the summary of this definitive report states: A two-year project has shown that oxygen concentrators may be used to provide long-term, high usage oxygen therapy to patients in the community and were well accepted by most of them". Are you not, Mr. Deputy Speaker, now getting the message? It looks as though different people have written these reports but that the same man has drawn up the findings. They are always the same. It is much cheaper, much better and the patients want it, yet 13 years later they are still not getting what they deserve.

The chairman of the British Oxygen Company would be well advised to ask some of his senior advisers, who know what is going on and are experts in the use of oxygen, why they have not taken the initiative in the production of oxygen concentrators, which can be provided at a lower cost for the benefit of the patient.

I end where I began in the hope that if there is an altercation the Minister will allow me to intervene. At the end of the day we will judge this decision, if it is cheaper, by the attitude of the patients. The survey that was commissioned asked: Have you ever felt the machine may have let you down? Ten per cent. said, "Yes," and 90 per cent. said, "No". It asked: Have you experienced any problems caused by the machine? Eighty-six per cent. said, "No problem." It asked: Have you encountered any difficulties in using the machine? Ninety-six per cent. said, "No problem."

If the patient wants it, if it is in his best interests, if it cares well for him, is cheaper and five times more people can be served by its extended use, why, oh why, cannot we have it now?

10.56 pm
The Minister for Health (Mr. Kenneth Clarke)

I congratulate the hon. Member for Eccles (Mr. Carter-Jones) on his good fortune in winning an Adjournment debate on this subject. I thank him for doing so. He rightly described himself as an old friend and adversary in the Chamber, but on this occasion he has—as we would all expect—raised a subject of considerable interest and importance. I am grateful for the opportunity of replying to his criticisms, which from time to time have been made in the newspapers.

The hon. Gentleman is talking about long-term oxygen therapy, which without doubt is of considerable benefit to a large number of people. He talked about a new method of delivering that supply of oxygen, by changing to the use of concentrators rather than cylinders, which appears to have great economic benefits when one is dealing with patients who require large quantities of oxygen. Therefore, he is understandably concerned about the delay in moving over to this better and apparently more economical and efficient way of providing the treatment. It is necessary to reply to the allegations of delay.

Let me begin by underlining what the hon. Gentleman has already said about the undoubted clinical benefits of the treatment that he has described. We now have enough work to establish the value of long-term oxygen therapy for people suffering from a variety of chronic respiratory diseases, including some of those arising from exposure to industrial pollution, such as coal dust and so on.

It is now quite clear that particular benefits can be given to people suffering from the more serious chest diseases, including those with cardiac complications. They acquire great benefit and relief, sometimes from large quantities of oxygen given over many hours during the day.

At the moment, such long-term oxygen therapy is provided usually by means of cylinders installed in the person's home. The cylinders given for the majority of patients about whom we are talking provide 10 to 11 hours of treatment per cylinder. They are prescribed by GPs but provided by retail pharmacists, who provide the cylinders and all the associated equipment as if they were drugs. They deliver them to the patient's home and are reimbursed for so doing.

It is true that the existing supply arrangements for cylinders are proving expensive, and as this form of treatment has become more popular, so the costs are rising and we are therefore looking at the alternative of moving to concentrators. No one denies that it could be more economical to provide the treatment by means of concentrators, and we shall look at that possibility, using our existing machinery through the family practitioner committees.

That is where we are now. The hon. Member for Eccles asked why it has taken so many years to become so clear about the clinical benefits of long-term oxygen therapy, and why we appear still to be delaying in moving to a more economical system of providing large quantities of oxygen in a way which is cheaper for the Health Service — which then has more resources for other things, including more oxygen—and also seems to be entirely acceptable nowadays to the patients who receive the treatment.

As the hon. Gentleman said, all these problems have been subjected to studies over the past years. The hon. Gentleman went back some years in his speech and pointed out that the first signs that concentrators might have some value go back to the early 1970s, and even before that. In fact, in the 1970s, as the provision of long-term therapy became more popular, there were still doubts about the use of concentrators. They were new, and although not too complicated, they were untried technology. There were still clinical uncertainties about the use of this form of therapy. Moreover, there was by no means unanimous medical opinion that patients could benefit from the long-term use of these quantities of oxygen.

The machines themselves were more cumbersome in those days, and they were not always as reliable as they are now. As a result—entirely wisely—my predecessors as Ministers, and previous officials in the Department in which I am now a Minister, decided that there was a case for some studies, before plunging into the widespread use of this therapy or the provision of oxygen by concentrators.

The Medical Research Council was the appropriate body to carry out the first studies. It was first commissioned to do so in the 1970s, and it carried out most of its work during the 1970s, when it studied the clinical efficacy of long-term oxygen therapy and had a look at concentrators as well. The work was carried out, as I said, in the 1970s, but the report took some time to compile. I have to say that the reports from the Medical Research Council—the first substantial evaluation of all that we are now talking about — was not received by our Department until December 1982. The reports were favourable about the therapy and favourable about the concentrators. However, they included the advice that consultant specialist doctors were required to be involved in providing the treatment for patients, and that general practitioners should refer patients to consultants before long-term oxygen therapy was given to patients.

Our Department did not wait, however, for the MRC to finish all that work before looking at other problems which had to be solved before matters could be taken any further. In particular, the Department began to commission work on the feasibility of providing concentrators and looking at the way in which we provided long-term oxygen therapy.

