§ Motion made, and Question proposed, That this House do now adjourn—[Mr. John M. Taylor.]
9.34 am§ Mr. Gareth Wardell (Gower)I am delighted to have this opportunity to debate the subject of the treatment of leukaemia patients at the University hospital of Wales, Cardiff, which is the only bone marrow transplant facility in Wales. I am also pleased to provide the new Under-Secretary of State for Wales with his first opportunity of gripping the Dispatch Box while the House is in Session. I am sure that one of the reasons why he was promoted to that hallowed position was his tremendously useful contribution as a member of the Select Committee on Welsh Affairs, of which I am proud to be the Chairman.
Huge steps have been taken in a short time to improve the life chances of our fellow human beings who contract the terrible disease of leukaemia. Until about 10 years ago, the vast majority of people would die from that disease within a few months. Fortunately, recent advances, including bone marrow transplantation, mean that many patients with leukaemia can now look forward to a cure.
Paragraph 49 of the document on cancers launched yesterday by the Under-Secretary states:
a rise in the use of bone marrow transplants will decrease death from haematological malignancies.I was also pleased to read in a publication on cancers produced yesterday by the Welsh Health Planning Forum the acknowledgement, on page 7, that survival rates for many cancers five years after diagnosis are improving, especially for the leukaemias.However, the medical staff working at the University hospital of Wales, Cardiff, face difficult problems in treating seriously ill patients under their care. I first became aware of the problems through the sad loss of a young man to a family in my constituency whom I knew well and then through discussions with the senior doctor looking after those patients at the University hospital of Wales.
When I checked through the public expenditure White Paper and through the Welsh Office commentary published in March this year to assess the level of Welsh Office funding, I was surprised to find that those sources gave no assistance in quantifying the funding by the Welsh Office of this regional service. On 24 October, in the Select Committee on Welsh Affairs, I raised the issue with the Secretary of State, and I reiterate my request here. I ask that a meeting take place between the Secretary of State and the consultant in charge of the unit to discuss the changes necessary to improve patients' treatment.
The fundamental point to be addressed is the fact that there are only 18 beds in a treatment ward for the whole 518 range of haematology services, The beds are not ragionally funded and are not all dedicated for occupation by patients requiring bone marrow transplantation. The ward includes patients with a wide variety of haematological conditions, including haemophilia. The patients on the wards are not only those who are suffering from leukaemia who are waiting for bone marrow transplantation.
The existing haematology unit should have a minimum of 25 beds, with a high proportion of beds being in single cubicles because of the dangerously high risk of cross-infection. That number is the minimum needed and would eliminate the shortage of beds, which has meant that patients have been discharged earlier than their medical condition warranted.
Because of the continuum of care from pre-treatment to transplants, only the transplant is regionally funded. The underfunding of the pre-transplant phase is markedly reducing the effectiveness of the unit. The removal of that segmentation of funding is vital in order to improve the standard of care.
Prior to bone marrow transplantation, leukaemia patients require intensive treatment. It makes no sense for that treatment to be funded differently from the treatment provided when bone marrow transplantation occurs. I want now to identify the problem areas that arise from that unsatisfactory system of funding.
First, the senior doctor is currently not permitted by the unit manager at University hospital of Wales to prescribe certain drugs which, in the doctor's clinical judgment, are necessary for the treatment of certain kinds of leukaemia. Because of cost, a crazy situation arises in which a patient cannot be prescribed the drug alpha interferon, for example—I emphasise that that is only one example—by the regional specialist at his unit in Wales, but the same patient can be perscribed that drug by a consultant haematologist outside the South Glamorgan district health authority area.
One patient, who in the consultant's view and in his clinical judgment, should have been treated with alpha interferon was denied that treatment from the budget of the University hospital of Wales. However, the leukaemia research appeal chaired by my constituent Mr. Bernard Lewis for Llangennith provided the money to pay for the drug. I have a copy of the invoice from the pharmacy department of the University hospital of Wales for two months' supply of interferon paid for by the appeal in August. Two months' supply of the drug costs well over £300. Will people in Wales and Britain soon see pleas on their television screens and in their newspapers for anyone to provide life-prolonging drugs denied them through the nation health service?
Consultants have been able to cushion the effects of drug cost limitations by persuading GPs to perscribe the drugs. Now GPs throughout the country are deciding on legal advice that they cannot continue that practice. Specifically, a general medical practitioner who prescribes a drug at a consultant's request, which the GP would not normally be able to monitor on the basis of his own expertise and practice facilities, places himself in a position where he could be liable for an action for negligence.
Furthermore, the GP could be regarded as being in breach of his terms of service and liable to disciplinary proceedings. That view is based on an interpretation of paragraph 36 of schedule 1 to the National Health Service (General Medical and Pharmaceutical Services) Regulations 1974 which requires a GP to 519
order any drugs … which are needed for the treatment of any patient to whom he is providing treatment under these terms of service by issuing to that patient a prescription form, and such a form shall not be used in any other circumstances.Therefore, a GP could be held not to be providing treatment in some cases, for that treatment is being provided by the hospital consultant with the GP acting merely as a facilitator to provide drugs.Through correspondence with a GP in my constituency, I have been alerted to the same situation regarding the drug erythropoeitin which is used for the effective treatment for the anaemia of chronic renal failure. I use the example erythropoeitin to show that GP's awareness of the possibility of negligence claims is not simply confined to the treatment of leukaemia patients. That is why I am beginning to be haunted by the spectre of patients, including children, begging for prescribed drugs. I hope that the Minister will be able to comfort me with good Christmas cheer and guarantee that that spectre is completely unfounded and that the Government would never allow it to happen.
Specifically, I should like the Minister to accept that if a cancer treatment service is to be run satisfactorily, all the drugs that the clinician deems necessary for the treatment of his patients should be available to the unit including alpha interferon and similar substances such as aclarubicin and idarubicin. It is also important that the clinician is able to add to his armoury the new drug regimens that emerge and which will continue to improve cancer treatment. That is mentioned in paragraph 48 of the Welsh Health Planning Forum publication on cancers.
My second area of concern relates to the uncertainty about the availability of an anaesthetist for the bone marrow transplant programme. The department of anaesthetics at the University hospital of Wales has had to reduce its work load because of the non-filling of consultant and clinical assistant posts by the chief administrative medical officer for the South Glamorgan district health authority.
Bone marrow transplantation is not one of the specialties that are exempt from those cuts. In the rescheduling of anaesthetics lists there have been only two protected services—the provision of anaesthetic time at Rhydlafar for the treatment centre and anaesthetic services to provide cardiac surgery in accordance with achieving the target quota of operations.
In practice, therefore, even though bone marrow transplantation is a regional service which funds a weekly session for an anaesthetist, the policy of the University hospital of Wales of cancelling theatre sessions because of the non-availability of hospital anaesthetic staff has been extended to bone marrow transplantation.
I hope that the Minister will accept that the planning for a patient to receive a bone marrow transplant from a donor takes many weeks. In the last two weeks, cytotoxic drugs are administered to the patient and marrow is taken from the donor. If the transplant is cancelled at that stage, there is a potential danger to the patient. There is deep concern that, unless greater certainty can be introduced about the availability of anaesthetists, patient survival may be jeopardised.
The third and final problem area that I want to identify is nursing. There is a major problem with the inadequate number of nurses available to nurse leukaemia patients. 520 Nurses who have special training in oncology or leukaemia care are graded staff nurse or a sister and only five of the staff are in those grades. Those five nurses are expected to cover the two day-time shifts totalling over 13 hours. This means that, at any one time, there will not be more than two or three fully trained nurses for a ward which often has 18 very sick patients.
I hope that the Minister can accept that a regionally funded unit vertically integrated from pre-treatment ward to transplant and post-transplant treatment is the way to eradicate the problems which I raised.
§ The Parliamentary Under-Secretary of State for Wales (Mr. Nicholas Bennett)I thank the hon. Member for Gower (Mr. Wardell) for his kind remarks on my first appearance at the Dispatch Box in my new role. I appreciated his comments. I also appreciated his chairing of the Select Committee of which I was a member for three and a half years. I have always found the hon. Gentleman to be fair-minded and sensible on issues that are not matters of party political controversy. I shall reply to his comments in a similar manner.