A study was carried out in the North-West regional health authority, to which the hon. Member for Eccles referred. It was asked to start its studies in September 1981, and it did not provide its report until January of this year. That report is now available, and it clearly shows the economic advantages of concentrators in the case of patients who use large volumes of oxygen. I have recently been asked many parliamentary questions by a number of hon. Members interested in the subject, and I keep referring them in my answers to the report of the North-West regional health authority's study, which is now deposited in the Library of the House.

Mr. Carter-Jones

Before I come to the main point of my intervention, may I point out that I was asking parliamentary questions before that report was produced? I say that to stress that the matter has been of interest for some time. It is sad that that study was using foreign-manufactured oxygen concentrators which had been initially made in this country. So other people had some work. The value of concentrators had been proved overseas. Why were there no consultations?

Mr. Clarke

Investigations into the clinical value of long-term oxygen therapy has been carried out in the United States as well as Britain and, no doubt, elsewhere, as has the manufacture and use of concentrators. We commissioned the work at an early stage, but the results of the work reached us from the MRC in December 1982 and from the North-West regional health authority's study in January 1984. By that time there was a body of work available which showed the clinical value of providing long-term oxygen therapy and concentrators. The clinicians involved in both studies raised queries about the way in which oxygen was being prescribed in Britain. Both came to the conclusion that the provision of oxygen should not just depend on the decision of general practioners, which at the moment is the practice in Britain, but should also involve the advice of a consultant and specialist in respiratory disease.

We had both reports by January this year. While the trials were taking place and we were awaiting the studies, doctors were finding that in practice the treatment was valuable to their patients and the prescribing of long-term oxygen therapy was daily getting more popular in Britain. That meant that more patients were receiving it, the cost to the NHS was going up, the machines were becoming more reliable and it was becoming increasingly clear that savings were possible. For some time now Ministers have not denied that since savings are possible.

The result was that we had to look at the possible solutions and some were being offered to us before we had either of the reports that I have described. In particular, BOC, the major supplier of oxygen in cylinders in Britain, began to put proposals to us a year or two ago. In August 1982, before we had the results of the MRC's work or the North-West regional health authority's study, BOC approached us with proposals to provide us with concentrators which were not costed.

Since that time BOC has worked up its proposals in more detail and has put to us a proposition to provide the NHS with concentrators in a way that seems extremely attractive. The BOC deal is based upon the concept of direct delivery by the company to the patients, with savings, many of which are achieved by eliminating pharmacists, who at the moment deliver the oxygen cylinders to the homes of patients. BOC estimated that its proposals would save at least £1 million per year. Both sides are agreed that the savings could be more than that.

Therefore, the clinical research by the MRC, the feasibility study in the North-West regional health authority and the proposals being put to us by BOC all pointed in the direction of clinical benefits and some financial savings. But we still required some testing of the proposition being put to us by the company to supply us. In effect, BOC was putting to us the suggestion that it should take over the monopoly supply of domiciliary oxygen to the NHS.

I have no doubt that BOC was anxious to accelerate the provision of concentrators, but I do not think that the hon. Gentleman, or those who, as he acknowledged, helped him with his speech — he mentioned a Guardian journalist — would have welcomed the Government signing up with BOC on a monopoly deal to provide concentrators without further work into the financial feasibility of what was being suggested. Therefore, we commissioned further work and I have asked that Arthur Andersen and Company should advise us on the financial implications of the deal that we are being offered to ensure that we are achieving the most cost-effective service with the maximum benefit to patients. If it is not the best proposal, we should look at the options.

Arthur Andersen and Company is carrying out the final study, which we are awaiting. I understand that it is likely to be in a position to report to us by April 1984, at which time we shall have all the advice that we need. We will have the Medical Research Council work, giving the clinical efficacy and the possible benefits of concentrators. We will have the work in the North-West regional health authority on the feasibility, establishing that it is practical to provide concentrators to family practitioner committees. We will also have some hard-headed financial advice of our own from Arthur Andersen and Company about the attractiveness to the Health Service, to its patients, and to the taxpayer of the deal that we are being offered by the British Oxygen Company.

I do not think that the House would want to press the Government to anticipate and to rush to a decision before receiving the results of all the studies. By April 1984, I am sure that we will have firmly established the value for those patients who require domiciliary provision of large quantities of oxygen by means of concentrators.

There will be obvious economic benefits from concentrators. We still have to address the question raised by the studies of who shall prescribe the long-term use of high volume oxygen. We now have two studies showing that consultants and specialists should be involved, and that the matter should not be left to general practitioners only. That may well cause debate in the medical profession. We need to consult the profession before we issue advice to it. We shall also have to examine sensibly the financial propositions that have been put to us in a variety of ways to decide how we should finance the provision of concentrators to patients.

Mr. Carter-Jones

Does the Minister not think that the British Oxygen Company has had its chance? The people who are using concentrators have proved their usefulness. Why should BOC have a second chance? History has shown that it should have taken its chance years ago, when it had the expertise, but did not take advantage of it.

Mr. Clarke

I do not quite follow the hon. Gentleman's point. The British Oxygen Company has bought about 100 concentrators, made by various people, and has put to us an arrangement whereby it would provide concentrators directly to patients. It is a very attractive proposition, but one that we must study with care. It would offer savings to the Health Service, and the savings would be not only at the expense of the cylinder provision, which is largely done by the British Oxygen Company at present, but also at the expense of the pharmacists who currently dispense the cylinders to the home. We must examine the alternatives to British Oxygen Company provision. The study that we await from Arthur Andersen and Company was provoked in the first place by the offer that was made to us by the British Oxygen Company.

The Question having been proposed after Ten o'clock and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.

Adjourned accordingly at twelve minutes past Eleven o' clock.