I congratulate the hon. Gentleman on obtaining this debate on an important subject—the treatment of leukaemia patients—which is of concern to all hon. Members. I welcome the opportunity that the debate provides to set out the progress that is being made to help those people in our community who are unfortunate enough to have contracted this dreadful disease.
It may be helpful if I begin by explaining the all-Wales context for health service expenditure. The revenue funding made available to district health authorities in Wales has risen £267.033 million in 1978–79 to £945.401 million in 1990–91—an increase in real terms, after taking account of inflation, of 44.87 per cent. In 1991–92, spending is planned to rise to £1.188 billion—nearly 55 per cent. more in real terms than in 1979. Revenue allocations to South Glamorgan health authority rose from £57.841 million to £186.075 million in the same period.
In 1990–91, South Glamorgan health authority received an increase of £12–7 million over the previous year and its capital allocation was £7.938 million—an increase of 122 per cent. over the 1989–90 figure. That increase reflects the implementation of the second capital formula update which was forecast in the previous year's planning assumptions. It is important to give the all-Wales figures, because too often the impression is given that expenditure on our national health service has been cut when, in fact, in that period it increased by leaps and bounds.
On the specific issue of bone marrow transplantion, it may be helpful if I begin by setting out the types of treatment and the ways in which leukaemia is tackled in Wales. It can be treated by a number of methods, including chemotherapy, radiotherapy and bone marrow transplantation. District health authorities are responsible for the provision of services to lekaemia patients, but radiotherapy and bone marrow transplanattions are designated as regional services. District health authorities provide facilities at many of our hospitals and these provide ease of accessibility to patients and reduce the need for very sick patients to travel long distances for regular treatment. Such facilities are based within the hospital haematology departments, and in recent years departments have been 521 improved as health authorities have responded to the needs of patients suffering leukaemia and other blood-related disorders.
Bone marrow transplants are becoming increasingly important in the treatment of leukaemia. We in Wales are fortunate in having a purpose-built bone marrow transplant unit at the University hospital of Wales capable of providing that complex specialist treatment. That unit was inspired by and evolved from the pioneering work of clinicians at the University of Wales college of medicine and the University hospital of Wales in the early 1980s. I am delighted to have this opportunity to pay tribute to all those who were involved in that pioneering work, especially Dr. Jack Whittaker and his colleagues in the bone marrow transplant unit.
In recognition of the need for a bone marrow transplant unit to be effective clinically and to make the best use of scarce medical expertise in this specialism, it was decided to designate the unit as a regional service. As such, it is funded by the Welsh Office to provide a service to health authorities in south Wales.
Regional designation was made in 1984 and central funds have been made available to South Glamorgan health authority to meet the capital and running costs of the purpose-built bone marrow transplant unit. It is funded to undertake 20 allogeneic transplants a year using bone marrow from suitable donors. Autologous transplants, which use the patients' own bone marrow, are also undertaken in the unit and are funded by the district health authority. In 1989–90, 21 allogeneic and 22 autologous transplants were carried out in the unit. As at 30 November 1990, seven allogeneic and 15 autologous transplants have been undertaken in the present financial year.
I am happy to give the figures for the first year: in 1988–89, there were 13 allogeneic and 18 autologous transplants. We have made progress in just two years. The health authority estimates that the cost of an allogeneic transplant is £60,005 and that of an autologous transplant is £54,210. We believe that that is money well spent on providing an opportunity for a patient to regain his or her good health. Reflecting the need to concentrate scarce clinical expertise, health authorities in north Wales secure bone marrow transplantation from neighbouring English regions.
The hon. Member for Gower raised several specific and important issues. If I cannot respond to all of them in detail today, I shall make sure that he receives a full explanation and letter from the Department as soon as possible after Christmas on those issues on which I am not able to pronounce.
The hon. Gentleman referred to the promise by my right hon. Friend the Secretary of State to respond to his questions at the Select Committee on Welsh Affairs on 24 October when he asked my right hon. Friend to visit the unit. I am pleased to inform the House that arrangements are in hand for that visit and, subject to confirmation with the hospital and the district health authority, my right hon. Friend hopes to visit the unit on 12 February. I, too, intend to visit the hospital and unit in the near future as part of my programme of visits to NHS facilities throughout Wales.
The hon. Gentleman referred to infection control and cross-infection. Advice is available to the hospital consultants and management from the control of infections officer to ensure a safe environment for the care 522 of patients, particularly those with blood-related diseases such as leukaemia, who may be at special risk. I assure the hon. Gentleman that that advice is available at all times to any clinician who needs it. I hope that, if there is a problem at the University hospital, Dr. Whittaker and his colleagues will take it up with that official.
The hon. Gentleman referred to the use of a drug called alpha interferon. In addition to meeting the cost of undertaking bone marrow transplants at the University hospital, we have made central funds available to South Glamorgan health authority to meet the associated costs falling on support services such as the blood transfusion service and radiotherapy services which play a significant part in the bone marrow transplant treatment process. We recognise them as an important factor which we must consider. The cost of drugs used in the treatment regime is centrally funded.
I understand that the head of the bone marrow transplant unit, Dr. Whittaker, wishes to use a new drug, alpha interferon, as opposed to the more usual cyclosporin, which is used at the hospital. I also understand that the authority's drugs and therapeutics committee, which is composed of medical experts, has concluded that, at present, no convincing evidence exists for the use of this comparatively new drug and that its use is not justifiable on cost grounds. It is not, therefore, included in the hospital formulary and the unit general manager will not, therefore, sanction its purchase. I understand that Dr. Whittaker disagrees with that view. The chief administrative medical officer is now pursuing the matter with the parties involved. The Department's health professional group advises that the more usual drug for leukaemia patients is cyclosporin, and it is understood that this is available.
I must emphasise, however, that the specific drugs that may be prescribed are a matter for the managing health authority and the hospital management themselves on the advice of the drugs and therapeutics committee and it would be inappropriate for those of us without the essential training, technical knowledge and expertise to intervene in the question of the relative efficacy of drug regimes. I include politicians in that category. It would not be right for us, as lay people, to become involved in saying which drug is more effective. This matter must be decided by the clinicians. There is clearly a difference of professional view on this and it would not be right for the Government or Ministers to become involved in saying what should be done.
However, I emphasise that, as I understand it, central funding of drug costs has not been a factor militating against the availability of transplants where that treatment is regarded as the appropriate one for a patient. The same applies to the points made by the hon. Member for Gower about discharges from hospitals. Again, that is not a matter on which Ministers can make rulings; it must be for the clinicians in the hospital to make their own decisions, based on the health of the patient at the time, about whether that patient should, at an appropriate point, be discharged from the hospital.
The hon. Gentleman also referred to alpha interferon in connection with general practitioners. Professional advisers understand that, in the absence of convincing evidence about the wider use of alpha interferon, clinicians are voluntarily restricting the prescription of the drug to the treatment of hairy cell leukaemia. That is happening in 523 authorities other than South Glamorgan which are utilising other available therapies that they consider appropriate. That, of course, includes cyclosporin.
It is important that we should look at the allegations that have been made by the hon. Gentleman and I shall therefore ask for a further review aned report on the points that he has made. I have asked officials to look at this as a matter of urgency. In the letter that I shall send to the hon. Gentleman in the new year, I shall include any further information that we receive on this matter. I assure him that no life-prolonging drugs have been withheld from patients. It is simply a matter of which drug is most appropriate for the patient. It is right that the health service should take account of costs. If a drug is an effective means of dealing with a complaint and is a lot cheaper than another drug, it would be ethically wrong to spend money on the more expensive drug. It is therefore right to ask the clinicians to make the judgment on that matter. However, we shall have another look at this and I shall write to the hon. Gentleman.
The hon. Gentleman also referred to the drug erythropoeitin, which is known as EPO for short. Funds have been made available to the health authorities managing the main renal units in Wales. They include South Glamorgan, West Glamorgan and Clwyd. The drug is used to counter the effects of anaemia. I understand that it costs about £6,000 per patient per year. We are making funds available to assist with the costs of providing EPO. This year, recurring funds of £240,000, which were first provided in 1989–90, have been continued and an additional £150,000 of funding has been brought forward. The total for the two sets of figures for 1990–91 is now £390,000. The hon. Gentleman, who is a fair man, will recognise that we are providing considerable funds for that drug.
Health officials are not aware of any instructions issued in Wales that would restrict the present arrangements whereby a general practitioner who accepts clinical responsibility for a condition requiring the use of the drug may use it. If the hon. Gentleman has any information to the contrary, I should be happy to receive it and will take the matter up. My understanding at the moment is that there is no restriction on general practitioners using EPO.
The hon. Gentleman also referred to anaesthetists and radiologists. I understand from the unit general manager at University hospital Wales that the complement of anaesthetists at the hospital is at present two short, but that arrangements are in hand to recruit replacements. The job descriptions have been approved and advertisements will be placed shortly. Details of the amount of time spent by anaesthetists and radiologists working for the bone marrow transplant unit are not available. It is for the hospital unit to plan the use of its personnel. However, I understand that no operations have been cancelled in the BMT unit as a result of the temporary shortage of two anaesthetists. I shall bring the hon. Gentleman's remarks on this point to the attention of the unit general manager.
The hon. Gentleman also referred to the district health authority's funding of the bone marrow transplant unit. No representations have been made by the South Glamorgan health authority that it is in difficulty in managing the regional service for allogeneic bone marrow transplants.
524 However, in the context of the new arrangements that are to apply to regional services following their redesignation as district services with effect from 1 April 1991, the authority has indicated that, with the increased activity, the total running costs of the unit now exceed the funding provided by the Department. The latter relates to the level of service originally agreed—the 20 allogeneic transplants—and, as has already been said, the authority has not made any requests for additional funding in the intervening period. I shall, of course, ensure that the discussions that are taking place between South Glamorgan health authority and officials in my Department bear in mind the points that the hon. Gentleman has made when they consider the new arrangements that will be in place after 1 April 1991.
The hon. Gentleman also commented on what he said was the inadequate number of nurses available to the BMT unit. Again, we shall look at that matter and I will write to the hon. Gentleman about it. However, he will appreciate that it is not the job of the Department to monitor and control staffing at particular wards and units. Nevertheless, as the hon. Gentleman has raised this matter, we shall ensure that he gets an answer on it.
Looking to the future, the management and financial framework of the national health service is in the course of change to reflect the National Health Service and Community Care Act 1990. To ensure that the national health service is made increasingly responsive to the needs of patients, new arrangements are being brought in from 1 April 1991. Those new arrangements will be introduced in Wales from next year for the specialist services which, at present, are designed and provided as regional services. That includes the bone marrow transplant unit at University hospital.
The arrangements are being introduced in discussion with the relevant health authorities, following a comprehensive review of individual regional services and consultation with the health service in Wales. Individual health authorities will negotiate contracts with the providing units on services for patients, including any associated drug costs. However, because of their costs, the variable need for them or their heavy dependence on the availability of donors, a number of services are continuing to receive central protection, subject to periodic review.
It is a measure of our concern for leukaemia patients that the bone marrow transplant service at UHW is among those services that will benefit from that arrangement. That will mean that the level of service which has, in the past, been centrally funded and available to patients throughout south Wales will continue to be available to health authorities to meet the needs of leukaemia patients. Detailed arrangements are being considered in discussion with the managing health authority.
I reiterate that, in the haematology departments of hospitals throughout Wales, we have good caring facilities for the treatment of leukaemia patients. That is no less so in South Glamorgan where, in addition to the district service, the University hospital of Wales provides a highly specialised bone marrow transplant service to patients from its own and other districts. That service is funded centrally to provide an agreed level of treatment and, with the support of South Glamorgan health authority, has succeeded beyond expectation in extending the service available to leukaemia sufferers.
As the new Minister responsible for health in Wales, I want to take this opportunity to make clear for all to see 525 my commitment to the continuing work carried out over the past eleven and a half years to improve our health service. I use the national health service and I know how good it is. I believe that we can do even better. The policies that we have introduced to enhance health care by making it more responsive to the needs of patients and offering them greater choice will lead us forward to even greater excellence and quality and to a health service that will take Wales into the next century with a level of health care on course to rival the best in Europe.
I thank the hon. Member for Gower for introducing this subject which is of great concern to all of us in Wales and for giving me the opportunity, in my first debate, to reply on such an important subject.